Bria Of Chicago Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in South Chicago Height, Illinois.
- Location
- 120 West 26th Street, South Chicago Height, Illinois 60411
- CMS Provider Number
- 145898
- Inspections on file
- 30
- Latest survey
- February 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Bria Of Chicago Heights during CMS and state inspections, most recent first.
The facility failed to protect a resident with moderate cognitive impairment and dementia from physical abuse when he was struck in the nose by another resident during a dining room altercation before staff could separate them. The resident was evaluated medically and returned, but the abuse coordinator initially deemed the event unsubstantiated based on a determination that the aggressor lacked intent to harm, despite the facility’s policy defining physical abuse to include hitting. Police were notified but did not file a report, and surveyors were unable to obtain statements from frontline staff who first intervened in the incident.
A resident with multiple medical and psychiatric conditions was found with unexplained bruising, swelling, and scratches after a series of behavioral incidents involving staff. Despite the facility's abuse policy requiring prompt reporting and investigation of suspicious injuries, staff did not report or determine the cause of the injuries, and the origin remained unknown.
Two residents were involved in a physical altercation in which one struck the other in the face with a shoe, resulting in visible injury. The incident was reported to the Assistant Administrator and a family member, but no investigation or required reporting to the State Department occurred, and the injury was not documented in the medical record.
A resident with a history of cancer and chronic pain managed with narcotics developed severe constipation and was hospitalized with Stercoral Colitis after the facility failed to effectively monitor and manage her bowel regimen, despite known risks and available PRN medications. Additionally, two residents with seizure disorders did not receive required monthly lab monitoring for their seizure medications, and there was no documentation that missed labs were reported to the physician, contrary to facility policy.
The facility did not consistently administer influenza and pneumococcal vaccines or document education and refusals as required. Several residents either did not receive the influenza vaccine despite consent or lacked documentation showing they were educated or offered the vaccines. Orders for annual immunizations were present, but records were incomplete, and facility policy on documentation was not followed.
Two residents were involved in an incident where one allegedly struck the other in the face with a shoe, resulting in a visible bruise. The injury was reported to the Assistant Administrator, who observed the bruise but did not report it to authorities or initiate an investigation as required by policy. The incident was not documented in the medical record, and the Administrator was unaware of it until later, resulting in a 44-day delay in investigation.
Two residents were involved in an incident where one allegedly struck the other in the face with a shoe, resulting in a visible bruise and petechia. The injury was reported to the Assistant Administrator, who observed the injury but did not report it to authorities or initiate an investigation, contrary to facility policy. The incident was not documented in the medical record, and the Administrator was unaware until surveyors brought it to attention, resulting in a 44-day delay in reporting.
Staff failed to accurately code the MDS for two residents: one was incorrectly documented as having a stage 3 pressure ulcer despite no evidence or treatment, and another was inaccurately coded as a planned hospital discharge when the resident actually left AMA to the community. Errors were confirmed through interviews, record reviews, and staff admissions.
A resident with diagnoses of major depressive disorder and schizoaffective disorder was not referred for a required PASRR Level II screening. Despite the presence of serious mental illness, the facility did not conduct or document the necessary follow-up screening after the initial Level I screen indicated no PASRR condition.
A resident with a stage 3 pressure ulcer did not have the wound properly documented or addressed in the care plan until after the wound had healed. The wound care nurse confirmed that the care plan initially lacked specific information about the wound's stage and history, and the goal for wound care was not specified.
The consultant pharmacist did not identify or report missing or inadequate indications for use of medications for two residents during monthly drug regimen reviews. One resident was prescribed apixaban for tachycardia without a supporting diagnosis, and another was prescribed benztropine mesylate for an unclear indication. The pharmacist's reviews did not note any irregularities, contrary to facility policy.
Two residents were affected when the facility did not follow its transmission-based isolation policy after a resident was diagnosed with ESBL in the urine. The roommate was not relocated during the isolation period, despite available open beds, and the contact isolation order was not discontinued after treatment was completed, as required by facility policy.
The facility did not effectively implement its pest control program, as evidenced by two residents encountering a mouse in their room and another room having numerous flies present, particularly around soiled linen left on the floor. Staff confirmed the presence of both rodents and insects, indicating the facility was not kept free of pests as required by policy.
Staff did not properly document or address concerns raised by residents during council meetings, including issues with nursing staff behavior and food suggestions. Although residents reported voicing these concerns, they were not reflected in meeting minutes or grievance logs, and residents indicated their rights were not being reviewed.
