Avantara Joliet
Inspection history, citations, penalties and survey trends for this long-term care facility in Joliet, Illinois.
- Location
- 210 North Springfield Avenue, Joliet, Illinois 60435
- CMS Provider Number
- 145029
- Inspections on file
- 30
- Latest survey
- December 24, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Avantara Joliet during CMS and state inspections, most recent first.
Several residents with significant care needs did not receive timely or adequate staff assistance for ADLs such as toileting, incontinence care, nail and hair care, and oral hygiene. Residents were observed with soiled briefs, untrimmed nails, disheveled hair, and poor oral hygiene, and some reported not receiving grooming or oral care for extended periods despite repeated requests. Staff interviews and documentation revealed lapses in following care plans and facility policies for regular incontinence checks and daily hygiene support.
Facility staff failed to consistently assess, cleanse, and dress G-tube sites for multiple residents dependent on staff for care, resulting in observations of unclean sites, drainage, and missing dressings. Physician orders and facility policy required daily site care and monitoring, but documentation and direct care were lacking on several occasions, with staff acknowledging the omissions and the need for more frequent inspection and intervention.
Two residents experienced deficiencies in skin care management when staff failed to obtain or follow treatment orders for a skin tear and incontinence-associated dermatitis. In both cases, required documentation and assessments were missing, and treatments were not consistently administered or recorded as ordered by the physician.
A resident suffered a large laceration to the left lower leg requiring 18 sutures during a transfer from wheelchair to bed performed by a CNA. Staff were unsure if wheelchair footrests were in place, and it was unclear whether the injury was caused by the bed or wheelchair. The facility lacked specific policies on safe transfers and fall prevention, providing only a limited gait belt policy without comprehensive guidance.
A resident did not receive enough food and fluids to maintain their health, as surveyors found that the facility did not adequately meet the individual's nutritional and hydration needs.
A resident with dementia and constipation was not properly monitored for bowel movements, leading to a fecal impaction and colon inflammation. Despite orders to monitor and notify the physician if no bowel movement occurred in three days, the facility failed to administer PRN laxatives or conduct necessary assessments. The resident was eventually hospitalized, where the condition was discovered.
A facility failed to develop an adequate discharge plan for a resident with multiple diagnoses, including COPD and congestive heart failure, who aimed to return to the community. The facility did not arrange necessary DME and home health services, leading to discharge delays. The resident's supportive living facility expressed concerns about the lack of preparation and documentation for the resident's safe return.
A resident admitted with chronic respiratory conditions was receiving continuous oxygen therapy without a physician's order. Despite the resident's documented need for oxygen, the facility failed to obtain the necessary order until it was identified during a survey. Staff interviews confirmed the oversight, which contradicted the facility's policy requiring a physician's order for oxygen administration.
A resident with multiple health conditions, including mild cognitive impairment, was sent alone to an outside imaging appointment using a ride-sharing service. The facility's ward clerk arranged the transportation based on insurance company protocols, which did not require an escort. The resident did not return in a reasonable time, leading staff to search for him. He was found unharmed in a nearby hospital ER, highlighting a lapse in communication and assessment of his need for supervision.
A resident on anticoagulant medication experienced a fall and hit their head, resulting in a significant delay in notifying the healthcare provider. The facility's policy required immediate notification, but the initial call was made two hours after the fall, and the resident was sent to the hospital over six hours later. This delay in communication and action deviated from the facility's policy.
The facility failed to assist six residents with personal hygiene and grooming, despite their care plans indicating the need for maximum or total assistance. Residents were observed with long, unclean fingernails and unshaven facial hair, and some expressed a desire for help. Staff did not adequately address these needs, indicating a systemic failure to provide necessary care.
The facility failed to provide adequate incontinence care for four residents, potentially leading to UTIs. CNAs did not follow proper cleaning procedures, such as separating labial folds and cleaning deeper into groin folds, as required by the facility's policy. The DON confirmed the necessity of thorough cleaning to prevent infections.
