Bridgeway Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Bensenville, Illinois.
- Location
- 111 East Washington, Bensenville, Illinois 60106
- CMS Provider Number
- 145420
- Inspections on file
- 40
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Bridgeway Senior Living during CMS and state inspections, most recent first.
A resident admitted with multiple serious conditions, including infective endocarditis, had orders for IV antibiotics to be administered via a PICC line but no corresponding orders for PICC care, such as flushing or dressing changes. Staff, including an RN and the DON, stated that PICC care is usually done routinely and included in batch admission orders, but acknowledged that these orders were not entered for this resident, resulting in IV therapy being provided without documented PICC line maintenance orders.
A resident with multiple serious diagnoses, including infective endocarditis, was ordered IV Vancomycin every 12 hours for infection, but several scheduled doses were not administered and the physician was not notified of these missed doses. An LPN could not clearly explain why the antibiotic was not given on multiple occasions, despite pharmacy records showing more doses delivered than documented as administered on the MAR. A Vancomycin trough was reported as critically low, and a subsequent dose was given before pharmacy recommendations based on that lab were received, with no documented physician notification regarding the missed doses.
A resident with multiple medical and cognitive conditions was found living in a room with raised, uneven floor tiles, a window with rotting wood and a non-functioning crank that allowed cold air to enter, and a malfunctioning refrigerator unable to maintain safe temperatures. These environmental deficiencies were known to maintenance staff for months but were not adequately addressed, and facility leadership was unaware of the ongoing issues, despite policy requirements for preventive maintenance and communication.
A resident with multiple chronic conditions experienced a significant change in condition, including shortness of breath and low oxygen saturation, after being transferred to bed. The LPN assessed the resident and provided oxygen but did not notify the resident's family representative as required by facility policy, and there was no documentation of such notification or escalation to the DON or Medical Director.
A resident with multiple chronic conditions became lethargic and required oxygen, but nursing staff did not perform or document a thorough assessment, including vital signs and neurological status, as required by facility policy. The nurse did not seek additional help or notify the physician in a timely manner, and documentation of the resident's condition and interventions was incomplete prior to the resident's emergency transfer and subsequent hospital admission for serious medical issues.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
A resident with cognitive intactness and multiple diagnoses, including congestive heart failure and Parkinson's disease, was found with disheveled hair, overgrown nails, and a wet brief. Despite a care plan addressing her needs, the resident reported being left wet for extended periods, with CNAs observed not attending to her needs. The facility's policy lacked specific guidelines on the frequency of perineal care checks.
A resident with multiple health conditions was left without a working call light for over a day, resulting in delayed assistance while she was wet and unable to call for help. Despite being aware of the issue, the facility did not provide an alternative method for the resident to contact staff, and the call light was not repaired promptly.
The facility failed to follow standardized recipes, resulting in substandard meal quality for residents. Observations revealed that meals did not adhere to prescribed recipes, with residents reporting issues such as overly salty food and unpleasant tastes. The kitchen staff deviated from recipes for items like pizza and strawberry shortcake, leading to meals lacking nutritional value and quality. The dietary manager confirmed the importance of following recipes to ensure proper nutrition and taste.
The facility's kitchen was found to have several deficiencies related to food safety and storage. The walk-in cooler was operating above the safe temperature, and food items were improperly stored, including staff lunches without labels. Staff members were not wearing required hair and beard restraints, and the kitchen lacked a garbage can near the handwashing sink. In dry storage, several food items were expired or improperly labeled. These issues indicate non-compliance with the facility's food safety policies.
The facility failed to maintain the kitchen walk-in cooler at a safe temperature, with readings of 58 and 55 degrees Fahrenheit observed, exceeding the safe range of 41 degrees Fahrenheit or below. Despite this, perishable food items were stored in the cooler, contrary to facility policy, which requires transferring food to another unit if temperatures exceed safe levels. This affected all residents receiving oral nutrition from the facility kitchen.
The facility failed to provide written notification to residents and their families or POA regarding hospital transfers and did not notify the ombudsman. This affected five residents transferred for conditions like acute cystitis, wound infection, sepsis, and respiratory distress. The ADON stated that written documentation was only given to alert residents and the ombudsman was notified only upon discharge, not during hospitalizations.
The facility failed to provide written notification of bed hold policies to residents and/or their POA at the time of hospital discharge. Five residents were transferred for various medical conditions without receiving the required documentation. The ADON admitted that the facility only verbally notified families and lacked a formal bed hold policy.
The facility failed to provide adequate ADL care for five residents dependent on staff for personal hygiene. Observations showed residents with unshaved facial hair, long nails with brown substances, and oily hair. Residents expressed dissatisfaction, indicating staff did not provide necessary assistance. The residents had various medical conditions requiring staff help, but the facility did not meet these needs, as evidenced by their unkempt appearances and reports of inadequate care.
