Beacon Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Lombard, Illinois.
- Location
- 2400 South Finley Road, Lombard, Illinois 60148
- CMS Provider Number
- 145522
- Inspections on file
- 23
- Latest survey
- July 14, 2025
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Beacon Hill during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
The facility did not provide the required six daily servings of grains/breads on its menu for all residents, with multiple days showing missing servings across general and specialized diets. The Director of Nutrition Systems and the Dietitian confirmed the shortfall during review, despite facility policy and menu planning guidelines requiring nutritional adequacy and dietitian approval.
The facility did not have a complete or properly implemented water management plan for Legionella, as required by federal regulations. The only monitoring performed was infrequent water testing, with the last test conducted over a year ago. Essential elements such as flow diagrams, risk area identification, and control measures were missing from the plan, and there was no documentation of ongoing monitoring or interventions. All 40 residents were affected by this deficiency.
A resident with congestive heart failure did not have daily weights obtained and documented as ordered by the physician. The DON confirmed that staff did not follow the order, and facility policy required weights to be taken as prescribed.
A resident with multiple medical conditions and insomnia did not receive prescribed temazepam for two nights because the facility failed to obtain the required prescription in a timely manner. Nursing staff did not effectively communicate with providers to secure the necessary script, and the pharmacy did not receive the order, resulting in missed medication doses.
A resident with multiple medical conditions and recent abdominal surgery, who required maximum assistance for transfers, was manually transferred by two CNAs without the use of a mechanical lift, contrary to her care plan. This resulted in the resident sustaining a large bruise and a severe leg laceration requiring 29 staples. Staff interviews revealed inconsistent use of the mechanical lift and confusion about transfer protocols, while environmental hazards such as exposed metal edges contributed to the injuries.
The facility failed to provide timely medications to two residents, resulting in missed doses of prescribed supplements. One resident did not receive Magnesium Chloride-Calcium Carbonate for three days, while another missed Calcium-Vitamin D doses over two days. Documentation showed medications were unavailable, and the facility did not promptly address the issue, leading to a deficiency in pharmaceutical services.
The facility failed to prevent and manage pressure injuries for two residents, leading to the development and worsening of deep tissue injuries. One resident developed a heel injury that was not identified until it became unstageable, due to missed weekly skin assessments. Another resident's care plan for offloading heels was not consistently followed, resulting in a significant increase in the size of a heel injury. These deficiencies highlight lapses in adherence to the facility's protocols for pressure injury prevention and management.
The facility did not conduct an annual review of its Facility Assessment Tool, affecting all 35 residents. The last assessment was dated February 2023, and the Administrator acknowledged the oversight, stating that the review process was in progress. The facility's policy requires an annual review to evaluate resident needs and resources.
The facility failed to follow its Water Management plan, lacking necessary diagrams and assessments for Legionella prevention, and did not conduct required water testing since 2022. Additionally, staff did not use the required PPE for a resident on Enhanced Barrier Precautions, despite the care plan specifying gown and glove use during high-contact care.
The facility failed to maintain resident dignity by not covering urinary drainage bags for two residents. One resident with multiple diagnoses, including Alzheimer's, was observed with a visible urinary drainage bag containing cloudy urine. Another resident was also seen with a visible urinary drainage bag. The DON confirmed the need for covering these bags, as outlined in the facility's Dignity Policy.
A facility failed to address a resident's advance directive status upon admission. The resident, admitted with multiple health issues, had no code status listed in their electronic medical record until prompted by a surveyor. A FULL code status was entered on June 10, but the resident later requested a do not resuscitate status. The facility's policy mandates documentation of advance directives in clinical records.
A resident with multiple diagnoses, including dementia, did not have quarterly care plan meetings as required. The facility's records show a gap from August 2022 to January 2024 without a care plan meeting. The Social Service Director and Administrator acknowledged the lapse, citing issues with the scheduling process.
Two residents were not screened for or offered the pneumococcal vaccine upon admission, contrary to the facility's policy. The Infection Preventionist confirmed the oversight, noting that assessments should have been conducted within five days of admission.
The facility failed to screen and offer the COVID-19 vaccine to two residents, as required by their policy. One resident tested positive for COVID-19 during an outbreak but was asymptomatic. The Infection Preventionist confirmed the oversight, acknowledging that the residents were not screened or offered the vaccine upon admission.
