Community Care Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4314 South Wabash Avenue, Chicago, Illinois 60653
- CMS Provider Number
- 146164
- Inspections on file
- 37
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Community Care Nursing Center during CMS and state inspections, most recent first.
A resident with intact cognition and significant medical history was unable to access his monthly personal funds allowance in a timely manner, despite multiple requests to staff. The resident only received the funds after threatening to report the issue, and records confirmed that sufficient funds were available but not disbursed until late in the month, contrary to facility policy on resident rights.
A resident with cognitive impairment and significant physical limitations was physically assaulted by another resident with a known history of aggression, resulting in facial injuries. Staff intervened after the altercation began, but the facility did not effectively implement its abuse prevention policy to protect vulnerable individuals from harm.
The facility did not report an allegation of physical abuse between two residents to IDPH within the required timeframe and failed to submit the final investigation report within five business days. The incident involved a cognitively impaired male with multiple medical conditions who was assaulted by another male with a history of violent behavior, resulting in visible injuries and emergency medical care. Staff and leadership were aware of the incident, but reporting requirements were not met according to facility policy.
A resident with multiple chronic conditions and intact cognition was not assisted by staff in obtaining a Social Security card, despite repeated requests and attempts to arrange transportation. Staff were aware of the need but did not follow up or document any actions, resulting in the resident not receiving necessary identification for housing and financial assistance.
A resident with a history of violent behavior physically assaulted another cognitively intact resident in the dining room, causing pain and emotional distress. The LPN present noticed the aggressor's anxious behavior but did not intervene before the attack, and the facility failed to implement preventive measures despite the known risk. The incident resulted in the victim feeling humiliated, fearful, and depressed.
A resident experienced ongoing issues with cold water in their hand sink, resulting in uncomfortable bed baths. Staff and the resident confirmed the water temperature was below comfortable levels, and the facility lacked consistent monitoring, documentation, and a policy for water temperatures. Concerns reported by the resident and their emergency contact were not effectively resolved, and no water temperature logs or policy were provided to the surveyor.
The facility was found deficient in maintaining proper food storage and preparation standards. Ice build-up was observed in the walk-in freezer, and the food prep area was not adequately separated from the sanitization area. Additionally, improper drying practices were noted for kitchen equipment, violating the facility's policies on safe food handling.
The facility failed to implement Enhanced Barrier Precautions (EBP) correctly, with signs not posted on doors and PPE not accessible, leading to staff not using gowns and gloves as required. Residents with medical devices or wounds did not have EBP included in their care plans, and staff were unaware of the need for such precautions, increasing the risk of infection spread.
A facility failed to obtain a code status order for a resident with multiple health conditions, despite completing a POLST form. Interviews with staff indicated that the process involves obtaining a physician's order to document the resident's code status, but a review showed no such order was present, highlighting a lapse in following the facility's policy.
A resident with a history of falls and severe cognitive impairment was not provided with the prescribed non-slip socks, as per their care plan, leading to a fall and injury. The facility failed to update the care plan with new interventions after the fall, and staff were unaware of the necessary precautions. The Director of Nursing and MDS Coordinator acknowledged that the care plan was not revised, and the new intervention of one-to-one supervision was not documented.
A resident with multiple health conditions, including cachexia and diabetes, experienced significant weight loss due to the facility's failure to conduct a nutritional evaluation upon readmission. Despite the resident's poor appetite and multiple hospitalizations, the required assessment was not completed, leading to an 8.5% weight loss over a month. The facility's policy mandates such evaluations, but this was not adhered to, resulting in delayed nutritional intervention.
A facility failed to date and store a nebulizer mask for a resident, leading to potential contamination risks. The mask was observed undated and not in a plastic bag over several days. A nurse and the DON confirmed the expectation for proper storage to prevent infection. The resident had an active order for Albuterol Sulfate Nebulization Solution for shortness of breath, and facility policy requires labeled and dated storage of nebulizer equipment.
