Elevate Care Country Club Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Country Club Hills, Illinois.
- Location
- 18200 South Cicero Avenue, Country Club Hills, Illinois 60478
- CMS Provider Number
- 145967
- Inspections on file
- 48
- Latest survey
- March 21, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Elevate Care Country Club Hill during CMS and state inspections, most recent first.
A resident with a history of CVA, hemiplegia, impaired balance, and documented need for supervision with sliding-board transfers and assistance for LB dressing activated the call light and waited an extended period without staff response. The resident, identified as high fall risk by a leaf symbol, independently retrieved clothing from the closet, transferred using a sliding board without supervision, and dressed himself incompletely, while staff later acknowledged that such a wait time and lack of response were inappropriate. Review of the MDS, care plan, OT discharge summary, and facility policies on call lights, comprehensive care planning, and fall prevention showed that required fall-prevention interventions and supervision were not implemented as planned, resulting in a deficiency related to accident hazards and inadequate supervision.
A resident with cerebral palsy, vascular dementia, reduced mobility, and high fall risk was care planned as dependent for transfers, requiring two-person assist with gait belt and use of a full-body or Hoyer lift. Multiple assessments documented the need for two staff for chair/bed to chair transfers and ADLs. Despite this, the resident was transferred from bed to wheelchair by a single CNA, with the wheelchair improperly positioned and the resident lifted under the arms and then released on one side, causing the resident—who had left-sided weakness and was wearing an AFO brace—to slide to the floor and sustain a left tibia-fibula fracture requiring hospitalization. Staff interviews revealed that nursing staff were unaware of or did not follow the documented two-person transfer interventions, even though facility policies required implementation of fall prevention measures and adherence to the plan of care.
A resident admitted to hospice care experienced untreated pain due to the facility's failure to transcribe physician orders for comfort care medications. Despite the availability of morphine, the absence of a written order in the electronic health record delayed pain management until the Director of Nursing intervened. The deficiency highlights a lapse in following established protocols for documenting and processing physician orders.
A resident with malignant colon cancer did not receive prescribed hospice medications due to a failure to transcribe orders into their electronic health record. The resident's representative raised concerns about the resident's pain to the facility's administrator via email, but the grievance was not documented or addressed, violating the facility's grievance policy.
A resident, who is nonverbal and fully dependent on staff for ADLs, fell from bed during incontinence care due to inadequate assistance, resulting in a head laceration requiring hospital treatment. The facility lacked a resident safety policy, and staff interviews indicated that the CNA should have pulled the resident closer to prevent the fall.
A resident with reduced mobility and incontinence developed a pressure injury on the coccyx, progressing from Stage 2 to Stage 3 within a week. Despite being assessed as at-risk and having a care plan to prevent skin pressure, the resident's dissatisfaction with night shift care and the progression of the injury indicate a lapse in care practices.
Two residents in a facility were victims of physical abuse by staff. One resident, with a history of cerebral palsy and dementia, reported being abused by CNAs, resulting in injuries requiring hospital evaluation. Another resident, with Alzheimer's and Parkinson's, was slapped by an NP, who admitted fault. The facility's policy mandates abuse prevention training for staff, but the NP, part of an external group, did not receive such training.
A resident with a penile prosthesis in an erectile position for twenty-two days was admitted to the facility with an opening on the penile shaft and excoriation on the penile head/tip. The facility failed to implement a treatment plan, leading to the resident developing a full-thickness moisture-associated skin dermatitis (MASD). The treatment nurse was unaware of how to manage the condition, and the assistant director of nursing confirmed that no treatment was in place upon admission. The wound doctor noted the need for monitoring and surgery, but the resident was discharged before any resolution.
A facility failed to identify and treat pressure ulcers for a high-risk resident with complex medical conditions, leading to advanced-stage ulcers. Despite the resident's care plan indicating a high risk for skin breakdown, staff did not consistently report or address new skin openings promptly. Discrepancies in documentation and delayed treatment were noted, with pressure sites found during treatment of other wounds, indicating inadequate proactive skin assessments.
