Complete Care At Sheriden Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4538 North Beacon, Chicago, Illinois 60640
- CMS Provider Number
- 145776
- Inspections on file
- 30
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Sheriden Commons during CMS and state inspections, most recent first.
The facility failed to ensure proper infection control measures, including the use of PPE during high-contact care for residents on Enhanced Barrier Precautions, the absence of EBP signage and PPE bins, and the lack of sanitization of medication trays between residents. These deficiencies were observed during wound care and medication administration, potentially affecting all residents on the affected floors.
A facility failed to ensure Low Air Loss Mattresses (LALM) were set correctly for four residents, leading to potential harm. Residents with varying cognitive impairments and medical conditions had mattresses set at incorrect weights, contrary to facility policy. This oversight was identified through observations and interviews, highlighting a significant deficiency in pressure ulcer prevention.
The facility failed to properly store and label medications, affecting multiple residents. A nurse did not label multidose medications with open and discard dates, and an unopened insulin vial was not refrigerated as required. The refrigerator used for medication storage was not within the acceptable temperature range, potentially compromising medication efficacy. Additionally, an unattended and unlocked treatment cart was observed, posing a risk of unauthorized access. The DON acknowledged these issues and the associated risks.
The facility failed to serve hot foods at the required temperature of 135 degrees F, affecting residents on the third floor. Despite initial appropriate food temperatures, delays in serving led to a drop in temperature, with a test tray showing pork and vegetables below the standard. Staffing issues during meal service contributed to the deficiency, as only one CNA was initially observed passing trays, contrary to facility policy.
A facility failed to maintain the dignity of a resident with an indwelling catheter by not covering the catheter drainage bag with a privacy bag. The drainage bag was observed facing the resident's door without a cover, which was confirmed by the Assistant Director of Nursing. The resident had a history of cerebral infarction and other conditions, with a moderately impaired cognitive status. The facility's policy requires catheter bags to be covered to ensure resident dignity.
A facility failed to assess and authorize a resident's self-administration of medication. The resident had Trimove oral drops and Calamine lotion at their bedside without a physician's order or proper assessment. The staff was unaware of the medications, and the facility's policy requires notifying the doctor and assessing the resident's ability to self-administer medication safely. The resident's cognitive status was intact, but there was no documented order for self-administration in the electronic health record.
The facility failed to properly manage respiratory care equipment for two residents, both cognitively intact and with significant respiratory conditions. One resident's BIPAP mask was left uncontained, while another's nasal cannula was found on the floor, undated and not contained. The facility's policies require such equipment to be stored in plastic bags when not in use and dated when changed, which was not followed.
A resident with moderate cognitive impairment and multiple health issues has not received dental services in over six years while living in the facility. The resident's teeth were observed to have a black substance and multiple holes. The DON acknowledged the resident's dental issues and the difficulty in securing dental appointments for Medicaid patients, despite the facility's policy requiring routine dental services.
A resident with metastatic cancer experienced untreated left arm pain and a fracture for 34 days due to the facility's failure to review x-ray results and communicate with the physician. The resident's pain was not properly assessed or documented, and there was confusion over a lidocaine patch order, which the attending physician did not authorize.
A resident with multiple health conditions, including chronic respiratory failure and morbid obesity, was hospitalized due to acute kidney injury and fecal impaction after the facility failed to properly monitor fluid intake and bowel output. Despite having a care plan that required monitoring intake and output, the facility did not perform these assessments unless on fluid restriction. Staff interviews revealed a lack of communication and adherence to care plans, contributing to the resident's critical health issues.
Infection Control Deficiencies in PPE Use and Medication Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by several observations and interviews. Staff did not don appropriate PPE while providing high-contact care to residents on Enhanced Barrier Precautions (EBP). Specifically, a registered nurse and a certified nursing assistant entered a resident's room without wearing gowns to perform wound care, and hand hygiene was not performed during the procedure. Additionally, a Purewick canister was observed on the floor, which is against infection control protocols. Further deficiencies were noted in the absence of EBP signage and PPE bins outside the rooms of residents who required them. This was observed for two residents who had wounds or indwelling catheters, and the lack of signage and PPE availability was acknowledged by the Assistant Director of Nursing. The absence of these precautions could lead to cross-contamination and infection spread among residents and staff. The facility also failed to sanitize a medication tray between uses for different residents. A licensed practical nurse was observed preparing medications for one resident and then using the same unsanitized tray for another resident, which is against the facility's infection control expectations. This oversight was recognized by the Director of Nursing, who admitted there was no specific policy for sanitizing medication trays but acknowledged the importance of doing so to prevent cross-contamination.
