Birchwood Plaza
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1426 West Birchwood, Chicago, Illinois 60626
- CMS Provider Number
- 145532
- Inspections on file
- 20
- Latest survey
- April 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Birchwood Plaza during CMS and state inspections, most recent first.
Staff at the facility failed to maintain residents' dignity by feeding them while standing, contrary to policy. Observations showed CNAs and the DON standing over residents in wheelchairs during meals, affecting four residents with varying cognitive and physical impairments. The facility's policy requires staff to sit while feeding to ensure respect and dignity.
The facility failed to implement adequate fall prevention measures for residents at risk, leading to repeated falls for three residents and potential risk for another. Residents were observed without proper footwear, such as non-skid socks, despite care plans indicating their necessity. The facility's policy requires such measures, but they were not consistently applied, contributing to the deficiency.
The facility failed to ensure call light devices were within reach for two residents, leading to a deficiency. One resident with Alzheimer's and other conditions had a call light cord on the floor, while another with multiple diagnoses had the call light behind the bed. Staff confirmed the devices should be accessible, aligning with the facility's policy.
The facility failed to coordinate PASARR assessments and refer residents for Level II reviews upon significant changes in mental status, affecting three residents and potentially impacting 34 others. A resident's bipolar disorder was not reflected in the PASARR form, and another resident with a new diagnosis of schizoaffective disorder did not receive a Level II screening. The receptionist responsible for PASARR screenings was not informed of new diagnoses, leading to a lack of necessary assessments.
A facility failed to include a resident's psychiatric diagnoses in the PASARR screening, affecting the accuracy of the pre-admission process. The resident had documented diagnoses of schizoaffective disorder and schizophrenia, which were omitted by the non-clinical staff responsible for the PASARR. This led to an incorrect initial determination that no Level II screening was needed, later corrected to require further evaluation.
The facility failed to provide timely oral care and personal hygiene shaving for two dependent residents. One resident had significant facial hair and was not offered shaving assistance, despite requiring substantial help due to cognitive impairment. Another resident had visible dental plaque, indicating a lack of oral care, and reported not receiving assistance for a long time. These deficiencies reflect lapses in adhering to facility policies on grooming and hygiene.
The facility failed to implement pressure ulcer prevention interventions for three residents with dementia who were at risk for pressure ulcers. Observations revealed that these residents were seated in wheelchairs without pressure-relieving cushions, contrary to their care plans and the facility's policy. An LPN acknowledged the issue, noting that cushions were sometimes sent to the laundry, but did not ensure their immediate use.
A resident with severe malnutrition and quadriplegia did not receive the correct amount of Enteral g-tube feeding due to the feeding machine being turned off. The LPN on duty was unaware of the machine's status, resulting in the resident receiving only 100 ml instead of the expected 280 ml over four hours. The facility's policy requires adherence to physician orders for tube feeding to ensure proper nutrition and hydration.
The facility failed to label and change respiratory equipment for two residents receiving oxygen therapy. A resident with COPD had a nasal cannula that was not dated, and the oxygen tubing and humidifier bottle were not changed weekly as required. Another resident with multiple diagnoses also had a nasal cannula that was not dated, and the humidification bottle was overdue for a change. These lapses were identified during a survey, affecting the quality of care.
Staff at the facility failed to perform proper hand hygiene during resident feeding, potentially spreading infections. CNAs were observed not sanitizing hands between feeding different residents and after touching personal body parts. Residents with cognitive impairments and requiring assistance with eating were affected. The DON acknowledged the importance of hand hygiene, but facility policies were not followed.
The facility did not meet the required 80 square feet per resident in multiple resident bedrooms for 19 rooms, affecting 29 residents. Despite having an annual waiver from the State Department of Public Health, the facility confirmed that some rooms are below the required square footage, although all necessary furnishings and equipment are provided.
The facility failed to secure medication and treatment carts, posing a potential hazard to 40 residents. A medication cart was left unattended and unlocked in the hallway, contrary to facility policy requiring carts to be locked when not in use or out of sight. Similarly, a treatment cart was found unattended and unlocked with resident medications. The DON confirmed the policy mandates all medication storage areas be locked unless in use and under direct observation.
The facility failed to properly store and label food, with dented cans mixed with undented ones, unlabeled beef patties, and expired pastrami. The ice machine was also found dirty, lacking cleaning records. These issues could affect all 145 residents consuming meals from the facility's kitchen.