Failure to Implement Fall-Prevention Interventions and Timely Call-Light Response
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-prevention interventions and provide timely response to a call device for a resident identified as at risk for falls. On the morning of 03/20/2026, the call device monitoring screen at the nurses’ station showed that the call device in this resident’s room and bed had been activated for 24 minutes. A leaf symbol was displayed beside the resident’s name, indicating high fall risk. Despite the active call device, the resident was not in the room when checked and was later observed seated in a wheelchair across from the nurses’ station wearing gray pants that were not fully pulled up, with his incontinence brief visible. The resident reported he had been waiting 30–40 minutes for staff to respond to his call device. He stated he became impatient, retrieved pants from his closet himself, and put them on without being able to pull them all the way up. He also stated he still needed help putting on socks and was wearing shoes without socks. The resident further reported that no one supervised him while he transferred himself using a sliding board and that no one assisted him in getting his pants from the closet. A CNA confirmed that the leaf symbol by the resident’s name signified fall risk and acknowledged that a resident should not wait 24–40 minutes for assistance, and that if the resident activated the call device, staff should have answered it so the resident would not attempt to get items independently. Record review showed the resident had a history of stroke with hemiplegia affecting the left non-dominant side, contractures in both knees, and used a wheelchair as the primary mobility device. The MDS documented that he required partial/moderate assistance for lower body dressing. An OT discharge summary indicated he had achieved the goal of performing lower body dressing with supervision or touching assistance. The care plan documented that he had ADL self-care performance deficits related to hemiplegia, impaired balance, and limited ROM, used a sliding board for transfers, and required supervision for transfers with the sliding board. Another care plan focus identified him as at high risk for falls related to deconditioning, history of falls, and impulsive behavior, with interventions including reminding and encouraging him to call for assistance and keeping the call light within reach. Facility policies required timely response to call lights, development and implementation of a comprehensive care plan, and a fall prevention program with appropriate supervision and use of transfer devices. Despite these documented needs and policies, the resident’s call device was not answered promptly, and he transferred and dressed himself without required supervision, constituting the failure to implement fall-prevention interventions for a resident at risk for falls.
Failure to Follow Two-Person Transfer and Lift Requirements Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement fall prevention measures and follow the resident’s care plan for transfer assistance. A resident with extensive medical and functional impairments, including cerebral palsy, spastic hemiplegic cerebral palsy, vascular dementia, reduced mobility, prior left fibula fracture, and multiple psychiatric diagnoses, was care planned as dependent for transfers and requiring two-person assistance. Multiple assessments and care plans documented that the resident was at high fall risk and required substantial to total assistance: the post-fall observation assessment identified a high fall risk; Section GG assessments and functional abilities assessments documented that chair/bed to chair transfers and putting on/taking off footwear required two staff assist; and care plans dated 1/8/24, 1/24/25, and 4/30/24 specified moderate to substantial assist x2 with gait belt for all transfers due to increased weakness and behaviors, mechanical Hoyer lift x2 for transfers, and use of a full body lift with two-person assist for all transfers. Despite these documented needs and interventions, on the date of the incident the resident was transferred by only one certified nurse aide from bed to wheelchair. The resident reported that the wheelchair was not positioned correctly, that the aide grabbed her under the arms, stood her up, then let go from her left side, causing her to slide down to the floor. The resident, who had left-sided weakness and was wearing a left Ankle Foot Orthosis (AFO) brace, stated she heard a cracking sound when she slid to the floor and immediately reported leg pain. The facility-reported incident documented that the resident was found sitting on the floor with her back to the bed and legs flat on the floor and that she sustained a left tibia-fibula fracture, for which she was hospitalized and treated. Interviews with staff showed a lack of awareness and adherence to the resident’s care plan and fall prevention interventions. A registered nurse on duty at the time of the fall stated she was unsure of the resident’s transfer status prior to the fall and confirmed that only one staff member assisted with the transfer when the resident fell and sustained a fracture. An LPN stated she was not aware of the fall care plan intervention requiring two-person transfer due to increased weakness and behaviors. Another RN stated that care plan interventions are to be followed for all residents, and the DON and Administrator both stated their expectations that care plans be updated as needed and followed by staff. Facility policies on the Fall Prevention Program and on transfer/manual gait belt and mechanical lifts required assessment of transfer needs, documentation in the care plan, and use of transfer conveyances and mechanical lifts according to the plan of care, but these were not implemented for this resident at the time of the incident.
