Dupage Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheaton, Illinois.
- Location
- 400 N County Farm Rd, Wheaton, Illinois 60187
- CMS Provider Number
- 145050
- Inspections on file
- 25
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Dupage Care Center during CMS and state inspections, most recent first.
The facility failed to follow proper food handling and hygiene practices, affecting all residents receiving oral nutrition. A chef was observed not washing hands after touching contaminated surfaces and using the same gloves to handle food and equipment. Additionally, undated and unsealed food items were found in storage, and a package of roast beef was improperly labeled, posing a risk of serving expired or contaminated food.
The facility failed to date and discard insulin vials when opened and did not store medications in their original packaging until administration. Insulin vials were not dated or discarded after the 'do not use after' date, and a nurse improperly stored medications in a cart before administration. These actions violated the facility's medication administration policy.
The facility failed to adhere to infection control protocols, with staff not using appropriate PPE or performing hand hygiene during resident care. CNAs were observed neglecting to change gloves or wash hands after handling soiled materials, and a resident on contact isolation was not assisted with hand hygiene before therapy. These actions contravened the facility's policies on Enhanced Barrier Precautions and contact isolation.
The facility failed to ensure call lights were within reach for residents, impacting their ability to request assistance. One resident, with a history of falls and cognitive impairment, was unable to reach her call light, while another resident with severe cognitive impairment also had her call light out of reach. A third resident was found in pain with her arm trapped, unable to access her call light. Staff interviews confirmed the expectation for call lights to be accessible, aligning with the facility's protocol.
A resident with multiple diagnoses reported verbal abuse by a CNA, but the facility failed to report the allegations to the IDPH within the required 24-hour timeframe. Despite the resident informing the DON and Social Services Manager about the abuse, the report was delayed until the DON received a voicemail, prompting the filing. The facility's policy requires immediate reporting of such allegations, which was not followed.
Two residents in an LTC facility were inadequately monitored and cared for, leading to deficiencies. One resident, with multiple health issues, developed a new wound due to improper incontinence management and lack of repositioning. Another resident, with dementia and mobility issues, experienced pain from her arm being trapped in her wheelchair, with her call light out of reach. The facility failed to adhere to care plans and ensure resident safety.
Two residents with cognitive and mobility impairments were improperly transferred by staff using their pants instead of gait belts, contrary to care plans and facility policy. Staff interviews confirmed the correct procedure was not followed.
A resident with multiple medical conditions, including recurrent UTIs and parkinsonism, did not receive adequate hydration despite being dependent on staff for assistance with drinking. Over several days, the resident reported not having enough water and was observed without water at the bedside. Facility staff confirmed that residents should be offered fluids, but this was not consistently done, leading to a deficiency in care.
A facility failed to manage and label feeding tube equipment for a resident with a G-tube. The tubing was used beyond the recommended period and was not labeled, contrary to protocol. Staff interviews revealed inconsistencies in understanding the policy for changing and labeling feeding tube equipment, and the DON could not provide a specific policy. The resident had severe cognitive impairment and relied on staff for eating.
A facility failed to document monthly medication reviews and obtain physician responses to pharmacy recommendations for a resident with multiple diagnoses, including paraplegia and hypertension. The pharmacy manager noted missing documentation for specific review dates and a lack of physician response to a recommendation for a dose reduction of Citalopram Hydrobromide due to QT prolongation risks. The Director of Nursing indicated that while the facility expects daily physician rounds, there is no policy on the timeframe for addressing pharmacy recommendations.