The facility did not submit the MDS for three residents within the required timeframe. Although the assessments were completed, they were not transmitted to the State, exceeding the 28-day deadline. The MDS Coordinator was unsure why the submissions were delayed and acknowledged the oversight.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Provide Required Daily Grain/Bread Servings on Facility Menu
Penalty
Summary
The facility failed to provide the required six servings of grains or breads daily on its menu for all 40 residents, as identified through review of the facility's Spring/Summer 2025 Diet Extensions for various diet types. Specific deficiencies were noted on each day of the week, with missing servings ranging from one to three for general diets and up to four for specialized diets such as Mechanical Soft, Pureed, Consistent Carbohydrate, and Heart Healthy. The Diet Type Report confirmed that 39 residents were receiving oral diets, and the menu audit checklist indicated the expectation of six daily grain servings. During interviews, the Director of Nutrition Systems and the Dietitian acknowledged that the menus were short on grain servings and confirmed that the menus were planned using USDA My Plate and state regulations. The facility's policy required menus to meet nutritional needs in accordance with national guidelines and to be approved by a dietitian or qualified nutrition professional. Despite these requirements, the menus did not consistently provide the mandated grain/bread servings for all diet types throughout the week.
Incomplete and Unimplemented Legionella Water Management Plan
Penalty
Summary
The facility failed to maintain a complete and compliant water management plan for Legionella, as required by federal regulations. The Director of Plant Operations confirmed that the only monitoring conducted was periodic water testing for Legionella, with the last test occurring over a year prior. The facility's water management plan was missing essential elements such as flow diagrams, identification of risk areas for Legionella growth, and specific control measures. Additionally, there was no documentation of monitoring or interventions related to control measures, and the plan did not include an assessment to identify where Legionella could grow and spread. The facility's policy required random testing of at least three water supply sources twice per year, but there was no evidence that this was being followed. The most recent Legionella water testing report recommended ongoing regular monitoring, but there was no documentation to show that water testing had been conducted since the last recorded date. The facility census at the time was 40 residents, all of whom were affected by the lack of a comprehensive and properly implemented water management plan.
Failure to Follow Physician Orders for Daily Weights in CHF Resident
Penalty
Summary
The facility failed to follow physician orders for a resident diagnosed with congestive heart failure by not obtaining and documenting daily weights as prescribed. The electronic medical record indicated that the resident, who had multiple diagnoses including congestive heart failure, was only weighed on three specific dates rather than daily as ordered. The Director of Nursing confirmed that daily weights were not performed, and the facility's own policy required weights to be taken and recorded according to physician orders. There was no documentation to show that the daily weights were completed as required for this resident.
Failure to Timely Obtain and Administer Ordered Medication
Penalty
Summary
The facility failed to ensure that medications were obtained and administered in a timely manner, resulting in a resident missing prescribed doses of temazepam for insomnia. The resident, who was cognitively intact and had multiple diagnoses including lumbosacral spinal fusion, lumbar spine stenosis, anxiety, and breast cancer, did not receive temazepam as ordered on two consecutive nights. Documentation in the electronic medical record and medication administration record confirmed that the medication was not available and had not been administered as prescribed. Nursing staff noted that a script was required for the pharmacy to fill the temazepam order, but there was a lack of effective communication and follow-up with the providers to obtain the necessary prescription. The pharmacy account manager confirmed that the medication was not on the resident's profile, indicating the script was never received. The administrator acknowledged that the process should not have taken over 24 hours, but the resident ultimately did not receive the medication as ordered due to these lapses.
Failure to Safely Transfer Resident and Prevent Accident Hazards
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including encephalopathy, muscle weakness, congestive heart failure, morbid obesity, and recent abdominal surgery, was not safely transferred according to her assessed needs. The resident was documented as requiring maximum or total assistance for transfers and had a care plan indicating the use of a mechanical lift device with two staff for transfers. However, over multiple days, staff inconsistently used the mechanical lift, and on at least two occasions, the resident was manually transferred by two CNAs without the lift, despite her dependence and physical limitations. During these manual transfers, the resident sustained injuries. On one occasion, she developed a large bruise on her left leg, and on the following day, she suffered a significant laceration to the same area, requiring 29 staples at the hospital. Interviews with staff and family members confirmed that the mechanical lift was not used during these transfers, and there was confusion among staff regarding when the lift should be used. Documentation and care plans were inconsistent, and there was no clear assessment or directive specifying the use of the mechanical lift for this resident. Environmental hazards were also present in the resident's room, including an exposed metal wheelchair locking mechanism and an uncapped metal bed rail post, both of which were in close proximity to the resident during transfers. These hazards contributed to the injuries sustained. The facility's policy required the use of appropriate assistive devices and consistent transfer techniques, but these were not followed, and no assessment was documented to ensure the resident's safety during transfers.
