Complete Care At Margate Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4920 North Kenmore, Chicago, Illinois 60640
- CMS Provider Number
- 145881
- Inspections on file
- 54
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Complete Care At Margate Park during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities sustained a full thickness burn on the leg while unsupervised. Staff were unaware of how the injury occurred, and the incident was not reported or investigated as required by policy. The facility failed to provide adequate supervision and did not follow procedures for reporting and investigating injuries of unknown origin.
A resident with severe cognitive impairment and multiple chronic conditions sustained a significant burn of unknown origin. Facility staff documented the injury but did not notify the resident's representative until nearly two weeks later, despite policy requiring prompt notification. The delay was confirmed by staff interviews and absence of documentation in the health record.
A resident with multiple chronic conditions and cognitive impairment sustained a severe full-thickness burn of unknown origin. Staff observed and documented the injury, but the DON was not notified, and no investigation or report to the State was initiated as required by facility policy. The incident was not reported or investigated until much later, despite clear procedures mandating immediate action for injuries of unknown origin.
A resident with multiple comorbidities and severe cognitive impairment sustained a full-thickness burn of unknown origin. Staff observed the injury and provided wound care, but no immediate investigation or State report was initiated as required by facility policy. The DON and administrator confirmed that the incident was not reported or investigated until prompted by surveyors.
The facility did not ensure that a resident was protected from abuse, punishment, or neglect by any individual, resulting in a deficiency related to resident safety and well-being.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, as evidenced by insufficient demonstration of required skills and knowledge to meet residents' individualized needs.
A resident with a known history of violent behavior physically assaulted another resident in the dining room, resulting in a facial bruise and hospital evaluation. Staff, including an LPN and CNA, were present but unable to prevent the attack. The incident was substantiated as abuse, and both residents were sent to the hospital.
The facility did not provide timely, approved x-ray services and did not have an agreement with an approved provider to obtain them, resulting in a deficiency.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with cognitive impairment, seizure history, and moderate fall risk was left unsupervised in the dining room during a busy meal period when all CNAs were occupied elsewhere. The lack of supervision led to the resident attempting to rise from a wheelchair, resulting in a fall, head laceration, and subsequent hospitalization. Facility policies required continuous supervision, but staff failed to ensure coverage in the dining area.
Two residents experienced abuse: one was physically struck by another resident during a dispute in an elevator, and another was verbally abused with derogatory language by a receptionist during a disagreement in the lobby. Both incidents were witnessed by staff, confirmed through interviews and facility documentation, and found to be substantiated cases of abuse according to facility investigations.
A resident with multiple complex medical conditions and intact cognition was subjected to verbal abuse by a staff member during a late-night altercation. Although the incident was witnessed by several staff, internal communication delays and the unavailability of key personnel led to the abuse report being submitted to the state agency well beyond the required two-hour window, in violation of facility policy and state regulations.
A resident was twice petitioned for involuntary hospital admission without adequate documentation or substantiation of the behaviors cited as justification. Staff cited medication refusal and alleged aggressive behaviors, but records lacked supporting notes and staff interviews revealed inconsistencies regarding the events described.
The facility failed to maintain accurate and consistent medical records for two residents, including discrepancies between physician orders, MAR, and controlled substance documentation for one resident, and unsupported behavioral documentation in petitions for involuntary hospital admission for another. Staff interviews confirmed that required documentation was either missing or not based on direct observation.
A resident with multiple diagnoses and a recent functional decline was not provided with individualized fall interventions after a significant change in condition. Despite being at high risk for falls and requiring substantial staff assistance, only standardized fall prevention measures were in place. The resident was able to ambulate unassisted, leading to a fall and head injury, as staff were not adequately informed of the resident's fall risk or the need for specific interventions.
A resident in an LTC facility did not receive their blood pressure medication as ordered on multiple occasions. The resident, who is non-verbal, reported that an LPN attempted to crush their medication, leading to refusal. The LPN did not notify the physician or check the resident's blood pressure, which is consistently high. The facility's policy requires physician notification for medication refusals, which was not followed.
A facility failed to maintain effective pest control, resulting in cockroach sightings in resident rooms. A resident, who is aphasic, reported seeing roaches, confirmed by staff and other residents. The Maintenance Director stated pest control visits weekly, but cockroaches are still seen. The facility's policy emphasizes cleanliness, yet the presence of pests indicates a lapse in maintaining a safe environment.
The facility did not update fall care plans for two residents after fall incidents, contrary to its Fall Prevention Program policy. One resident had multiple falls without timely care plan revisions, and another resident's care plan was updated only after a delay. Interviews confirmed that care plans should be updated after each fall, but this protocol was not followed.
A resident at moderate risk for falls fell in the washroom after waiting over 15 minutes for assistance that never arrived. Despite requiring partial to moderate assistance, the resident attempted to transfer independently, resulting in a fall. Staff interviews revealed that call lights were not answered promptly, contrary to the facility's Fall Prevention Program, which mandates timely responses and assistance for residents at risk of falling.
A resident with bilateral below-knee amputations did not receive consistent restorative therapy, as required by the facility's policy. Despite being cognitively intact and expressing a desire for therapy, the resident reported only receiving three therapy sessions over three months. Staff shortages and errors in documentation contributed to the inconsistency, placing the resident at risk of not maintaining their highest practical level of function.
A facility failed to provide enough restorative nurse aides, causing a resident to miss multiple therapy sessions over 90 days. The resident, who uses a prosthesis, reported losing strength due to inconsistent therapy. Staffing shortages led to restorative aides being pulled to assist CNAs, disrupting the restorative program. The facility's schedule confirmed the shortage, with only one aide working on certain days.
A resident with severe cognitive impairment and multiple medical conditions was found with a large bruise on her thigh, diagnosed as a hematoma, after being restrained by staff during care. Despite the resident's protests, staff continued care without documenting refusal, contrary to facility policy. The facility's policies emphasize residents' rights to be free from abuse, but staff actions were inconsistent with these guidelines.
A resident with severe cognitive impairment and high fall risk experienced multiple falls due to inadequate supervision at an LTC facility. Despite the Care Plan requiring one-on-one monitoring, staffing issues led to a lack of proper oversight, resulting in serious injuries. The facility's failure to adhere to fall prevention policies and the resident's Care Plan contributed to these incidents.
A resident with schizoaffective disorder and other conditions received psychotropic medication without documented informed consent, despite a previous refusal. The ADON claimed verbal consent was given but lacked documentation, violating the facility's policy requiring signed or witnessed verbal consent.
A resident with severe cognitive impairment was found with a bruise on her thigh, which was not reported to the state survey agency by the facility. The CNA noticed the bruise but delayed reporting it, and the DON and administrator did not consider it abuse. The resident's daughter raised concerns, leading to a hospital visit where elder abuse was diagnosed. The facility's policy mandates immediate reporting of such incidents, which was not followed.