Improper LALM Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that Low Air Loss Mattresses (LALM) for pressure ulcer prevention were set at the correct weight settings for four residents. This deficiency was identified through observation, interview, and record review. The residents affected included those with varying degrees of cognitive impairment and medical conditions that increased their risk for pressure ulcers. For instance, one resident with a Braden scale score indicating moderate risk had their mattress set for a weight significantly higher than their actual weight, which could lead to inadequate pressure relief. Another resident, with severe cognitive impairment and a high risk for pressure ulcers, was found to have their mattress set at a weight much higher than their actual weight. This discrepancy was noted by a Licensed Practical Nurse who was unaware of the reason for the incorrect setting. The Director of Nursing acknowledged that incorrect settings could cause harm by making the mattress too firm. Additionally, a resident with a stage 4 pressure ulcer was found to have their mattress set too low, causing it to deflate and become less firm, which the resident reported as uncomfortable. The facility's policy required that LALMs be set according to the manufacturer's guidelines based on the resident's weight and desired firmness. However, the survey revealed that staff did not consistently adhere to these guidelines, leading to potential harm for residents at risk of pressure ulcers. The failure to properly adjust the LALM settings according to the residents' weights and needs was a significant oversight in the care provided to these residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, affecting multiple residents. During a survey, it was observed that a registered nurse on the second floor did not label multidose medications with open and discard dates, specifically for Dorzolamide and Timolol eye drops, and a Glargine vial. Additionally, an unopened Novolin R vial was not stored in the refrigerator as required by the pharmacy's auxiliary label. The Director of Nursing confirmed that the facility's policy mandates labeling multidose medications with open dates to ensure timely disposal and maintaining unopened insulin vials in the refrigerator to preserve potency. Further inspection revealed that the refrigerator used for medication storage on the second floor was not maintaining the required temperature range. The thermometer inside the refrigerator registered a temperature of 52°F, exceeding the acceptable range of 36°F to 46°F. This improper storage condition could potentially compromise the efficacy of medications stored within, including insulin vials and Tubersol for TB tests. The Director of Nursing acknowledged the importance of maintaining the correct temperature to ensure medication potency. Additionally, the surveyor observed an unattended and unlocked treatment cart on the third floor while the Director of Nursing was performing wound care in a resident's room. The facility's policy requires that treatment carts be locked when not in use to prevent unauthorized access and potential harm to residents. The Director of Nursing admitted that the cart should have been locked and recognized the risk of residents accessing medication solutions, which could lead to poisoning.
Failure to Serve Hot Foods at Required Temperature
Penalty
Summary
The facility failed to serve hot foods to residents at the required temperature of 135 degrees Fahrenheit, as per their policy. During a resident council meeting, multiple residents reported that their food was cold when served. Observations on the same day revealed that while the food was initially at appropriate temperatures before plating, the process of serving the food led to a significant drop in temperature. Specifically, a test tray served to residents on the third floor showed that the rice was at 135 degrees F, but the pork and vegetables were at 120 degrees F and 116 degrees F, respectively, which is below the facility's standard. The deficiency was further compounded by staffing issues during meal service. Only one CNA was observed passing lunch trays to residents in their rooms, which took approximately 8 minutes before additional help arrived. The Director of Nursing later stated that there should have been more than one person passing trays, as all CNAs, nurses, and staff are responsible for this task. The facility's policy and job descriptions indicate that hot foods should be served at 135 degrees F or higher, and CNAs are responsible for assisting with meal service, highlighting a lapse in adherence to these guidelines.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident with an indwelling catheter by not covering the catheter drainage bag with a privacy bag. This deficiency was observed during a survey when the drainage bag was found facing the resident's door without a privacy cover. The Assistant Director of Nursing/Infection Preventionist confirmed the observation and acknowledged that the drainage bag should have been covered to maintain the resident's privacy. The resident affected by this deficiency had a history of cerebral infarction, benign prostatic hyperplasia, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy. The resident's cognitive status was moderately impaired, as indicated by a BIMS score of 09. The facility's policy on dignity explicitly states that urinary catheter bags should be covered to promote the resident's sense of well-being and self-esteem, which was not adhered to in this instance.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to complete a Medication Self-Administration Safety Screen Assessment and did not obtain a physician's order for a resident to self-administer medication and treatment. This deficiency was identified during an observation where a resident had Trimove oral drops and Calamine lotion on their bedside table. The resident stated that they used the Trimove as a vitamin and the Calamine lotion for itching due to heparin shots. The registered nurse present was unaware of why the resident had these medications and confirmed that the facility's policy requires notifying the doctor, care planning, and assessing the resident's ability to self-administer medication safely. Further investigation revealed that the resident's primary care physician was not informed about the medications at the bedside, and there was no order for self-administration of the Trimove oral drops. The resident's cognitive status was intact, as indicated by a BIMS score of 15, but the facility did not document an order for self-administration of the medications in the electronic health record. The facility's policy requires that all medications to be self-administered should be ordered by a doctor, and any medications found at the bedside without authorization should be returned to the nurse in charge.