The facility failed to secure medications during administration and did not obtain physician orders for over-the-counter medications, leading to unauthorized storage in residents' rooms. An RN left medications unattended, and several residents had medications without proper orders or assessments. The DON acknowledged the need for assessments and orders for self-administration or bedside storage, which were not followed.
The facility failed to maintain proper temperature logs and storage of food in residents' personal refrigerators, affecting five residents. Observations showed missing temperature logs and thermometers, with some refrigerators containing potentially spoiled food. The DON was unsure of staff responsibilities for temperature checks, later identifying housekeeping as responsible, but they were not consistently performing the task. Facility policies require food to be labeled, dated, and discarded per guidelines, with daily temperature checks recorded.
The facility failed to implement proper infection control practices, affecting all residents. Staff did not use Enhanced Barrier Precautions (EBP) as required, with missing signage and PPE for residents with wounds and catheters. Improper disposal of PPE and inadequate hand hygiene were observed. The facility also lacked updated infection control policies and had missing records for water testing to prevent legionella.
A resident with severe cognitive impairment was fed by a nurse in a demeaning manner, with the nurse standing over her and instructing her to eat in a demeaning tone. The Director of Nursing acknowledged that staff should sit at the same level as residents during feeding to maintain dignity, as per the facility's Resident Rights Statement.
A resident in a LTC facility was unable to reach her call light while sitting in a recliner, as it was attached to her bed across the room. The resident, who has moderately impaired cognition and is dependent on staff for hygiene, expressed frustration about the inaccessibility. The MDS Coordinator and DON confirmed that call lights should be within reach, aligning with the facility's policy to ensure communication means are accessible to residents.
A facility failed to invite a resident to care plan meetings, resulting in the resident being unaware of discharge goals. The Social Services Director confirmed the lack of documentation showing invitations to the resident or family, despite the facility's policy requiring their involvement in the care planning process.
The facility failed to properly monitor blood glucose levels and administer insulin according to physician orders for two residents. An RN administered insulin without aligning with meal times, and an LPN checked a resident's blood glucose while they were eating, contrary to orders. The DON acknowledged the need for pre-meal checks, but some nurses administered insulin with meal trays to avoid hypoglycemia.
A facility failed to implement a physician's order for a resident with dysphagia, leading to the use of a straw despite orders against it. The resident's care plan and physician's orders specified no straws and aspiration precautions, which were not followed by CNAs and an SLP. The facility lacked a policy for implementing physician's orders, as acknowledged by the ADON.
A resident with a history of hemiplegia and hemiparesis following a cerebral infarction did not receive restorative services as recommended. Despite being on programs for bed mobility, dressing, and active range of motion, there was no documentation of these services being provided over the past 30+ days. The resident expressed that he no longer receives therapy and is unable to get out of bed on his own, highlighting a lapse in the facility's adherence to its restorative nursing policy.
The facility failed to properly position catheter drainage bags for three residents during wound and incontinence care, leading to potential urine backflow. One resident's bag was placed above the bladder line, causing backflow, while another's was mishandled during care. A third resident was not switched to a larger collection bag when in bed, risking backflow. Staff acknowledged the improper handling, which could lead to UTIs.
The facility did not post current daily staffing information, affecting all 159 residents. The Daily Staff Posting was outdated, showing a previous date and census. The DON explained that the receptionist updates and posts staffing information after receiving the census email between 9:30 AM and 10:00 AM. However, the receptionist's schedule may cause delays. The facility's policy requires posting staffing data at the start of each shift, as per regulations.
A resident with a complex medical history experienced a slow deterioration due to the facility's failure to identify a change in condition, provide frequent monitoring, and communicate effectively with the physician. The resident was transferred to the hospital in critical condition and later died from septic shock. The facility did not take vital signs after the initial assessment and delayed notifying the physician, leading to a delay in hospital transfer.
The facility failed to conduct the required quarterly Quality Assessment and Assurance (QAA) meetings with the necessary members, impacting all residents. The last QAPI meeting was in December 2023, and subsequent meetings were missed. The April 2024 QA meeting lacked attendance from the Administrator and Medical Director, contrary to the facility's policy requiring their presence.
The facility failed to maintain a safe and sanitary environment in the B-wing hallway, affecting several residents. Observations showed missing ceiling tiles with water dripping from exposed plumbing, saturating the carpet. A malfunctioning air conditioning unit was identified as the cause, with temporary fixes leading to leaks. The Maintenance Director acknowledged the safety concern of water dripping onto an electrical source, but no immediate resolution was provided. The issue persisted for several days, impacting residents and staff.