The facility failed to serve ground chicken to residents on mechanical soft diets, instead providing chopped chicken due to equipment unavailability. This affected four residents, including those with poor dentition and edentulous conditions, who could not consume the improperly prepared food. The facility's policy on modified texture foods was not followed, as confirmed by the dietary staff and registered dietitian.
The facility failed to follow infection control protocols during incontinence care for five residents. CNAs wore the same soiled gloves throughout various stages of care, including cleaning residents and handling clean linens, contrary to the facility's hand hygiene policy. This breach in infection prevention practices was observed despite the policy emphasizing the importance of hand hygiene in preventing infections.
A resident with dementia had conflicting code status documentation, with a POLST form indicating DNAR and a physician's order indicating full code. The facility's practice of using color-coded name tags also reflected this inconsistency, leading to confusion among staff about the appropriate action in a medical emergency.
A resident with cognitive impairment and physical disabilities was transferred using a mechanical lift by a single CNA, contrary to the facility's policy requiring two staff members for such transfers. The resident expressed dissatisfaction with the frequency of assistance provided, and the Director of Nursing confirmed the need for two-person assistance to ensure safety.
A resident with a gastrostomy tube (g-tube) was found with a soiled dressing that had not been changed for four days, contrary to physician orders for daily changes. The g-tube site exhibited redness, maceration, and a small open area, indicating neglect in care. The nurse practitioner was unaware of the skin breakdown, and the care plan's interventions for daily skin inspections and reporting changes were not followed.
A medication administration error occurred when a nurse failed to administer all prescribed medications to a resident, resulting in a 7.69% error rate, which is above the acceptable threshold. The Director of Nursing confirmed the expectation for nurses to follow the five rights of medication administration.
The facility did not transmit discharge MDS records within the required 14-day period for several residents, as confirmed by the MDS Coordinator. This failure to comply with state and federal regulations was identified during a review of MDS transmission for a sample of residents.
A resident with severe cognitive impairment and a high fall risk fell during a transfer with a mechanical lift, resulting in a head injury. The incident occurred because a CNA attempted the transfer alone, contrary to the facility's policy requiring two staff members. The resident's medical history included conditions that increased her fall risk, and the facility's policy was not followed, leading to the fall.
A facility failed to perform wound treatments and weekly skin assessments for a resident with an arterial heel ulcer, as ordered by a physician. Despite specific orders for care, the resident received only one out of four weekly skin assessments in November and missed wound care on multiple days in November and December. Interviews with staff indicated that treatments should be completed as ordered, but lack of documentation suggested they were not. The facility lacked a policy for treating non-pressure wounds.
A resident with severe cognitive impairment developed an unstageable pressure ulcer that was not properly assessed or treated in a timely manner. Despite initial documentation of skin redness, no assessment or physician's orders were obtained until a bandage was discovered, leading to a delay in care. The facility's policy for pressure injury prevention was not followed, resulting in a deficiency.
A resident with a history of urinary retention was hospitalized with urosepsis after the facility failed to perform bladder scans and catheterizations as ordered. Despite physician orders for scans every four hours and catheterization if more than 400 ml of urine was retained, the nursing staff did not consistently follow these orders, leading to significant urine retention and infection.
The facility failed to notify the POA of a resident's status changes, including fever, nausea, and burning during urination, leading to a diagnosis of urosepsis and the need for IV antibiotics. The DON was unaware of the communication lapses, which violated the facility's policy on notifying representatives of significant treatment or condition changes.
