Avantara Chicago Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago Ridge, Illinois.
- Location
- 10300 Southwest Highway, Chicago Ridge, Illinois 60415
- CMS Provider Number
- 145700
- Inspections on file
- 37
- Latest survey
- January 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Avantara Chicago Ridge during CMS and state inspections, most recent first.
A resident with vascular dementia, who was cognitively intact and previously described as calm and cooperative, was sent to the hospital for agitation and was not allowed to return based on behavior concerns decided by the Administrator and DON. The facility could not provide a physician assessment or psychiatric reassessment supporting that the resident could not be safely cared for, and the primary physician reported no evaluation had occurred. There was no written discharge notice, no discharge planning documentation, and no evidence the resident or representative was informed of appeal rights, despite facility policies requiring adherence to bed hold/readmission rules and proper discharge planning once a physician discharge order is obtained.
A resident with vascular dementia, CKD, CHF, A-fib, and diabetes did not have a documented physician visit within the required 60-day interval before a hospital transfer. Record review showed only an NP progress note, with no evidence that the attending physician evaluated the resident, supervised the NP visit, delegated care, or reviewed the resident’s medical management. The DON could not produce documentation of a timely physician visit, and the primary physician reported having neither seen the resident nor having records of NP visits, noting the last physician notes he saw were from another physician many months earlier. This failed to meet federal requirements and facility policy for physician visits and oversight.
A resident with multiple complex medical conditions and a gastrostomy tube had a physician order for continuous Osmolite 1.5 at 80 ml/hr with specified water flushes. During surveyor observation, an agency RN had the feeding pump set at 100 ml/hr and confirmed this rate, while the resident reported the nurse had increased the rate earlier. Review of the electronic record showed the ordered rate was 80 ml/hr, and the RN then reduced the pump setting to match the order. This resulted in the resident receiving enteral nutrition at a higher rate than prescribed, contrary to the facility’s enteral feeding policy and nursing job descriptions requiring adherence to physician orders.
A resident with a g-tube and complex medical conditions, including malignancies, COPD, CKD, and documented gastrostomy status, had a care plan and physician order requiring daily cleansing of the g-tube site with normal saline and application of a dry dressing. The order was not properly transcribed onto the Treatment Administration Record, and there was no documentation that g-tube site care was provided over multiple days. The resident reported that staff did not consistently clean the site or replace the dressing, and observation revealed a large amount of brownish-blackish crust around the stoma with no dressing in place. When the ADON and an agency LPN assessed the site, they acknowledged it should be cleansed and covered, and the resident exhibited pain on assessment, while facility policy and nurse job descriptions required daily stoma care and documentation of prescribed treatments.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and lacked proper oversight.
A resident with complex medical needs was financially exploited when a CNA stole the resident's credit card and made unauthorized purchases exceeding $1,000. The theft was discovered by the resident's family, who reported it to facility administration and law enforcement. Investigation confirmed the CNA's involvement, resulting in criminal charges for financial exploitation.
The facility failed to provide scheduled showers and grooming for residents dependent on staff for ADLs, affecting four residents. One resident with a pressure ulcer was left in urine and feces, while another reported never receiving a shower since admission. Documentation of showers or refusals was inconsistent, leading to the deficiency.
A resident at high risk for skin impairments developed a new moisture-associated skin disorder and experienced deterioration of an existing pressure ulcer due to the facility's failure to provide timely incontinence care. Despite being on a low air loss mattress, the resident was found soaked in urine and feces, and her call light was not answered. The facility did not adhere to its policies for skin care and incontinence checks, leading to significant harm.
The facility failed to label and store medications, such as insulin and inhalers, according to professional principles. Observations revealed that several insulin pens and inhalers on medication carts and in a medication room were not labeled with open dates, contrary to the manufacturer's guidelines. Staff interviews confirmed awareness of the requirement to date medications upon opening and discard them as recommended. This issue affected residents with conditions like Type 2 Diabetes Mellitus and COPD.
