Belhaven Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 11401 South Oakley Avenue, Chicago, Illinois 60643
- CMS Provider Number
- 145549
- Inspections on file
- 62
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Belhaven Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to follow its own policies and practice of offering daily menu alternatives by not providing consistent food substitutions on weekends. Cognitively intact residents reported that activity staff offer meal choices and alternatives only on weekdays, and that on weekends they are told they must eat the posted menu item, with some residents stating they go hungry or must obtain outside food if they dislike the meal. Staff interviews corroborated that menu substitutions are routinely offered Monday through Friday but not on weekends, despite management statements and written policies indicating that alternatives and an "Always Available Menu" should be offered every day at every meal.
The facility failed to maintain sanitary food service practices by transporting meal trays on open carts with only the main plate wrapped, while drinks, desserts, cereal, condiments, and utensils remained uncovered, and by allowing staff to handle and portion food without consistent use of hair restraints and beard guards. A resident reported that his food, juice, dessert, and silverware were not covered and that he had previously found hairs on his sandwich. Surveyors observed CNAs and dietary staff preparing and delivering trays with uncovered items on open, unattended carts in hallways, and noted dietary staff in the kitchen and on units without required beard protectors. The dietary manager, regional food service manager, and a CNA with prior dietary experience all acknowledged that carts and all tray items should be covered and that hair restraints are expected at all times when handling food, consistent with the facility’s infection control and hair restraint policies.
A resident with paraplegia and multiple medical conditions, who required substantial assistance with ADLs and was care planned to use the call light for help, experienced repeated delays in staff response to his call light. On separate occasions, the call light system showed his room light active for extended periods while the hallway light remained on, and the resident reported waiting over an hour for assistance with bathing after a CNA left him with a bucket of water and did not return. An LPN at the nurses’ station acknowledged the call light had been on for over an hour, and both the CNA and LPN stated call lights should be answered promptly, consistent with facility policy and the DON’s expectation of response within 15 minutes.
A cognitively intact wheelchair user with multiple chronic conditions and a history of suspected abuse was moving toward the smoking area with an unlit cigarette in his mouth so he could propel his wheelchair. An LPN allegedly approached, snatched the cigarette from his mouth, broke it, and, according to the resident and the Administrator, threw it at him, then yelled at him and threatened to call the police, which two CNAs described as intimidating and emotionally abusive. One CNA reported the incident to the DON that evening, but the LPN was allowed to finish the shift and continue working, despite facility policy and leadership expectations that any staff member alleged to have committed abuse be immediately separated from the resident, removed from the building, and reported to the Administrator and DON.
The facility failed to submit a final investigation report of alleged staff-to-resident abuse to the state agency within the required five business days. A resident with multiple chronic conditions, who uses a wheelchair and has a history that increases susceptibility to abuse, reported that an LPN snatched an unlit cigarette from his mouth, broke it, threw it at him, and threatened to call the police. Two CNAs corroborated that the cigarette was unlit and that the LPN’s actions and threats were verbally and mentally intimidating. The Administrator, serving as abuse coordinator, received the allegation, sent the initial report to the state, but did not submit the final written investigation report until several days past the facility policy and regulatory five-business-day deadline.
A resident with Lennox-Gastaut syndrome and a history of seizures, hemiplegia, and other comorbidities reported missing doses of prescribed anti-seizure medications (Keppra, phenobarbital, and pregabalin/Lyrica) due to medications not being available, and described having a seizure episode after missed doses. A CNA and an LPN confirmed the resident had a recent seizure in the dining room. Review of the MARs showed multiple missing initials for scheduled doses of the resident’s anti-seizure medications across two months, indicating doses were not administered or documented as required, despite physician orders, a care plan directing administration of seizure medications, and facility policies requiring timely MAR documentation and adherence to physician orders.
A resident with severe cognitive impairment, osteoporosis, prior femur fracture, and a history of falls was dependent on staff for bed-to-chair transfers and had a care plan identifying fall risk and self-care deficits, but without a timely, specific focus on mechanical lift transfers despite staff reporting such dependence for over a year. A CNA with limited tenure attempted to transfer the resident alone using what was later recognized as a weight machine rather than the proper mechanical lift, during which the resident began to slide as the legs lifted off the bed. The DON and ADON, responding to the CNA’s call for help, found the resident in a sling off the bed with an insecure lower body position and assisted in lowering the resident to the floor. Facility policy required two caregivers for mechanical lift transfers and mandated notifying the resident’s responsible party of incidents and falls, yet the transfer was performed by a single CNA, the event was documented as an "other incident" rather than a fall, and the resident’s representative was not promptly informed.
Two residents with contrasting conditions—one with hemiplegia and one with schizophrenia and other psychiatric diagnoses—were placed as roommates despite the latter’s history of verbal aggression, intact mobility, poor hygiene, and intimidating behavior. During a dispute over room temperature and a complaint about odor, the mobile resident made physical contact with the other resident’s leg, which the impaired resident, who had left-sided weakness, later described as being hit and reported pain in the left arm, leading to an X-ray. The impaired resident then struck back with a reacher, causing a minor skin injury to the aggressor’s nose. The DON and Administrator/Abuse Coordinator determined that the contact by the aggressive resident met the facility’s definition of physical abuse, and a police report classified the event as simple battery.
The facility failed to follow its abuse reporting policy when two residents, one with hemiplegia and one with psychiatric diagnoses and intact cognition, were involved in a physical altercation in their shared room. An initial abuse report was submitted alleging that one resident struck the other, who retaliated with a reacher while in a wheelchair, and documentation showed the aggressive resident required hospital evaluation for agitation and aggression. Although facility policy required that a detailed final investigation report be forwarded to the state agency within five working days, the administrator/abuse coordinator acknowledged that the final report, which concluded that physical abuse occurred and referenced a police report for simple battery, was not submitted within the required timeframe because it was forgotten.
A resident with multiple complex medical conditions repeatedly reported feeling cold air entering through cracks in their room window. Despite raising the issue during resident council meetings and informing staff, maintenance was not notified, and no work orders were submitted. The problem was only confirmed during a surveyor's assessment, revealing a failure to provide a comfortable environment as required by facility policy.
Several residents did not receive meals according to their documented dislikes and preferences, with staff and direct observation confirming that disliked foods were repeatedly served despite being noted on meal tickets. Staff reported ongoing issues with the kitchen providing incorrect meals, and residents' requests for substitutions were not consistently honored, contrary to facility policy.
The facility did not provide meals and snacks at scheduled times, resulting in residents waiting for extended periods before receiving food. Staff and residents reported ongoing delays, particularly with lunch service, due to kitchen staffing shortages after a change in management. Facility leadership and the Dietary Director were aware of the issue, which affected all residents receiving oral meals.
Three residents did not receive their prescribed therapeutic diets as ordered by their physicians. One resident did not receive double portions as ordered, another did not receive double portion protein, and a third was given thin liquids instead of nectar thick liquids. Staff interviews and record reviews confirmed these failures to follow dietary orders.
A resident with a history of hypertension and other chronic conditions did not have daily vital signs monitored and documented as ordered by a provider. Although a nurse reported checking the resident's blood pressure, the readings were not entered into the electronic medical record, and documentation was missing for extended periods. This failure to follow physician orders and maintain proper records resulted in a deficiency related to quality of care.
A malfunctioning call light system on the second floor prevented staff from identifying which resident was calling for assistance, as reported by an RN and a CNA. The system's constant beeping and failure of room lights to activate required staff to check rooms individually. Housekeeping and maintenance staff were unaware of the issue, and 64 residents were affected according to the facility census.
Several residents experienced uncomfortably cold room temperatures due to non-functioning heating units, with some rooms having exposed wires after staff moved beds. Residents reported the issues to staff, but the Maintenance Director was unaware of the problems until the survey. Affected residents included those with significant medical needs, and room temperatures were found to be below the facility's required range.
Nursing staff failed to document and administer medications as ordered for three residents with complex medical needs, as shown by missing entries on the MARs for multiple medications and times. The DON confirmed that missing documentation means the medication was not given, and facility policy requires all administered doses to be recorded at the time of administration.
A resident with multiple sacral wounds did not receive timely wound care upon admission due to a lack of hospital paperwork and a delay in obtaining physician orders. The admitting nurse did not complete any treatments, and the wound care coordinator was unavailable. The resident expressed dissatisfaction and requested hospital transfer. Facility policy requires timely wound care to promote healing and prevent infection.
A resident with a history of hemiplegia and diabetes developed a worsening pressure ulcer due to the facility's failure to provide consistent care and documentation. The resident's care plan included turning and repositioning every 1-2 hours and specific wound care treatments, but these were not consistently documented or followed. The wound deteriorated, leading to infection and hospitalization. The facility's policies and job descriptions emphasize proper documentation and adherence to treatment protocols, which were not followed, contributing to the resident's condition worsening.
The facility failed to respond promptly to call lights for two dependent residents requiring assistance with self-care activities. Despite facility policies and job descriptions mandating prompt responses, staff did not adhere to these guidelines, leaving residents waiting for assistance. This deficiency was observed when a resident's call light was on for over 10 minutes while staff were at the nurse's station, and another resident's call light was ignored despite their need for cleaning.
A facility failed to administer medications within the scheduled time frame for a resident with conditions including paraplegia and hypertension. The resident reported consistent delays in medication administration across all shifts, confirmed by observations and record reviews. Medications were given outside the one-hour window before or after the scheduled time, with instances of significant delays. The facility's policy requires timely administration, but this was not adhered to, affecting the resident's care.