Failure to Provide Required ADL Assistance and Hygiene Care
Penalty
Summary
Multiple residents with significant medical and functional impairments did not receive required staff assistance for activities of daily living (ADLs), including toileting, incontinence care, nail care, hair care, and oral hygiene. In one instance, a newly admitted female resident with a recent hip fracture was left unattended for over five hours, resulting in her lying in bed with heavily soiled linens and incontinence briefs. Staff interviews and assignment board checks revealed that no CNA had been assigned to her, and no bedside care was provided during that period, despite her repeated calls for help. Other residents with diagnoses such as osteomyelitis, intellectual disability, chronic kidney disease, morbid obesity, and dementia were observed with long, unkempt fingernails, visible debris, and poor grooming. Family members and residents reported that oral care, hair brushing, and shaving were not performed daily as required, with some residents stating they had not received grooming or oral care for weeks or only on shower days. Observations confirmed the presence of thick dental plaque, disheveled hair, and facial hair that had not been addressed despite repeated requests from residents. Staff interviews confirmed that ADL care, including incontinence checks and grooming, was not consistently provided according to care plans and facility policy. In several cases, staff acknowledged that residents had not been checked or assisted for extended periods, and that care was only provided after deficiencies were brought to their attention. Facility policies required incontinence checks at least every two hours and daily grooming and oral care, but these procedures were not followed for multiple residents.
Failure to Provide and Document Required G-Tube Site Care
Penalty
Summary
The facility failed to assess and provide appropriate gastrostomy tube (G-tube) site care for four residents who were dependent on staff for all self-care and mobility. Observations revealed that G-tube sites were not properly cleansed or dressed as ordered by physicians. For example, one resident was found with a wet, undated gauze dressing and thick yellow-green drainage around the G-tube site, with moist, red, and rash-covered skin. Documentation showed that required site care was not performed or recorded on multiple occasions, particularly over weekends and specific dates. Another resident was observed with a large amount of yellowish-green drainage and no gauze dressing at the G-tube site, accompanied by foul odors. The nurse acknowledged that a dressing should have been present to manage drainage. Review of treatment administration records indicated missed documentation and lack of PRN orders for additional site care. The Assistant Director of Nursing confirmed that nurses are responsible for inspecting and cleaning G-tube sites every shift, regardless of the scheduled care orders, and should notify physicians of any signs of infection or skin breakdown. Additional residents were found with G-tube sites lacking dressings and with encrusted material present around the insertion area, sometimes seeping through clothing. Physician orders and care plans required daily cleansing and dressing changes, as well as monitoring for infection, but these interventions were not consistently documented or observed. Facility policy specified that G-tube stoma care must include daily cleansing and covering with dry gauze, which was not adhered to for the residents reviewed.
Failure to Obtain and Follow Treatment Orders for Skin Alterations
Penalty
Summary
The facility failed to obtain a treatment order, assess, and provide appropriate care for a resident who developed a skin tear on the left knee. The resident, who had multiple diagnoses including Alzheimer's disease and required substantial assistance with activities of daily living, sustained a skin tear during physical therapy. Although an incident report documented that the physician was notified and an order was obtained to cleanse the wound and change the dressing every three days, there was no corresponding treatment order on the physician order sheet, no documentation in the treatment administration record, and no evidence of wound assessment or care in the nurses' progress notes. The dressing on the resident's knee was found to be dirty and saturated, and staff were unaware of the wound or the need for ongoing care, indicating a lack of communication and documentation regarding the resident's condition and treatment needs. Additionally, the facility failed to follow a physician's order for another resident with moisture-associated skin dermatitis. The resident had a history of incontinence-associated dermatitis and was prescribed Zinc Oxide Ointment to be applied every shift as a preventative measure. Review of the electronic treatment administration record over several months revealed multiple instances where nurse signatures were missing, indicating that the treatment may not have been administered as ordered. Staff interviews confirmed that nurses are required to document treatments in the electronic record, and the facility's policy mandates prompt identification, documentation, and treatment of skin breakdown. Both deficiencies demonstrate failures in obtaining and following physician orders, documenting care, and ensuring that residents with skin alterations receive appropriate and timely treatment. The lack of documentation and communication among staff contributed to the deficiencies in care for residents with skin integrity issues.
