Berkeley Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Park, Illinois.
- Location
- 6909 West North Avenue, Oak Park, Illinois 60302
- CMS Provider Number
- 146013
- Inspections on file
- 27
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Berkeley Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with a history of atrial fibrillation and on anticoagulant therapy experienced an unwitnessed fall and was later found with altered mental status. Despite facility policy requiring 911 to be called for unresponsiveness or unstable vital signs, staff delayed calling advanced life support and initially arranged for basic life support transport. The resident's condition was later deemed critical by EMS, requiring intubation and ICU care.
Dietary staff did not change gloves or sanitize hands after handling multiple surfaces before serving food, worked without required beard coverings, and failed to label opened food items with open and expiration dates, contrary to facility food safety policies.
A resident requiring assistance with eating was addressed by a CNA as being fed 'like a baby' during mealtime. The resident, who is alert and oriented, expressed that being referred to in this manner is unwelcome and diminishes his sense of dignity. Facility leadership confirmed that such language is inappropriate and not in line with resident rights to dignity and respect.
A resident with quadriplegia and self-care deficits was found unable to access or use the call light, leaving them dependent on staff passing by and having to call out for assistance. The call light was out of reach and no alternative device was provided, despite the resident's documented need for staff support and the facility's policy requiring accessible means to request help.
A resident with hemiplegia who was fully dependent on staff for toileting was not provided incontinence care at least every two hours, as required by facility policy. The resident was observed sitting in a wheelchair with wet, soiled pants for nearly four hours after the last reported care, despite documentation and care plans indicating the need for frequent assistance.
Three residents with hemiplegia or contractures did not receive physician-ordered splints, braces, or soft foam devices as required by their care plans. One resident was unaware of a prescribed splint and was observed without it, another lacked a properly fitting orthotic for an extended period, and a third did not have a required foam device applied due to staff time constraints. Staff confirmed these devices were not consistently applied, contrary to facility policy and physician orders.
A resident with quadriplegia and acute respiratory failure experienced a significant decline in condition, including low blood pressure and oxygen saturation. Despite these changes, the facility failed to notify the physician, resulting in a delayed hospital transfer. The resident was later sent to the hospital in respiratory distress, suffered cardiac arrest, and expired. Interviews revealed a lack of communication and documentation by the nursing staff, contrary to the facility's policy.
A resident with quadriplegia and acute respiratory failure experienced a critical drop in blood pressure and oxygen level, but the LTC facility failed to conduct a comprehensive assessment or reassess vital signs. Despite being diaphoretic and in respiratory distress, the resident was not properly monitored, leading to their transfer to the hospital where they went into cardiac arrest and expired. Staff interviews revealed a lack of documentation and understanding of the importance of reassessment, contributing to the deficiency.
The facility did not display the [NAME] and [NAME] Retaliation Hotline poster, which informs residents of their rights, in accessible locations. Additionally, the facility failed to submit a monthly list of discharged residents to the [NAME] and [NAME] program. Staff were unaware of these requirements, potentially impacting all 42 residents.
A resident was found on a low air loss mattress set to static mode, contrary to the care plan requiring alternating pressure for wound healing. The ADON confirmed the static setting, which does not provide the necessary pressure relief. The DON stated that alternating pressure is essential for wound care, and the static setting should only be used temporarily. This failure to follow the care plan and manufacturer's instructions led to a deficiency in care.
The facility did not label medication bottles with the opened date, affecting three residents. An LPN noted the importance of the opened date for determining expiration and discard timing. The DON confirmed that nurses are responsible for labeling medications with the opened date, as per the facility's Medication Policy.
The facility failed to implement and complete pressure ulcer treatments and prevention interventions for three residents. One resident was not provided with a recommended low air loss mattress and had a soiled dressing. Another resident had missed wound care and lacked interventions for skin integrity. A third resident had discrepancies in the prescribed wound care treatments, with two different treatments signed off daily, neither matching the ordered regimen.
