Central Baptist Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Norridge, Illinois.
- Location
- 4747 North Canfield Avenue, Norridge, Illinois 60656
- CMS Provider Number
- 145853
- Inspections on file
- 18
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Central Baptist Village during CMS and state inspections, most recent first.
Staff failed to perform hand hygiene and change gloves between care activities, and did not consistently follow Enhanced Barrier Precautions, such as wearing gowns and gloves when required. For example, a CNA provided catheter and perineal care to a resident with an indwelling device without wearing a gown, and multiple staff members handled soiled materials, personal items, and environmental surfaces without proper hand hygiene. Facility leadership confirmed these actions were not in line with infection control policies.
Staff were observed mixing pureed food items together and standing over cognitively impaired residents while assisting with feeding, actions not directed by care plans and inconsistent with the facility's dignity policy. These practices failed to ensure residents were treated with respect and dignity during mealtimes.
Two residents who required staff assistance with ADLs, including toileting, personal hygiene, and grooming, did not receive the necessary care as outlined in their care plans. One resident was left waiting for help to use the bathroom and was not assisted with hair or oral care, while another repeatedly requested help with facial hair removal and did not receive it. The DON confirmed that staff are expected to provide these services, but the facility did not have a formal ADL policy.
A resident with severe cognitive impairment and upper extremity contractures did not have palm protectors applied according to physician orders. Staff interviews and observations confirmed that both the CNA and restorative aide forgot to apply the devices as scheduled, despite facility policy and documented care plans requiring their use to prevent worsening contractures.
A resident with an indwelling urinary catheter and a history of recurrent UTIs did not receive catheter care according to physician orders and facility policy. Observations showed the catheter drainage bag was stored in a visibly soiled privacy bag that touched the floor, and catheter care was performed without soap or cleaning of the catheter tubing. Staff interviews confirmed these actions did not meet required infection control standards.
Nursing staff failed to verify a resident's gastrostomy tube placement by aspirating gastric contents as required by the care plan and physician orders, instead using an outdated method of injecting air and listening for sounds in the abdomen. Staff reported they were trained to use this method, and the facility's enteral feeding policy had not been updated to current standards.
A nurse failed to administer prescribed doses of spironolactone, vitamin B12, and furosemide to a resident during a scheduled medication pass, resulting in a 10% medication error rate. The nurse admitted to forgetting the medications, and facility leadership confirmed that staff are expected to verify orders using the EMAR and follow established medication administration protocols.
Two residents in a facility experienced falls due to inadequate staff assistance and supervision. One resident, requiring two-person assistance for bed mobility, fell when a CNA on orientation attempted to reposition her alone. Another resident, needing supervision for ambulation, fell and sustained a laceration when left unsupervised in a wheelchair in the activity room.
The facility failed to document and track COVID-19 test results for HCPs during a COVID-19 outbreak, affecting all 102 residents. Despite several staff testing positive, there was no documentation of HCP testing, and staff reported testing themselves only when symptomatic. The facility's policy required immediate testing of all staff and residents in the affected unit, but this was not followed.
The facility failed to serve the correct portion sizes of Garlic Herb Roasted Pork Tenderloin to residents on mechanically altered diets. A food service worker used a 3-ounce scoop instead of the required 4-ounce spoodle due to concerns about insufficient supply, resulting in five residents receiving less than the intended portion size. The kitchen lacked standardized recipes for ground diet items, contributing to the inconsistency.
The facility failed to provide food substitutions with equivalent nutritive value to the planned menu items. Residents received half sandwiches with insufficient protein, such as 0.7 ounces of ham or a thin layer of peanut butter and jelly, instead of the required portions. Staff acknowledged the inadequacy, and the facility's policies required equivalent protein content in substitutions.
A resident at high risk for pressure wounds developed facility-acquired pressure injuries due to the facility's failure to follow the care plan. Despite the resident's need for pressure-relieving devices and regular repositioning, these interventions were not fully implemented, as confirmed by staff observations and interviews. The absence of a low air loss mattress, a critical component of the care plan, contributed to the development and reopening of pressure wounds.
The facility failed to follow its medication administration policy, resulting in a 9.09% error rate. A staff member attempted to administer an unauthorized medication to a resident and did not give the full dose of a prescribed medication. Additionally, a nurse administered a medication after breakfast instead of before, as ordered. These errors affected two residents.