The facility failed to follow professional standards for medication management, including leaving medications at a resident's bedside, not dating an opened insulin vial, and improperly storing insulin. An LPN acknowledged the potential for administering expired insulin, and the DON confirmed that medications should not be left at the bedside without a doctor's order. These actions reflect a lapse in adhering to medication storage and administration protocols.
A resident expressed a desire for dentures, but the LTC facility failed to schedule a dental appointment despite a care plan intervention. Staff interviews revealed a lack of communication and follow-through, with no dental visit order in the resident's records. The facility's guidelines emphasize necessary dental services, but these were not effectively implemented, leading to the deficiency.
A resident with severe dysphagia was not provided with nectar-thick liquids as ordered by the physician, leading to coughing episodes. Observations showed that staff, including a CNA and an Activity Aide, failed to properly thicken the resident's drinks, indicating a lack of adherence to the facility's policies on therapeutic diets.
The facility did not follow its Antibiotic Stewardship Program, failing to develop a report for residents on antibiotics without active infection criteria and maintain accurate surveillance tracking. Four residents were prescribed antibiotics without documented symptoms, and their antibiotic use was not recorded. The IP and DON had conflicting accounts regarding testing protocols, leading to incomplete logs and unsupported antibiotic use.
The facility failed to administer influenza and pneumococcal vaccines to three residents who had consented, despite their eligibility due to medical conditions. The IP and DON confirmed that vaccines should be given promptly upon consent, but the facility did not follow its policy, resulting in missed vaccinations.
A resident's call light was found non-functional during a survey, and the issue had persisted since a storm two weeks prior. The resident, unable to leave bed independently, expressed distress over the inability to call for assistance. Staff interviews revealed a lack of communication and awareness about the broken call light, with the RN, CNA, DON, and Maintenance Manager all acknowledging the importance of functioning call lights but unaware of the specific issue. The call light remained unfixed the next day, leaving the resident dissatisfied.
The facility failed to provide and acquire medications as ordered, affecting two residents. One resident did not receive her COPD inhalers since admission, despite staff awareness. Another resident received insulin at an incorrect time, deviating from the prescribed schedule. The facility's medication administration policy emphasizes the importance of correct timing to prevent errors.
A resident with a history of elopement and multiple psychiatric disorders successfully eloped from the facility due to the failure to complete an elopement risk assessment, develop an elopement care plan, and provide adequate supervision. The resident was found two days later at his mother's home. Insufficient staff monitoring and an unsecured gate on the smoking patio contributed to the incident.
Delay in Resident Access to Personal Funds
Penalty
Summary
The facility failed to maintain a resident's right to timely access to personal funds, impacting one resident who was unable to support his wants and needs due to lack of financial resources. The resident, who has a history of type 2 diabetes and a kidney transplant and is cognitively intact, reported requesting his monthly allowance of $30 at the beginning of the month but was repeatedly told by staff that it was not available. Despite multiple requests to the activity staff, the resident did not receive his allowance until he threatened to report the issue to the State, at which point the funds were provided. Review of records showed that the resident's itemization indicated sufficient funds were available at the start of the month, but the receipt for the August allowance was dated much later in the month. The business manager confirmed that while itemization is handled by the corporate office, the actual disbursement date may differ from the recorded date. The activity director stated that funds are given to residents as soon as they are received from the business office, but acknowledged that the allowance for the month in question was not provided until late in the month. Facility policy affirms residents' rights to manage their own money, but this was not upheld in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to follow its abuse prevention policy, resulting in a resident with cognitive impairment and multiple medical conditions sustaining physical injuries. The resident, who required maximal assistance with activities of daily living and was unable to ambulate, was involved in a physical altercation with another resident known to have a history of violent behavior and psychotic disturbances. The incident took place in a common area, where the aggressive resident struck the vulnerable resident multiple times in the facial area, causing bruising and swelling to the right eye and face. Staff interviews and clinical records confirm that the aggressive resident had previously exhibited physical aggression toward other residents and staff, and was being monitored for such behaviors. During the incident, staff responded after hearing commotion and yelling, intervening to separate the residents. The injured resident was promptly sent for an emergency eye appointment, and the aggressor was placed on one-to-one monitoring and later transferred for psychiatric evaluation. However, the facility's abuse policy required identification and prevention of potential mistreatment, which was not effectively implemented in this case, as the aggressive resident was able to physically harm another resident. The investigation revealed that the administrator could not recall the details or outcome of the incident investigation, despite the abuse allegation being substantiated. Documentation showed that the facility had policies affirming residents' rights to be free from abuse and required timely investigation and reporting of such incidents. The failure to prevent the altercation and protect the resident from physical harm constituted a breach of the facility's abuse prevention policy.
