Chateau Nrsg & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Willowbrook, Illinois.
- Location
- 7050 Madison Street, Willowbrook, Illinois 60521
- CMS Provider Number
- 145614
- Inspections on file
- 35
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Chateau Nrsg & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions fell off the bed during incontinence care, resulting in a femur fracture. The CNA involved turned the resident away from her, causing the fall. The facility lacked a specific policy on bed mobility, leading to inconsistent practices among staff. Other staff indicated the resident often required two-person assistance due to her weight and inability to assist in turning.
A resident with impaired cognition and a history of falls fell out of bed and sustained a forehead laceration requiring stitches after a CNA removed fall interventions to provide care. The CNA left the resident unattended to retrieve a mechanical lift sling, during which the resident fell. Staff interviews highlighted the need for fall mats and bolsters to be in place at all times, but the resident's care plan did not mention fall mats.
A resident with severe cognitive impairment was verbally abused by a CNA during a lunchtime incident, where the CNA used explicit language and threatened the resident. Despite being reported to the ADON and DON, the incident was not classified as abuse, violating the facility's abuse prevention policy.
A facility failed to report a verbal abuse incident involving a resident with severe cognitive impairment. A CNA used explicit language towards the resident during a dining room altercation. Despite staff witnessing and discussing the incident, it was not reported to the state agency as required. The DON sent the CNA home but did not classify the incident as abuse, leading to a deficiency in reporting.
A resident's personal gift check was improperly handled by the facility, as it was deposited into the resident's account for care costs without her consent. The resident, who is alert and oriented, was expecting a $500 gift check from the Policemen's Annuity and Benefit Fund of Chicago, which was not delivered to her. The facility's admission contract did not authorize handling of personal checks, yet the check was deposited into the transferring account. The facility issued a replacement check after the resident's inquiries.
The facility failed to maintain sanitary conditions in its kitchen, affecting food storage, preparation, and serving. Observations revealed improper use of the 3-compartment sink, incorrect sanitizer testing, and staff with long artificial nails. The walk-in cooler and freezer had unsanitary conditions, with food products improperly stored and freezer burnt. Staff did not adhere to hygiene practices, and facility policies on food storage and sanitation were not followed.
The facility failed to assist residents with personal hygiene, as observed in four residents with cognitive and physical impairments. Residents were found with unclean fingernails, food debris on clothing, and unshaven facial hair, despite care plans indicating the need for maximum assistance. The Director of Nursing acknowledged the expectation for staff to assist with ADLs, but these were not met, resulting in deficiencies.
The facility failed to follow the approved recipe for chef salad, resulting in residents receiving inadequate meals with only lettuce and minimal additional ingredients. Several residents expressed dissatisfaction, noting they were left hungry, and some filed grievances. The Dietary Director and Cook acknowledged the issue, but discrepancies in meal preparation persisted.
The facility failed to follow standard infection control practices during incontinence care and medication administration. CNAs and a nurse did not change gloves or perform hand hygiene between tasks, such as cleaning perineal areas, handling catheter bags, and administering medications via a g-tube. The facility's policy requires hand hygiene before and after glove use and between tasks to prevent infection.
Two residents with urinary catheters did not receive proper care, as CNAs failed to clean the catheter tubes and lifted urinary bags above the bladder, causing urine backflow. This was contrary to facility policy, which aims to prevent infections.
A nurse failed to check the placement of a gastrostomy tube (g-tube) before administering Hydrocodone-Acetaminophen to a resident, contrary to the care plan and medication administration record. The nurse admitted to forgetting this step, and the ADON confirmed the necessity of verifying g-tube placement by aspiration or auscultation to ensure proper medication delivery.
A resident with severe cognitive impairment and multiple diagnoses, including dementia, was not properly assessed or managed for pain during care. Despite moaning and showing signs of pain, CNAs continued applying hand splints without informing a nurse. A nurse later administered Morphine Sulfate, documenting a pain level of 10. The facility's policy emphasized pain assessment and management, which was not followed in this instance.
The facility failed to inform residents of their rights both orally and in writing. During a Resident Council meeting, residents expressed unawareness of their rights, and an Ombudsman found the display frame for rights empty. The Activity Director confirmed rights were not discussed in meetings, and the Administrator's claim of rights being posted was contradicted by their absence in common areas. Meeting minutes from the past year showed no discussion of resident rights.
Two residents experienced delays in receiving incontinence care, despite being cognitively intact and having care plans requiring frequent checks. One resident was left in soiled briefs for an extended period, while another was left wet for at least two hours. Staff failed to adhere to the facility's policy of checking residents every two hours, and there were ongoing issues with delayed response to call lights.