A resident, dependent on assistance for ADLs, fell and sustained injuries during a transfer when a CNA attempted to use a mechanical lift alone, contrary to the facility's policy requiring two staff members. The resident, with a history of falls and other medical conditions, reported discomfort with the sling used before falling and was later treated for a tibia fracture and occipital contusion.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper food handling and hygiene practices in the kitchen, affecting all residents who receive oral nutrition. During an observation, a chef was seen pureeing lunch items without washing hands after touching potentially contaminated surfaces, such as a garbage can and a face mask. The chef used the same gloves to handle food, equipment, and utensils, which could lead to cross-contamination. This lack of hand hygiene and improper use of gloves violated the facility's hand hygiene policy, which requires washing hands with soap and water after handling soiled equipment or touching the face mask. Additionally, the facility did not comply with its policy on labeling, dating, and storing food items. During a kitchen tour, undated and unsealed bags of crispy onions and croutons were found in dry storage. In Cooler #2, a package of roast beef deli meat was improperly labeled with a handwritten date that did not match the use-by date, leading to confusion about its safety. The Dietary Manager acknowledged that all food items should be labeled, dated, and sealed to prevent contamination and ensure resident safety. The failure to properly label and store food items poses a risk of serving expired or contaminated food to residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly date and discard insulin vials when opened, as well as store medications in their original packaging until administration. During an inspection, it was observed that several insulin vials for residents were not dated with the open date, which is necessary for proper medication storage. Additionally, some insulin vials were not discarded after the indicated 'do not use after' date, which is a requirement for ensuring safe medication storage and administration. Furthermore, a nurse was found to have removed medications from their original packaging and stored them in a medication cart before the scheduled administration times. This included loose pills and a powdery substance, which were not supposed to be stored in the cart once removed from their packages. The facility's policy requires that medications be prepared and administered at the scheduled times and not stored in the medication carts once removed from their packages. These actions were contrary to the facility's medication administration policy, which aims to ensure safe medication storage and administration.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by multiple instances of staff not using appropriate personal protective equipment (PPE) and neglecting hand hygiene protocols. For instance, a CNA was observed providing personal hygiene and incontinence care to a resident on Enhanced Barrier Precautions (EBP) without changing gloves or performing hand hygiene when transitioning from handling a soiled brief to a clean one. Additionally, the CNA left the resident's room without removing PPE, contrary to the facility's policy that requires PPE to be removed before exiting the room. Another incident involved two CNAs providing incontinence care to a resident without changing gloves or performing hand hygiene after handling soiled materials. One of the CNAs used a single towel multiple times without folding it, potentially spreading contaminants. The CNA then touched various surfaces and equipment with contaminated gloves, further breaching infection control protocols. The Director of Nursing confirmed that these actions were against the facility's expectations for infection control practices. Further deficiencies were noted with a CNA handling garbage and meal trays without wearing gloves or performing hand hygiene, despite the resident being on contact isolation due to an infection. Additionally, a resident with a diagnosis of enterocolitis due to Clostridium Difficile reported not receiving assistance with hand hygiene before attending therapy sessions, which is a requirement for residents on contact isolation. The facility's policies on contact isolation and hand hygiene were not adhered to, as evidenced by these observations.
Failure to Ensure Call Lights Within Reach of Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents, which is a critical aspect of accommodating their needs and preferences. On August 20, 2024, a resident, R145, was left in her wheelchair at the foot of her bed with the call light lying across the center of the bed, out of her reach. Despite her attempts to propel herself to reach the call light and asking another resident, R168, for help, neither could access it. R145 had a history of repeated falls, cognitive impairment, and required substantial assistance for daily activities, making the accessibility of the call light crucial for her safety and well-being. Similarly, R168 was observed sitting in her wheelchair with the call light out of reach on the bed. R168 had severe cognitive impairment and required assistance for personal hygiene and other activities, emphasizing the importance of having the call light accessible. Interviews with several CNAs and RNs confirmed that call lights should be within reach and sight of residents, typically clipped to their clothes or blankets. The facility's Call Light Protocol also mandates that a working call light must remain within reach of residents at all times. Another incident involved R155, who was found in her wheelchair with her right arm trapped and crying in pain. Her call light was tied to the bedrail at the head of the bed, out of her reach. Her husband confirmed that the call light was consistently out of reach during his visits. R155's situation highlights the facility's failure to adhere to its protocol, as her call light was not accessible, preventing her from calling for help when needed.
