Bella Terra Morton Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Morton Grove, Illinois.
- Location
- 8425 Waukegan Road, Morton Grove, Illinois 60053
- CMS Provider Number
- 145198
- Inspections on file
- 34
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Bella Terra Morton Grove during CMS and state inspections, most recent first.
A bedbound, cognitively impaired male resident with multiple comorbidities, including COVID-19 and atrial fibrillation, was care planned and assessed as high fall risk, requiring his bed to be kept in the lowest position with partial side rails and hourly monitoring while on strict isolation. On a morning shift, an agency CNA received incomplete handoff, did not conduct room-to-room checks, and, upon finding the resident’s bed empty and not in low position with no side rails up, assumed he was out for an appointment without checking the bathroom or around the bed. The assigned RN, who had not physically seen the resident since the start of her shift, incorrectly told the CNA the resident might be at dialysis and did not verify his location, despite facility expectations for hourly checks of isolation residents. More than two hours after the resident was last seen in bed, a staff member discovered him unresponsive under the bed; the bed was still not in the lowest position, required fall-prevention interventions were not in place, and there was no documentation of the required hourly monitoring prior to his being found and later pronounced deceased.
A resident with severe cognitive and visual impairment was subjected to rough handling and disrespectful treatment by two CNAs during in-bed care, including being forcefully pushed down, threatened to stop screaming, and slapped on the face while visibly distressed and resisting care. The incident was not fully documented in the facility's internal report, and staff interviews revealed a lack of specific training on dementia care and de-escalation techniques. Facility leadership acknowledged the actions did not meet standards, but did not clearly identify them as abuse.
A resident with severe cognitive and visual impairment was physically restrained and slapped by two CNAs during care, resulting in emotional and physical harm. The staff involved lacked adequate training in behavior de-escalation and dementia care, and the facility's incident report failed to accurately document the abuse or the resident's distress.
A resident with severe cognitive impairment and behavioral challenges was subjected to rough handling and a face slap by two CNAs during personal care, despite a care plan outlining specific behavioral management interventions. Video evidence showed the resident in distress, with staff failing to follow care plan strategies or seek supervisory assistance. Staff interviews revealed a lack of training on dementia care and de-escalation techniques, and the incident was not fully documented in the facility's internal report.
A resident with severe cognitive impairment and behavioral challenges was subjected to physically rough handling by two CNAs during personal care, including being pushed, restrained, and slapped, despite a care plan outlining person-centered interventions. Video evidence showed the resident in distress, and interviews revealed staff lacked specific training in dementia care and de-escalation techniques. The incident was not fully documented in the facility's internal report, and staff did not follow established protocols for managing care-resistant behaviors.
Two CNAs failed to demonstrate competency in dementia care and behavior management when providing care to a resident with severe cognitive impairment, resulting in physical restraint, rough handling, and a slap to the resident's face during an episode of care resistance. The CNAs did not follow the resident's care plan interventions, and interviews revealed a lack of specific training in dementia care or de-escalation techniques.
Multiple residents and family members reported prolonged call light response times, especially on weekends, due to insufficient nursing staff. Delays ranged from 30 minutes to several hours for assistance with toileting and personal care, with some residents left unattended or forced to seek help independently. Staff interviews confirmed frequent complaints about slow responses, and the DON acknowledged receiving such reports, particularly on weekends.
The facility did not follow its own policy allowing 24-hour visitation, instead requiring all visitors to leave by 8:00PM each day. This practice was confirmed by a family member, multiple residents, and staff, and had the potential to affect all residents in the facility.
Several dependent residents were not provided with scheduled showers or grooming, as observed by surveyors and confirmed by staff interviews and documentation review. Residents were found with matted hair, dirty skin, and long, untrimmed nails, and records showed inconsistent or missing documentation of hygiene care. Facility policy requiring regular showers and documentation of refusals or alternative care was not followed, and some care plans lacked bathing and grooming interventions.
A resident with complex medical needs experienced emotional and psychosocial harm when a CNA threatened to leave her naked and soiled during incontinence care. The incident, witnessed by another resident and a family member and confirmed by video, resulted in the resident becoming hysterical and distressed. The facility administrator viewed the video but did not indicate any follow-up, and staff training on managing behavioral challenges was unclear.
A resident with complex medical needs was subjected to a threatening statement by a CNA during incontinence care, as witnessed by a cognitively intact roommate and captured on video. The facility's investigation was incomplete, failing to interview key witnesses and omitting critical details about the verbal threat, contrary to its abuse policy requirements.
A resident with multiple chronic conditions and hand contractures did not receive physician-ordered palm protectors, as staff failed to apply the splints and were unaware of the order. Observations showed worsening contractures, poor hygiene, and unmet restorative care needs, despite facility policy and care plans requiring these interventions.
A facility failed to notify a resident's family and physician about the discontinuation of Amlodipine and subsequent increased blood pressure. The resident, with a history of hypertension and heart issues, had their medication stopped without proper consent or notification, leading to increased blood pressure episodes. The nurse practitioner involved was not informed of these changes, contrary to facility policy.
A resident with a language barrier experienced inadequate care following a fall, as the LTC facility failed to document and communicate her refusals of a restorative walking program and scheduled showers, and her severe pain was not addressed in a timely manner. The facility's staff did not utilize translators or communication aids effectively, leading to a lack of timely intervention and inadequate documentation of the resident's condition and care.