Delay in Emergency Response for Resident with Altered Mental Status After Fall
Penalty
Summary
The facility failed to follow its change in condition policy by not promptly calling advanced life support services (911) for a resident who was found with altered mental status and was verbally unresponsive. The resident, who had a history of atrial fibrillation, was on anticoagulant therapy, and was at high risk for falls, experienced an unwitnessed fall. Despite being found on the floor by a CNA and assessed by a nurse, the resident was not immediately sent to the hospital, even though facility staff acknowledged that residents on anticoagulants with unwitnessed falls should be evaluated for possible brain bleeds. The following morning, the resident was found unresponsive and not behaving as usual, with staff noting a significant change from his baseline mental status. The nurse notified the physician, who ordered a transfer to the hospital. However, instead of calling 911 as required by the facility's policy for medical emergencies involving unstable vital signs or unresponsiveness, staff called a basic life support (BLS) ambulance. Upon arrival, the BLS crew determined the resident's condition was critical and required advanced life support, prompting them to call 911 for an upgrade in care. Emergency medical services found the resident with decerebrate posturing, irregular bradypnea, and a Glasgow Coma Scale of 7, indicating severe neurological compromise. The resident was intubated and transferred to the ICU for ventilator management. Hospital records confirmed the resident had suffered rib fractures and was diagnosed with COVID and pneumonia. The delay in calling 911 and failure to follow the facility's change in condition policy resulted in a significant delay in appropriate emergency intervention for the resident.
Failure to Follow Food Safety and Sanitation Policies
Penalty
Summary
Dietary staff failed to adhere to the facility's Food Safety and Sanitation Policy by not changing gloves or sanitizing hands after handling multiple food ladles and other surfaces before directly scooping cornbread with the same gloved hand. This practice was observed during meal plating, and both the cook and dietary manager acknowledged that gloves should be changed after touching multiple surfaces to prevent cross contamination. Additionally, staff with beards were observed working in the kitchen without appropriate beard coverings, despite the policy requiring facial hair to be covered to prevent hair from contaminating food. Further, a bag of frozen peaches and a container of dried parsley were found in the kitchen without labels indicating the open and expiration dates. The dietary manager confirmed that labeling is necessary to ensure food is discarded appropriately and that all opened food items should be labeled with the open and expiration dates, as per facility policy. These failures in food handling, personal hygiene, and labeling practices have the potential to affect all residents on oral diets in the facility.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A resident with hemiplegia and visual loss, who required partial to extensive assistance with eating, was observed being fed by a CNA in the main dining room. During the meal, the CNA told the resident that she had to feed him 'like a baby.' The Director of Nursing confirmed that such language is inappropriate and diminishes resident dignity, stating that staff should instead offer assistance respectfully. The CNA later acknowledged that she should not have made the comment and was aware of the expectation to address residents by their names or appropriate titles. The resident, who was alert and oriented, reported that staff sometimes refer to him as a baby, which he dislikes and feels undermines his sense of dignity and manhood. Facility documentation on resident rights states that residents must be treated with dignity and respect, and care should promote their quality of life.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A resident with quadriplegia and documented self-care deficits was observed in bed without access to an appropriate call light. The call light string was hanging from the wall onto the nightstand, out of the resident's reach, and the resident reported being unable to use the call string due to his condition. The resident stated he had to wait until staff passed by his room and then yell for assistance, sometimes waiting a long time for help with activities of daily living. The care plan indicated the resident was dependent on staff for self-care due to contractures and quadriplegia, and the facility's policy required providing an alternative means to call for assistance if the call light was not functional. No other devices for calling staff were present in the resident's room at the time of observation.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with hemiplegia and total dependence on staff for toileting hygiene was not provided incontinence care at least every two hours, as required by facility policy. The resident was documented as always incontinent and had a care plan indicating staff assistance with toileting throughout the day. On the day of observation, the resident was found sitting in a wheelchair with wet, soiled pants in the peri-area. The resident's roommate, who was alert and oriented, reported that incontinence care was last provided around 9:30am. The resident confirmed being changed in the morning but could not specify the time. The CNA assigned to the resident stated that incontinence care was provided at 10:00am and was scheduled again for 2:00pm, but acknowledged that sometimes the resident needed to be changed before the scheduled time. At 1:56pm, nearly four hours after the last reported care, the resident was still observed in the same wet condition. Facility policy requires incontinent residents to be checked and provided perineal and genital care every two hours, which was not followed in this instance.