Failure to Timely Report Verbal Abuse Allegations
Penalty
Summary
The facility failed to report allegations of verbal abuse within 24 hours, as required by their policy. This deficiency involved a resident, identified as R141, who was admitted with multiple diagnoses including paraplegia, neuralgia, and depression, and was cognitively intact with a BIMS score of 15. On August 20, 2024, R141 reported that a CNA, identified as V40, verbally abused him by stating he was a bother and that no other CNAs wanted to work with him. Despite R141 informing the Director of Nursing (DON) and the Social Services Manager about these allegations the previous week, the initial report to the Illinois Department of Health (IDPH) was not submitted until August 19, 2024. Interviews revealed that the Social Services Manager and Social Worker were aware of R141's dissatisfaction with V40's care, but did not investigate the verbal abuse allegations thoroughly or report them promptly. The Assistant Administrator/Abuse Coordinator stated that any leadership member could file a report for abuse allegations, even on weekends, and that such reports should be submitted within two hours. However, the report was delayed until the DON received a voicemail from R141 on August 19, 2024, which prompted the filing. The facility's policy mandates immediate notification and reporting of alleged mistreatment, neglect, or abuse, which was not adhered to in this case.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to properly monitor, assess, and treat a resident, R104, who was at risk for potential pressure ulcers. R104, a female resident with multiple diagnoses including chronic kidney disease, diabetes, and schizoaffective disorder, was observed with a stage 3 pressure ulcer on her coccyx and a new open wound on her left buttock. The wound nurse and doctor identified the new wound as moisture-associated skin damage due to incontinence. Despite the facility's care plan indicating the need for regular repositioning and incontinence management, R104 was found lying on her back during observations, and her electronic records did not document the new wound prior to the surveyor's visit. Another resident, R155, was not properly monitored, leading to her arm being trapped in her wheelchair, causing her pain. R155, who has cerebral ischemia, vascular dementia, and a history of falls, was observed leaning to her right side in her wheelchair, with her arm caught between adaptive devices. Her call light was out of reach, preventing her from calling for help. Despite her husband's daily visits and reports of the issue, the facility staff did not address the problem, and the resident continued to experience pain and discomfort. The facility's failure to ensure proper monitoring and care for these residents highlights deficiencies in adhering to care plans and ensuring resident safety. The Director of Nursing expressed expectations for regular repositioning and accessible call lights, but these were not met, resulting in inadequate care for both residents. The lack of documentation and failure to address known issues contributed to the deficiencies observed by the surveyors.
Improper Use of Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to safely transfer residents using a gait belt, as observed in two cases. In the first instance, a CNA and a Restorative Aide assisted a resident with severe cognitive impairments and a history of falls from a lying to a sitting position. Despite the resident's care plan indicating the need for a two-person assist using a gait belt, the CNA pulled the resident up by her pants instead of using the gait belt. This action was contrary to the facility's policy and the resident's care plan, which required the use of a gait belt for transfers. In the second case, a CNA assisted another resident with moderate cognitive impairment and mobility issues into a wheelchair and later onto a toilet. The CNA used the resident's pants to pull her up instead of the gait belt, despite the resident's care plan indicating the need for substantial assistance with transfers. Interviews with various staff members, including CNAs, an RN, and the Director of Nursing, confirmed that the proper procedure was to use a gait belt for transfers, and pulling residents by their pants was not safe. The facility's Transfer-Gait Belt Policy also specified the correct method for using a gait belt, which was not followed in these instances.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to provide adequate hydration to a resident, identified as R30, who was at risk for dehydration. R30 had multiple medical diagnoses, including recurrent urinary tract infections and parkinsonism, and was dependent on staff for assistance with feeding and drinking. Despite being cognitively intact, R30 reported not receiving enough water and experiencing urinary discomfort. Observations over several days revealed that R30 did not have water at the bedside and was not offered sufficient fluids, even though she expressed a desire for more water. The facility's policy required offering fluids to residents, especially those with swallowing precautions like R30, but this was not adhered to. Interviews with facility staff, including the Head Unit Nurse and the Assistant Director of Nursing, confirmed that residents should be offered fluids between meals and have water available at the bedside. R30's care plan and nutritional assessment indicated a need for honey-thickened liquids and specified her estimated fluid needs. However, these interventions were not consistently implemented, as R30 continued to report inadequate fluid intake. The facility's hydration policy aimed to ensure residents received adequate fluids, but the procedures outlined were not followed, leading to the deficiency.