A facility failed to maintain infection control in a common shower room, where soiled clothing and towels were left on the floor. A family member had previously reported the issue, and the CNA responsible admitted to not following proper aftercare procedures. The facility lacked a written policy on maintaining a clean environment after resident showers.
The facility failed to provide adequate CNA staffing in two units, affecting residents' care. Despite a staffing plan requiring 1 CNA per 11 residents, only one CNA was assigned per unit, with 14 and 15 residents respectively. Residents experienced delays in care, and staff struggled with workloads, especially with agency CNAs unfamiliar with residents' needs. The facility's staffing data indicated a concern related to the One Star Staffing Rating.
Two residents in a LTC facility suffered injuries due to inadequate fall prevention measures. One resident, with cognitive impairments, fell and sustained a subdural hematoma after attempting to walk unassisted, lacking nonskid footwear and floor mats. Another resident, with a history of alcohol abuse and neuropathy, fell while transferring from a wheelchair to a bed without assistance, resulting in a laceration. Both incidents were due to insufficient supervision and failure to implement necessary interventions for high fall risk residents.
Two residents at high risk for falls were not provided with effective interventions in an LTC facility. One resident experienced multiple falls due to improper use of a walker and lack of supervision, while another resident's bed alarm was not functioning, increasing fall risk. Staff were unaware of the residents' needs and the status of safety equipment, leading to deficiencies in care.
The facility failed to implement pressure ulcer prevention measures for two residents at high risk, as they were observed without their prescribed bilateral heel protectors while in bed. This led to skin impairment in one resident and inconsistent application of preventive measures.
The facility failed to follow physician orders and implement care plan interventions for two residents with contractures. One resident was observed without the prescribed hand splint, and the restorative assessment inaccurately reflected the resident's condition. Another resident was observed without the prescribed bilateral palm splints, and the restorative aide denied the observation. The facility's policies on restorative nursing programs and physician orders were not followed, leading to the deficiencies observed.
A facility failed to ensure the safe keeping of a resident's smoking materials, as the resident was found with his cigarette and lighter in his possession, contrary to the facility's policy. The resident, who smokes outside without staff assistance, had likely had his smoking materials since the previous day, and the staff were unaware of this.
The facility failed to position a resident in Fowler's position while infusing enteral feeding and did not hold the feeding during incontinence care. Two CNAs performed incontinence care on a resident lying flat with a gastrostomy tube connected to Jevity 1.5 tube feeding. The CNAs did not inform the nurse to turn off the feeding machine, and the resident's medical history includes Multiple Sclerosis and Gastrostomy status. The RN and DON acknowledged the mistake.
The facility failed to document the reason for not attempting a gradual dose reduction (GDR) for a resident on an antidepressant medication. Despite quarterly reviews indicating that a GDR was contraindicated, the nurse practitioner did not provide specific reasons in the progress notes, contrary to facility policy.
The facility failed to ensure daily refrigerator temperature checks were completed, affecting two residents. The housekeeping aide responsible for monitoring and recording the temperatures admitted to forgetting to document them, despite the facility's policy on sanitary food practices.
The facility failed to perform proper hand hygiene during incontinence care for a resident. Two CNAs were observed changing gloves without performing hand hygiene after cleaning fecal matter, contrary to facility policy and CDC guidelines. The DON confirmed the correct procedure was not followed.
Failure to Monitor High Fall-Risk COVID Isolation Resident and Maintain Bed Safety
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall-prevention interventions for a bedbound, high fall-risk resident on strict COVID-19 isolation. The resident was an older male with multiple diagnoses including Type 2 diabetes with hyperglycemia, COVID-19, prior head injury with surgical aftercare, syncope and collapse, and paroxysmal atrial fibrillation. His MDS showed moderate cognitive impairment (BIMS 11), he used a wheelchair, and did not attempt to walk due to medical or safety concerns. A fall risk evaluation scored him as high risk (score 9). His care plan and fall coordinator documentation required the bed to be kept in the lowest position, use of two partial side rails, call light and personal items within reach, no clutter on the floor, and hourly checks for residents on isolation. Facility policy on routine resident checks required initial rounds at the start of the shift and at least every two hours thereafter, and the infection control/designee and DON stated that COVID isolation residents were to be monitored every hour, with nurses and CNAs alternating. On the morning of the incident, the night nurse reported seeing the resident at 6:30 a.m. in bed, in the lowest position, sleeping comfortably, with no signs of distress. The night nurse stated that hourly monitoring was done but not documented, and that report was given to the day nurse. The day RN assigned to the resident began her shift at 7:00 a.m., received report that the resident had slept comfortably, and then passed morning medications until about 9:00 a.m. She acknowledged that she had not physically seen the resident at any time after starting her shift and assumed the CNA had seen him when passing breakfast trays. The agency CNA assigned to the resident stated that when she arrived for her 7:00 a.m.