A facility failed to investigate an allegation of injury of unknown origin involving a resident with a large bruise on her thigh, which was reported by her daughter as potential elder abuse. The DON did not see the bruise before the resident was sent to the hospital, and the Administrator attributed the bruise to the resident's behavior, neglecting to investigate as required by the facility's abuse prevention policy.
A resident experienced multiple falls due to inaccurate fall assessments, which failed to reflect their need for substantial assistance and use of furniture for support. Despite severe cognitive impairment and a history of falls, the assessments did not align with the resident's care plan, which indicated a high risk for falls and required extensive assistance for mobility.
A resident with vascular dementia and cognitive impairments left an LTC facility unsupervised due to a lack of a physician pass privilege order. The resident got lost in the community and returned late at night. Staff interviews revealed communication lapses and failure to follow the facility's policy on pass privileges, contributing to the incident.
A resident's clothes went missing due to the facility's failure to document personal belongings upon admission. The resident, with conditions like cerebral palsy and reduced mobility, reported seeing others wearing their clothes. The facility's policy requires CNAs to inventory and label belongings, but this was not done, and the laundry department does not track unlabeled items. The DON confirmed the lack of an initial inventory list, and complaints were noted in resident council meetings.
A facility failed to schedule a cataract surgery for a resident, leading to continued visual difficulties. The resident, who is cognitively intact, had been waiting for nearly six months for the surgery. Additionally, two other residents missed doctor's appointments due to the facility's failure to provide necessary escorts and transportation. The facility's policy requires follow-up with physicians to ensure appointments are scheduled, but this was not done.
A resident with anxiety and PTSD reported discrepancies in the administration of Lorazepam, a psychotropic medication. The facility's records showed administration on certain dates, but these were not documented in the MAR. Interviews with the DON and LPNs revealed lapses in documentation, contrary to facility policy requiring narcotics to be signed out in the EHR and narcotic sheet.
The facility failed to implement a policy on strip searches, leading to two residents feeling humiliated and violated after being subjected to such searches. Both residents, who were cognitively intact, reported feeling coerced and exposed during the searches conducted by facility staff, despite no contraband being found.
A facility failed to investigate an alleged abuse incident involving a resident and a dietary aide in an elevator. Despite reports of the incident, no formal investigation or interviews were conducted with the involved parties. The Director of Nursing and Administrator did not take necessary steps to gather all sides of the story, resulting in a deficiency in the facility's response to the alleged abuse.
A resident with a history of opioid dependence tested positive for illegal drug use, but the facility failed to develop and implement a care plan addressing this issue. Despite the facility's policy requiring comprehensive care plans, the resident's plan was not updated to reflect their current needs after testing positive for cocaine, marijuana, and methadone.
A resident experienced a significant delay in receiving a necessary tongue biopsy due to a lack of coordination between the facility's staff and external medical providers. Despite multiple attempts to schedule the procedure, the biopsy was not completed in a timely manner, delaying critical diagnosis and treatment.
The facility failed to report an abuse incident involving two residents to IDPH within the required timeframe. One resident pushed another during an altercation, and the incident was reported the next day instead of within two hours. The final report was also submitted late, eight days after the incident, contrary to the five-business-day requirement.
The facility failed to ensure call lights were within reach for two residents, leading to their inability to contact staff when needed. One resident with moderate cognitive impairment and another with intact cognition but dependent on staff for transfers were both unable to reach their call lights, which were either hanging behind the bed or tangled with bed remote wires. Staff interviews confirmed the expectation that call lights should be accessible, aligning with the facility's policy.
The facility failed to document post-surgical wound assessments for two residents, including one whose surgical wound was not monitored after stitch removal. Interviews revealed confusion among staff about responsibilities, and the Wound Director noted the absence of a 'monitor wound order' for one resident. The facility's policy required documentation of wound care activities, which was not adhered to.
Two residents experienced delays in receiving therapy services due to the facility's process of obtaining administrative approvals for Medicaid patients. Therapy orders for a resident were placed, but occupational therapy was delayed by over a month, while another resident's physical therapy evaluation was delayed by nearly two weeks. The facility's policy required therapy assessments within 48 hours, which was not met, leading to dissatisfaction among residents.
A resident with a history of opioid dependence and mental disorders was involuntarily discharged to a hospital after becoming verbally aggressive when their community pass was revoked. The facility failed to document that the resident was notified of the reason for the transfer or discharge, as required by policy. The resident's progress notes lacked documentation of the necessary 30-day notice for involuntary discharges in April and June.
A resident with a history of opioid dependence and mental disorders was involuntarily discharged from the facility without receiving the required Bed Reserve Notification. The resident exhibited aggressive behavior towards the Social Service Director after being informed of the revocation of his community pass. Despite facility policies mandating written notice of a 10-day bed hold period during transfers, no documentation was found indicating that the resident was informed, resulting in a deficiency.
A resident with a history of opioid dependence and mental disorders was not allowed to return to the facility after hospitalization, despite the facility's bed-hold policy. The resident was involuntarily discharged following aggressive behavior towards the Social Service Director. The facility did not document the discharge notice properly and did not coordinate with the hospital regarding the resident's status, ultimately deciding not to accept the resident back based on legal advice.
A resident with a history of stroke and diabetes did not receive prescribed medications, including insulin, as documented in the MAR. The resident's blood pressure and blood sugar levels were uncontrolled, and the facility failed to notify the physician as required by policy. The DON acknowledged the need for physician notification but was unsure if it occurred.
Failure to Provide Adequate Supervision Resulting in Resident Burn Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision for a resident, resulting in the resident sustaining a full thickness burn on his left leg with a surface area of 136.90 cm^2. The incident was discovered when a staff member noticed the burn during a routine activity and sent the resident back to his floor. Multiple staff interviews revealed that no one knew how or when the injury occurred, and the resident, who is nonverbal and has severe cognitive impairment, was able to move independently between floors using the elevator without direct supervision. The resident's medical history included deafness, type 2 diabetes mellitus, hypertensive heart and chronic kidney disease, and chronic systolic heart failure. Documentation showed that the resident had severely impaired cognitive skills for daily decision making and memory problems. Despite these vulnerabilities, staff were unclear about the resident's whereabouts and level of supervision at the time of the injury. The wound was described as severe and required specialized wound care. Facility leadership, including the DON and administrator, were not notified of the injury in a timely manner, and no investigation or report to the State was initiated as required by facility policy. The injury was classified as of unknown origin, which should have triggered an abuse investigation and mandatory reporting. Staff interviews confirmed that the resident was not adequately supervised, and the facility failed to follow its own policies regarding accident prevention, supervision, and incident reporting.