Failure to Timely Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Program Policy by not reporting an allegation of physical abuse between two residents to the Illinois Department of Public Health (IDPH) within the required two-hour timeframe. The incident involved a cognitively impaired male resident with multiple medical conditions, including Parkinson's Disease and schizophrenia, who was physically assaulted by another male resident with a history of violent behavior and psychotic disturbance. The assault resulted in visible injuries, including a bruised and discolored eye, and required emergency medical attention. Staff present at the time of the incident separated the residents and notified facility leadership, but the initial report to IDPH was not submitted until ten days after the event. Additionally, the facility did not submit the final investigation report to IDPH within the mandated five business days. The administrator acknowledged the delay and indicated that the final report was not uploaded until more than a month after the incident. The facility's policy requires immediate reporting of abuse allegations and submission of the final investigation report within five working days, but these procedures were not followed in this case, as confirmed by interviews and record reviews.
Failure to Assist Resident with Access to Social Security Card
Penalty
Summary
The facility failed to assist a resident with communication and access to services, specifically in obtaining a Social Security card. The resident, who has multiple medical conditions including type 2 diabetes, chronic kidney disease, and bilateral below-knee amputations, was cognitively intact and expressed a clear need for his Social Security card to apply for housing and financial assistance. Despite the resident's repeated requests and attempts to arrange transportation to the Social Security office, facility staff did not provide the necessary assistance. Staff members acknowledged being aware of the resident's request but did not follow up or document any actions taken to help him obtain the card. Interviews with the Business Office Manager, Admissions Director, and Psychiatric Rehabilitation Services Coordinator revealed a lack of coordination and follow-through. The staff discussed the resident's need but failed to ensure he was assisted, either by phone or in person, and did not document any efforts or appointments related to his request. The facility's policy requires meeting with residents to resolve issues and providing resources to exercise their rights, but there was no evidence that these steps were taken in this case. The resident's progress notes did not reflect any assistance or scheduled appointments for obtaining the Social Security card.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to follow its abuse prevention policy, resulting in a resident being subjected to physical and mental abuse by another resident. The incident took place in the dining room, where one resident, who had a documented history of violent behavior and schizoaffective disorder, aggressively struck another resident multiple times in the head, face, and chest while she was seated. The staff member present, an LPN, was administering medications and noticed the aggressor's anxious and pacing behavior but did not remove him from the area or call for additional assistance, despite feeling that something was wrong. The attack was only interrupted after the LPN intervened by yelling and physically separating the residents. The resident who was attacked, a female with schizoaffective disorder and other medical conditions, reported experiencing pain, humiliation, fear, and emotional distress as a result of the incident. She described being shocked, scared, and embarrassed, and expressed ongoing fear of retaliation. The aggressor admitted to the attack, stating he was provoked by the victim's yelling and used physical force to make her stop. The incident was witnessed by staff, and the victim was observed to be crying uncontrollably and unable to answer questions immediately after the event. The facility's records indicate that the aggressor had a known history of physical aggression and inappropriate behaviors, including previous altercations with other residents and staff. Despite this, the staff did not take preventive measures to separate or closely monitor the resident prior to the incident, even when warning signs were present. The facility's abuse policy affirms residents' rights to be free from abuse, but the failure to act on observed behavioral changes and to ensure adequate supervision directly contributed to the occurrence of abuse.