–3:00 p.m. shift, the night CNA was not present, she received no room-to-room report, and the nurse on duty said she was not familiar with the group. The CNA reported that she did not go room to room with the nurse and that the only information she received about the resident was that he needed to be checked and changed and that he had COVID. The agency CNA stated that between approximately 8:00 and 8:15 a.m., she went to deliver the resident’s breakfast tray, found the bed empty, and assumed he was out for an appointment. She did not check the bathroom, did not look around the room or on the other side of the bed, and noted that the bed was not in a low position and that no side rails were up. She left the tray and continued passing other trays. About an hour later, she returned and found the tray untouched, asked the nurse about the resident’s whereabouts, and was told he might be at dialysis; she accepted this explanation, although the resident was not a dialysis patient, and left the tray to warm later. The day RN confirmed that she mistakenly told the CNA the resident might be at dialysis, confusing him with another resident, and did not verify his presence in the room despite his being on strict isolation and requiring monitoring every one to two hours. Between 9:00 and 10:00 a.m., the social services director entered the resident’s isolation room after knocking and receiving no response, did not see him in bed, and then observed his feet and legs protruding from under the bed between the bed and the window. Most of his body was under the bed, and he was unresponsive. The social services director called for nursing staff. The rehab LPN and the day RN responded and found the resident lying between the heater and the bed, more under the bed, unresponsive, with no visible chest rise, no eye opening, and no communication. The bed was not in the lowest position. A code was called, CPR was initiated, oxygen was applied, and paramedics were summoned. Progress notes documented that at 9:12 a.m. the resident was found on the floor, unresponsive and not breathing, with blood pressure 106/66, pulse 171, respirations 0, and oxygen saturation 54% on room air. CPR and AED use were documented, and the resident was pronounced dead at 9:58 a.m. The death certificate listed cardiac arrhythmia, atrial fibrillation, and cerebrovascular disease as causes of death. Interviews with multiple staff confirmed that the resident was bedbound, unable to walk, on strict COVID isolation in a private room with the door to be closed, and identified as high fall risk by the fall coordinator, who specified that the bed should always be in the low position with both quarter-length side rails up. The DON, medical director, infection preventionist, and other nurses described expectations that staff perform initial physical checks at the start of each shift, conduct at least every-two-hour rounds for all residents, and hourly checks for isolation residents, with documentation in progress notes for COVID residents. However, review of the resident’s progress notes showed no documentation of hourly monitoring from the time he was placed on isolation. Staff interviews revealed that the day RN did not physically verify the resident’s presence after receiving report, the agency CNA did not thoroughly search the room or verify his location when he was not in bed, and the nurse gave incorrect information that he might be at dialysis. The bed was observed not to be in the lowest position and side rails were not in use when the CNA first entered the room and when the resident was later found under the bed, indicating that required fall-prevention interventions were not consistently implemented. As a result, the resident was not visually observed or assessed for over two hours while on strict isolation and high fall risk status, culminating in his being found unresponsive on the floor under the bed and subsequently pronounced deceased in the facility.
Resident Subjected to Rough and Disrespectful Care During ADL Assistance
Penalty
Summary
A cognitively and visually impaired resident with severe cognitive impairment, Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia was subjected to rough and disrespectful care by two CNAs during an in-bed change. The resident, who was non-verbal and dependent for activities of daily living, was observed on video being physically handled in a rough manner, including having their head and torso forcefully pushed down while actively resisting and crying out. The CNAs were also heard threatening the resident to stop screaming and one was seen slapping the resident's face during care. The resident was visibly frightened, screaming, and resisting throughout the incident, but care continued without intervention from a nursing supervisor. The facility's internal incident report did not accurately document the full extent of the resident's distress, including the audible screams, resistance to care, threats, and the slap to the face. Interviews with staff revealed a lack of specific training on managing behaviors associated with dementia or de-escalation techniques. The CNAs involved did not recognize the resident's resistance as a behavioral response and did not employ appropriate interventions to address the resident's distress. One CNA admitted to being too rough and not receiving dementia-specific training, while the other acknowledged pushing the resident's head down and tapping the resident's cheek, later admitting this was inappropriate. Facility leadership, including the administrator and director of nursing, reviewed the video and acknowledged that the actions did not meet facility standards, but did not clearly identify the actions as abuse. The facility's policy emphasizes the right of residents to be treated with respect and dignity and to be free from mistreatment, but these standards were not upheld during the incident. The lack of appropriate assessment, intervention, and documentation contributed to the failure to ensure the resident's right to a dignified existence and respectful care.
Failure to Protect Resident from Abuse and Inadequate Staff Training on De-escalation
Penalty
Summary
A cognitively and visually impaired resident with severe dementia, major depressive disorder, and anxiety was subjected to physical and emotional harm during care provided by two CNAs. The resident, who was assessed as high risk for abuse and dependent in activities of daily living, was observed on video footage being physically restrained and slapped by one CNA while the other CNA assisted in changing the resident. The resident was visibly distressed, screaming, and resisting care, yet the CNAs continued with the care without seeking assistance from a nursing supervisor or employing de-escalation techniques. The facility failed to ensure that staff were adequately trained or monitored in behavior de-escalation and dementia care. Interviews with the involved CNAs revealed that they did not recall receiving specific training on managing behaviors associated with dementia or de-escalation techniques. One CNA admitted to not being trained in dementia care and only signing in on an inservice sheet, while the other could not recall any relevant training. Both CNAs minimized the resident's resistance, with one stating that the resident always cried out during care and the other describing the physical contact as a "love tap." The facility's internal incident report did not accurately document the severity of the incident, omitting details such as the resident's audible screams, resistance, threats made by staff, and the slap to the resident's face. The report also failed to reflect the emotional harm experienced by the resident. Staff interviews indicated a lack of understanding of appropriate interventions for residents exhibiting distress or resistance to care, and there was no evidence that the facility provided staff with the necessary training or guidance to prevent abuse or respond appropriately to challenging behaviors.