A resident with moderate cognitive impairment and mobility issues was affected by a malfunctioning call light system, which failed to register on the nurse's station board. Despite the CNA's acknowledgment of the issue, the Maintenance Director initially dismissed it. The facility's policy mandates daily checks and immediate reporting of defects, which were not followed.
A resident with a history of aggression assaulted another resident in the dining room. Despite the presence of an aide who intervened immediately, the facility failed to prevent the incident. The aggressive resident has severe cognitive impairment and a documented history of physical aggression, while the victim has mild cognitive impairment. The facility's abuse policy was not effectively implemented to protect the residents.
The facility failed to provide adequate supervision and medication administration, with residents left unattended and medications not given as ordered. Staff were unaware of their responsibilities, and medication carts were left unlocked. Unprofessional conduct was observed, with a nurse on a video call during medication prep and another yelling at a surveyor.
The facility failed to prevent physical abuse among residents, resulting in two incidents in the dining room. In one case, a resident was pushed from a wheelchair, and in another, a resident was hit in the face during an altercation. Both incidents occurred without adequate staff supervision, contrary to the facility's abuse prevention policy.
A lack of supervision in the dining room led to two separate physical altercations between residents, resulting in one resident being pushed from a wheelchair and another being hit in the face. Staff acknowledged the absence of supervision, which is contrary to facility policies requiring visual monitoring during mealtimes.
The facility failed to accurately log dish machine temperatures and ensure proper functionality, affecting 162 residents. A dietary aide used a temperature strip to test the dishwasher, which did not reach the required 160°F for sanitation. The aide admitted the issue persisted for over a week without informing the dietary manager. The temperature log showed falsification, with strips colored in 25 times, and documented failure to reach the required temperature. Facility policy mandates reporting deviations to the food service manager.
The facility failed to ensure proper infection control measures, including the availability of PPE for residents on enhanced barrier precautions and appropriate signage. Staff did not wear PPE when required, and soiled linens were improperly handled. Additionally, the facility had not conducted necessary Legionella water testing, compromising the water management program.
The facility failed to follow its policies for pneumococcal vaccinations, affecting several residents. Records showed no documentation of vaccine offering or education, and no physician orders for the vaccine were found. The IP admitted reliance on an annual mobile clinic visit without an alternative plan, while the ADON confirmed the expectation to offer vaccines upon admission. The facility's policy to obtain standing orders and provide vaccine information was not adhered to.
The facility failed to ensure proper documentation of controlled substance counts during shift changes, affecting residents on two units. Observations revealed missing signatures on accountability records, indicating that required counts were not consistently performed. This deficiency impacted residents prescribed controlled medications for conditions like seizures and pain management. Staff interviews confirmed the lapses, and the facility's guidelines emphasize the importance of accurate narcotic records.
A facility failed to obtain psychotropic medication consents for four residents before administering antipsychotic drugs, despite having a policy requiring consents at the start of medication usage. The residents, diagnosed with severe cognitive impairments, received medications like Quetiapine, Risperdal, and Trazadone without prior consent. The DON confirmed the absence of consents, and the ADON highlighted the necessity of consents due to potential sedative effects and classification as chemical restraints.
The facility failed to label multidose medications with open and discard dates, affecting four residents. Insulin pens and a vial were found without proper labeling, and a discharged resident's medication was not removed from the cart. The DON confirmed that facility policy requires labeling and removal of medications for discharged residents.
The facility failed to maintain heating unit vents in the third-floor dining room and hallway in a sanitary condition. Observations showed the vents were missing covers and filled with garbage. The Memory Care Director was informed, and the Maintenance Assistant began addressing the issue, noting a vent had stopped working due to resident interference.
The facility failed to document advance directives for two cognitively intact residents, as their electronic medical records lacked physician orders for code status. Interviews with staff revealed inconsistencies in following the facility's policy, which requires that residents' wishes for advance directives match the physician's order.
A resident with dementia and other health issues was found to have a privacy curtain soiled with a brown substance, identified as feces, in their room. The housekeeping staff acknowledged the issue but noted that the third floor was not their regular assignment. The resident expressed dissatisfaction with the curtain's condition. The facility's administrator confirmed that regular cleaning of curtains and linens is expected to maintain a comfortable environment.
A resident experienced a significant delay in receiving ADL care after requesting assistance for cleaning following a bowel movement. Despite informing a CNA and activating the call light, the resident waited 116 minutes before receiving help. The facility's policies on prompt call light response and resident dignity were not followed, resulting in a deficiency.
The facility failed to provide pressure ulcer prevention interventions for two residents at risk. Observations revealed that the residents were in wheelchairs without pressure-relieving cushions, despite facility policy and care plans indicating their necessity. The Director of Nursing confirmed the requirement for cushions, and risk assessments showed both residents were susceptible to pressure ulcers, with one already having a sacral ulcer.
A resident with an indwelling catheter was found with the catheter lying in bed instead of being hung below the bladder for proper drainage. Despite facility policies and job responsibilities for LPNs and CNAs, the catheter was not managed correctly, risking backflow and infection.
A resident with COPD and chronic respiratory failure was found to have an uncontained nebulizer mask and no oxygen signage outside their room, contrary to facility policy. Observations confirmed these deficiencies, and interviews with nursing staff highlighted the importance of proper storage and signage to prevent infection and ensure safety.
The facility failed to implement fall prevention interventions for two residents with dementia at risk for falls. Observations revealed that the residents were wearing smooth-bottomed socks instead of non-skid socks, contrary to their care plans. Despite being informed, the residents continued to wear inappropriate footwear, highlighting a lapse in adhering to the facility's fall prevention policy.
The facility failed to secure medications, leaving them at the bedside of two residents without orders, and did not provide adequate supervision to a resident with dementia who experienced falls. Additionally, a blood draw needle was left in a resident's room, posing a safety risk. These deficiencies highlight issues with medication management, supervision, and safety protocols.
A survey found that call lights were not within reach for several residents in a facility, despite the policy requiring them to be accessible. Staff acknowledged the oversight, and the DON confirmed that rounds should ensure call lights are properly placed. Residents affected had varying cognitive abilities.
A resident with a history of medical issues experienced an unwitnessed fall resulting in a head laceration, which was not reported to the IDPH as required by the facility's policy. The facility's administrator cited the lack of sutures as the reason for not reporting, and the new DON was unaware of the incident. No documentation was available to show that the incident was reported or investigated.
The facility failed to follow medical orders for wound care and pressure ulcer prevention for two residents, leading to the worsening of their conditions. One resident's stage four pressure wound was not properly managed, with saturated dressings and lack of a donut cushion in the wheelchair. Another resident's sacral wound was found covered in feces, with staff unaware of the need for dressing changes. These deficiencies highlight a lack of adherence to facility policies and communication among staff.
A resident with a history of severe pain conditions experienced unmanaged pain due to the facility's failure to administer prescribed Norco every four hours. The resident's pain was rated at 10 during wound care, as the medication was not reordered in time, leading to missed doses. The facility's policy on pain management was not adhered to, resulting in a significant deficiency in care.
The facility failed to provide timely incontinent care for four residents, resulting in them being soiled with urine and/or feces for extended periods during the overnight shift. A CNA cited a lack of linen as a reason for delayed care, while another mentioned an assignment change. Residents requiring maximal assistance were found with saturated briefs and bed linen, and one resident had a sacral wound filled with feces. The DON confirmed the expectation for prompt cleaning to prevent skin breakdown.
The facility failed to ensure proper documentation of medication administration for three residents, as required by physician orders. Missing entries on the MAR for various medications suggest they may not have been administered. Interviews with staff confirmed that blank spaces on the MAR indicate non-administration, contrary to facility policy.
A facility failed to update a resident's wound treatment plan promptly after receiving a verbal order from a wound doctor. The wound care nurse did not execute the order or update the PCC system immediately, resulting in a delay in care. The facility's policy mandates immediate recording of verbal orders, which was not followed, leading to a deficiency in care for the resident.
The facility failed to ensure that residents were free from physical restraints, as observed with three residents who were positioned in a manner that restricted their movement. Staff acknowledged that these residents were fall risks and were placed in this position to prevent them from moving unless they could be supervised one-on-one. The facility's policies emphasize the prohibition of restraints and the importance of maintaining residents' rights to be free from unreasonable confinement.
Failure to Offer Menu Alternatives on Weekends
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide menu alternatives and substitutions on weekends, despite policies stating that residents may choose foods they wish to have and that an alternative menu is available daily. Multiple cognitively intact residents reported that from Monday through Friday, activity staff visit units to review the day’s lunch and dinner options and offer a list of alternative items, which are then communicated to the kitchen. However, these residents stated that this process does not occur on weekends and that they are only served the posted menu items on those days. Several residents described that on weekends they are unable to obtain substitutions if they do not like the main entrée. One resident stated that CNAs tell him the kitchen does not do substitutions on weekends, so he must eat what is served. Another resident reported he can only get substitutions during the week and wishes weekend options were available for variety. A different resident stated that while he can order ahead and receive substitutions Monday through Friday, on weekends staff tell him there is no other food to give him if he dislikes the meal, resulting in him going hungry. Another resident reported that on weekends he has to eat whatever is served because no substitutions are available, and another said that when he does not like the weekend meal, he calls his family for money to buy snacks or order outside food so he has something to eat. Staff interviews confirmed that the practice of offering and documenting menu alternatives occurs only on weekdays. A dietary aide stated that substitutes are available Monday through Friday but not on weekends, and that any weekend changes depend on what food happens to be available. Activity aides reported that they solicit residents’ meal choices and offer alternatives only during the week, not on weekends, and that on weekends residents receive only the posted menu entrée. In contrast, the regional food service manager and dietary manager both stated that menu alternatives are supposed to be available and offered every day at every meal, consistent with facility policies and an “Always Available Menu” listing items such as cheeseburgers, hamburgers, grilled cheese, peanut butter and jelly, deli sandwiches, and chef salad. The discrepancy between stated policy and actual weekend practice led to residents not being offered menu alternatives on weekends.