Failure to Transcribe Hospice Orders Leads to Untreated Pain
Penalty
Summary
The facility failed to transcribe physician orders for comfort care medications for a resident who was admitted to hospice care services. This deficiency resulted in the resident experiencing untreated pain for several days before passing away in the facility. The resident, who had been diagnosed with malignant colon cancer, was admitted to hospice services following a hospitalization for adult failure to thrive. Upon returning to the facility, the resident's orders for hospice services were not properly transcribed, leading to a delay in administering necessary pain relief medications. The resident's representative reported that during a visit, they observed the resident in visible pain and sought assistance from the nursing staff. However, the nurse on duty was unable to administer morphine due to the absence of a written order in the electronic health record. It was only after the Director of Nursing intervened that the order was obtained and the medication was administered. Despite the availability of the medication, the lack of proper documentation and transcription of orders prevented timely pain management for the resident. Interviews with facility staff revealed that the hospice nurse had confirmed medication orders with the facility nurse on duty, but these orders were not transcribed into the electronic health record. The facility's policy for transcribing physician orders was not followed, as evidenced by the absence of the hospice orders in the resident's records. The failure to adhere to established protocols for documenting and processing physician orders contributed to the resident's prolonged discomfort and inadequate pain management during their final days.
Failure to Address Grievance and Transcribe Hospice Orders
Penalty
Summary
The facility failed to adhere to its grievance policy by not acknowledging a concern raised by a resident's representative. The resident, who had been admitted with malignant colon cancer, experienced a sudden decline in health and was subsequently placed under hospice care. Upon returning to the facility, hospice orders were not transcribed into the resident's electronic health record, resulting in the resident not receiving prescribed comfort medications. This oversight led to the resident experiencing significant pain before passing away. The resident's representative expressed these concerns to the facility's administrator via email, but the facility did not document or address the grievance. The administrator claimed to be unaware of any concerns related to the resident and had not received any documented grievances since the resident's passing. The facility's grievance policy requires that all grievances, regardless of how they are communicated, be documented and addressed promptly. However, the facility did not follow this policy, as evidenced by the lack of a grievance form for the concern raised by the resident's representative.
Failure to Provide Adequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure resident safety by not providing the required two-person assistance to a totally dependent resident, identified as R121, during incontinence care. This oversight resulted in R121 falling from the bed, leading to a head laceration that required hospital evaluation and the application of three staples. The incident occurred while a Certified Nursing Assistant (CNA) was providing care, and the resident began to slide off the bed. The CNA called for assistance, but the resident had already fallen, sustaining a moderate scalp laceration. R121 is a nonverbal resident with significant medical needs, including a tracheostomy and gastrostomy tube, and is entirely dependent on staff for activities of daily living (ADLs) and mobility. The resident's medical history includes anoxic brain damage, chronic respiratory failure, and contractures in all extremities, making her at high risk for falls and related injuries. The facility's assessment indicated that R121 required assistance from two caregivers for bed mobility and personal hygiene tasks. Interviews with facility staff revealed that there was no policy on resident safety, and the CNA involved in the incident acknowledged that she should have pulled the resident closer to her rather than rolling her away, which placed the resident at risk of falling. The facility's existing fall prevention program emphasizes the need for adequate supervision and the use of assistive devices, but it appears that these measures were not adequately implemented in this case.