Failure to Implement Behavioral Care Plan Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement care plan interventions related to behavioral management for a resident with severe cognitive impairment, Alzheimer's Disease, major depressive disorder, anxiety disorder, and dementia. The resident was care-planned as high risk for mistreatment and had documented behaviors of screaming and resistance during care, with specific interventions outlined to address these behaviors, such as speaking calmly, avoiding escalation, and taking steps to help the resident feel safe. Despite these interventions, two CNAs did not follow the care plan strategies during an incident where the resident was being changed. Video evidence provided by the resident's family showed the CNAs restraining the resident by pushing his head and chest down, removing clothing in a rough manner, and slapping the resident's face after he screamed in distress. The resident was visibly frightened, screamed audibly, and resisted care, but the CNAs continued the interaction without calling a nursing supervisor or stopping to address the resident's distress. The facility's internal incident report did not document the audible screams, resistance, threats, or the slap observed in the video. Interviews with staff revealed a lack of specific training on managing the resident's behaviors or dementia care, with both CNAs unable to recall receiving relevant training or in-service education. The LPN who assessed the resident after the incident did so the following day and did not observe physical signs of injury. The DON and other facility leaders acknowledged that the actions did not meet facility standards but did not classify them as abuse. The resident was later observed to be withdrawn and non-verbal, with staff not engaging him in activities.
Failure to Follow Care Plan and Professional Standards for Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, major depressive disorder, anxiety disorder, and dementia was dependent on staff for activities of daily living and exhibited behaviors such as screaming and resistance during care. The resident's care plan included specific interventions for managing care-resistant behavior, such as using calm, soft tones, avoiding escalation, and employing person-centered approaches to ensure the resident felt safe and respected. Despite these directives, two CNAs failed to follow the established plan of care during an incident in which they attempted to change the resident's incontinence brief. Video evidence provided by the resident's family showed the CNAs engaging in physically rough handling, including pushing the resident's head down, restraining his chest, and removing clothing in a swift and rough manner, which caused the resident to shriek audibly and appear visibly frightened. One CNA was observed slapping the resident's face after telling him to stop screaming. The care was continued despite the resident's clear distress, and no nursing supervisor was called during the incident. The facility's internal incident report did not document the audible screams, resistance, threats, or the slap captured in the video. Interviews with the involved CNAs revealed a lack of specific training on managing dementia-related behaviors and de-escalation techniques. One CNA stated she did not receive training specific to the resident or dementia care, and both CNAs did not recognize the resident's resistance as a behavioral issue requiring specialized intervention. The DON and other staff acknowledged that the actions did not meet the facility's standards, but did not classify them as abuse. The incident demonstrated a failure to provide care in accordance with professional standards and the resident's individualized care plan.
Failure to Ensure CNA Competency in Dementia Care and Behavior Management
Penalty
Summary
Two Certified Nursing Assistants (CNAs) failed to demonstrate appropriate competency in dementia care and behavior management for a resident with severe cognitive impairment, Alzheimer's Disease, major depressive disorder, and anxiety disorder. The resident, who was non-verbal and exhibited care-resistant behaviors, had a care plan that required staff to use de-escalation strategies and ensure the resident felt safe during care. However, during an observed incident, the CNAs did not follow these interventions. A video provided by the resident's family showed one CNA repeatedly telling the resident to put his head down, physically restraining the resident's head and chest, and another CNA removing the resident's clothing in a rough manner. The resident was visibly distressed, screaming, and resisting care, but the CNAs continued without calling for a nursing supervisor. The video also captured one CNA slapping the resident's face after telling him not to scream. Interviews revealed that the CNAs could not recall receiving specific training on dementia care or de-escalation techniques, and one CNA stated she was floated between assignments without dementia-specific training. The facility's internal incident report did not accurately document the resident's distress or the physical actions taken by staff, omitting key details such as the slapping and audible screams. Staff interviews further indicated a lack of understanding of appropriate interventions for care-resistant behaviors.
Insufficient Nursing Staff Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff to meet the needs of all residents, resulting in prolonged call light response times and delays in assistance with activities of daily living, including toileting and personal care. Multiple residents reported that on weekends, staffing was particularly inadequate, with only one nurse and one CNA assigned to their unit. One resident described waiting five hours for a diaper change, timing the delay from 4:00 PM to 9:00 PM, and noted that no staff communicated the reason for the delay. Another resident reported waiting forty to sixty minutes for staff to respond to call lights on several occasions, especially during the evening shift, and expressed concern about the lack of communication from staff regarding delays. Family members also reported difficulty reaching staff to request assistance for residents, with one family member making multiple unsuccessful attempts to contact the nurse's station about a soiled diaper. Residents and family members described hallways being empty and staff unavailable, particularly on weekends. One resident stated she had to walk to the bathroom unassisted due to unanswered call lights. Staff interviews confirmed that complaints about delayed call light responses were common, especially on weekends, and that agency staff required additional supervision. The DON acknowledged receiving complaints about prolonged response times, mainly from family members over the weekend. During a resident council meeting, all present residents unanimously expressed concerns about long wait times for staff to respond to call lights, with reported delays ranging from 30 minutes to over three hours, again noting weekends as the worst. The facility's own policy requires prompt response to resident calls for assistance, but the evidence gathered from resident, family, and staff interviews, as well as direct observations, demonstrates a consistent failure to meet this standard.