Uncovered Food Items and Lack of Hair Restraints During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to maintain sanitary conditions during food delivery and meal service, including not fully covering food and utensils during transport and not ensuring food service staff consistently wore hair restraints. A resident reported that his food was not always covered and that this bothered him because he did not want anyone talking while carrying his tray, as he was concerned spit could get on his food. He also stated that his juice, dessert, and silverware were never covered and reported finding two black hairs on top of the bread of his grilled cheese sandwich on an unspecified date. The facility’s own infection control and hair restraint policies require staff to wear hair restraints and beard guards and to follow regulations to assure a safe and sanitary dining services department. Surveyors observed multiple instances during meal distribution where food and utensils were not adequately covered. During lunch distribution on one unit, two dietary aides portioned food from a portable steam table, and one aide was not wearing a hair restraint or beard protector. CNAs preparing trays for residents who ate in their rooms placed uncovered drink cups and uncovered utensils on trays in open carts, and both CNAs stated that drink cups and silverware were never covered during transport, only the plates of food were wrapped. Additional observations on different floors showed open carts in hallways with trays where the main plate was covered in plastic wrap, but desserts, salsa containers, drink cups, bowls of cereal, and silverware remained uncovered. Carts were left open and unattended while CNAs delivered trays and set up residents in their rooms. Further observations in the main kitchen showed a dietary aide prepping lunch trays with a hairnet but without a beard protector, and another dietary aide in the food preparation area also without a beard protector. The dietary manager confirmed that these staff should have been wearing beard protectors and stated that staff in the kitchen and upstairs portioning food are expected to always wear hair restraints because of the potential for hair to fall into food and contaminate it. The dietary manager and regional food service manager both stated that food delivery carts are open and should be covered with large plastic covers during transport, especially when traveling long distances, left unattended, or placed where residents could touch the trays, because desserts, cereal, bowls, drinking cups, and silverware are not otherwise covered. A CNA with prior dietary and housekeeping experience also stated that carts and all tray items should be covered for infection control reasons, noting that the kitchen was only covering the plate of food and not the other tray items.
Failure to Respond Promptly to Resident Call Light
Penalty
Summary
The facility failed to respond to a resident’s call light in a timely manner, despite policies and job descriptions requiring prompt response. On multiple observations, the call light system monitor at the 2nd floor nursing station showed that the resident’s room call light had been activated for extended periods, with the hallway light outside the room remaining on. On one day, the call light for this resident’s room remained active from at least 12:53 PM until 1:11 PM, and the resident reported that it took staff a long time to check on him. On another day, the monitor showed the resident’s call light had been on for 62 minutes while an LPN sat at the nursing station; the LPN acknowledged that the system tracks minutes since activation and stated that someone likely went in but forgot to turn off the light, although the hallway light remained on. The resident involved had diagnoses including paraplegia, colostomy care, joint contractures, intestinal obstruction, UTI, and urogenital implants, and his MDS indicated intact cognition with substantial/moderate assistance needed for toileting, bathing, lower body dressing, personal hygiene, and transfers. His care plan identified him as at risk for falls related to generalized weakness and paraplegia, with interventions including keeping the call light within reach and encouraging its use for assistance. The resident reported that a CNA brought him a bucket of water at about 10:50 AM so he could bathe himself, but he could not wash his feet independently and activated his call light for help; more than an hour later, no staff had entered his room, and the CNA confirmed she had not returned since 10:50 AM and had been busy passing meal trays. Both the CNA and LPN stated that call lights should be answered right away or as soon as possible, and the DON stated that call lights should be responded to within 15 minutes, noting that staff do not know why a resident triggered the call light unless they check on them. Facility policy and the CNA job description both require call lights to be answered promptly.
Failure to Protect Resident From Emotional Abuse and to Immediately Remove Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from emotional/mental abuse and to immediately remove the alleged staff perpetrator from resident contact after an abuse allegation. A cognitively intact resident with multiple chronic medical conditions, including coronary artery disease, CHF, COPD, CKD, schizoaffective disorder (bipolar type), major depressive disorder, and nicotine dependence, used a wheelchair for mobility and depended on staff for transfers. The resident had a care plan noting a history of suspected abuse, neglect, exploitation, past trauma, and other factors increasing susceptibility to abuse/neglect, with an expectation that the resident would be treated with respect and dignity and live free from mistreatment. On the evening in question, the resident was propelling himself in his wheelchair toward the designated smoking area with an unlit cigarette in his mouth so that both hands were free to move the wheelchair. Two CNAs reported that the LPN at the nurses’ station got up, approached the resident, and snatched the unlit cigarette out of the resident’s mouth, broke it in half, and, per the resident and the Administrator, threw it at the resident. The CNAs stated the LPN did this without first speaking to the resident and described the LPN as rude. The resident and both CNAs reported that the LPN told the resident he was not supposed to have the cigarette in his mouth, and the CNAs further reported that the LPN yelled at the resident and threatened to call the police on him as a way to scare or intimidate him. The resident stated he was not trying to smoke in the building and that he was not scared by the threat, but he was upset and intended to report the LPN. One CNA stated she immediately texted the DON to report what she believed was emotional/mental abuse based on her training, and the other CNA stated she knew this report was made that night. Both CNAs later wrote statements dated two days after the incident. The DON stated that staff are expected to report abuse immediately, that staff-to-resident abuse requires immediate separation of the staff from the resident and removal of the staff from the building, and that this is necessary to ensure resident safety and prevent continuation of abuse. The Administrator, who is the abuse coordinator, similarly stated that staff must report suspected abuse immediately, that it is not their role to determine whether abuse occurred, and that any staff member involved in alleged abuse must be removed from the building and placed on administrative leave pending investigation. The Administrator stated that the first time he became aware of the incident was when the resident reported it to him two days later, at which time he learned that the LPN had snatched the cigarette from the resident’s mouth and threatened to call the police, actions he acknowledged could be intimidating, humiliating, and a form of abuse. Facility records showed the LPN continued to work after the incident and was not removed from the building the night of the alleged abuse, contrary to the facility’s abuse prevention policy, which requires immediate separation of the alleged perpetrator and notification of the Administrator and DON when abuse is suspected.
Late Submission of Final Abuse Investigation Report to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to submit a final investigation report of alleged staff-to-resident abuse to the Illinois Department of Public Health (IDPH) within the required five business days. The facility’s own Abuse Prevention Program policy, dated 01/2019, states that the final investigation report will be completed within five working days of the reported incident and that the Administrator is responsible for forwarding a final written report of the results of the investigation and any corrective action taken to IDPH within that same timeframe. The Administrator (V1), who serves as the facility’s abuse coordinator, confirmed that once abuse is reported, an initial report must be submitted to IDPH within two hours and the final report within five business days. The incident under investigation involved R6, a cognitively intact resident with multiple medical diagnoses including atherosclerotic heart disease, chronic diastolic heart failure, COPD, hypertension, hyperlipidemia, polyneuropathy, chronic kidney disease, schizoaffective disorder bipolar type, rheumatoid arthritis, gout, nicotine dependence, major depressive disorder, and anemia. R6 uses a wheelchair and is dependent on staff for transfers and has a care plan noting a history of suspected abuse, neglect, exploitation, past trauma, and other factors increasing susceptibility to abuse/neglect, with an expectation to be treated with respect and dignity and to reside free from mistreatment. R6 reported that while wheeling himself down the hallway toward the designated smoking area with an unlit cigarette in his mouth, an LPN (V21) snatched the cigarette from his mouth, broke it, threw it at him, and told him he should not have it in his mouth, and further threatened to call the police on him. Two CNAs (V22 and V23) corroborated R6’s account, stating that R6’s cigarette was unlit and in his mouth only so he could use both hands to propel his wheelchair, and that V21 abruptly got up from the nurses’ station, snatched the cigarette from R6’s mouth, broke it, and then verbally threatened him by saying she would call the police, which they characterized as intimidating and verbally/mentally abusive. R6 reported the incident to the Administrator on 12/09/25, stating it had occurred on 12/07/25. The facility submitted the initial report to IDPH on 12/09/25 at 5:23 PM. However, the final report was not submitted until 12/19/25 at 3:40 PM, which the Administrator acknowledged was late, noting that it should have been submitted by 12/16/25. This delay in forwarding the final written investigation report to IDPH beyond the five-business-day requirement constitutes the cited deficiency.