Failure to Prevent Pressure Injury in At-Risk Resident
Penalty
Summary
The facility failed to prevent the development of a pressure injury in a resident identified as at-risk due to reduced mobility and incontinence. Upon admission, the resident had a surgical wound from a right above-the-knee amputation, with no other wounds documented. However, a shower sheet dated 12 days later indicated an open sore in the coccyx area. The Wound Coordinator LPN confirmed that the resident was assessed as at risk for pressure injuries and was found to have a Stage 2 pressure injury on the coccyx, which progressed to Stage 3 within a week. The resident, who was alert and oriented, expressed dissatisfaction with not being changed by the night shift, as reported by a CNA. The resident's care plan included interventions to prevent skin pressure areas, but the development of the pressure injury suggests these interventions were not effectively implemented. The wound assessment and physician notes confirmed the progression of the pressure injury, highlighting a lapse in the facility's care practices for this resident.
Failure to Protect Residents from Abuse by Staff
Penalty
Summary
The facility failed to protect residents from physical abuse by staff, affecting two residents. The first resident, a female with a complex medical history including cerebral palsy and dementia, reported being physically abused by two CNAs. She sustained swelling and redness to her left eye and bruising on her right hand, which led to her being transferred to a hospital to rule out an orbital fracture. The incident was reported to the police, and the resident identified the CNAs as the perpetrators. Medical staff and facility personnel confirmed the resident's injuries and her allegations of abuse. The second resident, an elderly male with a history of Alzheimer's and Parkinson's disease, was involved in an incident where he was slapped by a nurse practitioner (NP). The resident was noted with redness on his face but denied pain. The NP admitted to the police that she was at fault, citing personal issues as a contributing factor. The facility's investigation concluded that the NP was aggressive towards the resident, and she was subsequently removed from the facility. The NP had not received abuse training from the facility, as she was part of an external provider group. The facility's abuse prevention policy states that residents have the right to be free from abuse and that new employees should receive training on abuse prevention. However, the NP involved in the second incident did not receive such training, as the facility did not consider her a staff member. This lack of training and oversight contributed to the failure to protect the residents from abuse, as evidenced by the incidents involving the two residents.
Failure to Implement Treatment Plan for Resident with Penile Prosthesis
Penalty
Summary
The facility failed to implement a treatment plan for a resident identified as very high risk for skin breakdown, who was admitted with an opening on the penile shaft and excoriation on the penile head/tip, with a penile prosthesis in an erectile position for twenty-two days. The treatment nurse was unaware of how to manage the resident's condition, including the proper placement of the adult brief to prevent friction. The resident developed a facility-acquired full-thickness moisture-associated skin dermatitis (MASD) measuring 8.00 cm x 3.00 cm x 0.10 cm. The assistant director of nursing acknowledged that no treatment was in place upon admission, and the doctor was not notified immediately, nor was the site measured upon admission. The wound doctor noted that the facility should have been monitoring the resident for any skin breakdown, and the resident required surgery. Hospital referral paperwork indicated the prosthesis was left in a semirigid position. A nursing note and physician order sheet dated 3/11/24 documented the presence of a pressure injury and the initiation of wound care. The wound doctor visit on 3/14/24 recorded a partial thickness abrasion that had not healed. The facility's failure to implement timely and appropriate treatment resulted in the resident sustaining a significant skin injury.
Failure to Identify and Treat Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to identify and treat pressure ulcers for a resident who was dependent on staff for care, resulting in the development of advanced-stage pressure ulcers. The resident, who had multiple complex medical conditions including anoxic brain damage, respiratory failure, and end-stage renal disease, was admitted to the facility with a high risk for skin breakdown. Despite this, the facility did not adequately monitor or document the resident's skin condition, leading to the discovery of multiple pressure ulcers at advanced stages during routine care. The resident's care plan indicated a high risk for skin issues, yet the facility's staff did not consistently report or address new skin openings in a timely manner. The report details several instances where the resident's pressure ulcers were not identified until they had progressed significantly. For example, a deep tissue injury on the sacrum was not documented until it was unstageable, and a stage 3 pressure ulcer on the left elbow was not treated until two days after it was first noted. Additionally, discrepancies in documentation were noted, such as differing reports on the number and location of open areas on the resident's body. The facility's wound care nurse acknowledged that the pressure sites were found during treatment of other wounds, indicating a lack of proactive skin assessments. This deficiency highlights a failure in the facility's processes for monitoring and managing pressure ulcers in high-risk residents.
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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