Failure to Prevent Resident Fall During Bed Mobility
Penalty
Summary
The facility failed to prevent a resident from falling off the bed during care, resulting in the resident sustaining a femur fracture. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including lack of coordination, morbid obesity, and muscle wasting. The resident required moderate assistance for bed mobility, and the incident occurred when a CNA attempted to change the resident's incontinence brief. The CNA turned the resident away from her, causing the resident's legs to fall off the bed, leading to the fall. The CNA involved in the incident stated that the resident was positioned closer to the right side of the bed rather than being centered. The CNA attempted to reposition the resident by turning her away, which resulted in the resident falling off the bed. The CNA acknowledged that the air mattress should have had bolsters to prevent such falls. Other staff members, including RNs and CNAs, indicated that the resident should have been pulled closer to the staff before being turned away to ensure safety. They also noted that the resident's weight and deconditioned muscles contributed to the risk of falling if not properly positioned. The facility lacked a specific policy regarding bed mobility, which contributed to inconsistent practices among staff. Several staff members reported that the resident often required two-person assistance for bed mobility due to her weight and inability to assist in turning. Despite this, the CNA involved in the incident attempted to provide care alone, which was contrary to the practices followed by other staff members. The absence of a clear policy and the failure to adhere to safe positioning practices led to the resident's fall and subsequent injury.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident at high risk for falls, resulting in the resident falling out of bed and sustaining a laceration to her forehead that required stitches. The resident, who has impaired cognition and a history of falls, was found by a CNA with her upper body out of the bed and her head on the floor after the CNA had removed the fall mat and bed bolsters to provide incontinence care. The CNA had left the resident unattended to retrieve a mechanical lift sling, during which time the resident fell. Interviews with staff revealed that the resident was known to be very active and at high risk for falls, requiring fall mats and bolsters to be in place at all times when in bed. The facility's policy on falls and fall risk monitoring emphasizes the need for staff to identify and implement interventions to prevent falls and minimize complications. However, the resident's care plan did not mention the use of fall mats, and the CNA did not have all necessary supplies ready before starting care, leading to the incident.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, violating its abuse prevention policy. The incident involved a resident with severe cognitive impairment who was verbally abused by a Certified Nursing Assistant (CNA) identified as V4. During a lunchtime incident, V4 removed the resident's tray, leading to a confrontation where the resident hit the tray, causing items to fall. V4 then verbally threatened the resident using explicit language, which was witnessed by other staff members, including a Registered Nurse (RN) and a Licensed Practical Nurse (LPN). Despite the incident being reported to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), the severity of the verbal abuse was not recognized or reported as such to the abuse coordinator. The DON sent V4 home for disruptive behavior but did not classify the incident as abuse. The facility's abuse prevention policy clearly states that residents have the right to be free from verbal abuse, which includes the use of disparaging and derogatory language. However, the failure to report and address the incident as abuse indicates a lapse in following the established policy.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not reporting a verbal abuse allegation involving a resident with severe cognitive impairment. The incident occurred when a CNA verbally abused the resident during a dining room altercation, using explicit language. Despite multiple staff members witnessing and discussing the incident, the verbal abuse was not reported to the state agency as required. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed, but the incident was not escalated appropriately, leading to a failure in reporting. The resident involved, who has vascular dementia, was unable to clearly recall the incident. Staff members, including RNs and LPNs, provided accounts of the event, indicating that the CNA used inappropriate language towards the resident. The DON sent the CNA home for being disruptive but did not classify the incident as abuse, resulting in a lack of formal reporting. The facility's abuse prevention policy allows employees to report directly to the state agency, but this was not utilized in this case, leading to a deficiency in the facility's handling of the situation.
Improper Handling of Resident's Personal Gift Check
Penalty
Summary
The facility failed to honor a resident's right to manage her financial affairs by improperly handling a personal gift check. The resident, who is alert and oriented, was expecting a $500 gift check from the Policemen's Annuity and Benefit Fund of Chicago, which she usually receives every Christmas. However, the check was not delivered to her, and after multiple follow-ups, it was discovered that the check had been deposited into the facility's account without her consent. The former Business Office Manager admitted that the check was deposited into the resident's trust fund account, which is used for care costs, rather than being given to the resident. The resident's daughter, who is also her Power of Attorney for medical decisions, confirmed that the facility was only entitled to deposit the resident's social security and pension checks for room and board, not personal checks like the one from the PABF. The facility eventually issued a replacement check to the resident after her inquiries. The facility's admission contract with the resident allowed for business mail to be directed to the business office, but personal mail was to be delivered to the resident. The contract did not authorize the facility to handle personal checks or other financial resources beyond the social security and pension checks. Despite this, the facility deposited the PABF check into the resident's transferring account, which was intended for care costs, without the resident's permission.