Failure to Consistently Administer and Document Anti-Seizure Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to prescribed anti-seizure medications. The resident, admitted with multiple diagnoses including spastic hemiplegic cerebral palsy, cerebral infarction with left-sided hemiplegia, Lennox-Gastaut syndrome, other seizures, atherosclerotic heart disease, and type 2 diabetes mellitus, was cognitively intact and ambulatory with a walker. During an interview, the resident reported that doses of her anti-seizure medications (phenobarbital, Keppra, and pregabalin/Lyrica) were missed because the medications were not available or the facility was “out of it,” and that she experienced seizure episodes when she did not receive these medications. She stated she had a seizure episode a couple of weeks prior that she associated with missed doses of Keppra, phenobarbital, and Lyrica. Staff interviews corroborated that the resident had a recent seizure episode. A CNA who regularly worked on the unit and was assigned to the resident reported observing a seizure 2–3 weeks earlier in the dining room, describing shaking while the resident was in her wheelchair and noting that it was a quick seizure and did not result in hospitalization. An LPN assigned to the resident stated he follows physician orders and the “5 rights” of medication administration and that he signs or initials the MAR after giving medications, acknowledging that if the MAR is not signed or initialed, it could mean the medication was not given. The DON similarly stated that nurses are expected to sign or initial the MAR after administering medications and that if the MAR is not signed, it could possibly mean the medication was not given, adding that standard nursing practice is that if it is not documented, it was not given. Record review showed multiple missing signatures/initials on the MAR for the resident’s anti-seizure medications, indicating doses were not administered as ordered. The physician orders included pregabalin 200 mg PO twice daily at 9 AM and 5 PM, phenobarbital 100 mg PO twice daily at 9 AM and 5 PM, and Keppra 1000 mg PO twice daily at 6 AM and 6 PM. The March MAR showed no signatures/initials for Keppra on three dates and for phenobarbital and pregabalin on one date, while the February MAR showed no signatures/initials for Keppra on two dates and for phenobarbital and pregabalin on one date. A nursing progress note documented a seizure on a prior date with jerking movements of all extremities lasting one minute. The resident’s care plan identified risk for seizure activity related to Lennox-Gastaut syndrome and directed staff to administer medications as ordered. Facility policies required medications to be administered as prescribed, documented on the MAR at the time of administration, and signed out as soon as given, with refusals and reasons documented, which was not consistently done in this case.
Failure to Safely Perform and Care Plan Mechanical Lift Transfer and Notify Representative After Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall, to accurately and timely care plan for mechanical lift transfers, to ensure two staff were present during a mechanical lift transfer, and to notify the resident’s representative of a fall. The resident had diagnoses including osteoporosis, Alzheimer’s disease, dementia, dysphagia, a displaced fracture of the left femur, and a history of falling, and was documented as severely cognitively impaired and dependent on staff for bed-to-chair transfers. The care plan identified the resident as at risk for falls and self-care deficits, with interventions to follow the facility fall protocol and anticipate and meet needs, and noted that assistance with transfers might occasionally increase due to fluctuating needs. However, the care plan did not include a specific focus on mechanical lift transfers until several days after the incident, despite multiple staff interviews indicating the resident had required mechanical lift assistance for more than a year. On the date of the incident, a CNA with a little over a month of employment at the facility attempted to transfer the resident from bed to chair using a mechanical device without assistance from a second staff member. During the transfer, when the resident’s legs lifted off the bed, the resident began to slide. The CNA realized the device being used was a weight machine rather than the appropriate mechanical lift for resident transfers. The CNA reported that the resident “kind of slid down slow,” and the CNA paused the transfer and called for help. The DON and ADON, who were rounding on the unit, heard the call for help and entered the room, observing the resident in a sling off the bed and the CNA attempting the transfer alone. Both the DON and ADON stated the resident’s lower body did not look secure or comfortable, and they, along with the CNA, lowered the resident to the floor. The facility’s own policies required two caregivers for mechanical lift transfers and directed that the resident’s responsible party be notified of incidents, accidents, and falls. The CNA had signed the Resident Handling Policy and completed a mechanical lift competency validation that specified use of a second caregiver. Despite this, the transfer was performed by a single CNA, and the incident was documented by the DON as an “other incident” rather than a fall. The DON stated the facility was calling the event an “assisted transfer” to the floor and not a fall, and both the DON and ADON acknowledged they did not inform the resident’s responsible party at the time of the incident. The responsible party was not notified about staff placing the resident on the floor until several days later, and the facility’s conclusion was that the event was not a fall, despite regulatory guidance defining a fall as unintentionally coming to rest on the floor or a lower level, including episodes where a resident would have fallen if not assisted to the floor.
Failure to Protect Roommates From Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse as required by its abuse prevention policy, resulting in two residents experiencing physical abuse. One resident with hemiplegia and hemiparesis following cerebrovascular disease shared a room with another resident diagnosed with schizophrenia, schizoaffective disorder, and major depressive disorder, who was admitted with a history of primarily verbal aggression. During a disagreement in their shared room, the cognitively intact resident with psychiatric diagnoses attempted to adjust the heat on the roommate’s side of the room. The roommate complained that the other resident smelled, after which the aggressive resident made physical contact with the roommate’s leg. The resident with hemiplegia, who had left-sided weakness and could not effectively block the contact, reported being hit first on the leg and later stated it was the arm, and complained of left arm pain, prompting an X-ray. The incident report and interviews documented that the resident with psychiatric diagnoses made physical contact with the roommate, and the facility’s Administrator/Abuse Coordinator and DON concluded that this contact met the facility’s definition of physical abuse. The roommate reacted by striking the aggressive resident with a reacher, causing a minor skin alteration to the aggressor’s nose. A police report characterized the event as simple battery, and social services documented that the aggressive resident required psychiatric evaluation due to aggression toward the roommate and difficulty with redirection. Despite known behavioral issues, lack of physical limitations, poor hygiene, and an intimidating demeanor, the aggressive resident had been placed and maintained as a roommate to a physically impaired resident who could not adequately protect herself from being hit on her weak side, resulting in the abusive contact and associated pain complaint.
Failure to Timely Submit Final Abuse Investigation Report
Penalty
Summary
The facility failed to follow its abuse reporting policy for two residents involved in a physical altercation. One resident with hemiplegia and hemiparesis and another resident with schizophrenia, schizoaffective disorder, and major depressive disorder, who had intact cognition with a BIMS score of 15, were roommates at the time of the incident. An initial abuse reportable incident was submitted alleging that the cognitively intact resident made physical contact with the other resident, who then retaliated by striking with a reacher while seated in a wheelchair. Social service notes documented that the aggressive resident was sent to the hospital for psychiatric evaluation due to aggression toward the roommate and difficulty with redirection, and census records showed that this resident later returned to the facility on the same floor but a different room. The facility’s Abuse Prevention Program required that abuse allegations involving one resident upon another be reported to the state agency and that a final written investigation report, including specified investigative details, be forwarded within five working days of the incident. The administrator/abuse coordinator acknowledged that the final report, which concluded that the aggressive resident did hit the roommate and that the act met the definition of physical abuse, was not submitted within the required timeframe. The final report, including reference to a police report documenting simple battery, was sent more than two weeks after the incident because the administrator forgot to send it and did not follow the policy requiring submission of the initial and final reports within five working days.
Failure to Address Resident's Environmental Concern Regarding Window Cracks
Penalty
Summary
The facility failed to provide a comfortable environment for one resident with multiple medical conditions, including paraplegia, osteomyelitis, pneumonia, a sacral pressure ulcer, major depressive disorder, chronic kidney disease, peripheral vascular disease, and anxiety. The resident, who was cognitively intact, reported feeling cold air coming from cracks in the window of his room on multiple occasions. These concerns were documented in resident council minutes, where the resident requested maintenance to check his room. Despite these repeated requests, the Maintenance Director stated he was not informed of the issue and had not received any work orders for the room. Upon assessment, both the surveyor and the Maintenance Director confirmed the presence of multiple cracks in the window and cold air entering the room, which the Maintenance Director classified as an emergency situation. A wound care technician reported that the resident had communicated feeling cold due to the window, and that maintenance had been informed. The facility's policies and job descriptions require prompt response to maintenance and life safety needs, and the Administrator confirmed that maintenance requests should be addressed as soon as possible or within 24 hours. However, the Administrator was unaware of the resident's repeated complaints about the window. Facility policies also emphasize the importance of providing a safe, clean, and comfortable environment and ensuring residents' rights and dignity, including timely response to concerns raised through the resident council.
Failure to Honor Resident Meal Preferences and Substitutions
Penalty
Summary
The facility failed to ensure that residents received meals in accordance with their documented preferences and dislikes, as well as requested substitutions. One resident repeatedly informed staff that he disliked ham, turkey, dressing, and oatmeal, and requested these dislikes be noted on his meal ticket. Despite this, his meal ticket only documented 'No Pork' and did not reflect his specific dislikes. The resident continued to receive oatmeal on his tray, and staff confirmed that the kitchen, operated by a new company, frequently provided incorrect meals, including items specifically listed as dislikes on residents' meal tickets. Staff interviews revealed that although residents' preferences were communicated to dietary staff, corrections were not consistently made, and disliked foods continued to be served. Another resident, who had a documented dislike of peanut butter and jelly sandwiches, received such a sandwich on her tray. When she requested a cheeseburger substitute, staff verified her dislike was noted on the meal ticket and contacted dietary for the substitution. The facility's policy states that residents should be able to choose foods from available items and that alternatives are available daily, with the activity department assisting in selections. Despite these policies, the facility did not consistently honor residents' meal preferences and substitutions, as evidenced by direct observations and staff and resident interviews.