Resident Sustains Severe Leg Laceration During Unsafe Transfer
Penalty
Summary
A resident sustained a 10-12 centimeter laceration to the left lower leg requiring 18 sutures during a transfer from wheelchair to bed. The incident occurred when a CNA was transferring the resident, and the resident's leg was closest to the bed. During the pivot, the resident expressed pain, and the CNA observed a significant laceration with substantial bleeding. It was unclear whether the injury was caused by contact with the bed or the wheelchair. Blood was later found on the bedframe, and medical documentation confirmed a large skin tear due to trauma during the transfer. Interviews with staff revealed uncertainty regarding whether the wheelchair footrests were in place at the time of the incident. The facility did not have specific policies for resident transfers or fall prevention, providing only a gait belt policy that lacked comprehensive guidance on safe transfer techniques, resident mobility, staff body mechanics, or injury prevention. The absence of clear protocols contributed to the unsafe transfer and subsequent injury.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Monitor and Manage Constipation
Penalty
Summary
The facility failed to adequately assess, administer medications, and notify the physician for a resident who had not had a bowel movement in over three days on several occasions. This failure contributed to the resident developing a fecal impaction, pain, and inflammation in her colon. The resident, who was admitted with diagnoses including unspecified dementia, Parkinsonism, and constipation, had a care plan that required monitoring and intervention for constipation. Despite having orders to monitor bowel movements every shift and notify the physician if no bowel movement occurred in three days, the facility did not adhere to these orders. The resident's records showed significant gaps between bowel movements, with intervals of four to five days without a bowel movement in January 2025. Despite having PRN medication orders for laxatives, these were not administered, and there was no documentation of abdominal assessments or physician notifications. The resident was eventually sent to a hospital for an unrelated issue, where a CT scan revealed a fecal impaction and inflammation of the colon. Interviews with facility staff confirmed that the expected protocol was not followed, and the physician stated he was not notified of the resident's condition, which could have been managed with timely intervention.
Failure to Develop Adequate Discharge Plan for Resident
Penalty
Summary
The facility failed to develop an adequate discharge plan for a resident who had a goal to return to the community. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, generalized muscle weakness, and syncope, experienced delays in discharge due to the facility's failure to identify and address her needs. The resident was frustrated by the delays, and her daughter had initiated discussions regarding discharge planning. However, the facility did not make proper arrangements for necessary durable medical equipment (DME) and home health services, mistakenly believing the family would handle these arrangements. The Director of Nursing at the resident's supportive living facility expressed concerns about the lack of preparation for the resident's return, noting that the facility had not documented training for the resident on using her new wheelchair and oxygen equipment. The facility's social services were contacted by the family to discuss discharge planning, but the discharge date was postponed due to these unresolved issues. The facility's policy required discharge planning to begin within 24-48 hours of admission, but the resident's care plan and social service notes indicated delays in addressing her discharge needs, leading to the deficiency.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen therapy for a resident who required continuous oxygen. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, and syncope, was observed receiving 2 liters of continuous oxygen via a nasal cannula. Despite the resident's need for continuous oxygen therapy being documented in the Minimum Data Set upon admission, there was no corresponding physician's order in the medical record until it was obtained during the survey. Interviews with facility staff revealed that the resident's need for oxygen was communicated during shift reports, but the necessary physician's order was not found in the resident's records. The Assistant Director of Nursing confirmed the absence of the order and stated that it is the facility's expectation for nurses to review and obtain all necessary admission orders, including those for oxygen therapy. The facility's policy on oxygen administration requires verification of a physician's order before proceeding, which was not adhered to in this case.