The facility failed to maintain proper sanitizer concentration in the kitchen's sanitation bucket, with test results showing levels significantly below the manufacturer's recommended range. This issue, observed during a survey, affects 158 residents who receive food from the kitchen, as improper sanitation can lead to foodborne illnesses. The Dietary Aide admitted to estimating the sanitizer solution, and the facility was unable to provide the manufacturer's dilution instructions.
The facility failed to ensure call lights were within reach for four residents, as observed on a specific date. Despite the facility's policy and care plans requiring accessible call lights, they were found on the floor, making them inaccessible. Staff confirmed the expectation for call lights to be within reach, highlighting a lapse in policy adherence.
The facility failed to adhere to infection control practices, including improper handling of respiratory equipment and inadequate disinfection of medical equipment between resident uses. A nebulizer mask was left uncovered, and a nurse did not disinfect equipment between residents. Additionally, staff did not follow proper procedures for residents on transmission-based precautions, such as wearing PPE and performing hand hygiene.
A resident with a fractured hip from a fall in the facility did not receive timely skilled therapy services as ordered by the physician. The resident, who was a fall risk, was initially hospitalized for chest pain and later diagnosed with fractures. Upon readmission, therapy services were delayed due to insurance approval processes, and the facility staff were unaware of the fracture diagnosis until after readmission. The facility lacked a policy on therapy services, leading to a deficiency in coordinated care.
Two residents at high risk for falls experienced incidents due to inadequate safety interventions. One resident, admitted for rehabilitation, fell while reaching for a phone, resulting in a laceration. Another resident fell during care due to improper positioning. The facility's fall prevention guidelines were not adequately followed, leading to these incidents.
A facility failed to refer a resident for a PASRR Level 2 screening after a new diagnosis of major depression was made. The Social Service Director was unaware of the diagnosis until the survey, despite the Administrator claiming to have informed her. The resident had a PASRR Level 1 screening before admission, but the facility policy requires updated screenings for new mental health diagnoses.
The facility failed to supervise two residents during medication administration, leaving them to self-administer without authorization. An LPN left medication with a resident during breakfast, and an RN left a resident with medication unattended. Additionally, the facility did not maintain accurate controlled substance records, with missing signatures and discrepancies in medication counts.
The facility failed to document incontinence care every shift for two residents dependent on staff for bowel and bladder incontinence. A review of records showed a lack of documentation indicating care was provided at least once per shift. Family members reported instances where residents were left soaked in urine, and the Director of Nursing confirmed the expectation for CNAs to document care per shift.
A resident with hemiplegia and hemiparesis developed a new stage II pressure ulcer despite being at risk and dependent on staff for care. The facility's failure to prevent this was linked to potential issues with turning, repositioning, and treatment plans, although no nutritional concerns were noted. Initial skin alterations were documented but progressed to a pressure ulcer, indicating insufficient preventive measures.
A facility failed to replace a damaged call light cord with exposed wires in a resident's room, which was identified during a survey. The resident, who had a femur fracture and cognitive communication deficit, was discharged before the issue was discovered. A family member reported the hazard, and a staff member removed the cord after being informed. The facility's policy requires the removal of hazardous items to ensure safety.
A resident with a history of falls and cognitive deficits sustained a foot fracture after attempting to toilet herself due to delayed assistance from staff. The facility failed to complete required fall risk assessments and did not provide timely toileting assistance, leading to the resident's fall and injury.
A resident with end-stage renal disease experienced severe complications, including sepsis and peritonitis, due to the facility's failure to properly manage her peritoneal dialysis catheter. The resident was found with a missing cap on her catheter, leading to an infection that required hospitalization and a switch to hemodialysis.