Unsanitary Food Handling and Storage Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, affecting the storage, preparation, and serving of food. During an inspection, it was observed that the 3-compartment sink used for washing, rinsing, and sanitizing dishes was improperly used, with dirty dishes found in the sanitizing sink. A dietary aide, V6, was unsure of how to properly test the sanitizer's strength and used incorrect test strips initially. Both V6 and another dietary aide, V7, were noted to have long artificial nails, which is against the facility's policy for handling food. Additionally, the high-temperature dish machine area was found to have grayish patches and food debris, and washed bowls were not stored properly, with some still containing food debris. The walk-in cooler and freezer were also found to be in unsanitary conditions. The cooler had open bowls of pudding, and the freezer had extensive ice buildup and debris, with food products improperly stored on the floor and covered in ice. Some of the frozen meat products were freezer burnt, and the administrator, V1, acknowledged the issue but stated that repairs were scheduled. A resident's power of attorney reported that residents were served inedible, freezer-burnt food, which was confirmed by the dietary director, V4, who admitted to using the compromised food items before discarding them. Further observations revealed that staff members, including V4, V5, and V10, did not adhere to proper hygiene practices, such as using hair restraints effectively. V4 was seen using a contaminated spatula during meal preparation, and both V5 and V10 had long dreadlocks that were not fully covered. The facility's policies on food storage, dishwashing, and personnel sanitation were not followed, contributing to the unsanitary conditions and potential food safety risks for the residents.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for residents who were identified as needing help with activities of daily living (ADLs). This deficiency was observed in four residents, each with varying degrees of cognitive impairment and physical limitations. The residents were found with unclean fingernails, food debris on clothing, and unshaven facial hair, indicating a lack of proper grooming and hygiene care by the staff. One resident with severe cognitive impairment and dementia was observed with black substances under her fingernails and food debris on her clothing. Despite being totally dependent on staff for ADLs, the resident's care plan was not adequately followed, resulting in poor personal hygiene. Another resident with chronic kidney disease and diabetes also exhibited long, jagged fingernails with black substances and food debris on her clothing, despite requiring maximum assistance for personal hygiene and dressing. Additional observations included a resident with cerebrovascular disease and dementia who had long facial hair and unclean fingernails, and another resident with Parkinson's disease and hemiplegia who expressed a desire for assistance with shaving and nail care. The facility's Director of Nursing acknowledged the expectation for staff to assist residents with ADLs to maintain dignity, comfort, and hygiene, yet these expectations were not met, leading to the identified deficiencies.
Failure to Follow Approved Recipe for Chef Salad
Penalty
Summary
The facility failed to ensure that the dietary staff followed the approved recipe for chef salad, affecting eight residents. The Spring/Summer 2024 menu specified a chef salad with turkey, ham, cheese, and other ingredients, but residents reported receiving only lettuce with minimal or no additional components like meat or cheese. This discrepancy was noted by several residents who expressed dissatisfaction with the meal, stating that it left them hungry and was not what they expected based on the menu. Interviews with residents revealed that they received a bowl of lettuce with little to no meat, cheese, or other expected ingredients. Some residents mentioned receiving a grilled cheese sandwich as an addition, but this was not part of the chef salad meal. The residents expressed their displeasure, with some filing grievances about the inadequate meal portions. A resident's family member even took pictures of the meal and considered escalating the issue to the media. The facility's staff, including the Administrator and Dietary Director, acknowledged the residents' complaints. The Dietary Director noted that the chef salad should have included turkey as the protein, and the Cook claimed to have followed the recipe, which included turkey, ham, cheese, and other ingredients. However, a CNA observed that the salad had less chicken and lacked other components like egg or cheese, leading to resident dissatisfaction.
Infection Control Deficiencies in Hand Hygiene and Gloving Practices
Penalty
Summary
The facility failed to adhere to standard infection control practices during the provision of incontinence care and medication administration, as observed in multiple instances involving certified nursing assistants (CNAs) and a nurse. In one instance, two CNAs provided peri-care to a resident without changing gloves or performing hand hygiene between tasks, such as cleaning the perineum, handling an indwelling urinary catheter bag, and straightening bed linens. Another CNA assisted a resident with toileting and incontinence care, but did not change gloves or perform hand hygiene after cleaning the resident's perineal area and before assisting the resident back to the wheelchair. Similarly, two CNAs provided incontinence care to another resident, failing to change gloves or perform hand hygiene between cleaning the perineum, changing bed linens, and handling a catheter bag. Additionally, a nurse administered medications via a gastrostomy tube to a resident without changing gloves or performing hand hygiene between tasks such as touching the bedside floor mattress, drawing the privacy curtain, and checking the placement of the g-tube. The facility's Director of Nursing confirmed that staff should perform hand hygiene before donning gloves, after contact with residents, and between different tasks to prevent infection. The facility's handwashing policy emphasizes the use of alcohol-based hand rubs when hands are not visibly soiled, particularly before and after putting on or removing personal protective equipment, and after contact with potentially contaminated objects.