Failure to Properly Manage and Label Feeding Tube Equipment
Penalty
Summary
The facility failed to properly manage and label the feeding tube equipment for a resident with a gastrostomy tube (G-tube). On August 20, 2024, it was observed that the resident was receiving enteral feeding at a rate of 50 milliliters per hour, but the tubing used was dated August 15, 2024, which exceeded the recommended usage period. Additionally, on August 21, 2024, the feed tubing was found to be neither labeled nor dated, contrary to the facility's protocol and manufacturer guidelines. Interviews with the nursing staff revealed inconsistencies in the understanding and application of the facility's policy regarding the changing and labeling of feeding tube equipment. One RN stated that the tubing should be changed whenever a new bottle is opened and should not be used for more than 24 hours. Another RN confirmed that all equipment should be new with each feeding and should be dated. However, the Director of Nursing was unable to provide a specific policy on the frequency of tubing changes, indicating a lack of clear guidance. The resident involved had severe cognitive impairment and was dependent on staff for eating, highlighting the importance of adhering to proper feeding tube management protocols.
Failure to Document Medication Reviews and Physician Responses
Penalty
Summary
The facility failed to provide documentation of monthly medication reviews and obtain a documented physician response to pharmacy recommendations for one resident, identified as R141, out of a sample of 37. R141 was admitted with multiple diagnoses, including paraplegia, neuralgia, and hypertension, and was cognitively intact with a BIMS score of 15. The pharmacy manager, V7, acknowledged the absence of documentation for medication reviews conducted on specific dates and noted that pharmacy recommendations made in November 2023 did not receive a physician response. The recommendation involved a dose reduction of Citalopram Hydrobromide due to the risk of QT prolongation, but the psychiatrist deferred the recommendation to the primary care physician, whose response was not documented. The Director of Nursing, V2, stated that the pharmacy delivers the monthly medication review to the head or charge nurse, who should then present it to the physician. However, there was no policy specifying the timeframe for the physician to address these recommendations. Despite the expectation that the physician or nurse practitioner makes daily rounds, the nurse should contact the physician within a week if recommendations are not addressed. The facility's policy allows the pharmacist to contact the physician directly for clarification if needed, but this was not documented in this case. R141's current orders showed an increase in the medication dosage, contrary to the pharmacy's recommendation.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in a fall and subsequent injuries. The resident, identified as R2, required assistance from two staff members for transfers as per their care plan and MDS. However, on the day of the incident, a Certified Nursing Assistant (CNA), identified as V12, attempted to transfer R2 alone using a mechanical lift. During the transfer, R2 reported that the sling used was too small, causing discomfort. Despite R2's complaints, V12 proceeded with the transfer, leading to R2 falling from the lift and sustaining a right tibia fracture and an occipital contusion. R2, who is cognitively intact but dependent on assistance for ADLs, has a medical history that includes muscular dystrophy, osteoarthritis, and a history of falls, among other conditions. The incident occurred when V12, without waiting for additional staff assistance, attempted the transfer alone, contrary to the facility's policy requiring two staff members for such transfers. The fall was witnessed, and R2 was subsequently sent to the emergency department for evaluation and treatment of the injuries sustained.
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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