Failure to Honor Return Rights and Complete Required Discharge Procedures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to return following hospitalization and to conduct proper discharge procedures. An older adult resident with vascular dementia, documented as cognitively intact with a BIMS score of 14/15 and described in an 8/31/2025 psychiatric evaluation as pleasant, calm, cooperative, and without behavioral issues, was transferred to the hospital on 9/29/2025 after exhibiting agitation and did not return. On interview, the DON stated that she and the Administrator decided not to allow the resident to return due to behavior concerns. The facility was unable to provide any physician assessment determining that the resident could not be safely cared for in the facility, and the resident’s primary physician confirmed he had not seen the resident and had no record of evaluation. No documentation was provided showing a psychiatric reassessment following the behaviors cited by the facility, and there was no change in condition noted in the resident’s medical record. Record review revealed no written discharge notice, no discharge planning documentation, and no evidence that the resident or representative was informed of appeal rights. When surveyors requested any and all documentation or assessments used in determining the resident’s involuntary discharge, none were provided. This failure occurred despite facility policies stating that the facility would adhere to federal regulations on bed hold and readmission, including permitting residents transferred for hospitalization to return to the first available bed after exceeding the bed hold period, and that proper discharge planning and instructions would be conducted once a discharge order is obtained from the attending physician.
Failure to Ensure Timely Physician Visits and Oversight of NP Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident and the attending physician had face-to-face visits within the federally mandated and facility-required 60-day timeframe. The resident, an older adult with vascular dementia, chronic kidney disease, congestive heart failure, atrial fibrillation, and diabetes, was transferred to the hospital on 9/29/2025 and did not return. Record review showed no documentation of a physician visit for more than 60 days prior to this hospital transfer, and the DON could not provide evidence of a required physician visit when requested on 1/24/2026. The only documentation provided was a nurse practitioner (NP) progress note dated 2/17/2025, with no documentation that the attending physician evaluated the resident, supervised the NP visit, delegated care, or reviewed or directed the resident’s medical care. During interview, the primary physician stated that he had not seen the resident, had no records of his NP seeing the resident, and that the last physician notes he saw in the electronic medical record were from another physician’s services dated 2/17/2024, adding that he would not see a resident who belonged to another physician. The facility’s own policy requires residents to be seen by a physician at least every 60 days with an evaluation of the resident’s condition and total program of care, which the facility was unable to demonstrate occurred within the required timeframes. The facility was therefore unable to show compliance with federal requirements and its own policy for timely physician visits and physician oversight of NP services for this resident.
Failure to Follow Physician Order for Enteral Feeding Rate
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of quality for a resident receiving enteral nutrition. The resident is an adult male with multiple complex diagnoses, including malignant neoplasms, COPD, chronic kidney disease, peripheral vascular disease, gait and mobility abnormalities, gastrostomy status, and several psychiatric conditions. His BIMS score of 11 indicated moderate cognitive impairment. According to the Medication Administration Record for January 2026, the physician’s order dated 01/07/2026 specified continuous enteral feeding with Osmolite 1.5 at 80 ml/hr for a total feed volume of 1920 ml over 24 hours, with water flushes at 40 ml/hr for a total flush volume of 960 ml over 24 hours. Facility policy for enteral tube feeding care required the nurse to check the POS/MAR for the enteral feeding order, including formula, type, rate, and duration. On 01/17/2026 at 10:48 a.m., the resident was observed awake and alert in bed with the gastrostomy tube feeding infusing at 100 cc/hr of Osmolite 1.5. The resident stated that the nurse had changed his feeding rate to 100 earlier that morning. At 12:18 p.m., the feeding was still infusing at 100 cc/hr. At 12:20 p.m., an agency RN (V15) confirmed to the surveyor that the feeding pump was set at 100 cc/hr. After reviewing the resident’s order in the electronic record (PCC/PointClickCare), V15 acknowledged that the ordered rate was 80 cc/hr and stated that the rate needed to be changed to match the doctor’s order. At 12:25 p.m., V15 adjusted the feeding rate from 100 cc/hr to 80 cc/hr, stating that they were supposed to follow the physician’s order. This sequence of events shows that the resident received enteral feeding at a rate higher than ordered, contrary to the facility’s enteral feeding policy and the job descriptions for floor nurses, which require adherence to physician orders and established nursing policies and procedures.