A newly admitted resident with a history of falls and dementia fell in the hallway, sustaining a laceration requiring hospital treatment. Despite being assessed as a high fall risk, the resident was not provided with adequate supervision or assistive devices. Staff interviews revealed that the resident was ambulatory with an unsteady gait and was not monitored during the night shift, leading to the fall.
A deficiency occurred when two residents with histories of aggression and mental health issues engaged in a physical altercation in the dining area due to inadequate staff supervision. The incident resulted in one resident sustaining injuries and being sent to the hospital. Witnesses reported insufficient staff presence, which allowed the situation to escalate.
A cognitively impaired resident with a history of wandering left the facility through an unsecured window without staff knowledge. The resident was found days later at a fire station and transported to a hospital. Staff were unaware of the resident's high elopement risk, and preventive measures were not in place.
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as roaches and ants. Multiple residents and staff reported sightings, and observations confirmed the issue. Despite scheduled pest control services, the facility did not adequately address the problem, leading to recurring pest sightings.
The facility failed to have the State inspection survey results readily available and accessible to residents, family members, and legal representatives. During a Resident council meeting, all residents stated they were unaware of the binder's location. The Office Manager and Administrator were also unable to locate the binder, despite the facility's policy stating residents have the right to examine these results.
The facility failed to label multi-dose medication and discard expired glucagon. Two vials of undated Tuberculin were found, and expired glucagon syringes were present in the emergency medication box, potentially affecting all 93 residents and 13 diabetic residents, respectively.
A facility failed to follow a resident's fall care plan by not placing the call light within reach, despite the resident's history of falls. Both a CNA and an LPN confirmed the call light was inaccessible, contrary to the facility's policy and the resident's care plan.
A resident with type 2 diabetes was found unresponsive with a low blood sugar level of 45. The nurse did not administer glucagon as required by the facility's hypoglycemia protocol because it was not available in the med cart. The resident was transported to the hospital by paramedics, who administered glucagon, leading to a slight improvement in responsiveness. The facility's policy mandates glucagon administration for unresponsive residents with low blood sugar, but this was not followed.
Failure to Substantiate and Protect Resident from Peer-to-Peer Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when an altercation occurred in the dining room and the event was not substantiated as abuse during the facility’s investigation. The involved resident, R3, was an older male with a BIMS score of 8, indicating moderate cognitive impairment, and diagnoses including Type 2 diabetes and unspecified dementia with mood disturbance. During a confrontation in the dining room, R3 approached and invaded another resident’s (R9’s) personal space, and R9 hit R3 in the nose before staff could separate them. R3 was sent for a medical evaluation and returned to the facility. The facility’s abuse policy defines physical abuse to include hitting and similar acts, and the policy states the facility will promote resident security and prevention of mistreatment. The administrator, who served as the abuse coordinator, conducted the investigation and initially concluded the incident was unsubstantiated because he determined that R9 did not show intent to hurt R3, despite acknowledging that contact occurred and that R3 was hit in the nose. Police were notified and came to the facility but did not make a report. The administrator later stated that he should have substantiated the event. The surveyor was unable to obtain statements from the CNAs and social work aide who were first on the scene and separated the residents, despite attempts to contact them by phone. Months after the altercation, R3 experienced a separate incident in the dining room in which he collapsed and was taken to the hospital; this was confirmed as a different event from the altercation in which he was hit in the nose.
Failure to Prevent and Investigate Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to prevent an injury of unknown origin to a resident and did not determine the cause of the injury. The resident, who had a history of stroke with hemiplegia, unsteady gait, and multiple psychiatric diagnoses, was found with swelling and discoloration to the left eye, bruising to the chest and right leg, scratches to the face and chest, and complaints of chest pain. These injuries were identified by emergency room staff after the resident was transported to the hospital for agitation. Staff interviews revealed that the resident had been involved in altercations with staff, including throwing rubbing alcohol and physically assaulting staff members, but no staff member reported witnessing or causing the injuries observed. Multiple staff members described escalating behavioral incidents involving the resident, including verbal and physical aggression. The nurse and assistant administrator intervened and monitored the resident after the incidents, but neither reported any visible injuries prior to the resident's transfer to the hospital. The nurse did not report the injury of unknown origin to the administrator as required by the facility's abuse policy. The resident later claimed that staff had assaulted him, but staff denied any physical altercation resulting in injury. The resident's medical record indicated minimal risk for aggression in prior assessments, with only one previous note of physical aggression months earlier. The facility's abuse policy required prompt reporting of suspicious injuries, but this protocol was not followed. The origin of the resident's injuries remained undetermined, and the facility did not take appropriate steps to investigate or report the injuries as required.