Failure to Provide Escort for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an escort for a resident with multiple health conditions, including mild cognitive impairment, for an outside imaging appointment. The resident, who was not considered at risk for elopement based on a screening score, was sent alone using a ride-sharing service. The transportation was arranged by the facility's ward clerk, who followed the insurance company's protocol for determining the type of transportation and whether an escort was needed. The resident had previously attended appointments without an escort without incident. On the day of the appointment, the resident did not return to the facility in a reasonable time, prompting staff to search for him. The facility's administrator and director of nursing acknowledged that the resident should have been accompanied due to his changing mental status, which sometimes led to confusion. The resident was eventually found sitting in the hospital emergency room next to the facility, unharmed but unsure of how he got there. The incident highlighted a lapse in communication and assessment regarding the resident's need for supervision during transportation.
Delayed Notification of Healthcare Provider After Resident Fall
Penalty
Summary
The facility failed to ensure immediate notification of a resident's Physician or Nurse Practitioner following a fall where the resident hit his head. This incident involved a resident who was on anticoagulant medication, specifically Coumadin, and had a history of venous thrombosis and embolism. The fall was unwitnessed, and the resident was found on the floor with a bruise and swelling on the right side of his face. Despite the potential severity of the situation, there was a significant delay in contacting the healthcare provider, which resulted in a delay of over six hours before the resident was sent to the hospital for further assessment. The facility's policy required immediate notification of the healthcare provider in the event of an accident or incident involving a resident, especially when there is a need to alter medical treatment or transfer the resident to a hospital. However, the initial call to the Nurse Practitioner was not made until two hours after the fall, and the call back from the Nurse Practitioner with orders to send the resident to the emergency room was not received until over six hours after the fall. This delay in communication and action was a clear deviation from the facility's policy and contributed to the delay in the resident receiving necessary medical evaluation and treatment.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and grooming for six residents who required help with activities of daily living (ADLs). These residents, identified as having various cognitive and physical impairments, were observed with long, jagged fingernails with substances underneath, and some had unshaven facial hair. Despite their care plans indicating the need for maximum or total assistance with personal hygiene, the staff did not adequately address these needs. Resident 13, with vascular dementia and hemiplegia, was found with long, unclean fingernails on multiple occasions, despite expressing a desire for assistance. Similarly, Resident 91, who had severe cognitive impairment, was observed with long facial hair and unclean fingernails, and also requested help. Resident 106, non-verbal and severely impaired, had long fingernails that posed a risk of self-injury, yet no action was taken by the staff. Other residents, such as Resident 125, who had dementia and required assistance, were found with long facial hair and unclean fingernails. Resident 49, with a contracted hand, had nails pressing into her palm, yet staff failed to trim them. Resident 44, primarily Spanish-speaking and with a contracted arm, also had long fingernails pressing into her palm. Despite the presence of staff during observations, these hygiene needs were not addressed, indicating a systemic failure to provide necessary care as outlined in their care plans.
Inadequate Incontinence Care Leading to Potential UTIs
Penalty
Summary
The facility failed to provide adequate incontinence care to prevent urinary tract infections (UTIs) for four residents. During observations, a CNA was seen providing incontinence care to a resident with a history of UTIs by wiping the frontal perineum up and down, which resulted in fecal matter contaminating the area. The CNA did not clean deeper into the groins, only the outer area, before proceeding to clean the back perineum. Another resident, who was wet with urine, was cleaned by a CNA who did not separate the labia to clean the inner folds. Further observations revealed that two CNAs provided incontinence care to a resident with multiple urological diagnoses, including obstructive and reflux uropathy, without cleaning the scrotal area or deeper into the groin folds. Another resident was cleaned from front to back, but the CNAs did not separate the labia to clean the inner folds and only cleaned the surface of the groins. The Director of Nursing confirmed that staff must clean thoroughly from front to back, including separating labial folds and cleaning the entire groin area, to prevent infections. The facility's policy emphasizes the importance of proper perineal care to prevent infections and skin irritation.