Improper Catheter Care and Handling
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to potential risks of urinary tract infections. One resident, who had multiple medical diagnoses including Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, was observed with an indwelling urinary catheter. During peri-care, the Certified Nursing Assistants (CNAs) did not clean the catheter tube, and the urinary bag was lifted above the bladder, causing urine to flow back towards the bladder. This improper handling of the catheter and urinary bag was observed during the care process. Another resident, also diagnosed with BPH and a urinary tract infection, was observed with a suprapubic urinary catheter. During incontinence care, the CNAs failed to clean the catheter and lifted the urinary bag above the bladder, resulting in urine flowing back into the bladder. The Director of Nursing confirmed that the facility's policy requires the catheter tube to be cleaned near the insertion site and the urinary bag to be kept below the bladder to prevent backflow and potential infections.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to check the placement of a gastrostomy tube (g-tube) before administering medication to a resident. On August 7, 2024, a nurse administered Hydrocodone-Acetaminophen to a resident via g-tube without verifying the tube's placement, as required by the resident's care plan and medication administration record. The nurse flushed the g-tube with water before and after administering the medication but admitted to forgetting to check the tube's placement. The Assistant Director of Nursing confirmed that staff should check g-tube placement by aspiration of residual or auscultation with a stethoscope to ensure proper medication administration.
Failure to Manage Resident's Pain During Care
Penalty
Summary
The facility failed to recognize, evaluate, and manage a resident's pain during care. The resident, who had multiple diagnoses including senile degeneration of the brain and dementia, was severely impaired with cognition and required total assistance with activities of daily living. On a specific day, the resident was heard moaning from outside her room, and upon entering, it was observed that she was in bed, confused, and unable to verbalize pain. Two CNAs had just finished providing morning care and were unaware if the resident had received any pain medication prior to care. Despite the resident's increased moaning and apparent pain when her hand was touched to apply hand splints, the CNA continued with the application without informing the nurse. A registered nurse later assessed the resident and administered Morphine Sulfate for pain, documenting a pain level of 10. The resident's care plan indicated she was at risk for pain and included interventions such as monitoring non-verbal signs of pain and administering medications. However, there was no evidence that any pain medication was administered before the Morphine Sulfate. The Director of Nursing and a Nurse Practitioner both stated that the CNA should have stopped the application of the hand splints and informed the nurse to assess the resident for pain and administer appropriate medication before continuing with care. The facility's pain management policy emphasized the importance of assessing and managing pain, especially when residents are unable to describe it verbally.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to provide residents with both oral and written information regarding their resident rights. This deficiency was identified during interviews and record reviews, affecting 7 out of 10 residents reviewed in a sample of 25. The residents, who were mostly cognitively intact, reported during a Resident Council meeting that they were unaware of their rights and did not know where to find a list of them. An Ombudsman pointed out that the rights were supposed to be displayed on a wall in the dining room, but the frame was empty. Additionally, the Activity Director confirmed that resident rights had not been discussed during council meetings. The facility's Administrator stated that resident rights are included in the admission packet and posted in common areas such as dining rooms and hallways. However, during an inspection, the rights were not visible in the first-floor dining room or near the elevators. A review of the Resident Council meeting minutes from September 2023 to July 2024 showed no documentation that resident rights were discussed, indicating a lack of communication and reinforcement of these rights to the residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. The first resident, a cognitively intact individual with a history of pressure ulcers and incontinence, reported having a bowel movement at 10:00 a.m. but did not receive assistance until much later, despite using the call bell and expressing distress. The resident was left in soiled briefs for an extended period, which was confirmed by the presence of dry feces on the inner thighs when care was finally provided. The staff, including a Registered Nurse and Certified Nursing Assistants, failed to respond promptly to the resident's needs, and there was a lack of communication and coordination among the staff to address the resident's incontinence care in a timely manner. The second resident, also cognitively intact and with limited functional abilities, experienced a delay in receiving incontinence care. The resident was left wet for at least two hours before staff changed her briefs, despite being on diuretic medications and having a care plan that required frequent checks and care to prevent skin breakdown. The facility's policy required residents to be checked every two hours, but this was not adhered to, as evidenced by the resident's report and the staff's acknowledgment of the care schedule. Additionally, the facility had a history of grievances and resident council meeting notes indicating ongoing issues with delayed response to call lights and care needs, further highlighting the deficiency in providing timely incontinence care.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