Failure to Provide Timely Medication to Residents
Penalty
Summary
The facility failed to ensure timely procurement of medications for residents, resulting in missed doses as prescribed by physicians. Resident 1, who was admitted with multiple diagnoses including respiratory failure and type 2 diabetes, did not receive their prescribed Magnesium Chloride-Calcium Carbonate supplement for three consecutive days in February 2025. Documentation by various RNs indicated that the medication was not available, and at one point, a request was made to the resident's family to obtain the medication, which the Director of Nursing later confirmed was the facility's responsibility. Similarly, Resident 2, admitted with conditions such as sepsis and chronic kidney disease, missed doses of their prescribed Calcium-Vitamin D supplement over two days. The EMR showed that the medication was not available and was awaiting delivery or house supply. The Director of Nursing acknowledged that the order should have been changed sooner to a medication in stock to prevent missed doses. These incidents highlight the facility's failure to provide pharmaceutical services to meet the needs of each resident as required.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to identify and manage pressure injuries effectively for two residents, leading to the development and worsening of deep tissue injuries. Resident R34 was admitted with a blanchable redness in the sacral area and later developed a deep tissue injury on the left heel, which was not identified until it became unstageable. The facility's records show a lack of weekly skin assessments between May 8 and May 29, 2024, which contributed to the oversight. The wound was only documented on May 31, 2024, and by then, it had deteriorated significantly. The facility's protocol required regular skin checks and pressure-reducing interventions, which were not adequately followed. Resident R12 was admitted with multiple diagnoses, including sepsis and Alzheimer's disease, and was identified as at risk for pressure injuries. Despite care plans and treatment records indicating the need for offloading heels and regular repositioning, observations showed that R12's heels were not consistently offloaded, and the resident was found with heels directly on the bed. This lack of adherence to the care plan led to the worsening of R12's deep tissue injury, which increased in size significantly over a short period. The facility's wound care policy emphasized evidence-based practices, but these were not effectively implemented for R12. The facility's failure to adhere to its own policies and protocols for pressure injury prevention and management resulted in significant harm to both residents. The lack of timely assessments and interventions allowed the pressure injuries to develop and worsen, highlighting deficiencies in the facility's care practices. The wound care nurse and nurse practitioner acknowledged the lapses in protocol adherence, which contributed to the adverse outcomes for the residents.
Failure to Annually Review Facility Assessment
Penalty
Summary
The facility failed to ensure that their facility assessment was reviewed annually, affecting all 35 residents residing in the facility. The Resident Census and Condition report dated June 10, 2024, indicated a resident census of 35. However, the Facility Assessment Tool was last dated February 2023, indicating that it had not been reviewed within the required annual timeframe. During an interview on June 12, 2024, the Administrator acknowledged that the review process was underway but admitted that some tasks had been overlooked since he assumed his position at the end of January. The facility's policy, dated September 8, 2017, mandates an annual review of the facility-wide assessment, which includes evaluating the resident population and the resources needed for their care.
Inadequate Water Management and PPE Use
Penalty
Summary
The facility failed to maintain and follow its Water Management plan to detect and prevent waterborne pathogens, specifically Legionella. The Health Center Prevention and Control of Legionella policy lacked facility water flow diagrams or assessments to identify potential growth and spread areas for Legionella and other pathogens. The Director of Plant Operations, who was new to the role, was unaware of any measures in place to prevent Legionella and confirmed that the facility had not conducted the required water testing since 2022, despite the policy mandating biannual testing. Additionally, the facility did not ensure that staff donned the necessary personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions. A resident with a urinary drainage device, colostomy bag, PICC, and a wound was not provided care with the required gown and gloves by the CNAs, who only wore gloves. The resident's care plan specified the need for gown and gloves during high-contact care, which was not adhered to, as confirmed by the Infection Control Nurse.