Failure to Prevent and Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault, resulting in one resident being struck in the face with a shoe by another resident. The assaulted resident sustained a purple discoloration to the right eyelid and petechia above the eyebrow. The incident was reported by the injured resident to both the Assistant Administrator and her son, and photographic evidence of the injury was provided. The progress notes indicated a verbal altercation between the two residents, after which the aggressor was relocated to another room. However, there was no documentation in the medical record regarding the injury, and the injured resident was alert and oriented at the time of the survey. The Assistant Administrator acknowledged being informed of the incident and observing the injury but did not report the injury of unknown origin to the State Department, nor did he initiate an investigation into the allegation of physical assault. He also did not consult the Administrator for guidance. The Administrator was unaware of the injury and confirmed the lack of documentation and reporting. The facility's abuse policy affirms residents' rights to be free from abuse, neglect, and mistreatment, but the policy was not followed in this instance.
Failure to Prevent Severe Constipation and to Follow Physician Orders for Seizure Medication Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two key areas. For one dependent resident with a history of malignant neoplasm of the right breast, constipation, and chronic pain managed with daily narcotic medication, the facility did not effectively prevent the development of severe constipation. Despite being on a bowel regimen and having PRN medications available, the resident developed a large stool burden and was hospitalized with a diagnosis of Stercoral Colitis secondary to severe constipation. Staff interviews revealed that while the resident was known to be at risk for constipation and had a history of bowel concerns, there was a lack of effective monitoring, assessment, and documentation regarding bowel movements and the administration of PRN bowel medications. The Director of Nursing confirmed that interventions were not effective and that there was insufficient documentation of assessments or progress notes related to the resident's bowel status prior to hospitalization. Additionally, the facility failed to follow physician orders for monthly laboratory monitoring of seizure medication levels for two residents with seizure disorders. For one resident prescribed carbamazepine, monthly lab draws were ordered to ensure therapeutic levels, but there were missed months where no labs were drawn or documented, and no evidence that the physician was notified of the missed labs. The resident's medication level was found to be low on one occasion, and the nurse practitioner expected a follow-up lab, which was not completed. Similarly, another resident with orders for monthly levels of multiple seizure medications did not have documentation of these labs being completed or the physician being notified of missed tests. Facility policy requires that physician orders be followed as written, including appropriate contact or notification for labs or pharmacy needs. The lack of adherence to these orders and insufficient monitoring and documentation contributed to the deficiencies identified in the care of residents at risk for constipation and those requiring therapeutic drug monitoring for seizure management.
Failure to Administer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to properly administer influenza and pneumococcal vaccines, as well as to document education and refusals for these vaccines, affecting four out of five residents reviewed for immunizations. Specifically, the Infection Prevention Nurse reported that she was responsible for educating residents and obtaining consent or refusals, but could not provide documentation of education for residents who refused vaccination. Additionally, it was noted that an outsourced clinic administered the vaccines, but there was a lack of documentation regarding education and refusals, particularly for residents who declined the influenza vaccine during the 2024 influenza season. Medical record reviews revealed that some residents had orders for annual influenza and pneumococcal vaccines and had received education and consented to both, but only received the pneumococcal vaccine. For several residents, there was no documentation of education or offers for the vaccines, despite orders being present. Facility policies required documentation of education and refusals in the medical record, but this was not consistently done, resulting in incomplete records and failure to follow established procedures for immunization documentation and administration.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy and did not investigate an injury of unknown origin involving two residents. One resident reported being struck in the face with a shoe by another resident, resulting in a visible bruise and petechia. The incident was reported to the Assistant Administrator, who observed the injury but did not report it to the State Department or initiate an investigation as required by facility policy. The Assistant Administrator also did not consult the Administrator for guidance and assumed the matter was resolved by separating the residents involved. There was no documentation of the injury in the resident's medical record, and the Administrator was unaware of the incident until informed by surveyors. The facility's abuse policy requires immediate external reporting and investigation of any allegations or suspicions of abuse, neglect, or injuries of unknown origin. Despite these requirements, the injury was not reported or investigated for 44 days. The resident's family member confirmed that the incident had been reported to him and expressed concern that it should have been investigated. The lack of timely reporting and investigation represents a failure to adhere to established protocols for resident safety and abuse prevention.