Failure to Allow 24-Hour Visitation as Required by Facility Policy
Penalty
Summary
The facility failed to follow its own visitation policy, which allows for 24-hour access for immediate family, other relatives, and authorized persons with the resident's consent. Instead, the facility enforced a policy requiring all visitors to leave by 8:00PM each day. This was confirmed through interviews with a family member/POA, several residents during a resident council meeting, the nursing supervisor, and the receptionist. The family member/POA reported being asked to leave by 8:00PM, with the nursing supervisor monitoring their departure. Residents also confirmed that visitors are routinely made to leave at 8:00PM. Staff interviews further corroborated that the facility's practice was to end visitation at 8:00PM, with the receptionist and nursing supervisor coordinating to ensure all visitors exited the building at that time. This practice was in direct contradiction to the facility's written policy, which permits 24-hour visitation for certain individuals. The daily census indicated that this failure had the potential to affect all 154 residents residing in the facility.
Failure to Provide Scheduled Showers and Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). Multiple residents were observed with poor hygiene, including matted hair, dirty skin, long fingernails with debris, and untrimmed beards. Documentation showed that showers and bed baths were not consistently provided as scheduled, and there was no record of resident refusals or preferences for alternative hygiene care. Staff interviews confirmed that some residents had not received showers or grooming for extended periods, and that documentation of care was incomplete or missing. One resident with significant medical conditions, including metabolic encephalopathy, chronic kidney disease, and osteoarthritis, was observed with contractures, matted hair, dry and flaky skin, and long, unclean fingernails. The resident reported not receiving showers and could not recall the last time her hair was washed. Another resident stated he had not received a shower or grooming in over a month, and his last documented shower was several weeks prior. Additional residents were observed with greasy, matted hair, dirty faces, and long toenails, with one resident's care plan lacking any mention of bathing or grooming needs. Facility policy requires that residents receive showers at least once weekly and as necessary, with refusals and alternative care to be documented. However, review of records and staff interviews revealed that these procedures were not followed. There was a lack of documentation for showers, refusals, or alternative hygiene care, and some residents' care plans did not address their bathing and grooming needs, resulting in unmet ADL care for several dependent residents.
Resident Threatened and Emotionally Harmed During Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) threatened a resident during incontinence care, resulting in emotional and psychosocial harm. The resident, a female with multiple complex diagnoses including Moyamoya disease, dysphagia, altered mental status, conversion disorder with seizures, and cerebral aneurysm, was being changed after a bowel movement. During the care, the CNA rolled the resident onto her left side, causing pain, which the resident communicated by kicking and swinging her arms. The CNA responded by telling the resident, "No, no, you better stop, or I am going to leave you here like this," while the resident was naked and soiled. This statement was perceived as a threat to leave the resident in a vulnerable and undignified state. The incident was witnessed by another resident and a family member, both of whom observed the resident become hysterical and emotionally distressed. A video recording of the incident confirmed the CNA's threatening statement and the resident's distress. The family member reported the incident to the facility administrator, who viewed the video but did not indicate any follow-up action. The administrator was unable to confirm whether staff received training on managing residents with behavioral challenges. The facility's abuse policy prohibits mental abuse, including threats and humiliation, but the actions of the CNA were inconsistent with this policy, resulting in documented emotional harm to the resident.
Failure to Properly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to properly investigate an allegation of abuse involving a female resident with multiple complex diagnoses, including Moyamoya disease, dysphagia, altered mental status, and conversion disorder with seizures. The incident in question involved a certified nursing assistant (CNA) changing the resident's incontinence brief, during which the resident exhibited signs of pain and distress, such as kicking and banging on the bed. The CNA was heard making a threatening statement to the resident, indicating she would leave the resident in a vulnerable condition if the behavior did not stop. A roommate, who was present and cognitively intact, witnessed the event and later reported not being interviewed as part of the facility's investigation. The facility's investigation was incomplete, as it did not address the verbal statement made by the CNA, failed to interview the eyewitness roommate, and contained inconsistencies regarding the date of the alleged incident. The facility's abuse policy requires thorough investigations, including interviews with all involved persons and witnesses, but these steps were not followed. Additionally, the facility's report did not reflect all relevant details observed in the video evidence or concerns raised by the resident's family member, who had reported the incident and shared the video with the administrator.