Failure to Obtain PICC Line Care Orders for Resident Receiving IV Antibiotics
Penalty
Summary
The facility failed to obtain and document provider orders for the care and management of a resident’s PICC (peripherally inserted central catheter) line despite ongoing IV antibiotic therapy. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder, and had admission orders for two IV antibiotics to be administered via the PICC line two to three times daily. However, the admission orders did not include any directives for PICC line care, such as flushing, dressing changes, or other maintenance. Nursing staff, including an RN and the DON, reported that routine PICC line care (flushes, weekly dressing changes, checking for a cap, measuring the line and arm circumference) is normally performed and is supposed to be included in batch orders entered at admission, but acknowledged that these orders were not entered for this resident. This omission resulted in the resident receiving IV medications through a PICC line without corresponding written orders for line care and maintenance, as confirmed by interview and record review.
Missed Vancomycin Doses and Lack of Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when ordered IV Vancomycin doses were not administered as prescribed and the physician was not notified of the missed doses. The resident was admitted with diagnoses including nontraumatic subarachnoid hemorrhage, acute and subacute infective endocarditis, pleural effusion, and psychoactive substance-induced mood disorder. The February 2026 MAR shows that Vancomycin 1750 mg/350 ml every 12 hours for infection was not given on multiple scheduled administrations: 2/26 at 9:00 PM, 2/27 at 9:00 PM, 2/28 at 9:00 AM, and 2/28 at 9:00 PM. An LPN stated she did not know why the Vancomycin was not given on those days, speculating that on the admission date it was probably not available, that on one date the resident went to the hospital after calling 911, and that on another date the medication might have been on hold pending blood test results, but she did not provide a clear reason for each missed dose. Laboratory data show that a Vancomycin trough drawn on 2/28/26 was reported as an alert low value of 3.6 (normal 10–20), with the result communicated to facility staff on the same day at 2:52 PM. The facility’s process, as confirmed by staff, was to notify the pharmacy after receiving such results. The next progress note entry, dated 3/1/26 at 3:19 PM, documents a call from the pharmacy with instructions to continue the same Vancomycin dose and obtain additional labs, and staff confirmed that a Vancomycin dose was administered on 3/1/26 at approximately 9:30 AM before the pharmacy’s recommendations based on the 2/28/26 lab were received. Pharmacy packing slips show that a total of 8 Vancomycin doses were delivered between 2/26 and 3/3, while the MARs for February and March 2026 document administration of only 5 doses. Progress notes from 2/27 through 3/1 do not contain any documentation that the physician was notified of the missed Vancomycin doses.
Failure to Maintain Safe and Comfortable Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for a resident with multiple diagnoses, including Parkinson's disease, bipolar disorder, paranoid schizophrenia, unspecified dementia, hypertension, and chronic diastolic heart failure. The resident was noted to have impaired cognition, impaired mobility, poor safety awareness, and an increased risk of falls. During observation, two floor tiles in the resident's room were found to be raised and uneven, creating an unstable surface that contributed to the instability of furniture, including a television stand. The Maintenance Director acknowledged awareness of the uneven tiles and stated they should have been repaired earlier. Additionally, the window in the resident's room had rotting wood, peeling paint, and a non-functioning crank, resulting in a gap that allowed cold air to enter the room. The window had been in this condition for several months, and work orders submitted to address the issue were either marked as completed without full resolution or left incomplete. The room temperature was measured at 67°F, and the in-room refrigerator provided by the facility was found to be malfunctioning, with an internal temperature of 48°F, water accumulation in the freezer, and moisture along the interior edges. Staff confirmed the refrigerator was unable to maintain appropriate temperature. The Assistant Administrator was unaware of the issues with the floor, window, or refrigerator, and acknowledged these conditions posed a safety concern. The facility's Safety Policy requires preventive inspections, maintenance, and a system for communicating and addressing repair needs, but these procedures were not effectively implemented in this case.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to follow its policy regarding prompt notification of a resident's representative after a significant change in the resident's condition. A resident with multiple diagnoses, including type 2 diabetes, congestive heart failure, gout, chronic kidney disease, and morbid obesity, experienced shortness of breath and a drop in oxygen saturation to 87% after being transferred to bed with the assistance of four staff members. The LPN on duty assessed the resident and applied oxygen via nasal cannula but did not notify the resident's family representative of this change in condition, as required by facility policy. Documentation in the resident's electronic medical record and progress notes did not indicate that the family representative was informed, nor was there evidence that the physician or the Medical Director or DON were contacted when the physician did not respond. The DON later confirmed that the family representative had not been notified and that the LPN stated it had not occurred to her to do so. The facility's policy specifically requires prompt notification and documentation of such events, which was not followed in this instance.