Failure to Timely Notify Resident Representative of Injury
Penalty
Summary
The facility failed to notify a resident's representative of an injury of unknown source in a timely manner. On the day of the incident, a staff member observed the resident with a significant burn on his leg and directed him to return upstairs. The agency RN on duty documented the injury in the progress notes but did not contact the family. Interviews with staff confirmed that there was no immediate notification to the resident's family or representative regarding the injury, and review of the electronic health record showed no documentation of family notification at the time of the incident. The resident involved had multiple complex medical diagnoses, including type 2 diabetes mellitus, chronic kidney disease, and congestive heart failure, and was noted to have severely impaired cognitive skills. The wound was later evaluated as a full-thickness burn, and the family was not notified until 13 days after the injury, when consent was needed for a surgical debridement. Facility policy requires prompt notification of a resident's representative in the event of an injury, but this was not followed, as confirmed by staff interviews and record review.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the reporting and investigation of an injury of unknown origin for one resident. On the day of the incident, a staff member observed a significant burn on the resident's leg and sent the resident upstairs, noting that the injury could not have occurred in the patio area. The agency RN who received the resident upstairs cleaned the wound, informed the incoming nurse, and stated she notified the DON before leaving. However, the DON later reported not being notified of the injury and confirmed that no investigation or report to the State was initiated at that time. The resident in question had multiple complex medical diagnoses, including type 2 diabetes, chronic kidney disease, and heart failure, and was cognitively impaired. Documentation showed that the injury was a full-thickness burn of significant size, described as severe by the wound care doctor. The injury was first documented in a progress note as a skin tear, and a subsequent wound evaluation confirmed the extent of the burn. Despite the seriousness of the injury and the facility's policy requiring immediate reporting and investigation of injuries of unknown origin, no such actions were taken until much later. Interviews with facility staff, including the new administrator and DON, revealed a lack of awareness and follow-through regarding the required reporting and investigation procedures. The administrator acknowledged that the injury was not reported or investigated as required by policy and federal regulations. Additionally, an email from the administrator indicated no reportables for injury of unknown origin in the relevant period, further confirming the failure to report this incident. The facility's own policy mandates immediate reporting of such events to the State and other authorities, which was not followed in this case.
Failure to Investigate and Report Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source sustained by a resident, as required by policy and regulation. On the day of the incident, a staff member observed a significant burn on the resident's leg when the resident came to the dining room for a scheduled activity. The staff member immediately sent the resident upstairs and noted that the injury could not have occurred in the patio area. Despite this observation, the staff member was not interviewed about the incident at the time, and no immediate investigation was initiated. A registered nurse on duty at the time recalled seeing the injury when the resident was brought upstairs and provided initial wound care. She reported the injury to the incoming nurse and the DON before leaving her shift. The wound was later evaluated by a wound care physician, who determined it to be a full-thickness burn with severe pain and significant size. Despite the seriousness of the injury and the facility's policy requiring immediate investigation and reporting of injuries of unknown origin, the DON stated she was not notified of the injury and no investigation or report to the State was made at the time. The facility's policy defines injuries of unknown source as potential abuse and mandates immediate investigation and reporting. However, the administrator and DON both confirmed that the injury was not reported or investigated as required. The resident involved had multiple complex medical conditions, including diabetes, heart failure, and chronic kidney disease, and was noted to have severely impaired cognitive skills, making thorough investigation and protection particularly important. Documentation showed that the injury was only reported to the State and investigated after the issue was raised during the survey.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. This deficiency indicates that there was an incident or observation where a resident was not safeguarded from such harm, as required by regulations. Specific details about the actions or inactions leading to the deficiency, or about the residents involved, are not provided in the report.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the optimal well-being of residents as required.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with a history of violent behavior, schizophrenia, and schizoaffective disorder physically attacked another resident in the dining room. The incident occurred when the aggressor confronted the other resident about seating, and after a brief interaction, ran towards the resident and struck them in the face, resulting in both residents falling to the floor. The assaulted resident sustained a bruise over the right eye and required hospital evaluation. Staff members, including an LPN and a CNA, were present in the dining room at the time of the incident but were unable to intervene before the assault occurred. The resident who committed the assault had a documented diagnosis of violent behavior, but staff reported they did not anticipate physical aggression towards others. The facility's abuse prevention policy was in place, but the event still occurred, resulting in physical harm to a resident. The incident was substantiated as abuse by the facility's Director of Nursing. Both residents were sent to the hospital following the event, and the aggressor was not present in the facility at the time of the report.
Failure to Provide Timely, Approved X-Ray Services
Penalty
Summary
The facility failed to provide timely, approved x-ray services or to have an agreement with an approved provider to obtain such services. This deficiency was identified based on the absence of either in-house x-ray capabilities or a documented agreement with an external, approved provider to ensure residents could receive necessary x-ray services as required.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who was at moderate risk for falls and had a history of seizures and cognitive impairment. The resident required substantial to maximal assistance with activities of daily living, was incontinent, and used a wheelchair. The care plan included interventions to anticipate and meet the resident's needs and to monitor for signs and symptoms of tremors, rigidity, dizziness, changes in consciousness, and slurred speech. Despite these documented needs and interventions, the resident was left unsupervised in the dining room during a busy lunch period. On the day of the incident, all four CNAs assigned to the floor were occupied with passing meal trays and feeding other residents in their rooms, leaving the dining room without staff supervision. The nurse supervisor was also engaged in another resident's care and not present in the dining room. The CNA assignment sheet indicated that staff were scheduled to monitor the dining room in 30-minute increments, but at the time of the fall, no staff were present to supervise the residents in the dining room. The staff responsible for monitoring the dining room did not inform anyone before leaving, resulting in a lapse in supervision. As a result, the resident attempted to get up from the wheelchair and fell, sustaining a laceration to the right temple that required sutures. The fall was unwitnessed, and the resident was found on the floor exhibiting seizure-like symptoms. The incident was reported to the state agency, and the resident was transported to the hospital for evaluation and treatment. Facility policies required supervision of residents, especially those at risk for falls and seizures, but these were not followed at the time of the incident.