Failure to Timely Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy and procedures by not immediately reporting an injury of unknown origin involving two residents. One resident reported being struck in the face with a shoe by another resident, resulting in a bruise to the right eye and petechia above the eyebrow. The incident was reported to the Assistant Administrator, who observed the injury but did not report it to the State Department or initiate an investigation as required by facility policy. The Assistant Administrator also did not consult the Administrator for guidance and assumed the matter was resolved by separating the residents involved. There was no documentation of the injury in the resident's medical record, and the Administrator was unaware of the incident until informed by surveyors. The delay in reporting the injury of unknown origin lasted 44 days, and the facility did not follow its policy, which requires immediate external reporting of any allegations of abuse, neglect, or injury of unknown origin. The policy specifies that such incidents must be reported to the Department of Public Health immediately, or within two hours if serious bodily injury is suspected, and no later than 24 hours otherwise. The failure to report and investigate the incident as required affected two residents reviewed for reporting abuse and injury of unknown origin.
Inaccurate MDS Coding for Pressure Ulcer and Discharge Status
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) for two of three residents reviewed. For one resident, interviews with the resident and the Wound Care Coordinator confirmed that the resident had never been diagnosed with or treated for a stage 3 pressure ulcer while at the facility. Despite this, the resident's MDS documented the presence of one unhealed stage 3 pressure ulcer. Review of the resident's current and previous physician order sheets showed no wound treatment orders, further supporting that no pressure ulcer care was provided. For another resident, the MDS indicated a planned discharge to the hospital. However, progress notes and interviews with facility staff confirmed that the resident left the facility against medical advice (AMA) and was discharged to the community, not the hospital. The MDS nurse acknowledged the error, stating that the discharge destination was incorrectly coded due to a misunderstanding of the resident's actual discharge status. Documentation, including a signed Release of Responsibility form, supported that the resident left AMA.
Failure to Refer Resident for Required PASRR Level II Screening
Penalty
Summary
The facility failed to refer a resident with documented diagnoses of major depressive disorder and schizoaffective disorder for a Level II preadmission screening and resident review (PASRR), as required. The resident was admitted with alcoholic polyneuropathy and liver disease, and their medical records included diagnoses of major depressive disorder and schizoaffective disorder. Despite these diagnoses, the initial PASRR Level I screen indicated no evidence of a serious mental illness or related condition, and no Level II screening was conducted. The Assistant Administrator confirmed that the resident's diagnoses should have prompted a new PASRR screening, but no additional screening was performed or documented during the survey.
Failure to Timely Review and Revise Wound Care Interventions in Care Plan
Penalty
Summary
The facility failed to review and revise a resident's wound care interventions as required. A resident with a stage 3 pressure ulcer on the ankle, identified on 4/4/25, did not have the wound properly documented in the care plan until 5/29/25, despite the wound being present and later noted as healed on 5/23/25. The wound care nurse acknowledged that the care plan should specify the staging of the wound and differentiate between actual and at-risk skin impairments, but the care plan initially lacked this information. When the care plan was reviewed by the surveyor on the morning of 5/29, it did not include the stage 3 pressure ulcer or a history of the impairment, and the goal for wound care was not specified.
Pharmacist Failed to Identify and Report Inadequate Medication Indications
Penalty
Summary
The facility failed to ensure that its consultant pharmacist properly identified and reported the absence or inadequacy of indications for use of certain medications during the monthly drug regimen review, as required by facility policy. Specifically, for two residents, the pharmacist did not note irregularities in the use of apixaban and benztropine mesylate. One resident had an order for apixaban with the stated indication of tachycardia, but the medical record did not contain a diagnosis of tachycardia, and the resident's pulse rates were within normal limits. The Assistant Director of Nursing and the pharmacist both confirmed that apixaban is not used to treat tachycardia. Another resident had an order for benztropine mesylate with an unclear indication listed as "other symbolic functions." The pharmacist was unable to clarify what this diagnosis referred to and did not report any irregularities in the medication regimen review. The facility's consultant pharmacy services agreement requires the pharmacist to review each resident's medication regimen monthly, including ensuring that medications are prescribed for appropriate indications, but this process was not followed for the residents in question.