Improper Management of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to properly manage and contain respiratory care equipment for two residents, leading to deficiencies in their care. One resident, who has a history of Chronic Obstructive Pulmonary Disease (COPD), pneumonia, acute respiratory distress, heart failure, and dependence on supplemental oxygen, was observed with a BIPAP mask left uncontained on a nightstand. This resident is cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The facility's active orders indicated the use of BIPAP at nighttime every shift, yet the equipment was not stored properly when not in use. Another resident, also cognitively intact with a BIMS score of 15, has diagnoses including COPD, respiratory failure, congestive heart failure, bronchiolitis, and Respiratory Syncytial Virus (RSV). This resident's nasal cannula was found on the floor, undated, and not contained, despite active orders for oxygen use as needed for shortness of breath. The facility's Director of Nursing confirmed that oxygen equipment should be stored in a plastic bag when not in use to prevent contamination and that tubing should be dated when changed. The facility's policies and job descriptions for RNs and LPNs emphasize the importance of maintaining high-quality care in accordance with standards and regulations, which were not adhered to in these instances.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, identified as R54, who has been living in the facility since 2019. R54, a [AGE] year old with diagnoses including cognitive communication deficit, cellulitis, dysphagia, hemiplegia, and hemiparesis following cerebral infarction, has a BIMS score of 12, indicating moderate impairment. During an investigation, a surveyor observed that R54 had a black substance on his teeth and multiple teeth with small holes. R54 reported not having received dental services in over six years. The Director of Nursing (DON) acknowledged that R54's teeth appeared discolored and decayed but noted that R54 did not report any pain. The DON also mentioned difficulties in securing dental appointments for Medicaid patients, despite the facility's policy stating that routine and emergency dental services should be available according to the resident's assessment and plan of care. R54's assessment indicated a need for maximal assistance with oral hygiene.
Failure to Address Resident's New Pain and Fracture
Penalty
Summary
The facility failed to identify and treat the cause of new pain in a resident's left arm, resulting in harm due to a left humerus fracture that went untreated for 34 days. The resident, who had a diagnosis of metastatic cancer of unknown origin, experienced significant left arm pain and limited mobility. Despite the resident's complaints of pain and the presence of a fracture, the facility did not timely review x-ray results or communicate these results to the physician. The resident's x-ray was ordered on 06/25/24 due to pain, but the results were not reviewed until 07/19/24. During this period, there was no documentation of an SBAR (situation, background, assessment, and recommendation) for the new pain, nor was there evidence that the physician or the resident's next of kin were notified. The facility's policies on pain management and change in condition were not followed, as the resident's new pain was not properly assessed or communicated. Additionally, there was confusion regarding the prescription of a lidocaine patch for the resident's pain, with the attending physician denying having ordered it. The facility's staff did not adhere to protocols for entering physician orders, as evidenced by the unauthorized use of the physician's name for the lidocaine order. This lack of communication and adherence to protocol contributed to the resident's prolonged pain and untreated fracture.
Failure to Monitor Fluid and Bowel Output Leads to Resident Hospitalization
Penalty
Summary
The facility failed to properly assess and manage the oral fluid intake, urinary output, and bowel output of a resident (R4) who was at risk for dehydration. This deficiency resulted in harm to R4, who required hospitalization for acute kidney injury and fecal impaction. R4 had a history of major depressive disorder, chronic respiratory failure, chronic obstructive pulmonary disease, morbid obesity, venous insufficiency, and sleep apnea. Despite having an intact cognition with a BIMS score of 13, R4 was not adequately monitored for fluid intake and output, as the facility did not perform intake and output measurements unless the resident was on fluid restriction. The care plan for R4 included monitoring and documenting intake and output, but this was not followed, leading to critical health issues. Interviews with staff revealed that there was a lack of communication and adherence to care plans. The RN stated that care plans are checked monthly or every two months, and the LPN mentioned that CNAs are supposed to notify nurses about bowel movements, but this could be missed if not asked. The DON confirmed that the facility does not routinely perform intake and output monitoring, and the expectation is for staff to follow care plans 100%. The CNA reported that they chart bowel movements in the computer, but there was no consistent follow-up by nurses. R4's preference for diet cola over water was noted, and despite being encouraged to drink more water, R4's fluid intake was not adequately managed, contributing to the resident's hospitalization for dehydration-related complications.
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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