Failure to Provide Properly Prepared Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food in the appropriate form for residents on mechanical soft diets, specifically by not serving ground chicken as required. During an observation of meal service, it was noted that the chicken breast intended for residents on mechanical soft diets was chopped into varying lengths instead of being ground. This discrepancy was observed in the secure unit dining room and affected four residents who were supposed to receive ground meat according to their diet tickets. The dietary aide, V8, confirmed that the chicken was pre-plated in the facility kitchen, and the dietary manager, V6, acknowledged the issue but needed to consult with the cook, V7, about the preparation method. The cook, V7, later explained that the chicken was chopped because the blender was in use by another staff member, indicating a lack of proper equipment availability or planning. The registered dietitian, V15, confirmed that a blender should be used to achieve the correct ground consistency, as chopping does not provide an even texture. The facility's policy on modified texture foods emphasizes the need for a standardized process to ensure the correct texture and nutritional value, which was not followed in this instance. The affected residents included those with poor dentition and edentulous conditions, who were unable to consume the improperly prepared chicken, highlighting the importance of adhering to dietary requirements for resident safety and nutrition.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection control protocols during the provision of incontinence care, as observed in multiple instances involving five residents. Certified Nursing Assistants (CNAs) were noted to have worn the same soiled gloves throughout various stages of care, including cleaning residents, applying barrier creams, and handling clean linens and bed controls. This was observed with residents who had bowel movements or were wet with urine, indicating a breach in infection prevention practices. The facility's policy on hand hygiene, dated August 2024, emphasizes the importance of hand hygiene in preventing infections and promoting resident safety. The policy specifies that hand hygiene should be performed before moving from a soiled body site to a clean body site on the same resident, after touching a resident or their immediate environment, and after contact with blood, body fluids, or contaminated surfaces. Despite this, the CNAs did not change gloves or perform hand hygiene between tasks, as required by the facility's policy, leading to a failure in maintaining infection control standards.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure consistency between a resident's signed POLST form and the physician's order regarding the resident's treatment wishes in the event of a medical emergency. The resident, who had multiple diagnoses including dementia with behavioral disturbances, was documented as having a full code status on the face sheet and active physician's order. However, the signed POLST form indicated a Do Not Attempt Resuscitation (DNAR) status, creating a conflict between the two documents. This inconsistency was observed during a review of the resident's medical chart and confirmed by the nursing staff. The inconsistency in the resident's code status was further highlighted by the facility's practice of using color-coded name tags to indicate code status, with a green tag for full code and a white tag for DNR. The resident's room displayed a green name tag, indicating full code, despite the POLST form indicating DNAR. Both the LPN and the Assistant Director of Nursing acknowledged the conflicting information and the resulting confusion about which code status to follow in a medical emergency. The facility's policy required that advance directives and code status identifiers be consistent and updated, but this was not adhered to in this case.
Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that two staff members assisted during a full body mechanical lift transfer for a resident, as required by their policy. The resident, who has diagnoses including hemiplegia following a cerebral infarct, unspecified osteoarthritis, and dementia, was found to be moderately impaired in cognition and dependent on staff assistance for transfers. On multiple occasions, the resident expressed a desire to be assisted out of bed, indicating that she was often not helped to get up. On one occasion, a Certified Nursing Assistant (CNA) used a mechanical lift to transfer the resident without the assistance of a second staff member. The facility's policy, revised in December 2017, clearly states that two nursing associates are required to perform a mechanical lift transfer to ensure the safety of the resident. Despite this, the CNA admitted to transferring the resident alone, and the Director of Nursing confirmed that two staff members should be present during such transfers. This failure to adhere to the established procedure compromised the safety of the resident during the transfer process.