Failure to Follow Transmission-Based Isolation Policy for ESBL Infection
Penalty
Summary
The facility failed to follow its transmission-based isolation policy for two residents when one resident was found to have Extended-Spectrum Beta-Lactamases (ESBL) in the urine. Despite a physician order for contact isolation, census records show that the resident's roommate was not relocated during the period of isolation, even though open beds were available. The facility's policy requires that either the infected resident or their roommate be moved to prevent transmission, but this was not done according to the census documentation. Additionally, the order for contact isolation was not discontinued after the completion of treatment, contrary to facility policy, which states that isolation should end once treatment is completed. The residents involved included one with a history of dysuria, weakness, hernia, major depressive disorder, and ulcerative colitis, who required maximal assistance with toileting and was frequently incontinent. The roommate had diagnoses including Alzheimer's disease, dementia, bipolar disorder, and schizoaffective disorder, with moderately impaired cognition. The Infection Prevention RN confirmed that the roommate should have been moved and that the isolation order should have been discontinued after treatment, but these actions were not reflected in the records.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of rodents and flying insects in resident rooms. On one occasion, a resident was observed screaming after seeing a mouse in her room, and both she and another resident reported hearing mice days prior, prompting the Maintenance Director to place traps. A housekeeper later confirmed removing a mouse caught in a trap from under the resident's bed. Additionally, numerous flies were observed in another resident's room, particularly around soiled linen left on the floor, which was confirmed by both a CNA and a housekeeper. The facility's pest control policy requires the building to be kept free of insects and rodents, but these incidents demonstrate that the policy was not effectively implemented.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that staff thoroughly assisted and documented resident concerns and grievances during monthly resident council meetings over a five-month period. Review of resident council meeting minutes revealed no documented concerns, despite residents stating that issues were raised during the meetings. The president of the resident council specifically noted that concerns about nursing staff behavior during overnight shifts and suggestions related to food were discussed but not recorded in the minutes. Additionally, a review of the facility's grievance records showed only three listed concerns, none of which matched those mentioned by the resident council president. Interviews with the activity director confirmed that residents had voiced concerns during recent meetings, but these were not documented in the official minutes. The activity director stated she removes concerns from the minutes and gives them to Social Services, but could not recall the specific concerns raised. Residents also reported that their rights were not being reviewed during meetings. The facility's policy requires staff to document and address grievances, but the lack of documentation in both meeting minutes and grievance logs indicates this process was not followed.
Failure to Supervise High-Risk Resident Leads to Fall
Penalty
Summary
The facility failed to adequately monitor and supervise a newly admitted resident with a known history of falls, confusion, and assessed to be at high risk for falls. This deficiency resulted in the resident sustaining a laceration to her left eyebrow that required hospital treatment with sutures after a fall in the facility hallway. The resident, a female with a history of dementia, hypertension, and hypothyroidism, was admitted to the facility and assessed as having impaired memory, unsteady gait, and a history of falls. Despite being identified as a high fall risk, the interim fall care plan did not include provisions for assistive devices. On the night of the incident, the resident was found on the floor with a laceration above her left eyebrow, which was not witnessed by staff. The resident was ambulatory with an unsteady gait and was continuously walking up and down the hallway, not yielding to redirection. The staff, including the CNA assigned to the resident, were not monitoring the hallway at the time of the fall as they were engaged in other duties. The facility's fall prevention policy requires individualized interventions for residents at risk, but these were not adequately implemented for the resident. Interviews with facility staff, including the DON, LPN, and CNA, revealed that the resident's fall risk was known, but the necessary supervision and monitoring were not provided. The fall coordinator stated that residents should be monitored during the night shift, with CNAs staying close to resident rooms and rounding every 1 to 2 hours. However, the CNAs were not monitoring the hallway during rounds, contributing to the lack of supervision that led to the resident's fall.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to protect residents from abuse by not ensuring adequate staff supervision in the dining area, particularly for residents with a history of aggression. This deficiency was evident in an incident involving two residents, one with a history of schizophrenia, delusional disorders, bipolar disorder, dementia, and legal blindness, and another with schizoaffective disorder and a history of aggressive behavior. The incident occurred in the dining hall where the two residents engaged in a verbal altercation that escalated into a physical confrontation, resulting in one resident being hit in the face and sustaining injuries. The facility's staff did not adequately monitor the residents in the dining area, which led to the altercation. Witnesses reported that there was only one Certified Nursing Assistant present during the initial stages of the incident, and she was unable to stop the altercation on her own. It took additional staff members to intervene and separate the residents. The lack of sufficient staff presence and supervision allowed the situation to escalate, resulting in one resident being sent to the hospital for evaluation and treatment of injuries sustained during the altercation. Interviews with staff members revealed that there were inconsistencies in the supervision of residents in the dining area. Some staff members stated that there should always be at least one staff member present, while others indicated that the presence of staff was not consistent, especially during shift changes. The facility's abuse policy states that residents who allegedly abuse another resident should be removed from contact with others during the investigation, but this was not effectively implemented in this case, contributing to the deficiency.