Failure to Provide Ordered G-Tube Site Care and Maintain Clean, Dressed Stoma
Penalty
Summary
The deficiency involves the facility’s failure to follow its own enteral tube feeding care policy and physician orders for a male resident with a gastrostomy tube (g-tube). The resident, admitted with multiple diagnoses including malignant neoplasms, COPD, chronic kidney disease, peripheral vascular disease, bipolar disorder, and documented gastrostomy status, had a care plan dated 11/6/25 indicating he was receiving gastric tube feeding due to atresia of the esophagus with tracheoesophageal fistula and was at risk for infections, fluid overload, dehydration, and aspiration pneumonia. The care plan included an intervention to check the g-tube site for signs and symptoms of infection and notify the physician. An order dated 1/05/2026 at 1:30 p.m. directed staff to cleanse the enteral tube feeding site with normal saline and apply a dry dressing, and the facility’s policy required the g-tube stoma site to be cleansed and covered with dry gauze daily. Record review showed that this g-tube site care order was not transcribed onto the scheduled area of the Treatment Administration Record, and there was no documentation that g-tube site care was performed from 1/5/2026 through 1/16/2026. Nursing progress notes for 1/5/2026 also contained no documentation of g-tube care. During an observation on 1/16/2026 at 1:18 p.m., the resident reported that staff were supposed to clean his g-tube site and apply a dressing but did not do so consistently, stating that sometimes they cleaned it and sometimes they did not. He reported that a nurse removed the gauze the previous day and did not clean the site or replace the dressing. The surveyor observed a large amount of brownish-blackish crust encircling the g-tube stoma and noted that there was no dressing in place. When the ADON assessed the g-tube site at 1:36 p.m. on the same day, she stated that the site should be covered and appeared to need cleaning due to crust build-up; the resident winced in pain and stated the area was sore. After the ADON left, the resident stated that because staff did not clean his g-tube site, he would clean it himself with alcohol and that removal of the gauze the previous day had hurt. Later, an agency LPN entered the room and stated she had not changed the dressing because it was changed on night shift, but acknowledged that the g-tube was supposed to be cleansed with normal saline and gauze applied, and that the site had crust around it. The DON stated that nurses should be changing the g-tube dressing daily, ensuring the area is cleaned, and documenting it on the TAR or MAR, consistent with the facility’s enteral tube feeding care policy and the floor nurse job descriptions for LPNs and RNs, which require administering and supervising prescribed treatments such as tube care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper oversight and the presence of hazards in the area, as directly observed by surveyors.
Resident Financial Exploitation by Facility Staff
Penalty
Summary
A resident with multiple medical conditions, including a history of femur fracture, major depressive disorder, diabetes, COPD, hypertension, anemia, and generalized anxiety, was admitted to the facility and later became the victim of financial exploitation. The resident's family member discovered unauthorized charges totaling over $1,000 on the resident's credit card, which had been stolen. The charges were made at local restaurants and stores, and the card was never returned to the resident. The family reported the incident to the facility and filed a police report, providing documentation of the charges and the police report number to the facility administrator. Investigation revealed that a CNA who worked on the same floor as the resident during the relevant period was identified as a suspect. Security camera footage and police investigation led to the arrest and felony charge of financial exploitation against the CNA. The facility's abuse and neglect policy, which prohibits misappropriation and exploitation of resident property, was not adhered to, resulting in the resident's loss of property and financial exploitation by facility staff.
Failure to Provide Scheduled Showers and Grooming for Residents
Penalty
Summary
The facility failed to ensure that staff provided scheduled showers and grooming for residents dependent on staff for Activities of Daily Living (ADLs). This deficiency affected four residents, who were observed to have unmet hygiene needs. One resident, who has a history of Parkinson's disease and severe protein-calorie malnutrition, was reported by family members to be left sitting in urine and feces multiple times a week, despite having a pressure ulcer that should not be exposed to moisture. The resident was scheduled for showers twice a week, but documentation was lacking, and there was no record of shower refusals. Another resident, with a history of chronic obstructive pulmonary disease and type 2 diabetes, reported never receiving a shower since admission and only occasionally receiving bed baths. This resident was found wearing two incontinence briefs, one saturated with urine and feces, which the CNA stated was against facility policy. The resident was scheduled for showers twice a week, but there was no documentation of showers being given or refused. Additional residents were also affected, including one with a history of malignant neoplasms and chronic kidney disease, who appeared unclean and reported not receiving showers, only bed baths. Another resident, with a history of hemiplegia and chronic heart failure, was observed to have not been washed up and had no documentation of receiving scheduled showers. The facility's policy required documentation of showers or refusals, but this was not consistently followed, leading to the deficiency.