Failure to Prevent Physical and Verbal Abuse of Residents
Penalty
Summary
The facility failed to protect residents from both physical and verbal abuse, as evidenced by two separate incidents involving residents and staff. In the first incident, a resident with multiple medical conditions, including chronic obstructive pulmonary disease, amputation, and chronic pain, was physically struck in the arm by another resident while in an elevator. The aggressor, who has a history of schizoaffective disorder, violent behavior, and cognitive impairment, admitted to hitting the other resident after a dispute over space in the elevator. This event was corroborated by a third resident who witnessed the altercation and confirmed that the aggressor used a closed fist to strike the victim. Facility staff and documentation confirmed the occurrence of physical abuse. In the second incident, a resident with paraplegia and multiple pressure ulcers was verbally abused by a staff member, specifically a receptionist, during a disagreement in the lobby area. The resident and the staff member exchanged words, and the staff member was reported by two nursing supervisors to have used derogatory and profane language towards the resident, including telling the resident to "shut up" followed by a curse word. Witness statements from both supervisors and facility documentation confirmed the use of abusive language by the staff member towards the resident. Both incidents were substantiated through interviews with the involved parties, witnesses, and review of facility records. The facility's own investigations concluded that abuse had occurred in both cases, with the physical abuse incident involving resident-to-resident aggression and the verbal abuse incident involving a staff member. The facility's policies prohibit such abuse and require the protection of residents from mistreatment by anyone, including staff and other residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely submit an initial abuse report to the state agency within the required two-hour window after an incident involving a resident and a staff member. The incident occurred in the early morning hours when a resident, who is cognitively intact and uses a manual wheelchair, had a verbal altercation with a receptionist. During the disagreement, the staff member directed derogatory and abusive language toward the resident, which was witnessed by multiple staff members, including two LPNs and a CNA. Witness statements confirm that the staff member told the resident to 'shut up b****,' and both parties exchanged curse words. Following the incident, staff attempted to notify the facility's administrator, who serves as the abuse coordinator, but were unable to reach them due to a religious holiday. The staff then attempted to contact the DON, who also missed the initial call. Eventually, the DON was informed of the incident close to 7:00 am, several hours after the event. The preliminary abuse report was submitted to the state agency at 8:33 am, which exceeded the two-hour reporting requirement outlined in both facility policy and state regulations. The resident involved had significant medical conditions, including paraplegia, multiple stage 4 pressure ulcers, chronic osteomyelitis, and other complex diagnoses, but was assessed as cognitively intact. The facility's own abuse prevention policy requires immediate reporting of abuse allegations to the administrator or designated personnel and mandates that such incidents be reported to the state agency within two hours. Despite these requirements, the delay in internal communication and subsequent reporting resulted in noncompliance with regulatory timelines.
Failure to Document and Substantiate Involuntary Transfer and Discharge
Penalty
Summary
The facility failed to meet regulatory requirements for the involuntary transfer and discharge of a resident, as evidenced by two separate petitions for involuntary admission to a hospital that lacked adequate supporting documentation. In the first instance, the petition cited ongoing medication refusals, non-compliance with care, and behavioral concerns such as irritability, agitation, aggression, and emotional distress. However, a review of the resident's records for that day revealed no documentation of these behaviors, aside from a note about medication refusal and the resident's response to education about high blood pressure. Both the social worker and the LPN confirmed that while the resident had a history of non-compliance, there was no documentation of behavioral concerns on the day of the transfer to support the petition. In the second instance, the petition alleged that the resident was physically aggressive, including slamming a laptop against a wall and pushing a door into a nurse. However, there were no notes in the record to support these claims, and interviews with staff revealed inconsistencies regarding the events described. The social worker who signed the petition did not witness the alleged behavior and acknowledged that no one had seen the resident throw the laptop. The nurse involved could not recall if the resident had a laptop, only that the resident used an iPad for communication. These failures resulted in the resident being twice petitioned for involuntary hospital admission without the required documentation or substantiation of the behaviors cited as justification.
Inaccurate and Inconsistent Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and consistent documentation in the medical records of two residents. For one resident with multiple complex diagnoses, there were inconsistencies between the physician's orders, medication administration records (MAR), and controlled substance documentation. Specifically, a nurse reported receiving a verbal order for laboratory blood work but did not enter it as an official order in the electronic record. Additionally, the MAR indicated that Methadone was administered on a day when the resident was out for an appointment, while the controlled substance proof of use form did not reflect administration on that date. The Director of Nursing acknowledged that documentation should have indicated the medication was not given due to the resident's absence, rather than being signed as administered in the facility. For another resident, documentation related to petitions for involuntary or judicial admission to the hospital was inconsistent with the clinical notes. The first petition described behaviors such as medication refusal, non-compliance, irritability, agitation, aggression, and manipulative behavior, but there was no supporting documentation in the resident's notes for the day the petition was filed. The Social Service Director confirmed that while the behaviors were ongoing, there was no specific documentation on the day of the petition to support the claims made. In a second petition for the same resident, the documentation stated that the resident was physically aggressive, including slamming a laptop against a wall and hitting a nurse with a door. However, there were no clinical notes to support these events, and staff interviews revealed uncertainty about whether the resident had a laptop and confirmed that no one witnessed the alleged incident. The Social Worker who completed the petition admitted that the documentation was not based on direct observation.
Failure to Individualize Fall Interventions After Resident Decline
Penalty
Summary
The facility failed to ensure individualized and appropriate fall interventions were identified and implemented for a resident at high risk for falls. The resident, who had diagnoses including chronic obstructive pulmonary disease, schizophrenia, dementia, and exhibited restlessness and agitation, was re-admitted to the facility with a significant decline in function. The resident required substantial maximal staff assistance for walking, transferring, and toileting, and had a history of falls and impaired gait. Despite these risk factors, the resident's fall care plan was not revised or individualized following a significant change assessment, and only standardized interventions were in place. On the evening of the incident, the resident was observed walking unassisted in front of the nursing station, carrying a Foley catheter, when he lost balance and fell, hitting the back of his head. Staff interviews revealed that the resident was considered bedridden and not at risk for falls by some staff, leading to a lack of fall interventions such as non-skid socks or staff assistance when ambulating. There was also confusion among staff regarding the resident's fall risk status and the need for individualized interventions, with one LPN stating they were not informed of the resident's high fall risk and that no interventions were in place because the resident was thought to be bedridden. The facility's policy required that fall risk assessments and individualized interventions be implemented and updated as needed, especially after significant changes in a resident's condition. However, the resident's care plan was not updated to reflect his increased needs and functional decline, and staff were not adequately informed or prepared to provide the necessary supervision and interventions to prevent the fall. The lack of individualized care planning and communication contributed to the resident's unassisted ambulation and subsequent fall.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's medication was administered as ordered by the physician, resulting in significant medication errors. The resident, who is non-verbal and uses a tablet to communicate, reported that they were not provided with their morning medications, including blood pressure medication, on two separate occasions. The resident expressed that they have no issues swallowing whole medications, yet a Licensed Practical Nurse (LPN) attempted to crush the medication, leading to the resident's refusal to take it. The LPN did not notify the physician of the refusal or check the resident's blood pressure, which is consistently high. The LPN admitted to not administering the blood pressure medication on one occasion because the resident requested it after the scheduled time. The LPN acknowledged that they should have contacted the physician to adjust the medication timing. The failure to administer the medication as ordered and the lack of communication with the physician could potentially increase the resident's blood pressure, posing a risk of another stroke. The resident's electronic medical record confirmed that the blood pressure medication was not administered on three specific dates, and there was no documentation of physician notification for the refusals. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both stated that it is expected for nurses to document medication refusals and notify the physician immediately. The DON confirmed that there was no specific order to crush the resident's medication and emphasized the importance of notifying the physician to prevent medical emergencies. The facility's policy on medication administration requires that the physician be notified when medications are not administered as per orders, which was not adhered to in this case.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in a resident's room. A resident, who is aphasic and uses a tablet to communicate, reported seeing roaches in their room, pointing out three dead roaches on the floor and one in a dresser drawer. This resident has a history of hemiplegia, aphasia, and major depressive disorder, among other conditions, and is cognitively intact with a BIMS score of 15. Another resident, with moderate cognitive impairment, reported seeing both live and dead cockroaches daily, although the surveyor did not find any in their bathroom. A third resident, also cognitively intact, mentioned seeing cockroaches in the bathroom, noting a hole in the wall as a possible entry point, but no roaches were observed by the surveyor in their room. The Maintenance Director confirmed responsibility for pest control, stating that pest control services visit weekly, although cockroaches are occasionally seen. The Housekeeping Supervisor and a CNA also acknowledged seeing roaches, with the Housekeeping Supervisor noting a recent sighting and reporting it to the front desk. The Director of Nursing was unsure of the exact frequency of pest control visits. The facility's pest control policy and job descriptions emphasize maintaining a clean and safe environment, yet the presence of cockroaches indicates a lapse in these responsibilities.