Failure to Provide Timely Meal Service to Residents
Penalty
Summary
The facility failed to provide meals and snacks to residents at appropriate and scheduled times, as required by federal regulations. Observations revealed that residents were left waiting in dining rooms for extended periods before receiving their meals, with some residents not receiving food trays at the scheduled meal times. Staff interviews confirmed that meal service, particularly lunch, was consistently delayed due to food being sent late from the kitchen. Multiple staff members, including CNAs and restorative aides, attributed the delays to kitchen staffing shortages following a change in the company managing kitchen duties. Residents reported that their concerns about late meals had been voiced to staff and during resident council meetings, but the issue persisted. The Dietary Director, who had recently started, acknowledged the ongoing problem of delayed meal service and stated that efforts were being made to address the staffing issues in the kitchen. The Assistant Director of Nursing and other facility leadership were aware of the residents' complaints and confirmed that the kitchen, operated by an independent vendor, was not meeting the scheduled meal times. Review of facility policy indicated that meals were to be served according to a planned schedule, but observations and interviews demonstrated that this was not being followed, affecting all 199 residents who received oral meals from the facility's kitchen.
Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were provided as ordered by the attending physician for three residents. One resident, who had an order for a double portion regular diet with thin liquids, reported not receiving the required double portion of food on multiple occasions, as confirmed by both his statements and direct observation of his meal tray. Another resident, with an order for a general diet with mechanical soft texture, thin liquids, and double portion protein, was observed receiving only a single portion of protein on his tray. Both residents' medical records confirmed the dietary orders, and staff interviews acknowledged the importance of following these orders. Additionally, a third resident with orders for a no added salt, pureed texture, nectar thick liquids, and a magic cup supplement was observed receiving thin liquid juice instead of the prescribed nectar thick consistency. The staff member who provided the tray was unsure of the liquid's consistency and later replaced it with thickened juice after the deficiency was noted. The DON confirmed that not following diet orders, such as providing thin liquids instead of thickened liquids, can compromise resident safety and is an example of not adhering to physician orders.
Failure to Follow Physician Order for Daily Vital Sign Monitoring
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order to monitor and document a resident's vital signs daily. The resident, who has a history of hypertension, COPD, and asthma, reported experiencing frequent migraines and sensations of elevated blood pressure. Although a nurse practitioner had recently ordered daily vital sign monitoring, the resident stated that staff were not checking his blood pressure daily, and the nurse confirmed that while she had monitored the vital signs, she did not document them in the electronic medical record. Instead, the nurse wrote the readings on a piece of paper, which was later discarded. A review of the resident's records revealed significant gaps in documentation, with only one blood pressure reading logged for June and none for April and May, despite an active order for daily monitoring. The resident's care plan included monitoring for hypertension and symptoms associated with high blood pressure, but the lack of consistent documentation and adherence to the physician's order resulted in a failure to provide appropriate care as directed. Facility policy requires all physician orders to be implemented and followed, but this was not done in this case.
Failure to Maintain Functional Call Light System on Second Floor
Penalty
Summary
The facility failed to ensure that the resident call light system was functioning properly on the second floor, affecting 64 residents. During the investigation, a constant beeping sound was observed near the nurse's station, and staff members, including an RN and a CNA, reported that the malfunctioning system made it impossible to determine which resident was calling for help. The CNA further explained that the lights outside patient rooms did not always illuminate when a call was made, requiring staff to physically check each room to identify who needed assistance. Housekeeping staff were unaware of the issue and unable to disarm the alarm, while the Maintenance Director stated he was not informed of the malfunction. Facility policy requires a working call system to allow prompt staff response to resident calls and to ensure the system is in proper working order. Despite this, the malfunction persisted, with staff indicating that unresolved call alarms could result in resident calls being ignored. The facility census confirmed that 64 residents resided on the affected floor at the time of the deficiency.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment by not ensuring proper room temperatures for four out of seven residents reviewed for heating. Multiple residents reported that the heat in their rooms had not been working for two weeks, with one resident specifically pointing out exposed wires from the heating unit after staff moved beds. Residents expressed discomfort due to cold room temperatures, and one resident stated they had informed several nurses about the issue. Observations confirmed that some rooms had temperatures as low as 65°F, below the facility's stated acceptable range of 72°F to 82°F. The Maintenance Director was unaware of the heating issues and the exposed wires until informed by the surveyor during the inspection. Residents affected included individuals with significant medical conditions, such as paraplegia, hypertension, opioid abuse, anxiety disorder, and colostomy. One resident, who was cognitively intact, reported fluctuating room temperatures and had previously requested adjustments. The facility's policy requires a safe, clean, and comfortable environment, but the failure to promptly address heating malfunctions and exposed wiring resulted in residents experiencing discomfort and unsafe conditions in their rooms.
Failure to Document and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for three residents, as evidenced by missing entries of nurses' signatures, initials, or codes on the medication administration records (MARs) for multiple medications, dates, and times. The Director of Nursing (DON) confirmed that the absence of documentation on the MAR indicates that the medication was not administered, and stated that it is the expectation for nurses to document on a progress note if a medication is unable to be given for any reason. The facility's policy also requires that the person administering medications records the administration on the MAR at the time the medication is given and reviews the MAR at the end of each medication pass to ensure all doses are documented. The affected residents had complex medical histories and required multiple medications. One resident had diagnoses including metabolic encephalopathy, severe malnutrition, diabetes, dementia, and other serious conditions, and was noted to have severely impaired cognitive skills. Another resident, with intact cognition, had diagnoses such as paraplegia, pressure ulcers, anemia, and osteomyelitis. The third resident, also with intact cognition, had conditions including seizures, diabetes, hypertension, anemia, and a stage 4 pressure ulcer. For each of these residents, specific medications and administration times were identified where documentation was missing, indicating a failure to administer or record the administration of prescribed medications. Review of facility policies and job descriptions confirmed that both registered nurses and licensed practical nurses are required to perform routine charting duties in accordance with established documentation policies. The facility's drug administration guidelines specify that only licensed personnel may administer medications and must record the administration on the MAR at the time the medication is given. The policy further states that all administered doses must be documented before the end of the medication pass, and any withheld, refused, or rescheduled doses must be properly noted on the MAR.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of existing wounds for a resident, leading to a potential worsening of the resident's condition. The resident, who was admitted with multiple sacral wounds and a history of Fournier's gangrene and necrotizing fasciitis, did not receive timely wound care. Upon admission, the resident's wounds were not immediately treated due to a lack of paperwork from the hospital and a delay in obtaining physician orders. The admitting nurse, who was responsible for assessing the resident and obtaining orders, did not complete any treatments, and the wound care coordinator was unavailable to assess the resident's wounds. The Director of Nursing confirmed that standing orders to clean the wounds with normal saline and apply dry dressings were not documented or executed. The resident expressed dissatisfaction with the care received and requested to be transferred to a hospital for medical attention. The facility's policy requires that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection, which was not adhered to in this case.
Failure in Pressure Ulcer Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide necessary treatment and services to a resident with a pressure ulcer, resulting in the worsening of the wound and subsequent hospitalization for infection. The resident, who had a history of hemiplegia, type 2 diabetes, and a sacral pressure ulcer, was supposed to be turned and repositioned every 1-2 hours as per physician orders. However, documentation for these interventions was missing on multiple dates, indicating that the care may not have been provided consistently. Additionally, the resident's wound care treatment was not documented on specific dates, and the wound showed significant deterioration over time. The wound increased in size and developed a strong odor, with cultures revealing infection. The resident's wound care was compromised by the lack of proper supplies, as a Licensed Practical Nurse (LPN) admitted to improvising with available dressings due to the treatment cart being located on a different floor. This lack of adherence to the prescribed wound care regimen contributed to the resident's condition worsening. The facility's policies and job descriptions emphasize the importance of documentation and adherence to treatment protocols, yet these were not followed. The Director of Nursing acknowledged that undocumented care is considered not done, highlighting a systemic issue in the facility's care delivery. The resident's condition was further complicated by the development of a new wound, suspected to be caused by friction from heel protectors, indicating a failure in preventive measures as well.
Failure to Respond to Call Lights Promptly
Penalty
Summary
The facility failed to respond promptly to call lights for two dependent residents, R5 and R6, who require assistance for self-care activities such as toileting hygiene and bathing. R5, who is cognitively intact with a BIMS score of 15, and R6, who has moderate cognitive impairment with a BIMS score of 12, both rely on wheelchairs for mobility and are dependent on staff for self-care. On separate occasions, both residents activated their call lights for assistance, but the facility staff did not respond within the expected timeframe. R6's call light was on for over 10 minutes while staff were observed sitting at the nurse's station, and R6 expressed a need for pain relief. Similarly, R5's call light was on for an extended period, and R5 expressed a need to be cleaned. The facility's policy and job descriptions require staff to respond promptly to call lights, regardless of room assignments. However, during the survey, staff at the nurse's station did not adhere to this policy. When questioned, a CNA acknowledged that all call lights should be answered, even if the assigned CNA is unavailable. The Director of Nurses confirmed that call lights should be answered within 10-15 minutes by any staff member. Despite these guidelines, the facility's failure to respond promptly to the call lights of R5 and R6 indicates a deficiency in meeting the residents' needs and preferences for assistance.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to adhere to its policy for scheduled medication administration time frames, affecting a resident who was reviewed for medication administration. The resident, who is cognitively intact and requires substantial maximal assistance for mobility and self-care, reported that their medications were consistently administered late across all shifts. Observations and record reviews confirmed that medications were given outside the one-hour window before or after the scheduled time, with specific instances noted where medications were administered significantly later than scheduled. For example, on one occasion, medications scheduled for 9:00 am were given at 12:46 pm. The resident's medical history includes conditions such as paraplegia, hypertension, and anxiety, with a care plan indicating a risk for elevated blood pressures related to hypertension. Despite the facility's policy requiring medications to be administered within a specific time frame and the expectation for staff to follow these guidelines, the resident's medications were not administered as ordered. The Director of Nursing acknowledged the expectation for timely medication administration and the need for staff to contact a doctor for orders if medications are administered late. However, no new orders for schedule changes were noted in the resident's records.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to provide a functioning call device for a resident requiring assistance, which was identified during a survey. The resident, who has a history of osteoarthritis, congestive heart failure, spinal stenosis, hypertension, and glaucoma, was noted to have moderate cognitive impairment and requires a wheelchair for mobility. The resident is dependent on staff for self-care activities such as toileting hygiene and bathing. During the survey, it was observed that the resident's call light was on in their room, but it did not register on the call light board at the nurse's station, indicating a malfunction. A Certified Nursing Assistant (CNA) confirmed that the call light should be visible on the call light board at all times when activated. The Maintenance Director was notified of the issue but initially dismissed it, stating the call light was working after turning it off and on again. However, the Director of Nursing later confirmed that the call light system should light up and make a noise at the nurse's station, and any malfunction should be reported immediately. The facility's policies require daily checks of call lights and logging of any defects, which were not adhered to in this instance.