Failure to Assess and Document Change in Resident Condition
Penalty
Summary
The facility failed to follow its policy and perform a timely assessment on a resident who exhibited a change in condition. The resident, who had multiple diagnoses including type 2 diabetes, congestive heart failure, chronic kidney disease, and morbid obesity, was noted to be lethargic and required oxygen after a drop in oxygen saturation. Nursing staff did not complete or document a thorough assessment, including vital signs and neurological status, when the resident's condition changed. The nurse on duty did not seek assistance from other nurses, did not call an internal code, and only called 911 after the resident became barely responsive. Documentation of vital signs and the use of oxygen was incomplete, with the last recorded vital signs taken hours before the emergency transfer and delayed progress notes regarding oxygen administration. The facility's policy required staff to assess and document vital signs, neurological status, and changes in level of consciousness when a resident experiences an acute change in condition. Staff were also expected to notify the physician and monitor the resident's progress. In this case, the nurse did not collect or report the necessary information to the physician, and there was a lack of monitoring and documentation as required by facility policy. The resident was ultimately transferred to the hospital, where they were diagnosed with hypothermia, septic shock, thrombocytopenia, and hypernatremia.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a resident, identified as R9, who was reviewed for activities of daily living. On multiple occasions, R9 was observed with disheveled hair, overgrown nails with brownish debris, and a wet disposable brief. R9 reported that she had been left wet for almost an hour and had experienced a previous incident where no perineal care was provided, leaving her wet for an entire shift. R9 also mentioned that her call light was not functioning, requiring her to wait for staff to check on her or to call out for assistance. Despite the care plan addressing R9's needs appropriately, the CNAs were observed sitting in the dining hall and not attending to R9's needs. The CNAs stated they check on residents every 1-2 hours, but R9 remained in a wet brief for an extended period. The Director of Nursing confirmed that staff are expected to check on residents every 1-2 hours, especially those who are frequently wet. The facility's policy for ADL care, revised in 2008, does not specify the frequency for checking and providing perineal care, contributing to the deficiency in care provided to R9.
Failure to Maintain Functional Call Light System
Penalty
Summary
The facility failed to ensure that a resident's call light was in working condition, resulting in the resident not receiving timely assistance. On January 21, 2025, a resident was observed lying in a bariatric bed with a wet disposable brief, bedsheet, and blanket. The resident, who was alert and oriented, reported that her call light had been broken since the previous day, and she had been wet for almost an hour without assistance. The resident had no alternative method to call for help, and the call light was confirmed to be non-functional by two CNAs the following day. The resident, who was admitted with diagnoses including congestive heart failure, Parkinson's disease, bipolar disorder, and anxiety, required moderate assistance with upper body functions and was totally dependent for lower body functions. Despite the facility's policy requiring daily checks of call lights by CNAs and maintenance personnel, the issue was not addressed promptly. The Director of Nursing stated that call lights must be answered as soon as they are noticed, but the resident's call light was not repaired until a work order was placed on January 22, 2025, leaving the resident without an alternative method to call for help in the interim.
Failure to Follow Standardized Recipes in Meal Preparation
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and at a safe and appetizing temperature, as evidenced by the failure to follow standardized recipes. Observations and interviews revealed that residents receiving regular diets, both regular and pureed textures, were served meals that did not adhere to the prescribed recipes. For instance, a resident reported that the food was consistently salty, leading her to rely on canned soup brought by her family. Another resident described the food as horrible and opted for simple sandwiches instead of the menu items. A third resident found a long black hair on her lunch tray and described the food as having an unpleasant taste, refusing to eat it. Further investigation showed that the kitchen staff did not follow the recipes for several menu items, including pizza, pureed pizza, strawberry shortcake, and side salad with dressing. The cook used red peppers instead of the specified green peppers and did not measure the vegetables as required. The strawberry shortcake was served with pound cake and half a strawberry instead of the specified biscuit and full portion of strawberries. The side salad lacked the required tomatoes and shredded cheese, consisting only of bagged lettuce. The dietary manager confirmed that recipes are designed to ensure nutritional value and quality, emphasizing the importance of following them. The facility's policy mandates the use of standardized recipes for all menu items, but this was not adhered to, resulting in substandard meal quality for the residents.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and storage protocols, as observed during a survey of the kitchen. The walk-in cooler was found to have a temperature of 58 degrees Fahrenheit, which is above the safe storage temperature of 41 degrees Fahrenheit. Despite being informed of the elevated temperature, food items such as bread and various vegetables were still stored in the cooler. Additionally, staff lunches were improperly stored in the walk-in cooler without labels or dates, contrary to facility policy. During the kitchen tour, it was noted that staff members, including the Dietary Manager and a Dietary Aide, were not wearing required hair and beard restraints while working in food preparation areas. This lack of compliance with the facility's policy on hair restraints poses a risk of cross-contamination. Furthermore, the kitchen lacked a garbage can near the handwashing sink, which is necessary for proper hygiene practices. In the dry storage area, several food items were found to be improperly stored or expired. An opened carton of Au Gratin potatoes was not sealed, and five boxes of muffin mix and two cartons of rainbow sprinkles were past their expiration dates. An opened bag of cake mix was also found without a label or date. These findings indicate a failure to follow the facility's policies on labeling, dating, and discarding expired food items, which are essential for maintaining food safety and preventing foodborne illnesses among residents.