Failure to Maintain Comfortable Hot Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain hot water at a comfortable level in a resident's hand sink, as observed and confirmed by both staff and the surveyor. The Maintenance Director received a complaint from a resident on the third floor regarding cold water in the hand sink, which was corroborated by the resident, who reported receiving cold bed baths and stated that the issue had persisted for three to four weeks. The Maintenance Director acknowledged that water temperatures were not consistently logged or monitored, and no temperature logs were provided to the surveyor. When the water temperature was measured in the resident's room, it was found to be 97.3 degrees Fahrenheit, which was described as cold by both the Maintenance Director and the resident. Further investigation revealed that the issue was not isolated to the resident's room, as the shower room on the same floor also had water temperatures at 97 degrees Fahrenheit. The Maintenance Director admitted to not keeping a log of water temperatures and only checking them sporadically as part of the water management program, without recording the results. The facility did not have a specific policy for water temperatures, and no documentation was provided to show regular monitoring or corrective actions taken in response to the complaints. Interviews with staff and the resident's emergency contact confirmed that concerns about cold water and inadequate bathing had been reported but not resolved to the satisfaction of the resident or their family. Maintenance requests and concern forms documented the ongoing issue, but there was no evidence of timely or effective resolution. The lack of consistent monitoring, documentation, and policy regarding water temperature contributed to the deficiency in providing a safe and comfortable environment for residents.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards, as evidenced by several observations during a survey. In the walk-in freezer, there was significant ice build-up on the condenser, food boxes, metal shelves, and the floor, which was attributed to the freezer door being left open by a cook. This condition violates the facility's policy on refrigerator and freezer maintenance, which requires regular inspections and immediate repairs for any maintenance needs. Additionally, the food preparation area was not adequately separated from the sanitization area, as observed when a cook was slicing potatoes next to buckets filled with soapy solutions, which were part of the sanitation process. Further deficiencies were noted in the dishwashing and drying process. After pureeing bread, a cook rinsed the blender container and blade, ran them through a high-temperature dishwasher, and then used a paper towel to dry the inside, leaving liquid residue. This practice contradicts the facility's policy that requires items to air-dry after washing. Similarly, a metal pan used for pureed potatoes was not properly dried before use. These practices were inconsistent with the facility's food preparation policy, which mandates that food be prepared in a manner that complies with safe food handling practices.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement Enhanced Barrier Precautions (EBP) for several residents, as observed during a survey. Signs indicating EBP were not posted on the doors of residents' rooms, but rather above their beds, which led to confusion among staff and residents. For instance, a resident with a gastric feeding tube had the EBP sign over her bed instead of the door, and another resident with a wound had an outdated sign from a previous resident. Additionally, personal protective equipment (PPE) was not readily accessible, as the PPE carts were located far from the residents' rooms, making it inconvenient for staff to use them when needed. The facility also failed to include EBP in the comprehensive care plan for a resident with an indwelling urinary catheter. There was no order for EBP in place for this resident, and the staff was unaware of the need for such precautions. The lack of signage and accessible PPE contributed to the staff not consistently using gowns and gloves when providing care, which is a requirement under the facility's policy for residents with indwelling medical devices or wounds. Furthermore, another resident on reverse isolation due to IV access did not have appropriate signage or PPE supplies near the room. The resident reported that nurses were not using disposable gowns when administering IV antibiotics. These deficiencies highlight a systemic issue in the facility's infection prevention and control program, as staff were not following the established protocols for EBP, potentially increasing the risk of infection spread.
Failure to Obtain Code Status Order for Resident
Penalty
Summary
The facility failed to adhere to its policy regarding obtaining a code status order from a prescriber for a resident, identified as R45, who was reviewed for advance directives. The resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disease, hypertensive heart disease, type 2 diabetes mellitus, and several other serious health conditions. Despite the completion of a POLST (Practitioners Order for Life Sustaining Treatment) form, the facility did not secure a corresponding code status order from the physician, which is crucial for guiding staff during emergencies. Interviews with the Director of Nursing and the Psychiatric Rehabilitation Services Director revealed that the facility's process involves assisting residents or their representatives in completing the POLST form and then obtaining a physician's order to document the resident's code status in their health record. However, a review of R45's physician order sheet showed no code status order, indicating a lapse in following the facility's POLST policy. This oversight could potentially impact the care provided to the resident during an emergency, as staff would be unaware of the resident's resuscitation preferences.