Failure to Prevent Pressure Ulcer Deterioration
Penalty
Summary
The facility failed to implement preventive measures to prevent the development and deterioration of pressure ulcers in a resident identified as R139, who was at high risk for skin impairments. The deficiency was observed when R139 was found soaked in urine and feces, with her bed wet from her upper back to her ankles. This incident was reported by her family member, who expressed concerns about the lack of incontinence care provided from the night shift until the morning shift. The resident, who was on a low air loss mattress, developed a new moisture-associated skin disorder (MASD) on her bilateral buttocks and her existing pressure ulcer on the sacrum deteriorated to an unstageable stage. R139, who was initially admitted with a stage 2 pressure ulcer on the sacral area, had a medical history that included hemiplegia, type 2 diabetes mellitus with diabetic neuropathy, obesity, and other conditions that increased her risk for pressure ulcers. Despite being on a low air loss mattress and having specific orders for wound care, the facility failed to ensure that incontinence care was provided every two hours as required. The resident reported that her call light was not answered, and her brief was not changed when soiled, contributing to the worsening of her skin condition. The facility's policies on skin care and incontinence care were not followed, as evidenced by the lack of timely incontinence checks and the improper functioning of the low air loss mattress. The Assistant Director of Nursing (ADON) and the Wound Care Coordinator confirmed the issues, acknowledging that prolonged exposure to soiled conditions could lead to the development and deterioration of pressure ulcers. The facility's failure to adhere to its own protocols resulted in significant harm to R139, as her pressure ulcer progressed from stage 2 to unstageable, and she developed a new MASD.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and store medications, specifically insulin and inhalers, according to the manufacturer's recommendations and professional principles. During an observation, it was found that several insulin pens and inhalers on the 2nd floor East-West and [NAME] medication carts, as well as in the 3rd floor medication room, were not labeled with the date they were opened. This included insulin glargine, insulin lispro, and various inhalers, which should have been discarded after a specific period as per the manufacturer's guidelines. Interviews with the nursing staff confirmed that they were aware of the requirement to date medications upon opening and to discard them according to the manufacturer's instructions. The report highlights specific instances where medications were not labeled with open dates, such as insulin glargine and lispro pens, and inhalers for residents with conditions like Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. The facility's policy on medication labeling, which requires opened medications to be labeled with the date of opening and discarded within a specified timeframe, was not adhered to. This oversight was observed across multiple medication carts and storage areas, indicating a systemic issue in medication management within the facility.
Improper Sanitizer Concentration in Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation levels in the kitchen, specifically in the sanitation bucket used for kitchen rags. During an observation, the Dietary Manager (DM) tested the sanitation bucket using Quaternary test strips and found that the sanitizer concentration was significantly below the manufacturer's recommended levels. The expected concentration should have been between 300 to 400 parts per million (ppm), but the test results showed only 0-100 ppm. This discrepancy was observed despite multiple attempts to achieve the correct concentration by stirring the solution. The Dietary Aide responsible for changing the sanitation bucket admitted to estimating the water and sanitizer solution rather than following precise measurements. The facility's policy requires that the sanitation bucket be filled with sanitizer according to the manufacturer's recommendations, which specify a concentration range of 150-400 ppm for Quaternary solutions. However, the facility was unable to provide the manufacturer's dilution instructions. Additionally, the Dietary Manager initially provided incorrect information regarding the acceptable concentration range, later correcting it to 200-300 ppm. The facility's failure to adhere to these guidelines has the potential to affect 158 residents who receive food from the kitchen, as improper sanitation levels can lead to foodborne illnesses.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that resident call lights were within reach, affecting four residents in a sample of 32. Observations on January 7, 2025, revealed that the call lights for residents R3, R15, R150, and R416 were hanging on the floor next to their beds, making them inaccessible. Certified Nurse Aides V23 and V24 confirmed that call lights should be within reach and not on the floor, as residents need to be able to call for assistance. The Director of Nursing also stated that call lights should be clipped to the bed or tied to the bed rail, according to resident preference. The medical records of the affected residents indicated various diagnoses and care plans that required assistance with activities of daily living. For instance, R15 had a history of cerebrovascular accident, visual impairment, and other conditions, with a care plan intervention to keep call lights within reach. Similarly, R150 and R416 had care plans emphasizing the need for accessible call lights due to their medical conditions. Despite the facility's policy, revised in July 2024, which mandates that call lights be within reach at all times, the deficiency was observed, indicating a lapse in adherence to the policy.