Failure to Maintain Safe Temperature in Kitchen Walk-In Cooler
Penalty
Summary
The facility failed to maintain the kitchen walk-in cooler in a safe operating condition, affecting all residents receiving oral nutrition and foods prepared in the facility kitchen. During a kitchen tour, the walk-in cooler was observed to have a temperature of 58 degrees Fahrenheit, which is above the safe temperature range for food storage. The Dietary Manager confirmed that the cooler's temperature should be below 41 degrees Fahrenheit to prevent the growth of pathogens and bacteria. Despite this, food items such as bread, tomatoes, potatoes, onions, cabbage, and spinach were found stored in the cooler, with packaging indicating they should be kept between 33-38 degrees Fahrenheit. The facility's policy on refrigerator and freezer temperatures requires that all cold storage units maintain a temperature of 41 degrees Fahrenheit or below. If temperatures exceed this range, the policy mandates that food be transferred to another unit and the affected unit be locked out. However, the walk-in cooler continued to operate at unsafe temperatures, as confirmed by the Maintenance Director's infrared thermometer reading of 55 degrees Fahrenheit. This failure to adhere to established guidelines and procedures for food storage compromised the safety and quality of food provided to residents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their families or Power of Attorney (POA) regarding the reasons for hospital transfers, as well as failing to notify the ombudsman of these transfers. This deficiency was identified in five residents who were transferred to the hospital for various medical conditions, including acute cystitis, wound infection, sepsis, acute on chronic abdominal pain, and acute chronic respiratory distress. The facility's Assistant Director of Nursing (ADON) admitted that written documentation of the bed hold policy was only provided to alert residents and that the ombudsman was only notified upon discharge from the facility, not during hospitalizations. The report highlights specific instances where residents were transferred to the hospital without proper written notification to their families or the ombudsman. For example, one resident was sent to the hospital due to elevated blood pressure and jerking movements, another for a wound infection requiring possible debridement, and another for respiratory distress. In each case, the facility failed to provide the necessary written documentation to the resident's family or representative, and the ombudsman was not informed of the hospital transfers, which is a requirement for compliance.
Failure to Provide Written Bed Hold Notification
Penalty
Summary
The facility failed to provide written notification of bed hold policies to residents and/or their Power of Attorney (POA) at the time of discharge to the hospital. This deficiency was observed in five residents who were transferred to the hospital for various medical conditions, including acute cystitis, wound infection, sepsis, acute on chronic abdominal pain, and acute chronic respiratory distress. In each case, there was no documentation in the medical records indicating that the residents or their representatives were informed in writing about the bed hold policy, which is a requirement. The Assistant Director of Nursing (ADON) acknowledged that the facility only verbally notified residents' families of hospital transfers and did not provide written documentation of the bed hold policy. The facility's existing policy stated that a bed hold agreement should be provided to residents or their representatives at the time of transfer, but this was not adhered to. The facility also lacked a formal bed hold policy, further contributing to the deficiency.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate ADL care for five residents who are dependent on staff for personal hygiene. Observations revealed that residents had unshaved facial hair, long and jagged nails with brown substances underneath, and oily hair. These residents expressed dissatisfaction with their personal hygiene care, indicating that staff did not provide necessary assistance. For instance, one resident with multiple sclerosis and quadriplegia was observed with facial hair and stated that she was unaware of it because staff never offered her a mirror or assistance with shaving. Another resident with severe cognitive impairment and mobility issues reported that staff only shaved her once a month, which caused her discomfort. The residents involved had various medical conditions, including multiple sclerosis, osteoarthritis, parkinsonism, type 2 diabetes, Alzheimer's, dementia, chronic obstructive pulmonary disease, and hemiplegia. Their care plans indicated a need for staff assistance with personal hygiene due to their physical and cognitive limitations. Despite these documented needs, the facility did not provide the necessary care, as evidenced by the residents' unkempt appearances and their reports of inadequate assistance. The Director of Nursing acknowledged that personal nail care and hair washing should be provided as needed, but the facility was unable to provide an ADL policy, highlighting a gap in ensuring residents' rights to a dignified existence and quality of life.