Failure to Prevent Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident (R2) from physical assault by another resident (R1), who has a documented history of physical aggression. R1, diagnosed with Dementia with Behavioral Disturbance, Schizophrenia, and Bipolar Disorder, has a severe cognitive impairment and is non-verbal. R2, who has Depression and Delusional Disorders, has mild cognitive impairment. On the day of the incident, R1 entered the dining room and physically assaulted R2, who was sitting at a table. The aide present immediately intervened and separated the residents. R2 was assessed and reported no injuries or pain, and both families and physicians were notified. R1's care plan, dated prior to the incident, documented multiple instances of physical aggression towards other residents and staff. Despite this history, R1 was able to approach and assault R2. The facility's abuse policy affirms the residents' right to be free from abuse and outlines the definition of physical abuse as the infliction of injury other than by accidental means. The incident report and progress notes confirm that R1's behavior was consistent with past aggressive actions, yet the facility failed to prevent the assault on R2.
Deficiencies in Supervision, Medication Administration, and Staff Conduct
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents, as evidenced by the observation of several residents in wheelchairs inside the dining room without any staff present to monitor them. This lack of supervision was acknowledged by the Assistant Director of Nursing, who stated that there should have been someone monitoring the residents. Additionally, a Certified Nursing Assistant was unaware of her responsibility to monitor the dining room, as she was not informed of the schedule. The facility also failed to ensure medications were administered as ordered by the residents' physician. One resident did not receive their Benztropine medication because it was not available in the medication cart, and the nurse did not have access to the automated medication dispenser. Another resident had not received their Escitalopram medication for five days, despite the medication administration record indicating it had been administered. The Director of Nursing was not informed of the medication unavailability until the surveyor's inquiry. Furthermore, the facility did not maintain professional standards in medication administration and staff conduct. A nurse was observed on a video call while preparing medications, acknowledging the potential for HIPAA violations and medication errors. Another medication cart was found unlocked and unattended, posing a risk of unauthorized access to medications. Additionally, a nurse exhibited unprofessional behavior by yelling at the surveyor during an interview, raising concerns about potential similar behavior towards residents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy, resulting in two separate incidents of physical abuse among residents. In the first incident, a resident pushed another resident from a wheelchair in the dining room, causing the latter to fall. This altercation was witnessed by a CNA who was present in the dining room at the time. The resident who was pushed expressed distress and was sent to the hospital for evaluation. The resident who pushed was also sent to the hospital and later stated that they could not remember the incident. The facility's LPN confirmed that there was a commotion and observed the resident on the floor, indicating a lack of adequate supervision in the dining room. In the second incident, two residents engaged in a verbal altercation over a jacket, which escalated to one resident hitting the other in the face, resulting in a swollen lip and a hospital visit for the injured resident. The LPN noted that there was no staff present in the dining room during this incident, highlighting a failure to provide necessary supervision to prevent such altercations. The facility's Director of Nursing, who was new to the position, acknowledged the expectation for staff to supervise residents in common areas to prevent incidents of abuse. The facility's abuse policy emphasizes zero tolerance for abuse, yet the incidents indicate a lapse in policy enforcement and supervision.
Lack of Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide appropriate supervision to four residents in the dining room, leading to two separate incidents of physical altercations. In the first incident, two residents engaged in a verbal altercation, which escalated when one resident pushed the other from a wheelchair, causing a fall. In the second incident, another resident hit a fellow resident in the face during a verbal dispute, resulting in a swollen lip and the injured resident being sent to the hospital. Interviews with the involved residents revealed that the altercations were related to personal disputes, and the staff confirmed that no supervision was present during these incidents. The facility's staff, including a CNA and the Director of Nursing, acknowledged that there should have been visual supervision in the dining room to prevent such incidents. The facility's policies on abuse prevention and standard supervision emphasize the need for proactive intervention and visual monitoring of residents during mealtimes. However, the lack of staff presence in the dining room at the time of the incidents indicates a failure to adhere to these policies, resulting in the physical altercations and subsequent injuries.
Dishwasher Temperature Logging and Functionality Issues
Penalty
Summary
The facility failed to accurately log dish machine temperatures and ensure the dish machine was functioning properly, potentially affecting 162 residents who receive meals from the facility kitchen. During a kitchen tour, a surveyor observed a dietary aide using a temperature strip to test the dishwasher's temperature. The strip indicated that the dishwasher was not reaching the required temperature of 160 degrees Fahrenheit for proper sanitation, as the white box on the strip did not turn black. The dietary aide admitted that the dishwasher had not reached the proper temperature for over a week and had failed to inform the dietary manager. The dietary manager stated that staff are expected to check the dishwasher after each meal to ensure it is functioning correctly and to report any issues immediately. The facility's dishwasher temperature log for October 2024 showed that the temperature strip was colored in with a black marker 25 times, indicating falsification of records. The log also documented that the required temperature was not reached on a specific date. The facility's policy requires the final sanitizing rinse to meet specific temperature guidelines, and any deviations should be reported to the food service manager.
Infection Control Deficiencies in PPE Availability and Water Management
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Residents on enhanced barrier precautions (EBP) did not have appropriate signage or readily available personal protective equipment (PPE) outside their rooms. Specifically, a resident with a gastrostomy tube did not have an EBP sign or PPE bin by their room, and other residents on EBP also lacked accessible PPE. The Infection Preventionist acknowledged that storing PPE in the clean utility room did not make it readily available for staff, which could delay the use of necessary protective measures. Additionally, staff failed to don appropriate PPE when providing care to residents on EBP. A Certified Nursing Assistant was observed performing personal care for two residents without wearing a PPE gown, despite EBP signs being posted on the doors. The Director of Nursing and other staff members confirmed that PPE should be worn when caring for residents on EBP to prevent potential infections. The facility also neglected proper handling of soiled linens and water management. Unbagged soiled linens were found coming out of the laundry chute and on the laundry room floor, contrary to the facility's policy requiring linens to be bagged and tied. Furthermore, the facility had not conducted required Legionella water testing since March 2022, failing to adhere to its water management program designed to reduce the risk of waterborne pathogens.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adhere to its policies and procedures for the immunization of residents against pneumococcal disease, as evidenced by the lack of vaccination for eligible residents. The deficiency was identified through interviews and record reviews, which revealed that nine residents had no documentation of pneumococcal vaccine offering or education in their records. Additionally, there were no physician orders for the pneumococcal vaccination for these residents, and their immunization records did not list a current pneumococcal vaccination. The Infection Preventionist (IP) acknowledged that the facility relies on a mobile vaccination clinic that visits only once a year, and no alternative plan was developed to vaccinate residents as needed. The Assistant Director of Nursing (ADON) stated that the facility's expectation is to offer pneumococcal vaccines to new residents upon admission if they are eligible and have not already received it. However, the facility's policy, which includes obtaining standing orders for the vaccine and providing information on its risks and benefits, was not followed, leading to the deficiency.
Failure to Document Controlled Substance Counts During Shift Changes
Penalty
Summary
The facility failed to ensure that controlled medications were properly counted and documented during shift changes, affecting residents on two different units. Observations and interviews revealed that the Shift Change Accountability Records for Controlled Substances on both 1-West and 2-East units had missing signatures, indicating that the required counts were not consistently performed or documented. This deficiency was noted during a survey conducted on October 28 and 29, 2024, where it was observed that the accountability forms for controlled substances had missing signatures, and the counts were not completed as required. The deficiency affected a total of 12 residents across the two units who were prescribed controlled medications for various conditions, including seizures, bipolar disorder, epilepsy, depression, and pain management. Specific residents were identified with active orders for medications such as Clonazepam, Lacosamide, Tramadol, Zolpidem, Clobazam, and Norco, which are classified as controlled substances. The lack of proper documentation and accountability for these medications raises concerns about the facility's adherence to federal and state regulations regarding the handling of controlled substances. Interviews with staff, including a Licensed Practice Nurse and a Registered Nurse, confirmed the missing signatures on the accountability records. The Director of Nursing acknowledged that nurses are expected to sign off on the shift change accountability sheet after counting the controlled substances. The facility's guidelines and job descriptions emphasize the importance of accurate narcotic records and the requirement for two licensed nurses to conduct and document a physical inventory of controlled substances at each shift change. However, the observed lapses in documentation indicate a failure to comply with these established procedures.