Failure to Apply Splints and Orthotics as Ordered for Residents with Limited Mobility
Penalty
Summary
The facility failed to follow physician orders and care plans regarding the application of splints, braces, or soft foam devices for three residents with hemiplegia or contractures. One resident with hemiplegia affecting the left side had a physician order and care plan requiring a splint to the left upper extremity for 4-6 hours daily, but the resident reported not knowing about the splint and was observed without it on multiple occasions. Staff confirmed the splint was not applied because the resident was in bed and only restorative staff applied splints, which did not occur on the observed days. Another resident with hemiplegia and aphasia had a physician order and care plan for a left foot orthotic to be worn daily when out of bed, but the resident reported not having the orthotic for months due to improper fit. Staff were unaware of the issue until the survey, and the resident was observed without the device, with the foot turned inward. A third resident with hemiplegia had a physician order and care plan for a soft foam/sponge to be applied to the left hand, but was observed without it, and staff confirmed it was not applied due to time constraints. The facility's restorative policy requires individualized restorative care to maintain or improve residents' range of motion, but these interventions were not consistently implemented.
Failure to Notify Physician of Resident's Acute Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's significant change in condition, which included a decrease in blood pressure and oxygen saturation. This oversight affected a resident with a history of quadriplegia, gastrostomy, and acute respiratory failure. The resident was found in a deteriorated state with symptoms such as diaphoresis, cool and clammy skin, and a respiratory rate of 60 breaths per minute. Despite these alarming signs, the physician was not notified, and the resident was only sent to the hospital 13 hours later, where they experienced cardiac arrest and subsequently expired. Interviews with the nursing staff revealed a lack of communication and documentation regarding the resident's change in condition. The nurse responsible for the resident during the overnight shift did not notify the physician despite noting a lower than usual blood pressure and oxygen level. The Director of Nursing emphasized the importance of recognizing changes in nonverbal residents and the necessity of immediate physician notification. However, this protocol was not followed, leading to a delay in appropriate medical intervention. The facility's policy on notifying physicians of significant changes in a resident's condition was not adhered to, as evidenced by the absence of documented communication with the physician. The resident's care plan required monitoring for signs of infection and notifying the physician, which was not executed. This failure to act on the resident's acute change in condition resulted in a critical delay in treatment, ultimately leading to the resident's death.
Failure to Reassess Vital Signs Leads to Resident's Death
Penalty
Summary
The facility failed to conduct a comprehensive assessment of a resident after experiencing a decrease in blood pressure and oxygen level, and did not reassess vital signs later in the shift. This deficiency affected a resident with quadriplegia, a gastrostomy, and acute respiratory failure, who was found diaphoretic with cool/clammy skin, a respiratory rate of 60 breaths per minute, and an oxygen level of 85%. Despite these critical signs, a blood pressure reading was not obtained, and the resident was transferred to the hospital in respiratory distress, where they went into cardiac arrest and expired. The report highlights that the nursing staff did not document any follow-up assessments or vital signs after the initial change in the resident's condition. Interviews with staff revealed that the resident was more sleepy than usual on the morning of the incident, but no further action was taken to monitor or reassess the resident's condition. The nurse on duty during the night shift noted a lower than normal blood pressure and oxygen level but did not document a reassessment or notify a physician, citing a lack of understanding of the importance of documenting reassessments. The Director of Nursing and Nurse Practitioner both emphasized the importance of reassessing abnormal vital signs and notifying a physician, especially for residents with communication barriers and chronic conditions. The facility's policies on patient monitoring and vital signs were not adhered to, as staff failed to proactively monitor and document changes in the resident's condition, leading to a delay in recognizing the severity of the situation and ultimately resulting in the resident's death.