Medication Security and Physician Order Deficiencies
Penalty
Summary
The facility failed to secure medications properly during administration and did not obtain physician orders for over-the-counter medications, leading to medications being stored in residents' rooms without authorization. In one instance, an agency RN left a medication cup with nine unlabeled pills on a resident's dresser while retrieving equipment, leaving the medication unsecured. The resident, who had multiple diagnoses including chronic kidney disease and schizoaffective disorder, had moderately impaired cognition, increasing the risk of medication mishandling. Another resident was found with a bottle of eye drops and a cup containing unlabeled pills, which the resident identified as ibuprofen for foot pain. The resident's medical record did not include a physician order for ibuprofen or permission to store medications in the room. Similarly, other residents were found with various medications, such as inhalers and eye drops, on their bedside tables without proper orders or assessments to self-administer or store medications at the bedside. Additionally, a medication cart was left unattended in a hallway with a cup of unlabeled pills, posing a risk of accidental ingestion by other residents. The Director of Nursing acknowledged that residents need an assessment and physician order to self-administer or store medications at the bedside, and that medications should not be left unattended. The facility's policy on medication storage was not followed, as evidenced by the lack of orders and assessments for residents to self-medicate or store medications in their rooms.
Failure to Maintain Proper Food Storage and Temperature Logs
Penalty
Summary
The facility failed to maintain proper temperature logs, storage, and labeling of food items in residents' personal refrigerators, affecting five residents. Observations revealed that several personal refrigerators lacked temperature logs and thermometers, with some containing potentially spoiled food items. For instance, one refrigerator contained liquid ice cream and sherbet, while another had an uncovered and unlabeled bowl of salad. Additionally, one refrigerator showed a temperature of 42°F, which is above the recommended range. The Director of Nursing (DON) acknowledged that temperatures should be checked and recorded daily, but was unsure which staff was responsible for this task. It was later discovered that housekeeping staff were supposed to manage the residents' personal refrigerators, but they were either not performing the task or doing so inconsistently. The facility's policy requires food to be labeled, dated, and discarded according to safe storage guidelines, and the temperature of refrigerators and freezers outside the kitchen to be checked daily and recorded.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, affecting all 159 residents. Several instances were observed where Enhanced Barrier Precautions (EBP) were not implemented as required. For instance, a resident with a stage 4 sacral ulcer and an indwelling catheter did not have EBP signage or PPE outside her room. Staff members, including a Wound Care Coordinator and a CNA, were observed providing wound care and handling the resident's urinary catheter with only gloves, without using gowns or other necessary protective equipment. This occurred despite a physician's order for EBP isolation due to the resident's wounds and catheter. Another resident with cellulitis and venous insufficiency also lacked EBP signage and PPE outside his room. A registered nurse provided wound care without wearing a gown, and there was no physician order for EBP for this resident. Similarly, a resident with a PICC line and multiple infections did not have precaution signage or PPE outside her room. A registered nurse assisted with incontinence care without wearing a gown, despite a physician's order for EBP being issued during the survey. The facility's infection control practices were further compromised by improper disposal of contaminated PPE. A red garbage container meant for disposing of PPE was placed outside a resident's room instead of inside, contrary to the facility's policy. Additionally, hand hygiene practices were not followed, as staff members failed to change gloves and clean their hands between tasks, such as wound care and incontinence care. The facility also lacked updated infection control policies, including those related to COVID-19, and there were missing records for water testing to prevent legionella growth.
Failure to Provide Dignified Care During Feeding
Penalty
Summary
The facility failed to provide care with dignity to a resident, identified as R139, who was observed being fed by a nurse, V9, in a demeaning manner. During the observation, V9 stood over R139 and repeatedly instructed her to eat in a demeaning tone. R139 is an elderly female with severe cognitive impairment and requires substantial assistance for eating, as indicated in her Minimum Data Set (MDS) assessments. The Director of Nursing, V2, acknowledged that staff should not stand over residents while feeding them, as it compromises their dignity. The facility's Resident Rights Statement emphasizes the right of residents to a dignified existence and care that enhances their quality of life and dignity.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were accessible to dependent residents, specifically affecting one resident in the sample. During an observation, a resident was found sitting in a recliner chair in her room with the call light attached to her bed, which was by the window, while she was sitting closer to the door. The resident expressed frustration about not being able to reach the call light from her position, stating that she needed it for assistance. The MDS Coordinator confirmed that the call light should be within reach of residents at all times. The resident's MDS indicated moderately impaired cognition and dependence on staff for toileting and personal hygiene, with a care plan noting a risk for falls and the need to call for assistance. The Director of Nursing also acknowledged that call lights should be easily accessible to residents in their rooms. The facility's policy states that call lights should be within easy reach to meet residents' needs.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to invite a resident to care plan meetings, which is a requirement for developing and maintaining a comprehensive care plan. This deficiency was identified for one resident, who expressed a desire to know what was needed to be discharged home but was unaware of the care plan meetings. The resident reported never being informed about the goals or invited to participate in these meetings. The Social Services Director confirmed that there was no documentation or progress notes indicating that the resident or their family had been invited to the care plan meetings. The facility's policy requires the involvement of the resident and their family in the care planning process, but this was not adhered to in this case, as evidenced by the resident's Care Plan Meeting Attendance forms showing no attendance by the resident or family at any meetings.