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent a cognitively impaired resident, who requires supervision and has a history of wandering, from leaving the facility without staff knowledge. This incident involved a resident diagnosed with Encephalopathy, Drug Induced Subacute Dyskinesia, Malaise, Reduced Mobility, Adjustment Disorder, Type 2 Diabetes Mellitus, Seizures, and Hypertension. The resident, who had a cognitive assessment score indicating moderate cognitive impairment, left the facility through his bedroom window without staff noticing. The resident was found days later at a fire station and subsequently transported to a hospital due to knee pain. On the day of the incident, staff noticed the resident was missing around 2:00 PM, and a code purple was initiated. Despite searching the facility and surrounding areas, the resident was not found until he presented himself at a fire station three days later. Interviews with staff revealed that the resident's window was not secured to prevent it from opening fully, allowing the resident to exit through it. The maintenance director confirmed that many windows in the facility were not equipped with safety mechanisms to prevent them from opening wide enough for a person to pass through. The facility's social services and nursing staff were unaware of the resident's high risk for elopement, as the resident's behavior and cognitive assessments were not adequately reflected in his care plan. The resident's elopement risk was not properly assessed, and preventive measures were not in place. This lack of awareness and preventive action led to the resident's unauthorized departure and subsequent absence from the facility for several days, during which he did not have access to his medications and was exposed to potential harm.
Removal Plan
- Identification of Residents Affected or Likely to be Affected: nine other residents were identified as wanderers and were added to the elopement list following the completion of the reassessment.
- All nine residents were also added to the elopement binder.
- The Care plans were reviewed and updated accordingly for all nine residents. Eight of the nine residents were moved to rooms with windows that lead to a courtyard and are not directly accessible to the exterior/exit areas of the facility. One resident refused the room change; however, her room is located directly across from social services office and her windows have been secured.
- There is a total of 11 residents on the elopement list/binder.
- The facility has a total of 81 windows, all 60 windows were secured to only open three inches except for 21 windows. The 21 windows were not secured because they do not lead/have access to exit the premises as they lead to the patio/courtyard which is within the facility. The maintenance director assessed and secured all external windows that are accessible to exit the premises.
- The Asst. Administrator initiated an in-service/training on elopement protocol to staff.
- The trainings on elopement prevention mentioned in the section are new and have been integrated in the facility's policies and procedures regarding elopement prevention.
- The facility does not utilize agency staff at this time, nonetheless, if the need arises in the future, the DON/ADON/Charge nurse will provide training on elopement prior to start of shift.
- The IDT (Interdisciplinary Team) which includes the DON (Director of Nursing), unit manager, social services director, activity director reviewed R6's care plans to ensure that wandering behavior and elopement risks are addressed. Resident was moved to another room, with window that opens to a secured courtyard. The window was secured so it does not open fully.
- R6's elopement assessment was completed by the social services director. R6 was added to the elopement binder. Nurse Practitioner also completed an evaluation upon return to the facility.
- R6 was placed on one-to-one supervision for 72 hours.
- Resident head count of the whole facility was completed by the DON/clinical managers. There was no concern identified.
- Headcount is done during shift change as part of the nurse-to-nurse shift reporting and when completing the midnight census.
- Elopement/Wandering assessment will be completed for all residents. The assessment will be completed by the DON (Director of Nursing), unit manager, Administrator and Social Services.
- Any resident who is identified with wandering behavior/ elopement risk will have care plans developed. This will be completed by the IDT.
- The elopement binders will be updated and will have elopement binders in all nursing stations, kitchen, front desk, and department head offices.
- The elopement binder is not new, but it is updated when a new resident is added to the binder. A resident is added to the binder when the resident is identified with exit-seeking behavior/risk for elopement.
- The Maintenance Director/Environmental staff will assess all windows of the facility and will secure windows and prevent the windows from fully opening to prevent a resident from using the window to exit the building.
- The Maintenance Director/MOD (Manager on Duty) will conduct rounds of all windows daily to ensure windows are always secure. The QAPI team conducted an Ad-Hoc QAPI meeting and decided to secure the windows to only allow 3-inch opening to prevent a resident from using the window to elope. An Ad-Hoc resident council meeting is scheduled to discuss the new standard of securing the windows in the facility.