Failure to Apply Ordered Hand Splints for Resident with Contractures
Penalty
Summary
Staff failed to provide ordered care for a resident with decreased range of motion by not applying physician-ordered splints to both hands. The resident, who has a history of multiple chronic conditions including metabolic encephalopathy, chronic obstructive pulmonary disease, chronic kidney disease, osteoarthritis, and diabetes, was observed on two occasions without the required hand splints. Observations noted contractures in both hands, with fingernails on the left hand digging into the palm, and the resident was unable to open her hands. Additional observations included matted hair, dry and flaky skin, and long fingernails with brownish substances underneath. The resident's care plan and physician orders specified the use of palm protectors for both hands for at least 2-4 hours daily or as tolerated, with staff responsible for assisting with their application and monitoring for skin concerns. Interviews with staff revealed a lack of awareness and follow-through regarding the splint orders. The assigned LPN was unaware of the need for hand splints, and the restorative aide admitted to not providing restorative care on the day prior to the survey and was unsure of the whereabouts of one of the splints. The restorative aide confirmed that all staff were supposed to assist the resident with the splints, but this was not consistently done. Facility policy required assessment and provision of restorative services, including contracture management and splint use, but these were not implemented as ordered for this resident.
Failure to Notify Family and Physician of Medication Discontinuation and Increased Blood Pressure
Penalty
Summary
The facility failed to notify a resident's family member and physician about the discontinuation of a hypertensive medication, Amlodipine, and the subsequent increase in the resident's blood pressure. The resident, who had a complex medical history including hypertension, heart failure, and dementia, was admitted with an order for Amlodipine to manage essential hypertension. On a specific date, a nurse documented notifying a nurse practitioner about a change in the resident's condition, leading to an order to stop Amlodipine. However, the family member did not consent to the discontinuation and requested the medication be held for four days, which was not communicated to the nurse practitioner. The medication was not administered after this date, and the resident experienced increased blood pressure episodes without the physician or nurse practitioner being notified. The nurse practitioner, who was covering for the resident's primary care physician, stated she only ordered the medication to be held for four days and denied ordering its discontinuation. She was not informed of the discontinuation or the resident's increased blood pressure episodes. The facility's policy requires immediate notification of significant changes in a resident's condition to the resident, their physician, and family members, which was not adhered to in this case. This deficiency affected one of the three residents reviewed for notification of change in condition.
Failure to Provide Timely Care and Address Language Barriers
Penalty
Summary
The facility failed to provide necessary treatment and care in a timely manner to a resident with a language barrier who had been refusing to participate in a restorative walking program, scheduled showers, and was experiencing severe pain following a fall incident. The resident, who has a history of falls and a diagnosis including a fracture of the sacrum, was observed to be lethargic and arousable, with inadequate documentation of her condition and care. The facility's staff, including the receptionist and restorative aides, did not document or communicate the resident's refusals and pain effectively, leading to a lack of timely intervention. The resident's medical records indicated a history of unwitnessed falls and a comprehensive care plan that highlighted her high risk for falls and difficulty in communication due to a language barrier. Despite having a care plan that involved the use of translators and communication aids, these were not utilized effectively by the staff. The resident's pain assessments were inconsistent, and there was a lack of documentation regarding her refusals of care and treatment, which were not communicated to the family or the interdisciplinary team. The facility's policies on pain management and language line solutions were not adequately followed, contributing to the deficiency. The resident's family was not informed of her refusals of care, and there was a miscommunication regarding the decision to send the resident to the hospital for evaluation. The facility was unable to provide a policy on reporting and documenting reasons for resident refusal of treatment and care, further highlighting the gaps in communication and documentation that led to the deficiency.
Infection Control Lapse in Shower Room
Penalty
Summary
The facility failed to ensure appropriate infection control practices in one of the common shower rooms used by residents. During an observation, soiled resident clothing, towels, and washcloths were found on the floor of the shower room. A family member had previously reported the issue of the shower room being dirty and not cleaned, with soiled items left behind. The housekeeping supervisor and an LPN confirmed that the CNA should have placed all soiled items in a plastic bag after the shower, rather than leaving them on the floor. The CNA responsible for the shower admitted to forgetting to place the soiled items in a plastic bag and acknowledged that they should not have been left on the floor. The Director of Nursing confirmed that aftercare procedures require gathering all soiled items and placing them in a plastic bag, but the facility did not have a written policy on this procedure. Despite a previous grievance being filed and addressed, the issue persisted, indicating a lapse in maintaining a clean environment in the shower room.
Inadequate CNA Staffing in Facility Units
Penalty
Summary
The facility failed to provide adequate staffing for Certified Nursing Assistants (CNAs) in two units, Suites North and Suites South, affecting three residents reviewed for staffing and potentially impacting 29 residents residing in these units. The facility's staffing plan, as per the Facility Assessment Tool 2024, requires 1 CNA per 11 residents for the day and evening shifts, and 1 CNA per 13 residents for the night shift. However, the Daily Schedule from 10/6/2024 to 11/3/2024 showed only one CNA working per shift on each unit, despite Suites North having 14 residents and Suites South having 15 residents on 11/4/2024. Interviews with residents and staff revealed concerns about the adequacy of care, with residents experiencing delays in call light responses and personal care, and staff expressing difficulties in managing workloads, especially with agency CNAs unfamiliar with residents' needs. Observations and interviews highlighted specific issues, such as a resident not receiving regular showers and another resident requiring two-person assistance for transfers, which further strained the limited staffing resources. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) on duty reported that they often had to assist CNAs with tasks like transfers and feeding, which impacted their ability to perform other duties, such as medication administration. The Nursing Scheduler/CNA Supervisor confirmed that staffing was based on census numbers, and despite the facility being full, only one CNA was assigned per unit. The facility's Payroll-Based Journal Staffing Data Report for FY Quarter 3 2024 indicated a concern related to the One Star Staffing Rating, underscoring the staffing deficiencies observed during the survey.