Improper Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to obtain residents' blood glucose levels appropriately and did not follow physician orders for administering insulin, affecting two residents. For one resident, an agency RN checked the blood glucose level and administered insulin based on a sliding scale, but the timing was inconsistent with meal times, as the resident had breakfast hours earlier and lunch trays were served later. The RN was unaware of the meal schedule, which is crucial for accurate insulin administration. Another resident's blood glucose was checked by an LPN while the resident was already eating, which is contrary to the physician's order to check blood sugar before meals. Insulin was administered based on this reading. The DON confirmed that blood glucose checks should be done before meals to ensure accurate readings, but some nurses were administering insulin when they saw meal trays to prevent hypoglycemia, indicating a lack of adherence to proper procedures.
Failure to Implement Physician's Order for Aspiration Precautions
Penalty
Summary
The facility failed to implement a physician's order for a resident diagnosed with dysphagia, chronic obstructive pulmonary disease, and dementia. The resident, identified as R77, had a physician's order dated 6/28/23 that specified no straws every shift and aspiration precautions due to her condition. Despite this, on 12/10/24, a CNA provided R77 with a cup of water containing a straw, contrary to the physician's order and the resident's care plan. Additionally, on 12/12/24, another CNA placed a straw on R77's lunch tray, which was then taken by the SLP who conducted a bedside swallow study and confirmed that R77 should not use straws. The facility's failure to adhere to the physician's order was further highlighted by the absence of a policy for following or implementing such orders. The Assistant Director of Nursing acknowledged that staff should follow all physician's orders, including those for no straws and aspiration precautions. The resident's care plan, updated on 11/20/24, reiterated the need for aspiration precautions and no straws, aligning with the SLP's evaluation from 12/12/24 to 12/25/24, which also recommended no straw use.
Failure to Provide Restorative Services to Resident
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as R128, as recommended by the ADL Restorative Assessment. R128 is a male resident with a history of hemiplegia and hemiparesis following a cerebral infarction, affecting his right dominant side, along with aphasia, dysphagia, and repeated falls. The resident's MDS indicated impairments on one side of both upper and lower extremities, and he uses a wheelchair for mobility. During an interview, R128 communicated that he no longer receives physical, occupational, or speech therapy, and he does not receive any restorative therapy, despite having weak right arm and leg due to his stroke. The Director of Nursing (DON) confirmed that R128 was on three restorative programs: bed mobility, dressing, and active range of motion for upper and lower extremities. However, there was no documentation to show that these programs had been carried out over the past 30+ days. The resident's care plan, last revised in March, outlined interventions for his deficits, including a bed mobility program and active range of motion exercises, but these were not documented as being implemented. The facility's policy on restorative nursing programs emphasizes the importance of assessing and implementing appropriate nursing measures to achieve maximum independence, but this was not adhered to in R128's case.
Improper Positioning of Catheter Bags Leads to Potential Backflow
Penalty
Summary
The facility failed to properly position the indwelling catheter drainage bags for three residents during wound care and incontinence care, leading to potential backflow of urine. For one resident, the catheter drainage bag was observed hanging on the armrest of a motorized wheelchair above the bladder line, causing backflow of urine. During wound care, the same resident's catheter bag was placed on the bed, again resulting in backflow. This resident had a history of urinary tract infections (UTIs) and was recently on antibiotics for a UTI. The facility's policy requires that the urinary drainage bag be positioned lower than the bladder to prevent backflow. Another resident's catheter bag was similarly mishandled during wound care, being lifted above the bladder level and placed on the bed, contrary to the facility's policy. This resident also had a history of UTIs. Additionally, a third resident, who was supposed to switch from a leg bag to a larger urine collection bag when in bed, was not provided with the appropriate bag, risking backflow due to the lack of gravity with the leg bag. The facility's staff, including the Director of Nursing and Assistant Director of Nursing, acknowledged the improper handling of catheter bags and the potential for backflow, which could lead to UTIs.
Failure to Post Current Daily Staffing Information
Penalty
Summary
The facility failed to post the current daily staffing information, affecting all 159 residents. On December 10, 2024, at 10:36 AM, the Daily Staff Posting at the reception desk displayed a date of December 9, 2024, with a census of 160, indicating outdated information. The Director of Nursing (DON) explained that the admission staff emails the current census between 9:30 AM and 10:00 AM to the front desk, herself, and all managers. The receptionist is responsible for updating the staffing information and posting it after receiving the email. However, the receptionist's work schedule from 8:00 AM to 1:30 PM suggests a delay in posting the updated information. The facility's policy, dated August 2008, requires posting the number of nursing personnel responsible for direct care at the beginning of each shift, as mandated by state and federal regulations.