Failure to Update Fall Care Plans After Incidents
Penalty
Summary
The facility failed to adhere to its Fall Prevention Program policy by not revising fall care plan interventions after each fall incident for two residents. One resident experienced falls on three separate occasions, yet their care plan, initiated months prior, was not updated to reflect new interventions after these incidents. The care plan history showed that a new intervention was only added weeks later, indicating a lack of timely updates following each fall. Another resident also experienced a fall, but their care plan was not revised until ten days later. Interviews with the Restorative Director and the Director of Nursing confirmed that the facility's protocol requires care plan updates after each fall, based on a root cause analysis. The facility's policy mandates immediate changes in interventions following falls, but this was not followed, leading to the deficiency.
Failure to Follow Fall Prevention Program Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to its Fall Prevention Program and a resident's comprehensive care plan, resulting in a fall incident involving a resident (R2). R2, who was assessed as being at moderate risk for falls, required partial to moderate assistance with activities of daily living, including toileting. On the day of the incident, R2 pressed the call light for assistance to go to the washroom but waited over 15 minutes without receiving help. Consequently, R2 attempted to transfer independently to the washroom, where R2 lost balance and fell while trying to stand from the wheelchair. Interviews with staff revealed that the call light was not answered promptly, and R2 was found on the bathroom floor by an LPN. The facility's policy mandates that call lights should be answered within 15 minutes and that residents at risk for falls should not be left alone during toileting. Despite R2's care plan indicating the need for staff assistance, a CNA stated that R2 often performed tasks independently and did not call for help. The incident highlights a lapse in the facility's protocol to provide necessary supervision and assistance to prevent falls.
Inconsistent Restorative Therapy for Resident with Bilateral Amputations
Penalty
Summary
The facility failed to provide consistent restorative therapy to a resident, identified as R10, who has a history of heart failure, peripheral vascular disease, and bilateral below-knee amputations. R10, who is cognitively intact, expressed a preference for speaking in Spanish and reported that he had not received consistent restorative therapy for the past three months. He mentioned that he had only received three therapy sessions, each lasting 15 minutes, during this period. R10 expressed concerns about losing strength and not being able to use his prostheses effectively due to the lack of regular therapy. Observations and interviews with facility staff revealed that the restorative therapy program was not consistently implemented for R10. A Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) confirmed that R10 was alert and oriented, capable of making his needs known, and able to perform transfers independently. However, they could not recall when R10 last participated in restorative therapy. The Restorative Nurse Assistant indicated that restorative therapy sessions were often disrupted due to staff shortages, leading to inconsistent therapy for residents like R10. The facility's documentation showed discrepancies in R10's restorative care plan and assessments. The Restorative Director acknowledged errors in R10's assessments, including incorrect documentation regarding the use of prostheses. The facility's policy required obtaining a physician's order for restorative therapy, but R10's physician order set did not include such an order. The lack of consistent restorative therapy and accurate documentation placed R10 at risk of not maintaining his highest practical level of function.
Inadequate Restorative Staffing Leads to Missed Therapy Sessions
Penalty
Summary
The facility failed to ensure adequate staffing of restorative nurse aides, resulting in a resident missing restorative therapy sessions multiple times over the past 90 days. The resident, who uses a prosthesis, expressed concerns about losing strength and not improving due to the lack of consistent therapy. The resident reported that when other CNAs call off or there is a staffing shortage, restorative aides are pulled to work on the floor, leaving the therapy room closed. This situation was confirmed by the Lead CNA/Staffing Coordinator, who stated that pulling restorative aides to the floor is a last resort when there are call-ins, as it affects the residents' range of motion. The Restorative Director and a Restorative Nurse Assistant both acknowledged that restorative aides are frequently pulled to assist with CNA duties, which disrupts the restorative program. The Restorative Director noted that when aides are pulled, residents do not receive the necessary exercise to maintain their maximum capacity. The Restorative Nurse Assistant mentioned being behind on tasks due to illness and the closure of the facility's gym. The facility's nursing schedule and restorative staff time sheets corroborated the shortage of restorative aides, with only one aide working on specific dates. The resident's Minimum Data Set indicated cognitive intactness, and records showed several undocumented days for walking and active range of motion tasks.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R4, from physical abuse by staff, resulting in harm. R4, who has a severely impaired cognitive status with a BIMS score of 3, was found to have a large bruise on her right thigh, which was diagnosed as a hematoma. The resident's medical history includes conditions such as hemiplegia, hemiparesis, chronic obstructive pulmonary disease, and major depressive disorder. The incident was reported by R4's family member, who noticed the bruise and suspected abuse, leading to R4 being sent to the hospital for further evaluation. Interviews with staff revealed that R4 was often combative during care, requiring two staff members to manage her, with one holding her down while the other provided care. This practice was confirmed by multiple staff members, including CNAs and LPNs, who noted R4's resistance and the need to restrain her legs to prevent kicking. Despite R4's verbal protests during care, staff continued to provide care without documenting refusal, contrary to the facility's policy. The facility's policies emphasize the residents' right to be free from abuse and mistreatment, and the Director of Nursing acknowledged that holding a resident down would be considered abuse. The facility's abuse prevention policy outlines the need for a resident-sensitive environment and proper training for staff to handle difficult situations. However, the actions taken by the staff in R4's case were inconsistent with these policies, leading to the deficiency noted in the report.