Failure to Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that staff were feeding residents from a seated position during dining service, which affected four residents. Observations revealed that staff members, including CNAs and the Director of Nursing, were feeding residents while standing, contrary to the facility's policy that requires staff to be seated to maintain the residents' dignity. This practice was observed during lunch service, where staff were seen standing over residents in wheelchairs while feeding them, which is considered authoritative and not respectful of the residents' rights to dignity. The residents involved had various medical conditions that required assistance with eating. For instance, one resident had severe cognitive impairment and required partial to moderate assistance with meals, while another had moderate cognitive impairment and required extensive assistance. Another resident was cognitively intact but dependent on staff for feeding, and the last resident had severe cognitive impairment and required substantial assistance. Despite these needs, staff did not adhere to the policy of sitting while feeding, which is intended to promote dignity and respect. The facility's policy on feeding clearly states that staff should sit beside the resident to feed them, ensuring a respectful and dignified interaction. The Director of Nursing acknowledged the importance of this practice and admitted to standing while feeding a resident, which was against the facility's guidelines. The failure to follow this policy was observed and documented, highlighting a deficiency in maintaining the residents' rights to dignity and respect during meal times.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate fall prevention interventions for residents at risk for falls, resulting in repeated falls for three residents and potential risk for another. Resident R23 was observed sitting at the edge of the bed without proper footwear, despite having a history of falls and being at risk for falls due to poor safety awareness and mild cognitive impairment. The care plan for R23 indicated the need for proper footwear, yet the resident was found without non-skid socks, which are necessary to prevent falls. Resident R43, who also had a history of repeated falls, was observed in a wheelchair without proper footwear. The care plan for R43, who has mild cognitive impairment and difficulty walking, also required well-maintained footwear to prevent falls. Despite this, the resident was not wearing non-skid socks, which are part of the facility's fall prevention policy. Resident R58, with severe cognitive impairment and a history of falls, was observed walking with a walker without the necessary fall prevention measures in place. The facility's policy requires non-skid socks or shoes for residents at risk of falls, but this was not consistently implemented. Additionally, Resident R34, who is at high risk for falls due to cognitive and functional impairments, was observed without non-skid socks, contrary to the care plan's requirements. The facility's failure to ensure that residents at risk for falls were wearing appropriate footwear and receiving adequate supervision contributed to the repeated falls and potential risk for further incidents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident R103, diagnosed with Alzheimer's Disease, Type 2 Diabetes Mellitus, Hypertension, Abnormalities of Gait and Mobility, and Muscle Weakness, was observed with a call light cord hanging from the wall on the floor, out of reach. R103's care plan emphasized the importance of using the call light for assistance, yet the device was not accessible. Similarly, Resident R301, with diagnoses including Metabolic Encephalopathy, Pyothorax, Sepsis, Retention of Urine, and Hypertension, was found with the call light hanging behind the bed, also out of reach. R301 expressed unawareness of the call light's location and a need for instruction on its use. Interviews with facility staff, including a Registered Nurse (V26) and a Certified Nursing Assistant (V9), confirmed that the call light cords should be within reach of the residents. The Director of Nursing (V2) also stated that the call light device should be clipped to the resident and accessible. The facility's call lights policy, revised in January 2019, mandates that residents capable of using the call light should have it accessible within reach. The observations and staff interviews indicate a failure to adhere to this policy, resulting in the deficiency noted by the surveyors.
Failure to Coordinate PASARR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program and did not refer residents for Level II reviews upon significant changes in mental status. This deficiency affected three residents and potentially impacted an additional 34 residents with mental disorders or intellectual/developmental disabilities. Specifically, one resident was admitted with multiple mental health diagnoses, including bipolar disorder, which was not reflected in the PASARR form. Another resident had a new diagnosis of schizoaffective disorder, but no PASARR Level II screening was conducted following this significant change. The report highlights that the facility's receptionist, responsible for completing PASARR screenings, was not informed of new diagnoses by the nursing staff, leading to a lack of necessary Level II screenings. This oversight was evident in the cases of residents with serious mental health conditions, such as schizoaffective disorder and bipolar disorder, who did not receive the required assessments. The failure to update PASARR screenings upon significant changes in residents' mental health status indicates a breakdown in communication and procedural adherence within the facility.