Failure to Display Required Advocacy Information and Submit Discharge Lists
Penalty
Summary
The facility failed to display the [NAME] and [NAME] Retaliation Hotline poster in a public and accessible location, which informs residents of their rights regarding community transition and protection from retaliation. During an observation on 6/26/24, the surveyor, along with the Administrator (V1) and Admissions staff (V3), confirmed the absence of the poster on the first-floor bulletin board. Further inspections of the dining and activity rooms also revealed no signage of the required poster. Interviews with V1, V3, and Social Services (V8) indicated a lack of awareness about the necessity of posting this information for residents and family members. Additionally, the facility did not submit a monthly list of voluntary and involuntary discharge residents to the [NAME] and [NAME] program. V1 and V8 were unaware of this requirement, with V8 mentioning that only emails are sent to the agency when residents request community transfers. The facility's documentation, titled 'Health Care Council of Illinois,' outlines the requirement to post a list of pertinent state agencies and advocacy groups, yet this was not adhered to, potentially affecting all 42 residents in the facility.
Failure to Implement Effective Wound Care Interventions
Penalty
Summary
The facility failed to adhere to the Wound Care Plan for a resident, identified as R44, by not implementing effective interventions to prevent further skin integrity issues. On two separate occasions, R44 was observed lying on a low air loss mattress set to static mode, which does not provide the intended alternating pressure relief necessary for wound healing. The Assistant Director of Nursing (ADON) confirmed that the mattress was set to static, which is not suitable for continuous use as it does not offer the alternating pressure relief required for effective wound care. The Director of Nursing (DON) explained that the low air loss mattress is designed to promote wound healing through alternating pressure relief, and the static setting should only be used temporarily during position changes or care provision. The facility's Pressure Ulcer Prevention Protocol and the manufacturer's instructions both emphasize the importance of using pressure-reducing devices, such as alternating pressure mattresses, to prevent and manage pressure ulcers. The failure to utilize the mattress's alternating pressure setting as per the care plan and manufacturer's instructions contributed to the deficiency in care for R44.
Failure to Label Medications with Opened Date
Penalty
Summary
The facility failed to adhere to its Medication Policy by not labeling medication bottles with the opened date, affecting three residents. During an observation, it was found that a resident's Ketoconazole Shampoo 2%, another resident's levocarnitine Oral Solution, and a third resident's liquid Ondansetron were opened without any opened date on the label. A Licensed Practical Nurse (LPN) acknowledged the importance of the opened date for determining expiration and when to discard medications. The Director of Nursing (DON) confirmed that nurses are responsible for labeling medications with the opened date to ensure proper usage duration and adherence to expiration dates. The facility's Medication Policy requires that each prescribed medication label includes the date the medication was dispensed.
Failure to Implement Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to implement and complete pressure ulcer treatments and prevention interventions as ordered for three residents. One resident, R8, was observed lying on a regular mattress instead of a recommended low air loss mattress. R8 had a pressure ulcer on the sacrum, and the dressing was found to be soiled and unchanged since the previous day. The resident was not repositioned every two hours as required, and the care plan did not include an order for a specialty mattress, despite recommendations for a Group-2 mattress and frequent repositioning. Another resident, R3, had a history of cerebral infarction and vascular dementia, with two Stage 3 pressure wounds on the right foot. The treatment plan included specific dressing applications, but the Treatment Administration Record (TAR) showed missed wound care on several days in January 2024. Additionally, R3's care plan lacked interventions for skin integrity, and the facility's protocols for consistent treatment were not followed. The third resident, R6, had a Stage 4 pressure wound on the sacrum. The treatment orders included specific applications of calcium alginate with silver and foam dressing, but the TAR showed discrepancies in the prescribed treatments. Two different treatments were signed off daily, neither matching the ordered treatment, indicating a failure to adhere to the prescribed wound care regimen.
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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