Failure to Update and Implement Fall Care Plan Interventions
Penalty
Summary
The facility failed to adhere to the fall care plan interventions for a resident identified as R204, who had a history of falls and was at high risk for further incidents. R204 was admitted with multiple diagnoses, including seizures, epilepsy, repeated falls, and severe cognitive impairment. Despite being identified as high risk for falls, the care plan interventions, such as ensuring the resident wore non-skid socks, were not consistently followed. On one occasion, R204 was observed wearing regular socks instead of the prescribed non-slip socks, which was contrary to the care plan. The deficiency was further compounded by the facility's failure to update the care plan after R204 experienced a fall resulting in a fractured right femur. Although the care plan was supposed to be revised with new interventions after the fall, it remained unchanged, continuing with the same interventions that were in place before the incident. The Director of Nursing acknowledged that no changes were made to the care plan interventions after the fall, and the new intervention of one-to-one supervision was not documented in the care plan. Interviews with staff revealed a lack of awareness and communication regarding the specific interventions required for R204. A CNA was unaware of the need for non-slip socks, and the LPN incorrectly stated that no special socks were needed. The Director of Rehabilitation confirmed that R204 should be wearing non-slip socks due to the resident's impulsivity and high fall risk. The MDS Coordinator, responsible for updating care plans, confirmed that the interventions had not been updated following the fall, highlighting a breakdown in the facility's process for reviewing and revising care plans as required by their policies.
Failure to Conduct Nutritional Evaluation on Readmission
Penalty
Summary
The facility failed to perform a nutritional evaluation upon readmission for a resident, identified as R45, who experienced significant weight loss. R45 was admitted with multiple health conditions, including chronic obstructive pulmonary disease, type 2 diabetes, and cachexia, among others. Observations noted that R45 appeared underweight, with a protruding collarbone, and had a BMI of 16, indicating an underweight status. Despite eating 75% of his meals, R45 had a significant weight loss of 8.5% over the last month, with his weight dropping from 101.9 lbs in June to 93.2 lbs in July. The facility's policy required a nutritional evaluation upon readmission, which was not completed for R45 in June, contributing to his continued weight loss and hospitalization due to poor appetite and malnutrition. The Director of Nursing acknowledged the importance of referring residents with weight loss to a dietician for evaluation. However, the Registered Dietician, who worked remotely, confirmed that a nutritional assessment was not conducted upon R45's readmission in June, despite multiple hospitalizations. The dietician admitted responsibility for the oversight, noting that coverage was in place during her absence. The facility's policy mandates nutritional evaluations for new admissions, readmissions, and significant changes, but this was not adhered to in R45's case, as evidenced by the lack of a documented evaluation in June. This oversight led to a delay in addressing R45's nutritional needs, contributing to his significant weight loss and subsequent health issues.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to properly date and store a nebulizer mask for a resident, identified as R103, which was observed by a surveyor to be left undated and not stored in a plastic bag when not in use. This observation was made over several days, from July 30 to August 2, 2024. A registered nurse, V6, acknowledged that the nebulizer mask should be dated and stored in a plastic bag to prevent contamination and potential infection. The Director of Nursing, V2, confirmed the expectation that nebulizer masks should be dated and stored properly to prevent infection, noting that undated equipment could lead to uncertainty about when it was last changed, increasing infection risk. R103 had an active physician order for Albuterol Sulfate Nebulization Solution to be administered every four hours for shortness of breath. The facility's policy on nebulizer mist therapy, dated March 2021, requires that nebulizer equipment be stored in a labeled and dated plastic bag.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for medication management, resulting in several deficiencies. During an inspection, a surveyor observed that a multi-dose vial of Humulin R Insulin for a resident was opened and undated, contrary to the facility's policy which requires dating upon opening. This oversight was acknowledged by an LPN, who noted that the lack of dating could lead to the administration of expired insulin, potentially reducing its effectiveness. Additionally, an unopened vial of Lantus Insulin was found stored improperly in a medication cart instead of being refrigerated as recommended by the pharmacy. The LPN confirmed that the insulin should have been refrigerated to maintain its potency, as per the pharmacy's instructions. Another deficiency was noted when three unidentified pills were found at a resident's bedside. The DON confirmed that medications should not be left at the bedside without a doctor's order, and the RN on duty could not identify the pills, stating that the resident's scheduled morning medications had already been administered in the dining room. The facility's policy mandates that medications be stored securely and not left unattended, highlighting a lapse in following established procedures. These incidents reflect a failure to comply with medication storage and administration protocols, potentially compromising resident safety.