Failure to Obtain Psychotropic Medication Consents
Penalty
Summary
The facility failed to ensure that four residents had psychotropic consents signed prior to administering antipsychotic medication. This deficiency was identified during an investigation on 10/30/2024, where it was noted that residents R55, R104, R116, and R118 were administered psychotropic medications without the necessary consents. The Director of Nursing (DON) confirmed that there were no additional psychotropic medication consents for these residents, despite the expectation that consents should be obtained before administering such medications. Resident R55, diagnosed with Alzheimer's disease and severe cognitive impairment, was administered Quetiapine and Paroxetine multiple times in September and October 2024 without prior consent, which was only obtained on 10/10/2024. Similarly, Resident R104, with unspecified dementia and schizophrenia, received Hydroxyzine Pamoate, Risperdal, and Trazadone without consent until 10/30/2024. Resident R116, also with Alzheimer's disease and severe cognitive impairment, was given Quetiapine and Risperidone without consent, with only Risperidone consent obtained on 10/10/2024. Resident R118, with severe cognitive impairment, was administered Risperidone without any informed consent. The facility's policy on psychotropic drug usage mandates that informed consents be initiated upon the start of medication usage and upon any dosage increase. However, this policy was not adhered to, as evidenced by the lack of consents for the aforementioned residents. The Assistant Director of Nursing (ADON) emphasized the importance of obtaining consents due to the potential sedative effects and the classification of some psychotropic medications as chemical restraints. The facility's list of residents on psychotropic medication included 89 individuals, indicating a broader potential impact of this deficiency.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that multidose medications were properly labeled with open and discard dates, affecting four residents. During an inspection of the medication cart, it was observed that insulin pens for three residents and a vial for another resident were opened but lacked the necessary labeling. This oversight was confirmed by an LPN who acknowledged the absence of open and discard dates on the insulin pens and vial. The Director of Nursing later confirmed that the facility's policy requires nurses to label insulin with open and discard dates, as insulin is effective for only 28 days after opening. Additionally, the facility did not remove a multidose medication belonging to a discharged resident from the medication cart. The LPN verified that the resident was no longer at the facility, yet their insulin remained in the cart. The Director of Nursing stated that medications of discharged residents should be returned to the pharmacy, indicating a lapse in following the facility's procedures for medication management. The CMS Medication Storage and Labeling pathway, which the facility claims to follow, mandates that opened multidose vials be dated and discarded within 28 days.
Facility Fails to Maintain Heating Vents in Sanitary Condition
Penalty
Summary
The facility failed to maintain the wall heating unit vents in the dining room and hallway on the third floor in good repair and sanitary condition. Observations revealed that the vents were missing covers and were filled with garbage items such as paper, straws, plastic cups, hairbrush, and medication cups. This issue was identified during a survey conducted on the third floor, which houses 50 residents. The Memory Care Director acknowledged the problem and indicated that maintenance would be notified. The Maintenance Assistant later confirmed that he had been informed about the issue and was in the process of cleaning the vents and obtaining the necessary covers. He also mentioned that the heating vent in the hallway had stopped working after a resident urinated in it, and he planned to repair or replace it. The facility's maintenance staff job description includes responsibilities for performing inspections, documentation, and maintenance of facility equipment, which were not adequately fulfilled in this instance.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to obtain and document the code status in the electronic medical records of two residents, R9 and R41, who were reviewed for advance directives. Both residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15. However, their Physician Order Summaries (POS) did not include any physician orders for advance directives, such as Full Code or Do Not Resuscitate (DNR) status. Additionally, the Admission Record Forms for both residents had blank sections for advance directives. Interviews with facility staff revealed a lack of clarity and adherence to the facility's policy regarding advance directives. The Assistant Director of Nursing (ADON) acknowledged that advance directives should be documented in the resident's profile and that a doctor's order is necessary. The Director of Nursing (DON) stated that every resident should have an advance directive in the computer, but did not obtain an order if the resident was a full code. The facility's policy emphasized that residents' wishes for advance directives must match the physician's order, highlighting a discrepancy in practice.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as R115, who is an elderly individual with diagnoses including unspecified dementia, altered mental status, weakness, chronic obstructive pulmonary disease, and asthma. On October 28, 2024, a surveyor observed a large amount of a brown substance on R115's privacy curtain, which was later identified by a housekeeping staff member, V10, as feces. V10 acknowledged the issue and stated that housekeeping is responsible for changing the curtains, but noted that he did not work the previous weekend and that the third floor is not his regular assignment. The resident, R115, expressed dissatisfaction with the condition of the curtain, describing it as 'nasty' and requesting it be changed immediately. The facility's administrator, V1, confirmed that it is expected for residents' curtains and linens to be cleaned regularly to ensure a comfortable environment, as outlined in the facility's housekeeping job description and general cleaning policy.
Failure to Provide Timely ADL Care and Respond to Call Light
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to a resident, identified as R109, who required assistance. On the morning of 10/28/24, a Certified Nursing Assistant (CNA), V33, was observed leaving R109's room without addressing the resident's request for cleaning after a bowel movement. R109 was found lying in bed with an exposed incontinence brief and stool draining from it. Despite having informed V33 of the need for cleaning, R109's call light remained on for assistance, indicating a wait time of 84 minutes at one point. The CNA, V33, acknowledged being informed by R109 but stated she would notify the assigned CNA, which did not result in immediate assistance. The situation persisted as the call light continued to be active for a total of 116 minutes before a Restorative Aide, V32, entered the room to assist R109. The facility's policies emphasize the importance of prompt response to call lights and maintaining resident dignity and respect, which were not adhered to in this instance. The Assistant Director of Nursing (ADON), V29, confirmed that a call light on for such an extended period is unacceptable and that staff should deviate from routine to assist residents in need. R109's care plan specified toileting by nursing staff every two hours and as needed, which was not followed, leading to the deficiency in care.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions for two residents at risk for pressure ulcers. During an observation in the dining room, two residents were seen sitting in wheelchairs without pressure-relieving cushion devices, contrary to the facility's policy. A CNA present at the time acknowledged the absence of the cushions and indicated she would contact the Restorative department. Despite this, the residents remained without cushions for an extended period. The Director of Nursing later confirmed that the residents should have had cushions to prevent pressure ulcers. Both residents had documented risk assessments indicating their susceptibility to pressure ulcers, with one resident already having developed a sacral pressure ulcer. The care plans for these residents included interventions such as providing pressure-reducing mattresses and wheelchair cushions. The facility's policy on pressure injury prevention also emphasized the use of pressure-reducing devices as indicated by assessments. However, these interventions were not implemented, leading to the deficiency noted in the report.
Improper Indwelling Catheter Management
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling catheter, which was observed lying in the bed next to the resident instead of being hung below the bladder to allow for proper drainage. This deficiency was identified during an observation of a resident with paraplegia, chronic kidney disease, urinary tract infection, and hypertension. The resident was noted to be cognitively intact with a BIMS score of 15. The improper placement of the catheter was confirmed by both a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), who acknowledged that the catheter should be hanging below the bladder to prevent backflow and potential infection. The facility's policy on indwelling catheter care clearly states that the urinary drainage bag should always be kept below the level of the bladder. Additionally, the job descriptions for both LPNs and Certified Nursing Assistants (CNAs) include responsibilities for ensuring compliance with facility policies and providing daily indwelling catheter care. Despite these guidelines, the catheter was not managed according to the established procedures, posing a risk of urinary tract infection due to potential backflow of urine.
Failure to Ensure Safe Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as R159, who was affected by these deficiencies. R159 has a medical history of Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure, and experiences shortness of breath. Observations on two separate occasions revealed that the nebulizer mask used by R159 was left uncontained, lying face down on the bedside table and on the oxygen machine, which poses a risk of contamination. Additionally, there was no oxygen signage posted outside R159's room, which is a necessary precaution when oxygen is in use. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the nebulizer mask should be stored in a bag to prevent infection and dirt exposure. They also stated that an oxygen sign should be placed on the door of any resident receiving oxygen therapy. The facility's policy on oxygen administration requires that tubing, humidifier bottles, and filters be changed, cleaned, and maintained at least weekly and as needed, and that oxygen signage be posted on the door frame inside and outside the room. These lapses in protocol were identified during a survey, affecting the quality of care provided to R159.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents with dementia who are at risk for falls. During an observation on the third floor, two residents were seen wearing smooth-bottomed socks instead of the required non-skid socks, which are necessary to prevent falls. Despite being informed by a CNA that the socks would be changed, the residents continued to wear inappropriate footwear later in the day. The Memory Care Director confirmed that non-skid socks were supposed to be worn by residents at risk for falls. The care plans for both residents indicated that they were at risk for falls and required appropriate footwear to ensure stability and traction. The facility's policy on incident/accident/falls also emphasized the need for care plans to have measurable goals and appropriate interventions. However, the facility did not adhere to these guidelines, as evidenced by the residents' continued use of improper footwear, which was not in line with their care plans or the facility's policy.