Failure to Identify Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to identify a change in condition for a resident, R2, who experienced a slow deterioration from the morning until she was transferred to the hospital in critical condition. The failure began when an LPN did not recognize R2's change in condition, did not complete an assessment, obtain vital signs, or notify R2's physician. This oversight continued with another LPN who did not provide frequent monitoring, failed to provide accurate information to the physician, and delayed transferring R2 to the hospital. As a result, R2 was transferred to the hospital in critical condition and later died from septic shock. R2 had a medical history that included COPD, heart failure, peripheral vascular disease, insomnia, atrial fibrillations, major depressive disorder, anemia, a non-pressure chronic ulcer to the left foot, dementia, and osteoarthritis. On the day of the incident, R2 was noted to be confused, experiencing diarrhea, and unable to perform her usual self-care activities. Despite these changes, there were no vital signs taken after the initial assessment in the morning, and the physician was not notified of R2's deteriorating condition. The facility's failure to monitor R2's condition and communicate effectively with the physician led to a delay in transferring her to the hospital. The ambulance report indicated that R2 was in a lethargic state, with low oxygen saturation and critically low blood pressure upon arrival. The lack of timely intervention and accurate communication contributed to the severity of R2's condition, ultimately resulting in her death from septic shock.
Removal Plan
- V19 and V28 were in-serviced and educated on identification of a change in condition and continued monitoring. In-service/Education included: to ensure that assessments, monitoring and documentation is completed on residents with a change in condition, providing MD with accurate information regarding change of condition and transferring to emergency department in a timely manner.
- Initiated in-service and education to nurses including agency nurses on identification of a change in condition and continued monitoring, documentation of assessments, and monitoring is completed on residents with a change in condition, providing MD with accurate information regarding change of condition and transferring to emergency department in a timely manner.
- The Director of Nursing and MDS Coordinator in-serviced nurses on Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and documentation is completed on residents with a change of condition. V19 and V28 were already in-serviced and educated. Anyone who had not been in-serviced will be in-serviced in person or over the phone prior to their next shift by DON or designee prior to their next shift in this facility. This in-servicing includes nurses on FMLA & PRN and agency nurses. All new hires will be in-serviced during their orientation on the Identifying a Change of Condition in a Resident - in particular, to ensure that assessments, monitoring and documentation is completed on residents with a change of condition.
- DON or designee will audit all residents with a change of condition daily to ensure that all residents with a change of condition were properly assessed, monitored, and documented on, MD was notified with accurate information and transferred in a timely manner.
- QAPI Committee have met and discussed the measures that were put in place to ensure that deficient practice does not occur. Medical Director is in agreement of the measures that were put in place and has approved it.
Failure to Conduct Required QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met quarterly with the required members, affecting all residents in the facility. The facility's data sheet indicated there were 163 residents at the time of the survey. During an interview and record review, it was found that the last Quality Assurance and Performance Improvement (QAPI) meeting was held in December 2023, and the subsequent meetings that should have occurred in March/April 2024 and June/July 2024 did not take place. The Director of Nursing (DON) acknowledged that the facility was behind on these meetings, citing a busy period following their annual survey in January and the development of a Plan of Correction (POC) as contributing factors. The monthly QA meeting held in April 2024 was attended by various staff members, including the Restorative, MDS Coordinator, Infection Control Preventionist, and others, but notably absent were the Administrator and Medical Director. The facility's policy requires the Administrator to serve as the Chairperson of the QAA committee, and the committee is expected to meet monthly to address quality measures, improvement processes, and survey findings. The absence of key members and the failure to hold the required meetings indicate a lapse in the facility's adherence to its quality assurance policy.
Unsafe and Unsanitary Conditions in Resident Hallway
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents in the B-wing hallway, affecting seven residents. Observations revealed missing ceiling tiles with water steadily dripping from exposed plumbing and air ducts, saturating the carpet and creating a sloshing sound when walked upon. A large trash can and personal care basins were placed to catch the water, but the area remained wet, and a light fixture in an adjacent tile was saturated with water. The issue was reportedly due to a malfunctioning air conditioning unit, which had been temporarily fixed by running water on the condenser, leading to the leak. The Maintenance Assistant and Director confirmed the air conditioning unit needed replacement, and a contractor had been called but could not fix the unit immediately. The Maintenance Director acknowledged the safety concern of water dripping onto an electrical source, although the Maintenance Assistant initially dismissed it. The facility had not provided a policy for Building Maintenance and Repair when requested by the surveyor. The situation had persisted since the previous Monday, with residents and staff having to navigate the wet area, raising concerns about safety and sanitation.
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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