Failure to Provide Dental Care Services
Penalty
Summary
The facility failed to provide dental care services to a resident, identified as R20, who expressed a desire to obtain dentures. Despite having a care plan intervention dated January 28, 2024, to coordinate dental care arrangements, R20 had not been scheduled for a dental appointment. The resident mentioned that someone at the facility had promised to make an appointment with a dentist, but this had not occurred. Upon review of R20's electronic health record, it was confirmed that there was no order for a dental visit, although the care plan included an intervention to coordinate dental care as needed. Interviews with facility staff, including a Registered Nurse, the Minimum Data Set/Care Plan Coordinator, and the Director of Nursing, revealed a lack of communication and follow-through regarding R20's dental care needs. The Director of Nursing acknowledged the absence of a dental appointment and later entered an order for R20 to be seen by an outside clinic. The facility's guidelines and policies emphasize the importance of providing necessary dental services and maintaining a person-centered care plan, yet these were not effectively implemented in R20's case, leading to the deficiency.
Failure to Follow Physician's Orders for Nectar-Thick Liquids
Penalty
Summary
The facility failed to follow physician's orders for a resident with a medical diagnosis of moderate to severe oropharyngeal dysphagia, which required a pureed diet with nectar-thick liquids to prevent aspiration. Despite the documented orders, the resident was served thin liquids on multiple occasions. During an observation, a CNA provided the resident with a thin consistency pink lemonade, which caused the resident to cough. The CNA admitted to not having stirred the thickener into the drink before serving it. Additionally, the CNA was unsure of the exact consistency required for the resident's liquids. Further observations revealed that an Activity Aide also failed to thicken the resident's coffee to the required nectar consistency, as the aide did not measure the thickener and was unaware of the specific liquid consistency needed. The facility's Director of Nursing stated that nurses are responsible for thickening liquids, but CNAs and aides can do it if trained. However, the Activity Director indicated that activity aides should inform nurses to thicken the liquids, as they are not CNAs. The facility's policies require that therapeutic diets, including altered consistency, be provided as per the physician's orders.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program by not developing a report for the number of residents on antibiotics that did not meet criteria for active infection and by failing to maintain accurate surveillance tracking. Specifically, the facility's Infection Control Log from January 1, 2024, to July 23, 2024, revealed that four residents were prescribed antibiotics without documented signs or symptoms of an active infection. These residents were tested for urinary bacterial growth upon admission, and despite the absence of symptoms, they were prescribed antibiotics. The organism causing the bacterial growth was not documented, and their antibiotic use was not recorded on the facility's surveillance tracking log. The Infection Preventionist (IP) and Director of Nursing (DON) provided conflicting accounts regarding the protocol for ordering urinary tests and cultures upon admission. The IP stated that they were instructed by nursing administration to conduct these tests on all admissions, while the DON was unaware of such a directive and emphasized the need for symptoms before testing. This miscommunication and lack of adherence to the established criteria for testing and antibiotic prescription led to the deficiency, as the facility's logs were incomplete and did not reflect the necessary information to support the use of antibiotics in these cases.