Inadequate Fall Prevention Leads to Resident Injuries
Penalty
Summary
The facility failed to implement adequate fall prevention interventions for two residents, resulting in significant injuries. One resident, who had a cognitive communication disorder and poor safety awareness, fell while attempting to walk unassisted. Despite being known for impulsive behavior and having a history of falls, the resident was left without nonskid footwear or floor mats, and the bed was not in the lowest position. The resident sustained a subdural hematoma and was hospitalized, where they later died from cardiac arrest and aspiration pneumonia. Another resident, with a history of alcohol abuse and neuropathy, attempted to transfer from a wheelchair to a bed without assistance, resulting in a fall and a laceration requiring sutures. This resident was known to refuse assistance and had a high fall risk score. Despite being close to the nurses' station, the resident was not adequately supervised, and the call light was not utilized. The resident's impulsive behavior and poor safety awareness were contributing factors to the fall. Both incidents highlight the facility's failure to provide necessary supervision and interventions for residents at high risk of falls. The lack of appropriate footwear, supervision during transfers, and failure to ensure the use of assistive devices contributed to the accidents. These deficiencies resulted in harm to the residents, with one sustaining a serious head injury and the other requiring medical attention for a facial laceration.
Failure to Prevent Falls Due to Inadequate Supervision and Equipment Monitoring
Penalty
Summary
The facility failed to provide effective resident-centered interventions for residents identified to be at high risk for falls, affecting two residents. One resident, identified as R1, experienced multiple falls, including an unwitnessed fall on 6/28/24, which resulted in a head injury requiring medical glue. R1, who has severe cognitive impairment and a history of impulsive behavior, was observed using a walker improperly and without adequate supervision. Staff members assigned to R1's unit were unaware of his identity and care needs, indicating a lack of communication and supervision. Another resident, identified as R3, was observed walking unassisted in his room despite being at high risk for falls due to cognitive impairment and other medical conditions. R3's bed alarm, intended to alert staff when he attempted to get out of bed, was not functioning properly, and staff were unaware of its status. This lack of awareness and failure to ensure the alarm was operational contributed to the risk of falls for R3. The facility's fall occurrence policy mandates that residents at high risk for falls should have interventions in place, which should be reevaluated and revised as necessary. However, the observations and interviews revealed that these interventions were not effectively implemented or monitored, leading to the deficiencies noted in the report. The lack of proper supervision and failure to ensure the functionality of safety devices like alarms were significant factors in the deficiencies identified by the surveyors.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement interventions to prevent skin impairment in residents at high risk for developing pressure ulcers. Specifically, two residents, R107 and R64, were observed without their prescribed bilateral heel protectors while lying in bed. R107, who has multiple diagnoses including Multiple Sclerosis and altered mental status, was found without heel protectors on multiple occasions, leading to blanchable redness on the right heel. The assigned CNA admitted to forgetting to apply the heel protectors. Similarly, R64, who has a history of pressure ulcers and multiple comorbidities, was also observed without heel protectors on two separate days. The CNA responsible for R64 confirmed the requirement for heel protectors but failed to apply them consistently. Both residents have care plans indicating the need for offloading heels to prevent pressure ulcers, and the facility's policy mandates prompt identification and treatment of skin breakdown. Despite these measures, the facility did not ensure the consistent application of heel protectors, as evidenced by the observations and staff interviews. The wound care nurse confirmed the importance of heel protectors in preventing pressure ulcers and acknowledged the residents' high risk for skin impairment.
Failure to Follow Physician Orders and Implement Care Plan Interventions for Residents with Contractures
Penalty
Summary
The facility failed to follow physician orders and implement care plan interventions for two residents with contractures. One resident, who was totally dependent and had contractures in both hands, was observed lying in bed without the prescribed hand splint. The hand splint was found placed over a fluorescent light cover above the bed, and the resident's left hand was severely contracted. The family member of the resident expressed concerns about the condition of the splint and the lack of action from the facility. The resident's medical records indicated an active order for the left hand splint, but the restorative assessment inaccurately reflected the resident's condition, and no care plan was formulated regarding the restorative program for the left hand contractures. The restorative program log showed no application of the left-hand splint for a week, and the restorative nurse inaccurately completed the assessment and discontinued the care plan without proper justification. The Director of Nursing (DON) acknowledged the concerns and indicated a referral to an occupational therapist would be made. Another resident, who had multiple sclerosis and other significant health issues, was observed without the prescribed bilateral palm splints. The restorative aide responsible for applying the splints denied the observation made by the surveyors and the RN. The resident's medical records and care plan indicated the need for bilateral palm protectors to prevent digging of the palms and to be applied after morning care for at least four hours as tolerated. The restorative program log showed no application of the bilateral hand splints/palm protectors for a week. The facility's policies on restorative nursing programs and physician orders were not followed, leading to the deficiencies observed. The facility's policy on restorative nursing programs and physician orders emphasized the need for comprehensive assessments and adherence to physician orders. However, the facility failed to implement these policies effectively, resulting in the lack of proper care for residents with contractures. The deficiencies were identified through observations, interviews, and record reviews, highlighting the need for accurate assessments, proper documentation, and adherence to care plans to ensure the well-being of the residents.