Medication and Supervision Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were safely locked up in the treatment cart when not in use, leading to potential tampering and accidental hazards. During observations, medications were found left at the bedside of two residents without a physician's order. One resident had a medication cup with a Gabapentin capsule left on the over-bed table, which was supposed to be administered by the night shift nurse. Another resident had two medication cups with a total of five tablets, including Flexeril and Gabapentin, left on the bedside dresser. The facility's policy requires that medications should not be left at the bedside unless the resident is on a self-administration program, which was not the case for these residents. Additionally, the facility failed to provide adequate supervision to a resident who had a history of falls. This resident, who had dementia and required assistance with walking, experienced an unwitnessed fall resulting in a head laceration. The resident had previously fallen and sustained a femur fracture. Staff interviews revealed a lack of awareness and recall regarding the resident's needs and the circumstances surrounding the falls. The facility's policy emphasizes the importance of supervision and monitoring, which was not adequately provided in this case. The facility also failed to ensure that sharp objects, such as a blood draw needle, were not left in resident rooms, posing a safety risk. A blood draw needle was observed on an over-bed table, visible from the hallway, and staff were unaware of who left it there. The facility's policy requires that sharp objects be removed from resident rooms during regular rounds, which were not consistently conducted. These deficiencies have the potential to affect all residents in the facility, as they indicate a systemic issue with medication management, supervision, and safety protocols.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for seven residents, as observed during a survey. Residents R5, R7, R8, R9, R12, R13, and R14 were all found in their beds without their call lights within reach. This was confirmed through observations and interviews with facility staff, including CNAs and an LPN, who acknowledged that call lights should be placed within the residents' reach. The facility's policy, dated July 11, mandates that call lights must always be within reach and not placed on the floor or bedside stand. During the survey, it was noted that R5 did not have a call light at all, and R6, R7, R8, R9, R12, R13, and R14 had call lights that were not accessible. The Director of Nurses (DON) confirmed that staff are required to make rounds every two hours to ensure call lights are properly placed. Despite this policy, the survey found multiple instances where call lights were not accessible, indicating a failure to adhere to the facility's procedures. The residents involved had varying levels of cognitive function, as indicated by their BIMS scores, but all were affected by the inaccessibility of their call lights.
Failure to Report Unwitnessed Fall Incident
Penalty
Summary
The facility failed to report an unwitnessed fall incident with injury to the Illinois Department of Public Health (IDPH) within the required time frame for a resident who was reviewed for falls. The resident, who had a history of multiple medical conditions including a fracture of the neck of the left femur, dementia, and other health issues, experienced an unwitnessed fall on September 26, 2024, resulting in a head laceration. Despite the injury, the incident was not reported to IDPH as required by the facility's policy, which mandates reporting any unwitnessed fall injury within 24 hours. The facility's administrator, identified as V1, stated that the incident was not reported because the resident did not require sutures for the laceration. Additionally, the Director of Nursing (DON), identified as V2, was a new hire and unaware of the incident. The facility could not provide any documentation showing that the incident was reported to IDPH, nor was there any root cause evaluation documentation available. The facility's policy on incident/accident reporting emphasizes the importance of identifying, reporting, investigating, and resolving such incidents, but this protocol was not followed in this case.
Failure to Follow Wound Care Orders and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to adhere to medical orders for wound care and pressure ulcer prevention for two residents, leading to the worsening of their conditions. One resident, R1, who had a facility-acquired stage four pressure wound, did not receive the necessary PRN wound dressing changes. The wound dressing was observed to be saturated with bodily fluids, and R1 was not provided with a donut cushion in her wheelchair as ordered, which is crucial for offloading pressure from the wound area. The lack of adherence to these orders contributed to the deterioration of R1's wound from a deep tissue injury to a stage four pressure wound. Another resident, R6, with a stage four sacral wound, was found with a wound dressing saturated with feces. Despite having PRN wound care orders, the wound was not cleaned as needed, which could potentially worsen the wound. The staff, including the assigned nurse, were unaware of the need for a dressing change or the resident's bowel movement, indicating a communication breakdown and lack of awareness regarding the resident's care needs. The facility's policies require that residents with pressure ulcers receive necessary treatment and services to promote healing and prevent infection. However, the observations and interviews revealed that the facility did not follow these policies, as evidenced by the failure to change soiled dressings and provide necessary pressure-relieving devices. The lack of communication and awareness among staff members about the residents' care needs and medical orders contributed to the deficiencies observed.
Failure to Manage Resident's Pain Due to Medication Unavailability
Penalty
Summary
The facility failed to manage a resident's pain effectively, as evidenced by the lack of administration of prescribed pain medication. The resident, identified as R6, has a history of conditions including hidradenitis suppurativa, overactive bladder, repeated falls, and neuropathy. Despite being cognitively intact with a BIMS score of 13, R6 experienced severe pain rated at 10 on a scale of 1-10 during wound care and activities of daily living. The resident's care plan included the administration of Norco every four hours for pain management, but this was not adhered to. On the morning of 09/24/2024, R6 was observed in significant pain during wound care, with a sacral wound described as the size of a football. The assigned nurse, V15, acknowledged that R6 had run out of Norco and had been given Tylenol instead, which was not as effective. The nurse admitted that R6 missed several doses of Norco, including those scheduled for 2 AM and 6 AM, due to the medication not being reordered in time. This oversight resulted in R6 enduring severe pain during necessary care activities. The facility's Director of Nursing, V2, confirmed that the protocol for reordering controlled medications like Norco was not followed, leading to the medication being unavailable when needed. The facility's policy on pain management emphasizes the importance of maintaining an effective pain management plan to ensure resident comfort and dignity. However, the failure to reorder and administer the prescribed medication as per the care plan resulted in a significant deficiency in the resident's care.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for four residents, resulting in them being soiled with urine and/or feces for extended periods during the overnight shift. Resident 2, who requires maximal assistance with personal hygiene due to osteoarthritis and weakness, was found with a saturated brief and bed linen. The CNA responsible for Resident 2 stated that a lack of linen prevented timely care. Resident 5, who is cognitively intact and requires maximal assistance, was also found with saturated bed linen and expressed having waited to be changed. The CNA assigned to Resident 5 mentioned an assignment change and admitted to not rounding on the resident since 2:00 AM. Resident 6, who has a self-care deficit and requires assistance with ADLs, was found with a sacral wound filled with feces and saturated bed linen. The CNAs responsible for Resident 6 confirmed the presence of feces on the wound. Resident 8, who requires maximal assistance with personal hygiene and has cognitive communication impairment, was found with saturated pants and a room smelling of urine. The CNA attending to Resident 8 acknowledged the resident's resistance to being cleaned but proceeded to provide care. The Director of Nursing confirmed that residents are expected to be cleaned promptly to prevent skin breakdown and maintain comfort.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure that residents' medications were administered as ordered by the physician, affecting three residents. The surveyor reviewed the medication administration records (MAR) for August 2024 and found missing entries of nurses' signatures, initials, or codes for several medications, dates, and times for all three residents. This lack of documentation suggests that the medications may not have been administered as prescribed. Resident 1, with a BIMS score indicating intact cognition, had several medications with missing documentation, including Fluticasone-Salmeterol, Famotidine, Polyethylene Glycol, and Docusate Sodium. Resident 2, with moderately impaired cognition, also had missing entries for medications such as Famotidine, Colace, Hydrochlorothiazide, Atorvastatin, and Clopidogrel. Resident 3, with intact cognition, had numerous medications with missing documentation, including Melatonin, Carvedilol, Amlodipine, Cyclobenzaprine, Gabapentin, Polyethylene Glycol, Sertraline, Tamsulosin, and Apixaban. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that the nurses are responsible for administering medications and documenting them on the electronic MAR. The staff acknowledged that blank spaces on the MAR indicate that the medication was not administered. The facility's policy requires that the MAR be initialed by the person administering the medication, and any deviations from the scheduled administration should be documented with appropriate codes. The failure to document medication administration as per the facility's policy and best practice standards led to the deficiency.
Failure to Update Wound Treatment Orders
Penalty
Summary
The facility failed to follow provider orders and update the wound treatment plan for one resident, identified as R4, out of a sample of three residents. On June 18, 2024, the wound care nurse, V7, received a verbal order from the wound doctor, V20, to change R4's wound treatment plan. However, V7 did not carry out the order immediately or update the orders in the Point Click Care (PCC) charting system. V7 admitted to not remembering why the order was not executed and expressed a belief that it was not a significant issue if orders were not changed immediately, as an old order was still in place. This inaction resulted in a delay in care, as the new treatment order was only implemented by the wound coordinator, V15, on June 21, 2024. The facility's policy requires that verbal orders be recorded immediately in the resident's chart by the person receiving the order, including the date of the order, and that they be recorded on the physician's order sheets in the resident chart. The treatment administration record for June and July 2024 showed no documentation or orders placed in the Electronic Medical Record (EMR) for the new treatment order documented in the wound evaluation and management summary notes dated June 18, 2024. This oversight was identified during a review of R4's care plan, progress notes, physician orders, and other relevant documentation, highlighting a deficiency in the facility's adherence to its own policies and procedures regarding timely execution and documentation of physician orders.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as observed with three residents (R8, R9, R10) who were positioned in a manner that restricted their movement. On 5/23/2024, these residents were observed sitting in wheelchairs at a dining room table with the back wheels of their wheelchairs against the wall and the table positioned against their armrests, preventing them from standing up. Staff members, including an Activity Aide and a CNA, acknowledged that these residents were fall risks and were placed in this position to prevent them from moving unless they could be supervised one-on-one. The Director of Nursing and other staff members confirmed that the facility is supposed to be restraint-free and that the observed positioning of the residents constituted a restraint, which should not have happened. The medical records of the residents involved indicate that R8 is moderately cognitively impaired with a history of falling, R9 is severely cognitively impaired with Alzheimer's disease, and R10 is moderately cognitatively impaired with mobility issues. Despite the facility's policy against the use of restraints, the staff's actions resulted in the unreasonable confinement of these residents. An in-service report conducted by an LPN reiterated that the facility is restraint-free and that no objects should be used to prevent residents' movement. The facility's Abuse Prevention Program and Physical Restraints/Seclusion policies also emphasize the prohibition of restraints and the importance of maintaining residents' rights to be free from unreasonable confinement.
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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