Failure to Provide Proper G-Tube Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a gastrostomy tube (g-tube), as ordered by the physician. The resident, who has multiple medical diagnoses including epileptic seizure, encephalopathy, and dementia, was found with a g-tube dressing that had not been changed since four days prior, despite orders for daily changes. The dressing was soiled with dry brown discharge and emitted an odor, indicating neglect in care. Upon further assessment by the nursing supervisor, the g-tube site was found to have redness, a small open area, and maceration, with an odor emanating from the site. The physician's orders required monitoring for signs of infection and maintaining cleanliness and dryness of the g-tube site every shift. However, these orders were not followed, as evidenced by the condition of the g-tube site and the lack of awareness by the nurse practitioner of the skin breakdown. The resident's care plan highlighted the risk for impaired skin integrity and included interventions such as daily skin inspections and reporting any changes, which were not adhered to, leading to the deficiency.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to administer medications according to the physician's orders, resulting in a medication error rate of 7.69%, which exceeds the acceptable threshold of 5%. This deficiency was identified during the review of medication administration for one resident out of a sample of 21. On August 27, 2024, a nurse administered a series of medications to a resident, including Loratadine, Sitagliptin, Vitamin B12, Docusate Sodium, Escitalopram, Carvedilol, Amiodarone, Metformin, Magnesium, and Artificial Tears. However, the Medication Administration Record (MAR) indicated that additional medications, specifically Polyethylene Glycol and Medi-Pads for hemorrhoids, were also scheduled to be administered at that time but were omitted. The Director of Nursing confirmed that nurses are expected to administer medications as per the physician's orders and adhere to the five rights of medication administration: right patient, dose, medication, time, and route. This oversight in medication administration was observed and documented, highlighting a lapse in following established protocols.
Failure to Transmit Discharge MDS Records Timely
Penalty
Summary
The facility failed to transmit discharge Minimum Data Set (MDS) records within the required 14-day period as mandated by state and federal regulations. This deficiency was identified for five residents who were part of a sample of 21 residents reviewed for MDS transmission. On August 27, 2024, the MDS Coordinator, a Registered Nurse, confirmed that the completed discharge records for these residents were not transmitted within the stipulated timeframe. Specifically, the discharge MDS records for these residents were either transmitted late or not transmitted at all by the required deadline. The facility's policy, dated January 2024, mandates that all MDS assessments, including discharge records, be completed and transmitted to the CMS QIES ASAP system in compliance with current regulations, which was not adhered to in these cases.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to provide a safe transfer for a resident using a mechanical lift, resulting in the resident falling and sustaining a significant head injury. The resident, who had severe cognitive impairment and required maximum assistance with transfers, fell off the side of her bed during a transfer. The incident occurred when a CNA was transferring the resident alone, contrary to the facility's policy that requires two staff members for such transfers. The resident hit her head on a table and the floor, resulting in an 8cm laceration that required 15 staples. The resident's medical history included lymphedema, repeated falls, hypertension, cognitive impairment, and morbid obesity, making her a significant fall risk. Her care plan indicated a high risk for falls and required her to be within visibility of staff when up in a chair. Despite these precautions, the CNA attempted the transfer alone, which led to the resident's fall. The CNA admitted to being too far from the resident to prevent the fall due to the positioning of the lift. Interviews with other CNAs and the Director of Nursing confirmed that the facility's policy mandates two staff members for sit-to-stand transfers to ensure resident safety. The Director of Nursing acknowledged that the incident could have been avoided if the policy had been followed. The nurse practitioner also noted that the resident's cognitive impairment made her unable to follow directions, further emphasizing the need for adequate supervision during transfers.
Failure to Perform Wound Treatments and Assessments
Penalty
Summary
The facility failed to perform wound treatments and weekly skin assessments as ordered by a physician for a resident with an arterial heel ulcer. The resident had multiple diagnoses, including a non-pressure chronic ulcer of the left heel, heart failure, and atrial fibrillation. The wound was initially labeled as a pressure ulcer but was later identified as arterial after a Doppler study. Despite physician orders for weekly skin assessments and specific wound care treatments, the resident received only one out of four weekly skin assessments in November 2023. Additionally, the resident did not receive the prescribed wound care for eight days in November and seven days in December 2023. Interviews with the wound care nurse and the Director of Nursing revealed that treatments ordered by physicians should be carried out as prescribed. The wound care nurse indicated that floor nurses were responsible for completing daily wound care, and the absence of documentation suggested that treatments were not performed. The Director of Nursing acknowledged that blank areas in treatment records implied that treatments were not completed, which hindered wound healing. The facility was unable to provide a policy regarding the treatment of non-pressure wounds.