Infection Control Deficiencies in Equipment Handling and Precautionary Measures
Penalty
Summary
The facility failed to ensure proper infection control practices in handling respiratory equipment and disinfecting medical equipment between resident uses. An observation revealed that a nebulizer mask used by a resident was left uncovered and hanging from a nightstand, contrary to the facility's policy that requires such equipment to be stored in a labeled plastic bag. Additionally, a Licensed Practical Nurse was unaware of who left the nebulizer mask in this condition, indicating a lapse in adherence to infection control protocols. Further deficiencies were noted in the disinfection of medical equipment. A Registered Nurse was observed taking vital signs of multiple residents without disinfecting the blood pressure apparatus and pulse oximeter between uses. This practice was contrary to the facility's policy, which mandates cleaning reusable equipment between residents. The Director of Nursing and the Infection Preventionist both acknowledged that the equipment should have been disinfected after each use. The facility also failed to implement appropriate infection control practices for residents on transmission-based precautions. A Certified Nurse Assistant entered a resident's room without performing hand hygiene and without wearing the required personal protective equipment. Additionally, a Licensed Practical Nurse did not change gloves or perform hand hygiene between different procedures on a resident. The transmission-based precaution setup outside certain residents' rooms lacked necessary personal protective equipment, such as gloves and masks, and some rooms did not have hand soap available, further compromising infection control measures.
Delayed Therapy Services for Resident with Fractured Hip
Penalty
Summary
The facility failed to provide coordinated care services to a resident who suffered a fractured hip from a fall within the facility. The resident, identified as R74, was not provided with skilled therapy services as ordered by the physician in a timely manner. The deficiency was identified during an observation, interview, and record review, affecting one of the three residents reviewed for quality of care. The resident was found in bed, alert but with some confusion, and was identified as a fall risk. Despite the fall occurring on 12/14/24, the facility staff, including the Director of Nursing, were not aware of the fracture diagnosis until after the resident's readmission. The resident was initially sent to the hospital due to chest pain and was diagnosed with a non-ST-elevation myocardial infarction (NSTEMI). During the hospital stay, the resident reported right thigh pain, and a subsequent CT scan revealed an intertrochanteric fracture of the right femur and closed fractures of the right superior and inferior pubic ramus. The resident underwent right hip pinning on 12/23/24. Upon readmission to the facility, the resident had orders for occupational, physical, and speech therapy, but there was a delay in starting these therapies due to insurance approval processes. The Rehab Director was unaware of the fracture diagnosis until notified by the Nurse Practitioner on 12/30/24, and therapy services did not commence until early January. The delay in therapy services was attributed to the need for pre-approval from insurance, as stated by the facility's Administrator. The facility was unable to provide a policy on therapy services and skilled rehabilitation services, highlighting a lack of coordination and communication regarding the resident's care needs and therapy orders.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to ensure safety interventions were in place for a resident, identified as R216, who was at high risk for falls. R216, who had a history of falls and was admitted for rehabilitation following a humerus fracture, experienced an unwitnessed fall on the day of admission. The fall occurred when R216 attempted to reach for a phone on the nightstand, resulting in a laceration to the right eyebrow that required hospital treatment. The admission assessment identified R216 as high risk for falls, but no specific interventions were documented in the care plan to mitigate this risk. Another resident, R27, also experienced a fall due to inadequate supervision and positioning. R27, who has a history of hemiplegia and hemiparesis following a cerebral infarction, was turned by a CNA during care and slid off the bed because they were positioned too close to the edge. The CNA did not realize the resident's proximity to the edge, which led to the fall. A post-fall investigation confirmed that R27 was too close to the edge of the bed, and staff were reminded to ensure proper positioning before performing activities of daily living. The facility's fall prevention program guidelines require the implementation of safety interventions for residents identified at risk for falls. However, in both cases, the necessary precautions were not adequately implemented or maintained, leading to the incidents. The Director of Nursing acknowledged the oversight in R216's care plan and the need for baseline fall interventions to be indicated upon admission.