Failure to Include Psychiatric Diagnoses in PASARR Screening
Penalty
Summary
The facility failed to ensure that a resident's psychiatric diagnoses were accurately included in the pre-admission screening, specifically the PASARR (Pre-Admission Screening and Resident Review) process. This deficiency affected one resident, identified as R109, who had documented diagnoses of schizoaffective disorder and schizophrenia. Despite these diagnoses being present in the resident's medical records and active medication orders, they were not included in the PASARR Level I screening. As a result, the initial determination incorrectly indicated that no Level II screening was required, which could have impacted the assessment of the resident's needs. The error occurred because the receptionist/office manager, who was responsible for completing the PASARR, did not include the necessary psychiatric diagnoses. The associate administrator acknowledged that the receptionist/office manager, being non-clinical, should have been guided by the nursing and social service departments regarding the resident's diagnoses and medications. This oversight was later corrected when a subsequent PASARR Level I screen identified the need for a Level II evaluation, citing the resident's mental health disabilities, including schizophrenia and schizoaffective disorder.
Deficiencies in Personal Hygiene and Oral Care
Penalty
Summary
The facility failed to provide timely oral care and personal hygiene shaving care for two dependent residents. One resident was observed with significant facial hair, including a mustache and chin hair, which she expressed a preference to have removed. Despite requiring substantial assistance with personal hygiene due to moderate cognitive impairment and other health conditions, the resident reported not being offered shaving assistance by the CNAs. The facility's policy and the Director of Nursing confirmed that shaving is part of the daily grooming routine for all residents, including females, and should be documented if refused. Another resident was observed with a creamy brown substance on her teeth, indicating a lack of oral care. When questioned, the resident stated that it had been a long time since staff assisted with mouth care. The CNA present acknowledged not having provided mouth care to the resident but indicated an intention to do so later. The resident's care plan noted a self-care deficit requiring assistance with ADLs, and the facility's policy mandates daily oral hygiene. These deficiencies highlight a failure in the facility's adherence to its policies regarding personal hygiene and oral care, impacting the residents' dignity and quality of life. The facility's policies and job descriptions emphasize the importance of maintaining residents' grooming and hygiene, yet the observations and resident interviews indicate lapses in the execution of these duties.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions as outlined in the care plans for three residents with dementia who are at risk for pressure ulcers. On March 31, 2025, three residents were observed sitting in wheelchairs without any pressure-relieving devices, such as cushions, during activities in the dining room. This observation was made twice, first at 11:08 AM and again at 12:15 PM. A Licensed Practical Nurse (LPN) acknowledged the absence of cushions and mentioned that sometimes staff send the cushions to the laundry, promising to ensure the residents receive the necessary cushions. The records for the three residents indicated that they were at risk for pressure ulcers, as documented in their respective care plans and Minimum Data Set (MDS) assessments. Each care plan specified the use of pressure-relieving cushions when the residents were seated in chairs. The facility's policy on pressure ulcer prevention also emphasized the importance of using pressure-relieving devices for at-risk residents. Despite these documented interventions, the facility did not adhere to the care plans, resulting in the deficiency noted by the surveyors.
Failure to Administer Correct Enteral Feeding Amount
Penalty
Summary
The facility failed to ensure that a resident receiving Enteral g-tube feeding was administered the correct amount of feeding as per the physician's orders. On March 31, 2025, a resident was observed with their Enteral g-tube feeding machine turned off and not connected, despite the feeding bottle being dated for that day. The Licensed Practical Nurse (LPN) on duty was unaware of who turned off the machine or for how long it had been off. The resident, who is alert and talkative, was supposed to receive continuous feeding at a rate of 70 ml/hr for 20 hours, but only 100 ml had been infused over a four-hour period, instead of the expected 280 ml. The resident involved has multiple diagnoses, including severe protein-calorie malnutrition and quadriplegia, and relies entirely on tube feeding for nutrition. The Director of Nursing (DON) confirmed that the feeding should have been running according to the physician's orders and that the resident should have received the full amount of feeding to meet their caloric needs. The facility's policy and job descriptions emphasize the importance of maintaining proper nutrition and hydration through tube feeding, yet the deficiency occurred due to a lapse in following these procedures.