Failure to Administer Vaccinations as Consented
Penalty
Summary
The facility failed to adhere to its Influenza and Pneumococcal Immunization policy, resulting in three residents not receiving their vaccinations as consented. Resident 5 consented to both the influenza and pneumococcal vaccines on January 17, 2024, but did not receive either vaccine. Despite having a diagnosis of type II diabetes, heart disease, and chronic obstructive pulmonary disease, which made him eligible for the pneumococcal vaccine, there was no documentation of the vaccines being administered or any contraindication provided by the attending physician. Similarly, Resident 11 consented to both vaccines on February 16, 2024, but there was no record of administration in his clinical records. Resident 46, who consented to the pneumococcal vaccine on February 3, 2024, also did not receive the vaccine despite being eligible due to his diagnoses of type II diabetes and hypertensive heart disease. The Infection Preventionist (IP), who began tracking vaccinations in April 2024, was unaware of the missed vaccinations and stated that vaccines should be administered within one to two days of receiving consent. The Director of Nursing confirmed that vaccines are offered upon admission and should be administered promptly once consent is given. The facility's policy, dated October 2020, mandates offering the pneumococcal vaccine to eligible residents and requires documentation of any medical contraindications by the attending physician. However, the facility failed to follow these procedures, leading to the oversight in administering the vaccines to the residents.
Resident's Call Light Malfunction Unaddressed
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning, which was observed during a survey. The resident, identified as R22, was found lying in bed with a non-functioning call light. R22 reported that the call light had been broken since a storm occurred two weeks prior and that staff were aware of the issue. R22, who is unable to get out of bed independently, expressed distress over the inability to call for assistance, stating that they had to wait for staff to check on them. The resident also mentioned being wet and unhappy due to the non-functioning call light. Staff interviews revealed a lack of communication and awareness regarding the broken call light. A registered nurse (RN) confirmed the call light was not working and acknowledged the potential risk of skin breakdown due to the resident's inability to communicate needs. A certified nursing assistant (CNA) emphasized the importance of a functioning call light for resident safety and identified potential risks such as falls and emotional distress. The Director of Nursing (DON) stated that it is expected for staff to ensure call lights are operational and expressed unawareness of the issue. The Maintenance Manager also noted the critical nature of call lights but was not informed of the malfunction. Despite these acknowledgments, the call light remained unfixed the following day, leaving the resident dissatisfied.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide and acquire medications as ordered by the doctor to meet the needs of each resident, specifically affecting two residents. One resident, admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD), reported not receiving her prescribed inhalers (Symbicort and Albuterol) since admission. Despite being aware of the issue, the facility staff did not ensure the availability of these medications, which are crucial for managing her COPD. The resident expressed having constant mucus in her lungs and occasional breathing problems, although she was observed breathing easily at the time of the survey. Another resident, with a history of Type 2 diabetes mellitus and other chronic conditions, was administered Humulin R insulin at an incorrect time, deviating from the prescribed schedule. The Director of Nursing acknowledged that medications should be administered as prescribed, following the 5 R's of medication administration. The facility's medication administration policy also emphasizes the importance of adhering to the correct timing to prevent medication errors. The failure to provide timely and available medications as ordered could potentially lead to adverse reactions or unmet medical needs for the residents.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to complete an elopement risk assessment, develop and implement an elopement care plan, and provide a secure physical environment for a resident with a known history of successful elopement. This resulted in the resident eloping from the facility without staff awareness. The resident was found two days later at his mother's home. The resident had a history of Major Depressive Disorder, Paranoid Schizophrenia, Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Delusional Disorders, Bipolar Disorder, and Hallucinations, and was cognitively intact with a BIMS score of 15. Despite being identified as high risk for elopement, the elopement risk assessment and care plan were only completed after the resident had already eloped. The incident note documented that the resident was last seen going for a smoke break, and staff were unable to locate him afterward. The facility initiated a missing person protocol and notified 911, but the resident was not found until two days later at his mother's home. Interviews with staff revealed that there were insufficient staff members monitoring the smoking patio, and the gate on the patio was not secure, which allowed the resident to elope. Staff members acknowledged that there should have been at least three staff members on the patio during smoking breaks to ensure resident safety. The facility's elopement policy required residents to be evaluated for elopement risk on admission and throughout their stay, but this was not followed in the case of the resident. The resident's history of elopement from a previous facility was known, but appropriate measures were not taken to prevent a similar incident from occurring at this facility.
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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