Failure to Conduct PASRR Level 2 Screening for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a PASRR Level 2 screening after the resident received a new diagnosis of a serious mental illness. The Social Service Director (SSD) was responsible for ensuring that residents with new mental illness diagnoses received an updated PASRR Level 2 screening. However, the SSD was not made aware of the new diagnosis for the resident until the survey, at which point she contacted the agency to have the screening completed. The Admissions Director confirmed that a PASRR Level 1 screening was completed before admission and stated that social services would be responsible for obtaining a Level 2 screening if a new mental illness diagnosis was made. The Administrator acknowledged awareness of the resident's new diagnosis since admission and claimed to have informed the SSD of the need for a new PASRR Level 2 screening. The resident's medical records indicated a new diagnosis of major depression and other mental health conditions. The facility's policy, revised in August 2024, mandates that residents with mental disorders receive PASRR screenings within the allowed timeframe, but this was not adhered to in this case.
Medication Administration and Controlled Substance Management Deficiencies
Penalty
Summary
The facility failed to properly supervise residents during medication administration, as observed in two cases. In the first instance, a Licensed Practical Nurse (LPN) left a medication cup with three pills on a resident's food tray while the resident was eating breakfast, trusting the resident to take the medication independently. The Director of Nursing (DON) later confirmed that no residents in the facility are authorized to self-administer medications and that nurses are expected to supervise medication intake. The resident's Medication Administration Record indicated that the medications were recorded as administered, despite the lack of supervision. In another case, a Registered Nurse (RN) left a resident with a medication cup containing seven pills and a cup of water mixed with a laxative, then left the room to retrieve additional medication, failing to supervise the resident's medication intake. The RN assumed the resident would take the medications due to their alertness and orientation. Additionally, the facility failed to maintain accurate records for controlled substances, as evidenced by missing signatures on the Controlled Substance Count Log and discrepancies in the medication count for a resident's Tramadol prescription. The facility's policy requires nurses to sign the controlled medication sheet immediately after removing medication, which was not adhered to in this instance.
Failure to Document Incontinence Care Per Shift
Penalty
Summary
The facility failed to document incontinence care every shift as per its policy, affecting two residents, R1 and R2, who were reviewed for incontinence care. R1, a female resident with hemiplegia, hemiparesis, and a stage I pressure ulcer, was admitted on 8/6/24 and assessed as dependent on staff for bowel and bladder incontinence. R2, admitted on 8/30/24 with a femur fracture and cognitive communication deficit, was also dependent on nursing staff for mobility and incontinence care. A review of the point of care (POC) tasks over a 30-day period revealed a lack of documentation indicating that R1 and R2 received incontinence care at least once per shift every day. On 9/18/24, a family member of R2 expressed concerns that R2 did not receive overnight incontinence care, resulting in R2 being soaked in urine by morning. Similarly, on 9/11/24, a family member of R1 reported that R1 was left soaking in a disposable brief and did not receive incontinence care for over an hour after requesting assistance. Documentation for 9/11/24 showed only one instance of incontinence care for R1, recorded at 1:27 pm. The Director of Nursing confirmed that CNAs are expected to document incontinence care or toileting at least once every shift, as per the facility's policy revised in 7/24, which mandates rounds every 2 hours to check for incontinence.