Failure to Ensure Safe Keeping of Resident's Smoking Materials
Penalty
Summary
The facility failed to ensure the safe keeping of a resident's smoking materials when not in use, as observed during a survey. On the morning of 4/17/24, a resident was found lying on his bed with his cigarette and lighter in his possession. The resident, who is alert and oriented, stated that he smokes outside the building 2-3 times a day without staff assistance and keeps his smoking materials with him. This observation was contrary to the facility's policy, which mandates that staff should keep the resident's smoking materials for safe keeping when not in use. Further investigation revealed that the Director of Nursing and an Agency RN were unaware that the resident had his smoking materials with him. The Agency RN confirmed that the smoking materials were supposed to be kept in the medication room and provided to the resident only when he goes out to smoke. However, the RN found the plastic pouch meant for the resident's smoking materials empty and realized that the night shift had not endorsed the materials to her. The resident had likely had his cigarette and lighter since the previous day. The resident has a medical history that includes nicotine dependence, acute pulmonary edema, chronic obstructive pulmonary disease, and dependence on renal dialysis.
Failure to Properly Manage Enteral Feeding During Incontinence Care
Penalty
Summary
The facility failed to position a resident in Fowler's position while infusing enteral feeding and did not hold the enteral feeding administration during incontinence care. This deficiency was observed when two CNAs were performing incontinence care for a resident who was lying flat on their right side with a gastrostomy tube connected to Jevity 1.5 tube feeding in progress at 65ml/hr. The CNAs were unaware that the feeding tube should be turned off during such care, and they did not inform the nurse to turn off the feeding machine before starting the incontinence care. The resident's medical history includes Multiple Sclerosis, Altered mental status, Demyelinating disease of the central nervous system, and Gastrostomy status, with active physician orders specifying that the enteral feeding should be turned off during ADLs and the resident should be positioned in Fowler's position while the feeding is running. The CNAs and the RN acknowledged the mistake upon being informed of the observation, and the RN turned off the feeding machine afterward. The Director of Nursing also confirmed that the CNAs should have informed the nurse before performing incontinence care so the feeding tube could be turned off, and the resident should not have been in a flat position while the feeding was running.
Failure to Document Reason for Contraindicated Gradual Dose Reduction
Penalty
Summary
The facility failed to document the reason why a gradual dose reduction (GDR) was contraindicated for one resident (R126) who was on an antidepressant medication. This deficiency was identified during a survey when the psychotropic nurse (V14) was unable to provide a documented reason for not attempting a GDR for R126. The resident's medical records indicated that GDRs were reviewed quarterly, but the notes from the nurse practitioner (V28) did not specify why the dose reduction was contraindicated, despite being marked as such on multiple occasions. R126's medical history includes diagnoses such as Toxic Encephalopathy, Cerebrovascular Disease, Major Depressive Disorder, and Complications of Heart Transplant. The resident was admitted on 6/13/23 and was prescribed Sertraline HCl Oral Tablet 100 MG once per day. Progress notes from 6/28/23, 9/11/23, and 1/30/24 indicated that a dose reduction was not indicated and was contraindicated, but no specific reason was documented. The facility's policy requires that if no GDR is done, there should be a psychiatric note explaining why it is contraindicated, which was not adhered to in this case.
Failure to Complete Daily Refrigerator Temperature Checks
Penalty
Summary
The facility failed to ensure daily refrigerator temperature checks were completed, affecting two residents. On 4/16/24, it was observed that the refrigerator temperature log for one resident was not completed that morning, and the refrigerator contained various food items. The RN confirmed that the housekeeping aide was responsible for monitoring and recording the refrigerator temperature daily. The actual refrigerator thermometer reading was 40°F. Similarly, another resident's refrigerator temperature log was not completed on 4/15/24 and the morning of 4/16/24, with the refrigerator containing multiple food items. The RN again confirmed the housekeeping aide's responsibility, and the thermometer reading was also 40°F. The Director of Nursing was informed of these observations, and it was confirmed that either the housekeeping aide or maintenance was responsible for the daily monitoring and recording of the resident refrigerators. On 4/18/24, the housekeeping aide assigned to the unit admitted that she probably forgot to document the refrigerator temperatures. The facility's policy on food from the outside, revised on 7/28/23, states that the facility will comply with sanitary food practices, including placing food items requiring refrigeration inside the refrigerator.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to perform proper hand hygiene during incontinence care for one of the residents. On 4/18/24 at 9:13 AM, two CNAs were observed performing incontinence care on a resident. One CNA cleansed fecal matter from the resident's sacral area while the other CNA held the resident in a left-sided position. After cleaning the fecal matter, the CNA applied a clean disposable adult brief to the resident and removed the soiled linens. Both CNAs changed their gloves without performing hand hygiene in between, which is against the facility's policy and CDC guidelines for infection control. When informed of the observation, one CNA incorrectly stated that it was not necessary to change gloves after cleaning fecal matter, while the other CNA acknowledged the need to change gloves and perform hand hygiene. The Director of Nursing confirmed that the CNAs should have removed their gloves and performed hand hygiene after handling fecal matter and before handling clean objects. The facility's policies on hand hygiene and incontinence care, revised on 7/28/23, clearly state the importance of hand hygiene in preventing infections and the proper procedures to follow during incontinence care.
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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