Failure to Label and Change Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling and timely replacement of respiratory equipment for two residents receiving oxygen therapy. Resident R11 was observed using a nasal cannula that was not labeled with the date it was changed, and the oxygen tubing and humidifier bottle were not changed weekly as required. The Director of Nursing confirmed that the facility's policy mandates labeling the humidifier bottle with the date of change and replacing the nasal cannula weekly to prevent infection. R11, who has a diagnosis of shortness of breath and chronic obstructive pulmonary disease, was receiving oxygen therapy at 2-3 liters per minute, and the facility's policy requires changing the equipment every Wednesday night shift. Similarly, Resident R79, diagnosed with metabolic encephalopathy, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia, was found with a nasal cannula that was not dated, and the humidification bottle was last dated over a week prior. The Registered Nurse confirmed that the oxygen tubing and humidification bottle should be changed weekly on the night shift and dated accordingly. These lapses in following the facility's oxygen therapy policy were identified during the survey, affecting the quality of care provided to the residents.
Inadequate Hand Hygiene During Resident Feeding
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident dining services, which could potentially lead to the spread of infectious microorganisms. Observations revealed that a Certified Nursing Assistant (CNA), identified as V13, did not perform hand hygiene after touching a resident's meal tray and before feeding another resident. Similarly, another CNA, V11, was observed not sanitizing hands between feeding different residents and after touching personal body parts, such as the face and ears, while feeding a resident. The report highlights specific instances involving residents R28, R43, and R77, who were affected by these lapses in infection control. R43, with a diagnosis of severe protein-calorie malnutrition and moderate cognitive impairment, required partial assistance with eating. R77, with severe cognitive impairment and a dependency on staff for feeding, was also at risk. R28, with severe cognitive impairment and requiring substantial assistance with eating, was observed being fed by V11, who did not perform hand hygiene at various points during the feeding process. The Director of Nursing (DON), identified as V2, acknowledged the importance of hand hygiene in preventing infection transmission and stated that staff are expected to perform hand hygiene before and after resident contact, especially when feeding residents. The facility's policies on infection control and hand hygiene were not adhered to, as evidenced by the observations of CNAs not washing or sanitizing their hands between resident interactions and after touching potentially contaminated surfaces or their own body parts.
Facility Fails to Meet Room Size Requirements Despite Waiver
Penalty
Summary
The facility failed to provide the required square footage of 80 square feet per resident in multiple resident bedrooms for 19 rooms out of 86 in the facility. This deficiency affected 29 residents in the total sample of 75 residents. During the entrance conference, the Administrative Consultant mentioned that the facility has an annual waiver for room sizes, which is renewed every year. The Associate Administrator confirmed that some rooms have less than the required square footage for each resident, but stated that all required furnishings and equipment are provided. The facility has an annual waiver from the State Department of Public Health, allowing them to bypass the federal requirement for room size under 42 CFR 483.90. This waiver is granted for specific rooms and is subject to annual review. The facility's policy on Resident Room Waivers indicates compliance with both IDPH and CMS federal requirements for these waivers. The waiver covers the rooms identified in the report, which do not meet the 80 square feet per bed requirement in multi-patient rooms.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure that medication and treatment carts were secured, leading to a potential accident hazard for all 40 residents on the 1st floor. On December 24, at 10:30 AM, a medication cart was observed unattended and unlocked in the hallway without a nurse present. The LPN responsible for the cart admitted to leaving it to pick up something, acknowledging that the facility policy requires the cart to be locked when not in use or out of the nurse's sight. Additionally, at 10:40 AM, a treatment cart was found unattended and unlocked with resident treatment medications inside. The DON confirmed that the facility policy mandates that all medication storage areas, including carts, must be locked unless in use and under direct observation by the medication nurse. The facility's policy, revised in November 2011, clearly states these security requirements.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, which could potentially affect all 145 residents consuming meals from the facility's kitchen. During an inspection, dented cans of banana pudding and diced peaches were found co-mingled with undented cans in the dry storage room, contrary to the facility's policy that requires dented cans to be stored separately. Additionally, a white bucket labeled breadcrumbs lacked an open date and a use-by date. In the walk-in freezer, beef patties were found without open or use-by dates and were not in their original manufacturer's container. A tray of sliced pastrami was noted to be 13 days over the seven-day storage limit, and other food items in the refrigerator, such as pureed chicken and baked salmon, were also found to be past their allowed storage time without proper labeling. The ice machine in the kitchen was observed to be in an unsanitary condition, with blackish and brownish particles inside and whitish splashes on the outside. The Dietary Manager admitted that the machine should be cleaned monthly but could not provide a cleaning log or confirm the last cleaning date. The facility's policies on food labeling and ice machine cleaning were not followed, as evidenced by the lack of proper labeling and cleaning records. The Dietary Manager acknowledged the confusion caused by new labeling practices and the need for staff education to prevent foodborne illnesses.
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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