Failure to Perform Hand Hygiene and Adhere to Enhanced Barrier Precautions
Penalty
Summary
Multiple instances of non-compliance with infection prevention and control protocols were observed among staff providing care to residents. Certified Nursing Assistants (CNAs) and Registered Nurses (RNs) failed to perform hand hygiene before and after glove use, and did not change gloves between different care activities. For example, a CNA emptied a resident's urine drainage bag, did not clean the spout, and proceeded to perform perineal care, handle personal items, and touch environmental surfaces such as door knobs and wheelchairs, all while wearing the same soiled gloves and without performing hand hygiene. Another CNA provided incontinence care, then assisted with dressing and bed adjustments, again without changing gloves or performing hand hygiene. In several cases, staff exited resident rooms and immediately interacted with other residents or handled clean items without appropriate hand hygiene, increasing the risk of cross-contamination. Staff also failed to adhere to Enhanced Barrier Precautions as required for residents with indwelling medical devices. In one instance, a CNA performed catheter care for a resident with a history of urinary tract infections and an order for enhanced barrier precautions, but did not wear a gown as required. The signage at the room entrance instructed staff to wear both gown and gloves, but this protocol was not followed. Additionally, after providing perineal care and handling soiled materials, the CNA continued to use the same gloves to apply a clean incontinence brief, further breaching infection control standards. Interviews with facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Infection Preventionist (IP), confirmed that staff are expected to perform hand hygiene before and after glove use, clean equipment such as urine bag spouts after emptying, and wear appropriate personal protective equipment (PPE) according to enhanced barrier precautions. Despite these expectations and existing facility policies, direct observations revealed repeated failures to follow these protocols during resident care activities, including wound care, gastrostomy tube flushes, and meal tray distribution.
Failure to Maintain Dignity During Assisted Feeding
Penalty
Summary
Surveyors observed that staff failed to assist residents with feeding in a manner that preserved their dignity. Specifically, registered nurses were seen mixing together all pureed food items on residents' trays before feeding them, despite there being no care plan directive to do so. This practice was observed with three cognitively impaired residents who required physical assistance with eating. In one instance, a nurse mixed a resident's pureed entrée items together and fed her the combined meal. In another case, a nurse mixed all of a resident's pureed food items together after the resident exhibited anxiety and attempted to grab her meal. The care plans for these residents did not specify that their foods should be mixed together. Additionally, staff were observed standing over residents while assisting them with meals, rather than sitting at eye level, which is not consistent with promoting dignity during feeding. The facility's administrator confirmed that staff should not stand over residents or mix pureed food items together when assisting with feeding. The facility's policy on resident dignity emphasizes the importance of promoting quality of life, dignity, and respect, and creating a positive and enjoyable experience during mealtimes. These observations indicate that staff actions did not align with the facility's stated policy or the residents' care plans.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who required help, as evidenced by observations and interviews with two residents. One resident was observed waiting in her wheelchair in the hallway, crying and expressing an urgent need to use the bathroom, but was unable to do so because her roommate was occupying the shared bathroom. Despite activating her call light and requesting help, she waited a long time without assistance and ultimately feared she would be incontinent. Later, the same resident was noted to have greasy, uncombed hair and facial hair, and reported that staff had not combed her hair or brushed her teeth that morning. Her care plan indicated she required staff assistance for personal hygiene and toileting due to impaired mobility, vision, and a history of stroke, but these needs were not met as observed. Another resident was seen in the dining room with greasy, uncombed hair and noticeable facial hair, and reported that despite repeated requests for help with facial hair removal, staff had not provided the assistance. This resident's care plan also required staff to assist with ADLs, including personal hygiene and bathing, due to impaired mobility and other medical conditions. There was no documentation of care refusals or combative behavior in her record. The Director of Nursing confirmed that CNAs are expected to provide such care but acknowledged the facility lacked a formal policy on ADL provision.
Failure to Apply Palm Protectors as Ordered for Resident with Contractures
Penalty
Summary
A deficiency occurred when staff failed to apply left and right palm protectors as ordered by the physician for a resident with contractures and impaired upper extremity mobility. Observations showed the resident sitting in the activity room without a palm protector on the right hand, with the hand closed and fingers extended against the palm. Interviews with nursing staff revealed uncertainty about the resident's orders, and both the CNA and restorative aide admitted to forgetting to apply the palm protectors as required. The physician's orders specified that the left palm protector should be on at bedtime and removed in the morning, while the right palm protector should be on at all times except during meals, personal hygiene, and showers. The care plan and MDS documented the resident's severe cognitive impairment, upper extremity impairments, and need for assistance with ADLs due to dementia, stroke, contracture, and possible pain in the hands and fingers. The facility's policy required orthoses to be provided and applied as ordered, with training for all nurses and nursing assistants. Despite this, the palm protectors were not applied according to the physician's orders, as confirmed by staff interviews and direct observation. The failure to follow the prescribed schedule for applying and removing the palm protectors constituted a deficiency in care for the resident, who was at risk for worsening contractures and potential injury to the hands.