Failure to Cover Urinary Drainage Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner by not covering urinary drainage bags for two residents. One resident, admitted with diagnoses including sepsis, urinary tract infection, and Alzheimer's disease, was observed on two occasions with a visible urinary drainage bag containing cloudy urine, which was visible from the hallway. Another resident was also observed on multiple occasions with a visible urinary drainage bag containing urine, also visible from the hallway. The Director of Nursing confirmed that urinary drainage bags should be covered for the dignity of the residents. The facility's Dignity Policy emphasizes the importance of promoting residents' well-being and self-esteem, prohibiting demeaning practices, and specifically mentions the need to cover urinary catheter bags.
Failure to Address Advance Directive Status Upon Admission
Penalty
Summary
The facility failed to address a resident's advance directive status upon admission, as evidenced by the case of a resident admitted on April 16, 2024, with multiple diagnoses including gastrointestinal hemorrhage, muscle weakness, and chronic diastolic congestive heart failure. Upon review on June 10, 2024, it was found that the resident's electronic medical record did not list a code status. The order recap summary indicated that no orders for the resident's code status were entered until June 10, 2024, after a POLST form was requested by the surveyor. An order for a FULL code status was entered on that date. The Social Service Director (SSD) confirmed that the code status should be addressed upon admission and acknowledged that the resident's code status was not addressed until June 11, 2024, when the resident expressed a preference for a do not resuscitate status. The facility's policy requires clear documentation of whether a client has executed an advance directive in their clinical record.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for a resident, identified as R26, who was admitted with diagnoses including dysphagia, muscle weakness, history of falling, and dementia. According to the resident's daughter and power of attorney, there was a year-long gap without any care plan meetings. The facility's records confirm that a care plan meeting was held on August 30, 2022, but the next documented meeting did not occur until January 29, 2024. The Social Service Director (SSD) acknowledged the absence of care plan meetings in 2023 and stated that the receptionist is now responsible for arranging these meetings. The facility's policy mandates that care plans be reviewed and updated quarterly, in conjunction with the required quarterly MDS assessment. The Administrator confirmed that there was a lapse in scheduling care plans due to issues within the social services department.
Failure to Screen and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were screened for and received the recommended doses of the pneumococcal vaccine. Specifically, two residents, identified as R31 and R17, were not screened for or offered the pneumonia vaccine upon their admission to the facility. R31's medical records from April 18, 2024, to June 11, 2024, and R17's records from April 11, 2024, to June 11, 2024, showed no documentation of screening or offering of the vaccine. This oversight was confirmed by the Infection Preventionist (IP), who acknowledged that both residents should have been screened and offered the vaccine. The facility's policy on pneumococcal vaccination states that all residents should be assessed for eligibility and offered the vaccine series within thirty days of admission. The policy also requires that assessments of vaccination status be conducted within five working days of admission if not done prior. However, the facility did not adhere to this policy for R31 and R17, as there was no documentation of any such assessment or offer of vaccination. The IP confirmed the lapse in procedure, indicating a failure in the implementation of the facility's vaccination policy.
Failure to Screen and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that residents were screened for and received all recommended doses of the COVID-19 vaccine. This deficiency was identified for two residents, R31 and R47, out of a sample of 14 residents reviewed for COVID-19 vaccination. R31 was admitted to the facility and had no documentation of receiving any COVID-19 vaccines as per the immunization report dated 6/5/24. Additionally, R31's medical records from 4/18/24 to 4/26/24 showed no evidence of being screened for or offered a COVID-19 vaccine. During a facility outbreak that began on 4/1/24, R31 tested positive for COVID-19 on 4/27/24 but was asymptomatic. Similarly, R47 was admitted to the facility, and their medical records from 5/10/24 to 6/11/24 showed no documentation of being screened for or offered a COVID-19 vaccine or booster. The Infection Preventionist (IP), identified as V5, confirmed that residents should be screened and offered the vaccine upon admission, and acknowledged that neither R31 nor R47 had been screened or offered the vaccine. The facility's policy dated 11/17/23 emphasized the importance of COVID-19 vaccine education, documentation, and reporting, which are overseen by the IP.
Failure to Timely Submit MDS for Residents
Penalty
Summary
The facility failed to ensure timely submission of Minimum Data Sets (MDS) for three residents, as required by regulations. The MDS for these residents were completed but not transmitted to the State within the mandated timeframe. Specifically, the quarterly MDS for three residents were marked as 'ready to export' but had not been sent, exceeding the 28-day submission requirement. The MDS Coordinator acknowledged the oversight and was uncertain why the MDS were not exported, noting that they were past due and not included in the MDS Accepted batch report.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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