Inadequate Supervision Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to follow the Care Plan and provide adequate supervision to a resident assessed as a high fall risk, resulting in multiple falls and injuries. The resident, who has a severely impaired cognitive status and requires substantial assistance for mobility, experienced falls on several occasions, including two significant incidents that required hospitalization. The resident's Care Plan indicated the need for one-on-one monitoring due to poor safety awareness and impulsive behavior, but this was not consistently implemented. Interviews with staff revealed that the resident was not receiving the required one-on-one monitoring at the time of the falls. The Director of Nursing acknowledged staffing issues as a reason for the lack of one-on-one monitoring, which was a critical intervention outlined in the resident's Care Plan. Despite the resident's high fall risk and history of falls, the facility did not ensure the necessary supervision to prevent further incidents. The facility's policies on fall prevention and comprehensive care planning emphasize the importance of assessing fall risks and implementing appropriate interventions. However, the failure to adhere to these policies and the resident's Care Plan resulted in serious injuries, including a head laceration requiring staples. The lack of adequate supervision and monitoring contributed to the resident's repeated falls, highlighting a deficiency in the facility's care practices.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication to a resident diagnosed with schizoaffective disorder bipolar, violent behavior, generalized anxiety disorder, and paranoid schizophrenia. The resident, identified as R2, had a documented refusal of psychotropic medication consent dated nearly a year prior, yet continued to receive Fluphenazine Decanoate injections over several months. Despite the resident's refusal to sign the psychotropic consent, the Assistant Director of Nursing claimed that verbal consent was given, although no documentation was provided to support this claim. The Director of Nursing acknowledged that consent should be obtained before administering psychotropic medication and affirmed the resident's right to refuse medication. The facility's policy on psychotropic medication consent requires either signed or verbal consent, with verbal consent needing to be witnessed by two staff members. However, in this case, there was no evidence of such consent being documented or witnessed, leading to the deficiency in ensuring informed consent was obtained prior to medication administration.
Failure to Report Alleged Abuse of Resident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R4, to the state survey agency. R4, who has a severely impaired cognition with a BIMS score of 3, was found to have a bruise on her right thigh by a CNA on the morning of 11/10/24. The CNA initially forgot to report the bruise but did so later in the afternoon. Despite this, the Director of Nursing (DON) and the administrator did not report the incident to the state survey agency, as the administrator did not believe the bruise was a result of abuse. R4's daughter expressed concerns about potential abuse, leading to R4 being sent to the hospital, where elder abuse and a hematoma were diagnosed. The facility's policy requires immediate reporting of any suspicion of abuse to the administrator and the state survey agency within two hours if it involves serious bodily injury. However, the facility's preliminary incident investigation report was not completed until 11/19/24, nine days after the bruise was discovered. The facility's documentation indicated that the DON did not find the bruising concerning, despite the daughter's insistence on hospital evaluation. This inaction and delay in reporting violated the facility's abuse prevention policy and state reporting requirements.
Failure to Investigate Allegation of Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an allegation of injury of unknown origin, affecting one resident. The incident involved a resident who had a large bruise on her right thigh, which was reported by her daughter, who expressed concerns about potential elder abuse. The resident's hospital report documented a diagnosis of elder abuse and hematoma. Despite these concerns, the Director of Nursing (DON) did not investigate the bruise, as she was not present at the facility when it was reported and did not see the bruise before the resident was sent to the hospital. The Administrator also did not investigate the allegation, attributing the bruise to the resident's known behavior of thrashing during care. The facility's policy on abuse prevention requires prompt and aggressive investigation of all reports and allegations of abuse, neglect, and mistreatment. However, in this case, the policy was not followed. The DON and Administrator failed to initiate an investigation into the injury, despite the policy's stipulation that any incident involving abuse or injury of unknown origin should be investigated. The facility's failure to adhere to its own policy resulted in a lack of investigation into the resident's injury, which was classified as suspicious due to its location and the circumstances under which it was discovered.
Inaccurate Fall Assessments for Resident
Penalty
Summary
The facility failed to accurately complete fall assessments for a resident, identified as R1, which has the potential to affect the resident's safety and care. On 10/12/24, R1 was found on the floor with a laceration on the back of the head and was subsequently transferred to the hospital for treatment. The fall risk assessment conducted on 10/13/24 did not accurately reflect R1's mobility status, as it failed to note that R1 uses furniture for support. Additionally, the post-fall observation inaccurately documented R1 as independent with or without a device, despite the Minimum Data Set indicating that R1 requires substantial assistance for mobility tasks. R1's medical history includes severe cognitive impairment, unsteadiness on feet, and multiple diagnoses such as chronic obstructive pulmonary disease and schizoaffective disorder. The care plan indicates that R1 is at risk for falls due to weakness and requires extensive assistance for transfers and mobility. Despite these needs, R1 experienced six falls within the past year, highlighting discrepancies in the fall assessments and the care provided. The facility's policy mandates accurate assessments and individualized fall prevention measures, which were not adhered to in this case.
Failure to Supervise Resident with Dementia Leads to Unsupervised Departure
Penalty
Summary
The facility failed to provide adequate supervision and follow their policy regarding pass privileges for a resident diagnosed with vascular dementia and other cognitive impairments. The resident, who was moderately cognitively impaired, signed himself out of the facility without a physician pass privilege order in place. This incident occurred after a room change, and the resident left the facility unaccompanied, later getting lost in the community. The resident was eventually returned to the facility via transportation arranged by the night shift receptionist. Interviews with staff revealed a lack of communication and oversight regarding the resident's whereabouts and pass privileges. The Licensed Practical Nurse on duty did not recall being informed of the resident's intention to leave, and the Director of Nursing confirmed that no pass privilege order was in place. The Social Services Director assumed the order was being handled by another staff member. The resident's care plan indicated a need for supervision due to cognitive impairment, but this was not adequately followed, leading to the resident's unsupervised departure and subsequent distress.
Failure to Document Resident's Personal Belongings
Penalty
Summary
The facility failed to properly document a resident's personal belongings upon admission, leading to the resident's clothes going missing. The resident, who has diagnoses including morbid obesity, cerebral palsy, and reduced mobility, reported missing clothes and observed other residents wearing them. Despite raising the issue in resident council meetings, no action was taken. The facility's policy requires CNAs to inventory and label residents' belongings upon admission, but this was not done for the resident in question. Interviews revealed that the laundry department does not keep an inventory of residents' personal items, and misplaced clothes are only returned if labeled. The Director of Nursing confirmed the absence of an initial inventory list for the resident, with the only list dated months after admission. The facility's policy mandates that an inventory list be completed and uploaded to the resident's medical chart, which was not adhered to in this case. Complaints about missing clothes were also documented in resident council meeting minutes.
Failure to Schedule Surgery and Ensure Doctor's Appointments
Penalty
Summary
The facility failed to ensure that a cataract surgery was scheduled for a resident, resulting in the resident experiencing continued visual difficulties. The resident, who is cognitively intact, had been waiting for almost six months for the surgery and reported difficulties with reading and watching television due to the cataracts. The Director of Nursing acknowledged that the facility did not follow up with the ophthalmology office to confirm the surgery date, despite having received an order for an ophthalmology consult and findings of cataracts documented in the resident's records. Additionally, the facility failed to ensure that two other residents attended their scheduled doctor's appointments. One resident missed an orthopedic follow-up appointment because the facility did not provide an escort, which is their responsibility. Another resident missed several consultation appointments due to transportation issues. The facility's policy requires charge nurses to follow up with residents' physicians to ensure appointments are scheduled as per physician orders, but this was not adhered to, leading to missed appointments and necessary care not being provided.