Failure to Provide Proper Catheter Care and Maintain Infection Control
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter, a history of flaccid neuropathic bladder, recurrent urinary tract infections, urine retention, and dementia, did not receive catheter care in accordance with physician orders and facility policy. Observations revealed that the resident's catheter drainage bag was stored in a privacy bag that was visibly soiled with a dried white stain and was seen dragging on the floor. The same soiled privacy bag was used on both the resident's wheelchair and bed. During catheter care, a CNA provided perineal care using only water, without soap, and did not clean the catheter tubing as required. The CNA also placed a clean incontinence brief on the resident while still wearing the same soiled gloves used during perineal care. Interviews with facility staff confirmed that catheter care should include cleaning the catheter tubing with soap and water, and that soiled privacy bags should be changed to prevent contamination. Facility policy and the resident's care plan both specify that catheter tubing and drainage bags must be kept off the floor and that careful perineal care should be performed to keep the catheter free from crusting. Despite these requirements, the observed practices did not align with the established protocols, resulting in a failure to provide appropriate catheter care to prevent urinary tract infections.
Failure to Properly Verify Gastrostomy Tube Placement
Penalty
Summary
The facility failed to properly check the placement of a resident's gastrostomy tube (GT) as required by the resident's care plan and physician orders. Specifically, nursing staff used the method of injecting air into the GT and auscultating the abdomen to confirm placement, rather than aspirating gastric contents as directed. This practice was observed on multiple occasions, and staff confirmed they had been trained to use this outdated method. The resident's care plan and physician orders both specified that tube placement and gastric contents should be checked prior to feeding and medication administration. Additionally, the facility's policy on enteral feeding, last revised in 2013, had not been updated to reflect current standards of practice.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10% during a medication pass observation. Specifically, a registered nurse prepared a resident's scheduled morning medications but omitted spironolactone 25 mg, vitamin B12 1000 mcg, and furosemide 40 mg tablets. The nurse acknowledged forgetting to include these medications. Review of the resident's order summary confirmed these medications were prescribed to be given at 8:00 AM daily. Interviews with facility leadership indicated that nurses are expected to check the electronic medication administration record (EMAR) and verify medication rights prior to administration, as outlined in the facility's policy for safe oral medication administration.
Inadequate Staff Assistance and Supervision Lead to Resident Falls
Penalty
Summary
The facility failed to provide the required staff assistance for bed mobility and ambulation for two residents, leading to falls and injuries. One resident, an elderly female with vascular dementia and multiple sclerosis, was assessed as high risk for falls and required two-person assistance for bed mobility. However, during a care procedure, a CNA on orientation attempted to reposition the resident alone, resulting in the resident sliding off the bed and falling. The CNA was supposed to work with a mentor, but the mentor was unavailable, and the CNA proceeded alone, contrary to the care plan and MDS assessment. Another resident, an elderly female with vascular dementia, Alzheimer's disease, and psychosis, also experienced a fall due to inadequate supervision. This resident was assessed as high risk for falls and required assistance for ambulation. Despite this, she was left unsupervised in a wheelchair in the activity room, where she stood up abruptly and fell, sustaining a laceration that required stitches. The lack of staff presence in the activity room at the time of the incident contributed to the fall, as no one was available to supervise or assist the resident.