- The facility utilized an L-bracket (also called corner brackets or angle braces) which is fastened to the window frame to prevent the window from fully opening and only allow the 3-inch opening. The residents are not able to tamper with the security of the windows.
- The Administrator will provide training to the IDT regarding development of care plans to address residents who are identified with exit-seeking /wandering behaviors and elopement risk.
- The DON/Administrator/Social Services Director will provide education to the staff. The education items include but not limited to: a) Code Purple b) Use of the elopement binders c) Exit-seeking behaviors and interventions d) Elopement risk and wandering and interventions e) Policy on missing resident f) Responding to alarms and g) Resident safety and supervision h) Reporting to the Administrator/Maintenance Director any concern related to windows.
- The training will be completed. Any staff who are not available, on vacation or leave of absence will have training completed at the start of their shift upon return to work.
- To measure knowledge retention, posttests will also be started. The Administrator/Director of Nursing/Social Services Director will conduct posttests of five random staff to evaluate knowledge retention. Five posttests per week for four weeks will be completed. The acceptable score of the post-test is 100%. Any staff who will not meet the acceptable score will receive additional training. The Administrator/Director of Nursing/Social Services Director will provide the staff with training on specific areas based on the results of the post tests.
- To ensure that all staff are trained prior to the start of their next shift if off duty, the DON/Administrator will notify the staff to meet with their supervisor/charge nurse/DON when they return to work. The supervisor/charge nurse/DON will ensure that the training is done before starting their work shift. The Administrator/DON/Social Services Director will provide the training. If the DON/Social Services Director are not available, a trained nurse will provide the training.
- The facility will conduct the same training quarterly for four quarters, and then annually thereafter. The training will also be included in the orientation of new employees.
- At this time, the facility is not utilizing agency. In the future, if the facility will use agency, the DON/Social Services Director/Administrator will provide the same training to the agency staff.
- Actions to Prevent Occurrence/Recurrence: Ad-Hoc QAPI meeting was completed which were participated by the leadership team which includes the Director of Nursing (DON), Unit Manager (UM), Risk Manager (RM), Social services Director (SSD), Admissions Director, Minimum Data Set (MDS) Coordinators, Maintenance Director, Business office Manager (BOM), Rehabilitation Manager, Human Resource Director and the Activities Director (AD). The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events.
- Elopement drill will be completed by the Maintenance Director and Administrator. This will also be completed daily, for the seven days, and will be done at different shifts. After seven days, the elopement drills will be done weekly for three months, then monthly thereafter. The elopement drills will be completed per policy, as indicated above.
- All exit doors in the facility will also be checked by the Maintenance Director to ensure all doors were locked and secure and that delayed egress was functioning properly. Door checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The door checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed.
- The Maintenance Director/Environmental Service Director/MOD will also conduct window checks daily. Window checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The window checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed.
- Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/ exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD (manager on duty)/charge nurse, DON will also conduct weekend clinical meetings to review new or worsening exit seeking/wandering behaviors and ensure interventions are in place to prevent elopement.
- New admissions will be reviewed by the DON, Risk Manager, Wound Nurse or MDS for elopement risk and any resident identified as being at risk will be updated into the facility elopement books.
- The QAPI team will hold a weekly Ad-Hoc QAPI meeting to discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors. The QAPI team will determine if additional corrective actions are necessary based on concerns identified.
- The Administrator/Social Services Director/DON will conduct audits of the Elopement Binder daily for three months to ensure that identified elopement risk are included in the binder. Additionally, the Administrator/Social Services Director/DON will also review five residents weekly for three months to ensure that residents who are identified with new and/or worsening exit-seeking behaviors and wandering are being addressed in the care plans. After three months, the QAPI team will determine if additional monitoring or corrective actions are necessary.
- To evaluate the effectiveness of the removal plan, QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests such as roaches and ants. Multiple residents reported seeing roaches in their rooms and hallways, with some residents stating they had to kill the pests themselves. Observations by the surveyor confirmed the presence of a dead bug in the dining room, and staff members also acknowledged seeing roaches and other pests. Despite having a pest control service scheduled twice a month, the facility did not adequately address pest sightings reported by residents and staff, as evidenced by the lack of documentation in the pest control logbook and the continued presence of pests. Interviews with staff and residents revealed that pest sightings were not consistently reported or documented, leading to delays in addressing the issue. The maintenance staff and administration were aware of the pest problem but did not take timely action to resolve it. The facility's pest control policy, which mandates an ongoing pest control program, was not effectively implemented, as shown by the recurring pest sightings and the lack of follow-up on reported incidents. The pest control service records indicated evidence of cockroaches, but the facility failed to maintain a pest-free environment for its residents.