Failure to Document Psychotropic Medication Administration
Penalty
Summary
The facility failed to properly document the administration of a psychotropic medication, Lorazepam, for a resident with a history of generalized anxiety disorder, PTSD, primary insomnia, and other conditions. The resident, who is cognitively intact, reported receiving Lorazepam on three occasions without requesting it and noted a discrepancy in the administration record for a dose supposedly given at 1:00 AM, which she did not recall receiving. The controlled substance accountability record indicated administration on specific dates, but these were not reflected in the Medication Administration Record (MAR). Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) revealed lapses in documentation. The DON confirmed that all medications should be signed off in the MAR to prevent errors and account for controlled substances. However, the LPNs involved admitted to either forgetting to document the administration or not recalling administering the medication. The facility's policies require that narcotics be signed out in both the electronic health record and the narcotic sheet, which was not adhered to in this case.
Failure to Implement Policy on Resident Strip Searches
Penalty
Summary
The facility failed to develop and implement a policy addressing strip/body searches of residents, which led to two residents feeling humiliated and violated. Resident R13, a cognitively intact individual with a BIMS score of 15, reported being subjected to a strip search approximately 1.5 months prior due to a missing credit card belonging to his former roommate. The search was conducted in the office of the Psychiatric Rehabilitation Services Coordinator (V25) with the Restorative Director (V24) present. R13 was coerced into compliance under the threat of contacting his parole officer, leading to feelings of humiliation and shame. Similarly, Resident R4, also cognitively intact with a BIMS score of 15, experienced a strip search upon returning to the facility. Initially, R4 refused a purse search at the front desk but was later subjected to a strip search by the Social Service Director (V4) and the Restorative Nurse (V24) in V4's office. R4 described the search as invasive and felt violated. Despite the facility's policy on routine resident checks and safety room checks, it did not address strip searches, leading to these incidents where no contraband was found.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to conduct appropriate interviews following an alleged incident of abuse involving a resident and a staff member. The incident occurred when a dietary aide, who was transporting a food cart, and a resident were in an elevator together. The resident reportedly pushed the food cart out of the elevator, causing the dietary aide to exit as well. Despite the incident being reported by a patient escort to the Director of Nursing (DON) and the overnight supervisor, no formal investigation or interviews were conducted with the involved parties, including the resident, dietary aide, and witnesses. The report highlights that the facility's Director of Nursing and Administrator did not take the necessary steps to investigate the incident thoroughly. The DON acknowledged that she did not document her conversation with the resident and did not pursue further investigation, citing the information as hearsay. The Administrator, who is also the abuse coordinator, did not initiate an investigation, assuming that nursing or social services were handling the situation. This lack of action resulted in a failure to gather all sides of the story and understand the full context of the incident. The facility's policy requires immediate reporting and investigation of all incidents or allegations of abuse, neglect, or mistreatment. However, in this case, the policy was not followed, as the incident was not reported to the Illinois Department of Public Health (IDPH), and no comprehensive investigation was conducted. The failure to adhere to the policy and conduct a proper investigation represents a deficiency in the facility's response to alleged abuse incidents.
Failure to Implement Care Plan for Resident with Substance Abuse
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a history of opioid dependence, who tested positive for illegal drug use. The resident, who is cognitively intact, was admitted with multiple diagnoses including opioid dependence. Despite testing positive for cocaine, marijuana, and methadone, there was no care plan addressing the resident's illegal drug use. The facility's policy requires comprehensive care plans to be developed using the results of a comprehensive assessment, including measurable objectives and timetables to meet all resident needs. The resident's care plan was not updated to reflect the current needs after the resident moved floors and tested positive for illegal substances. The facility's policy mandates that care plans be reviewed and revised as necessary after each MDS assessment and quarterly. However, the interdisciplinary team did not update the care plan to address the resident's substance abuse issues, leading to a deficiency in meeting the resident's care needs.
Delay in Scheduling Biopsy for Resident
Penalty
Summary
The facility failed to provide timely medical care for a resident, R5, who required a tongue biopsy as ordered by an ENT doctor on April 15. Despite multiple attempts by the patient escort, V3, to bring the necessary paperwork from the hospital to the facility, the biopsy was not scheduled. The ENT doctor and the oncology doctor were both awaiting the biopsy results to proceed with further treatment. The transportation scheduler, V15, acknowledged the delay, stating that the hospital required the ordering doctor to schedule the biopsy, and this information was relayed to a nurse on the fourth floor. However, no follow-up was conducted to ensure the biopsy was scheduled. The Director of Nursing, V2, was aware of the situation and had inquired about the status of R5's appointments. Despite efforts to schedule follow-up appointments with the ENT doctor, the biopsy had not been completed by the time of the report. The facility's policy indicated that the charge nurse or designee was responsible for scheduling appointments, but there was a lack of coordination and communication between the nursing staff and the scheduler, leading to the delay. The biopsy was crucial for diagnosing potential cancerous lesions, as indicated in the hospital discharge paperwork. The report highlights the breakdown in communication and responsibility within the facility's staff, which resulted in a significant delay in obtaining necessary medical care for R5. The ENT doctor had recommended immediate action, but the facility's failure to follow through on scheduling the biopsy left the resident without a critical diagnosis for several months. This deficiency in care was identified during a survey, emphasizing the need for improved processes in managing resident appointments and follow-ups.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to adhere to its abuse policy procedures by not reporting an incident of abuse to the Illinois Department of Public Health (IDPH) within the required timeframe. The incident involved two residents, where one resident pushed another during a verbal altercation, causing the latter to fall. The initial incident report did not include the actual time of occurrence, only stating it happened in the evening. The facility reported the incident to IDPH the following day, which was not within the regulatory requirement of reporting within two hours. Additionally, the final report was submitted eight days after the incident, exceeding the five-business-day requirement. The facility's administrator, who was not employed at the time of the incident, confirmed the late reporting upon reviewing the reports. The facility's abuse policy mandates immediate reporting to the state licensing agency after assessing the resident and removing the alleged perpetrator, including the time and date of the incident. The policy also requires a complete written report of the investigation's conclusion within five days, which was not adhered to in this case.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to accommodate the needs of residents by not ensuring that call lights were within reach for two residents, R2 and R3. R2, who has a medical history including bipolar disorder and moderate cognitive impairment, was observed in bed unable to reach his call light, which was hanging behind the bed and touching the floor. R2 expressed that he was experiencing a stomachache but did not call the nurse because he could not locate his call light. Similarly, R3, who has intact cognition but is dependent on staff for various transfers and is frequently incontinent, was unable to find his call light after a bowel movement. The call light was tangled with bed remote wires and out of reach. Staff interviews confirmed the expectation that call lights should be within reach of residents to ensure they can contact staff in case of emergencies. A Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant, and the Director of Nursing all acknowledged that call lights should be accessible to residents. The facility's policy also states that call lights should be within reach when residents are in bed or confined to a wheelchair. Despite this policy, the observations and interviews revealed that the facility did not adhere to these standards, resulting in the deficiency.