Failure to Prevent New Pressure Ulcer in At-Risk Resident
Penalty
Summary
The facility failed to prevent the development of a new pressure ulcer in a resident who was already at risk for such conditions. The resident, a female with hemiplegia and hemiparesis following a cerebral infarction, was admitted with a stage I pressure ulcer on the sacrum. Despite being dependent on staff for activities of daily living, including turning, repositioning, and incontinence care, the resident developed additional skin alterations. These alterations were initially documented as a gluteal cleft tear and a right ischium skin tear, which were later reclassified as a stage II pressure ulcer. The Director of Nursing acknowledged that the worsening of the wounds could have been due to a lack of turning or repositioning, a decline in nutrition, or an ineffective treatment plan, although no nutritional concerns were noted for the resident. The facility's care plan, initiated prior to the development of the new ulcer, aimed to prevent additional skin breakdown by following facility protocols. However, the documentation and actions taken by the staff, including the application of wound paste and collagen, were insufficient to prevent the progression of the resident's condition.
Failure to Replace Damaged Call Light Cord
Penalty
Summary
The facility failed to replace a damaged call light cord in a resident's room, which was identified as a deficiency. A resident, who was admitted with a femur fracture, cognitive communication deficit, and generalized weakness, was discharged from the facility before the issue was discovered. On a subsequent visit, a family member informed a surveyor about the damaged call light with exposed wires in the resident's former room. The surveyor observed the damaged call light, which had been ineffectively taped to cover the exposed wires. A staff member from Guest Services, upon entering the room and seeing the damaged cord, removed it and stated it would be replaced immediately. The facility's policy on hazards, revised in July, mandates the removal of hazardous items to ensure resident safety, which was not adhered to in this instance.
Failure to Provide Timely Toileting Assistance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to its fall prevention policy and procedures, resulting in a resident, R2, sustaining a left foot fracture. R2, a female resident with a complex medical history including partial paralysis, a history of falls, and cognitive deficits, required assistance with activities of daily living, including toileting. Despite these needs, the facility did not provide timely toileting assistance, leading to R2 attempting to toilet herself, which resulted in a fall and subsequent injury. On the day of the incident, R2 activated her call light to request assistance with toileting. However, the assigned Certified Nursing Assistant (CNA), V16, was occupied with other residents and did not immediately respond to R2's request. Although V16 acknowledged R2's call light and informed her that assistance would be provided shortly, R2 attempted to transfer herself to the bathroom, resulting in a fall. The facility's Director of Nursing later confirmed that R2 should not have attempted to transfer herself due to her physical limitations. The facility's failure to complete fall risk assessments quarterly and annually, as required by their policy, further contributed to the deficiency. R2's medical records only contained an admission fall risk assessment and a post-fall risk assessment, indicating a lack of ongoing evaluation of her fall risk. This oversight, combined with the delayed response to R2's toileting needs, highlights the facility's failure to provide adequate supervision and timely assistance to prevent accidents.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to ensure dialysis services were provided in a manner consistent with professional standards for a resident who required peritoneal dialysis. The resident, who had a history of end-stage renal disease and was dependent on peritoneal dialysis, was found with a missing cap on her dialysis catheter. This incident was noted by the nursing staff prior to setting up the patient's dialysis, and the resident was subsequently transferred to an acute care hospital for a catheter exchange. The missing cap increased the risk of infection, and the resident was later diagnosed with sepsis and peritonitis, necessitating the removal of the peritoneal dialysis catheter and a switch to hemodialysis, which significantly altered her treatment regimen and required additional coordination for outpatient dialysis sessions. The resident's family reported that the facility's staff did not handle the dialysis in a sanitary manner, and the resident was left connected to the dialysis machine for an extended period, which contributed to the complications. The facility's policy required the peritoneal catheter to be capped when not in use and for the catheter site to be inspected daily for signs of infection, but these procedures were not followed, leading to the resident's severe infection and subsequent hospitalization.
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.