Failure to Assess and Obtain Orders for Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and obtain physician's orders for an unstageable pressure ulcer identified on a resident, referred to as R4. R4 was admitted with multiple diagnoses, including fractures and severe cognitive impairment, and initially had no pressure injuries. However, documentation from a bath and shower form indicated redness and a circle around the buttocks area, which was not assessed by a nurse or followed up with physician's orders. Later, R4 reported having a bandage on her backside, prompting a nurse to assess the area and find a pink and red wound with peeling skin, but no drainage or bleeding. A wound assessment on the same day identified the wound as an unstageable pressure ulcer, and treatment orders were pending. The Director of Nursing (V2) and the wound care physician (V9) confirmed that the wound should have been assessed and treatment orders obtained when first identified. The facility's policy requires new skin alterations to be documented and assessed, with physician notification and a change in the care plan. However, in R4's case, the wound was not properly assessed or treated until a bandage was discovered, indicating a lapse in following the facility's protocol for pressure injury prevention and management.
Failure to Perform Bladder Scans and Catheterizations as Ordered
Penalty
Summary
The facility failed to ensure a resident who was retaining urine had his bladder scanned and was catheterized as ordered. This failure resulted in the resident being hospitalized with urosepsis for eight days. The resident, who was alert and oriented, reported having bladder spasms and informed the nurses, but the bladder scans and intermittent catheterizations were not performed as ordered. The resident's medical records showed multiple instances where bladder scans indicated significant urine retention, but the necessary catheterizations were either not performed or not documented properly. This led to the resident developing a urinary tract infection and subsequently urosepsis, requiring hospitalization and IV antibiotics for a month. The resident had a history of urinary retention and had specific physician orders for bladder scans every four hours and straight catheterization if more than 400 ml of urine was retained. Despite these orders, the nursing staff failed to consistently perform the bladder scans and catheterizations. Progress notes indicated that the resident had significant residual urine volumes on multiple occasions, but there was no documentation of an indwelling urinary catheter being placed as ordered. Additionally, there were gaps in the progress notes, with no documentation for twelve days, during which the resident continued to experience symptoms of urinary retention and infection. Interviews with the nursing staff and the Director of Nursing revealed that they were aware of the orders but did not consistently follow them. The Director of Nursing acknowledged that the bladder scans and catheterizations should have been done as ordered and that the failure to do so could lead to urinary retention, infection, and sepsis. The facility's policy on catheterization and residual urine documentation was not followed, contributing to the resident's hospitalization and subsequent treatment for urosepsis.
Failure to Notify POA of Resident's Status Changes
Penalty
Summary
The facility failed to update the Power of Attorney (POA) on status changes of a resident. This deficiency was identified for one resident who was alert and oriented, and had a history of urinary retention. The resident reported experiencing fever, chills, and bladder spasms, which were not adequately addressed by the nursing staff. Despite receiving orders for a bladder scan and straight catheterization every four hours, the resident indicated that these procedures were not performed as required. Consequently, the resident was diagnosed with urosepsis and required intravenous antibiotics for a month. There was no documentation showing that the POA was notified of the new orders or the resident's condition changes on multiple occasions, including when the resident had a fever, nausea, and burning during urination, which led to further medical interventions without POA notification. The Director of Nursing (DON) acknowledged that she was unaware of the POA not being notified of the resident's status changes. The facility's policy on changes in a resident's condition or status, last approved in January 2024, mandates prompt notification of the resident's representative for any significant alterations in treatment or condition. However, this policy was not followed, resulting in a delay in care and communication breakdowns. The lack of documentation and communication with the POA was a clear violation of the facility's policy and contributed to the resident's deteriorating condition.
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.