Failure to Document Post-Surgical Wound Assessments
Penalty
Summary
The facility failed to adhere to professional standards of practice and its own policy regarding the documentation of post-surgical wound assessments for two residents. One resident, R5, reported that after their stitches were removed by a spine surgeon, no further assessments of their surgical wound were conducted by the nursing staff, which was confirmed by the surgeon's dissatisfaction. Observations revealed that R5's wound was well-approximated and healed, but there was a lack of documented assessments following the initial evaluation upon admission. Interviews with staff, including an LPN and the Wound Director, revealed a misunderstanding of responsibilities regarding surgical wound monitoring. The Wound Director stated that floor nurses should monitor surgical wounds and report concerns, but there was no 'monitor wound order' entered for R5. The Director of Nursing confirmed that documentation was insufficient, with only two notes found in R5's record, neither of which included a wound assessment. The facility's Wound Management Policy emphasized the need for documentation of wound care activities, which was not followed in this case.
Delayed Therapy Services for Residents with Medicaid
Penalty
Summary
The facility failed to provide timely therapy services and adhere to its policy for two residents, R1 and R5, out of a sample of 15. For R1, orders for physical, occupational, and speech therapy were placed on 5/7/2024, but there was a significant delay in initiating occupational therapy, which only began on 6/17/2024. The Director of Rehabilitation Services, V21, stated that the delay was due to the facility's process of obtaining approvals based on the resident's insurance type, particularly for Medicaid patients. R1 expressed dissatisfaction with the delay, stating that she could have sought therapy elsewhere had she been informed. For R5, therapy orders were placed on 6/6/2024, but the physical therapy evaluation was not completed until 6/19/2024. The delay was attributed to a new requirement for administrative approval for Medicaid patients, which was implemented on 6/7/2024. R5 reported feeling neglected during the initial week of her stay, as no therapy services were provided until after a friend intervened. The facility's policy required therapy assessments within 48 hours of referral, which was not met in these cases. The facility's policies and procedures for therapy services were not followed, leading to delays in therapy initiation for residents with Medicaid. The Director of Restorative Nursing, V12, noted that prior to V21's tenure, all residents were evaluated upon admission regardless of insurance, but changes in the process have led to inconsistencies. The facility's failure to adhere to its own policies and the lack of communication between departments contributed to the deficiencies observed.
Failure to Provide Proper Notice for Involuntary Discharge
Penalty
Summary
The facility failed to provide proper notice requirements to a resident who was involuntarily transferred to the hospital. The resident, who has a medical history of opioid dependence and mental and behavioral disorders, was initially admitted to the facility in October 2023. On June 3, 2024, the resident was involuntarily discharged to the hospital after becoming verbally aggressive towards the Social Service Director when informed that their community pass was revoked due to non-compliance with the facility's substance abuse policy. Despite the aggressive behavior and the subsequent transfer, the facility did not document that the resident was notified of the reason for the transfer or discharge, nor was there documentation of a 30-day notice being given as required by the facility's policy. The report highlights that the facility's Social Worker and Social Service Director acknowledged the lack of documentation regarding the notice given to the resident. The facility's policy on involuntary discharge requires that a 30-day notice be provided to the resident, along with the reason for the notice, and that public health authorities be informed via certified mail. However, the resident's progress notes for April, May, and June 2024 did not contain any documentation of such notifications for both the April 9, 2024, and June 3, 2024, involuntary discharges. This oversight affected the resident's right to be informed or notified of the reasons for their transfer or discharge.
Failure to Provide Bed Reserve Notification During Involuntary Transfer
Penalty
Summary
The facility failed to provide a Bed Reserve Notification to a resident (R1) during an involuntary transfer to a hospital, as required by their policy. R1, who has a medical history of opioid dependence and mental and behavioral disorders, was involuntarily discharged on 6/3/2024 after exhibiting aggressive behavior towards the Social Service Director (V4) when informed that his community pass was revoked. This incident was not the first, as R1 had a previous involuntary discharge in April of the same year. The facility's policy mandates that a Bed Reserve Notification be given to residents at the time of transfer, but this was not documented or provided to R1. Interviews with facility staff, including the Social Worker (V5) and the Social Service Director (V4), revealed that R1 was not informed about the bed hold policy, which allows a 10-day period for the resident to return to the facility. The facility's policy on Bed Reserve, dated 2008, and the Notice of Bed Hold and Return, dated 11/20/2017, both require that residents be given written notice of the bed hold policy at the time of transfer. However, there was no documentation in R1's progress notes for April, May, and June 2024 indicating that such notice was provided, leading to a deficiency in the facility's adherence to its own policies and federal regulations.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating their own bed-hold policy. The resident, who had a history of opioid dependence and mental and behavioral disorders, was initially admitted to the facility in October 2023. On June 3, 2024, the resident was involuntarily discharged to a hospital following an incident where they became verbally aggressive and threatening towards the Social Service Director after being informed that their community pass was revoked due to non-compliance with the facility's substance abuse policy. The facility's Social Worker and Social Service Director noted that the resident had a history of aggression and had previously been involuntarily discharged in April 2024. The facility's policy on involuntary discharge was not properly followed, as there was no documentation of notice given to the resident or the reason for the notice. The facility's Admission Director was informed by the hospital that the resident was returning, but the Director of Nursing and Social Service Director instructed that the resident should not be accepted back due to the involuntary discharge. The facility's Administrator stated that the decision not to accept the resident back was based on advice from the facility's attorney, following the incident on June 3, 2024. The facility's policy on bed-hold and return, which allows residents to return after hospitalization if their stay exceeds the bed-hold period, was not adhered to. The facility did not coordinate with the hospital to assess the resident's status post-hospitalization, and the resident's right to return was not honored.
Failure to Administer Medications and Document Physician Coordination
Penalty
Summary
The facility failed to document physician coordination for medications not received by a resident, and also failed to administer insulin as ordered by the physician for one resident. This resident, who has a history of stroke and diabetes mellitus, was observed to have swelling in the left foot and expressed concerns about not receiving medication. A review of the resident's medication administration records (MAR) for April, May, and June 2024 showed multiple instances where medications for diabetes and hypertension were not given, with reasons such as drug refusal, medication hold, or no documentation provided. The resident's blood pressure and blood sugar levels were not controlled, with systolic blood pressure reaching as high as 200 and blood sugar levels as high as 268. The MAR and progress notes indicated that on May 23, 2024, Humalog insulin was held by a nurse despite the physician's order to hold only if blood sugar was less than 100. The MAR for June 2024 showed that the resident did not receive the prescribed insulin on most days. The Director of Nursing (V2) was informed of these issues and acknowledged the need for physician notification when medication is refused. However, it was unclear if the physician was notified in this case. The facility's MAR policy requires physician notification and documentation in the Nurse's Notes when a resident refuses medication, but this was not consistently followed for the resident in question.
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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