State Inspection Survey Results Not Accessible
Penalty
Summary
The facility failed to have the State inspection survey results readily available and accessible to residents, family members, and legal representatives. During a Resident council meeting, all ten residents in attendance stated that they were unaware of the location of the State Inspection results binder and had not seen any signage indicating its location. The Office Manager also did not know where the binder was and could not locate it at the front desk. The Administrator and Assistant Administrator were unable to find the binder after searching for approximately five minutes. The facility's policy on Resident Rights states that residents have the right to examine the results of the most recent survey conducted by Federal or State surveyors, but this was not being upheld.
Failure to Label Multi-Dose Medication and Discard Expired Glucagon
Penalty
Summary
The facility failed to label multi-dose medication in accordance with professional principles, as observed in the first-floor medication storage room. Two vials of opened, undated Tuberculin, Purified Protein (Mantoux) 5TU/0.1ml, 10 dose vial were found. The Director of Nursing (DON) confirmed that the multi-dose vials should be labeled with an open or accessed date and a discard date of 28 days unless the manufacturer specifies a different date. This failure has the potential to affect all 93 residents currently residing in the facility, as per the facility policy on the storage of medications. Additionally, the facility failed to discard expired glucagon from their emergency medication box, which has the potential to affect all 13 diabetic residents in the facility. The expired glucagon syringes were found in the emergency medication box, with expiration dates documented as past due. The DON stated that the pharmacy is responsible for removing expired medication, but the pharmacy consultant reported not checking the emergency medication box for expired medications. This oversight led to the presence of expired glucagon in the emergency medication box, which should have been discarded and replaced with non-expired medication.
Failure to Ensure Call Light Accessibility for Resident with Fall Risk
Penalty
Summary
The facility failed to follow a resident's fall care plan by not placing the call light within reach. During an observation, the surveyor noted that the call light was clipped to the privacy curtain, approximately three feet away from the resident, making it inaccessible. The resident, who has a history of falls, confirmed that she could not reach the call light and had previously fallen when attempting to transfer to her wheelchair without staff assistance. Both a Certified Nurse Aide and a Licensed Practical Nurse verified that the call light was out of reach and acknowledged that it is the staff's responsibility to ensure call lights are accessible to residents. The resident's fall care plan, initiated on a previous date, specifically included an intervention to promote the placement of the call light within reach. Despite this, the call light was not positioned correctly, leading to a situation where the resident could not call for assistance. The facility's Fall Prevention and Management policy emphasizes the importance of creating a safe environment and implementing preventative strategies for residents at risk of falls. However, the failure to adhere to the care plan and policy resulted in the resident being unable to summon help, increasing the risk of further falls and injuries.
Failure to Follow Hypoglycemia Protocol
Penalty
Summary
The facility failed to follow their hypoglycemia protocol by not administering glucagon to a resident with a low blood sugar who was unresponsive. The resident, who has a history of type 2 diabetes, metabolic encephalopathy, and hemiplegia following a cerebral infarction, was found unresponsive with a blood sugar level of 45. Despite the protocol requiring glucagon administration for unresponsive residents with low blood sugar, the nurse did not administer glucagon because it was not available in the medication cart. Instead, the nurse called 911 and waited for the ambulance, which administered glucagon upon arrival. The resident's condition was first noticed by a CNA who found the resident unresponsive while passing breakfast trays. The nurse confirmed the low blood sugar and called for emergency assistance but did not follow the hypoglycemia protocol due to the unavailability of glucagon in the med cart. The nurse stated that glucagon is usually kept in the med cart but was not there at the time. The Director of Nursing confirmed that glucagon should have been administered and is stored in the emergency medication box in the medication room. The resident was transported to the hospital by paramedics, who found the blood sugar to be critically low at 20 and administered glucagon, which slightly improved the resident's responsiveness. The hospital records confirmed the resident was admitted with a diagnosis of hypoglycemia. The facility's policy clearly states that glucagon should be administered to unresponsive residents with low blood sugar, but this protocol was not followed in this case, leading to a delay in appropriate treatment for the resident.
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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