Failure to Track COVID-19 Testing During Outbreak
Penalty
Summary
The facility failed to document and track COVID-19 test results for healthcare providers (HCP) during a COVID-19 outbreak, affecting all 102 residents. The deficiency was identified during an annual survey when the administrator reported 16 COVID-positive residents on the second floor. The infection preventionist (IP) was unable to provide testing results for HCPs exposed to a COVID-positive resident, R66, and admitted that staff tested themselves without documentation. The facility's policy required immediate testing of all staff and residents in the affected unit, but this was not followed. The report details that several staff members tested positive for COVID-19, starting with a nurse educator who potentially interacted with all staff on both floors. Subsequent positive cases included a rehab/restorative nurse, social services staff, and CNAs, all of whom had contact with residents and staff. Despite these exposures, there was no documentation of HCP testing, and staff reported testing themselves only when symptomatic. The IP stated it was too much to track staff testing, focusing only on residents. Interviews with staff revealed a lack of guidance and communication regarding COVID-19 testing protocols. Several staff members, including CNAs and nurses, indicated they were not informed about testing requirements and only tested themselves when they felt unwell. The director of nursing (DON) also confirmed the absence of tracking for staff COVID-19 testing, assuming the IP was responsible. The facility's policy outlined a testing plan for outbreak situations, but it was not implemented, leading to the deficiency.
Inadequate Portion Sizes for Mechanically Altered Diets
Penalty
Summary
The facility failed to serve the correct portion sizes of Garlic Herb Roasted Pork Tenderloin to residents on mechanically altered diets as per the approved menu. Specifically, five residents who were supposed to receive ground meats were served portions that were smaller than the planned 4 ounces. During lunch service, a food service worker used a 3-ounce scoop instead of the required 4-ounce spoodle spoon due to concerns about insufficient ground pork supply. This resulted in the affected residents receiving less than the intended portion size. The Assistant Food Service Manager confirmed that the ground pork portions served were less than the planned 4 ounces. The dietitian also stated that the portions should have matched the serving weight for residents on regular diets. It was noted that the kitchen lacked standardized recipes for ground diet items, which contributed to the inconsistency in portion sizes. The facility's policy required that modified-texture menu items be provided in proper amounts according to the menu diet spreads, but this was not adhered to in this instance.
Inadequate Protein in Food Substitutions
Penalty
Summary
The facility failed to provide food substitutions equivalent in nutritive value to the originally planned menu items for four residents. During meal service, residents received half sandwiches with insufficient protein content compared to the regular menu items. Specifically, residents received sandwiches with only 0.7 ounces of ham or a very thin layer of peanut butter and jelly, which did not meet the required protein portions as per the facility's dietary guidelines. The regular menu items, such as garlic herb pork, were supposed to provide 4 ounces of protein, while the substitutions provided significantly less. The facility's food service staff, including the Assistant Food Service Manager and the Food Service Director, acknowledged the inadequacy of the protein content in the substitutions. The facility's policies and procedures required that substitutions should contain protein equivalent to the planned menu items, and the dietitian confirmed that the substitutions should have contained three ounces of protein. However, the sandwiches served did not meet these requirements, leading to a deficiency in providing adequate nutrition to the residents.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to adhere to a resident's care plan designed to prevent and treat pressure wounds, resulting in the development of facility-acquired pressure injuries for a resident identified as high risk. The resident, who had a history of hemiplegia, hemiparesis, congestive heart failure, vascular dementia, and other conditions, was noted to have developed a stage 3 pressure wound on the sacrum due to decreased mobility and incontinence. Despite interventions being outlined in the care plan, such as the use of pressure-relieving devices and regular repositioning, these measures were not fully implemented. Observations revealed that the resident did not have a low air loss pressure-relieving mattress in place, which was a critical component of the care plan. Interviews with staff, including a CNA, LPN, and the Director of Nursing, confirmed the absence of the necessary pressure-relieving mattress. The wound care nurse acknowledged missing the implementation of this intervention, and the DON admitted that the mattress should have been in place since the initial development of the pressure wounds. The facility's policy on pressure area prevention and treatment required the use of pressure-relieving devices for all stages of pressure wounds, yet this was not followed, contributing to the reopening of a previously healed wound and the development of a new pressure wound.
Medication Administration Errors
Penalty
Summary
The facility failed to adhere to its medication administration policy, resulting in a 9.09% medication error rate. In one instance, a staff member prepared and attempted to administer an extra, unauthorized medication to a resident, which was identified as irbesartan 75 mg, a blood pressure medication not prescribed to the resident. Additionally, the same staff member did not administer the full dose of a prescribed medication, polyethylene glycol, to the resident, despite the resident not refusing the medication. In another instance, a registered nurse administered a medication, empagliflozin 10 mg, to a resident after breakfast, contrary to the physician's order to administer it before breakfast. The facility's policy requires medications ordered to be given before meals to be administered approximately thirty minutes before mealtime. These actions demonstrate a failure to follow physician orders and the facility's medication administration policy, impacting two of the four residents reviewed for medication administration.
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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