Elevate Care Niles
Inspection history, citations, penalties and survey trends for this long-term care facility in Niles, Illinois.
- Location
- 8333 West Golf Road, Niles, Illinois 60714
- CMS Provider Number
- 145662
- Inspections on file
- 46
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Elevate Care Niles during CMS and state inspections, most recent first.
Two residents who were incontinent and dependent on staff for ADLs did not receive timely incontinence care, hygiene, or grooming. One resident with Alzheimer’s and dementia was repeatedly reported by a family member to be found soiled with urine and feces, and on observation was lying in a soiled brief with multiple superficial open wounds and redness on the sacral/buttocks area and discolored heels; the assigned CNA had not yet provided morning or incontinence care and had not reported the skin issues to the LPN. Another resident on COVID respiratory isolation, with cerebral palsy and COPD, reported not having had a bath or shower since ashes were placed on her forehead and stated she had not received morning care and was soiled; she was observed with facial hair, long dirty nails, and lying on a low air loss mattress with the machine on the floor, and when repositioned her brief and linens were soaked with urine. Staff interviews showed confusion about CNA assignments and practices, with CNAs delaying incontinence checks until after breakfast tray pass and limiting care to brief changes, despite facility policies requiring incontinent checks at least every two hours and including grooming tasks such as shaving and nail care within ADLs.
A resident with Alzheimer’s disease, dementia, MASD, bowel and bladder incontinence, and a history of a heel pressure ulcer, who is nonverbal and totally dependent for ADLs, was found on a LAL mattress with a soiled brief, no sacral or heel dressings, and no heel boots, despite active orders and a care plan for MASD treatment, foam dressings, and heel offloading. Surveyors observed multiple superficial open wounds and erythema over the sacral/buttocks area and discoloration of the inner thigh, as well as redness and scab formation on a heel, with no barrier or treatment cream present. The assigned LPNs and WCC reported they were unaware of these skin changes and had not been notified by CNAs, and the CNA assigned to the resident had not yet provided incontinence care or inspected the skin. Documentation showed prior wound assessments indicating improvement and intact heel skin, while facility policies required daily skin checks, frequent inspection during care, prompt reporting of changes, and use of positioning devices, which were not carried out.
Three dependent residents did not receive timely incontinence care as required by facility guidelines and their care plans. Staff failed to check and change residents every two hours, resulting in prolonged periods in soiled briefs and linens. Staff cited other duties as reasons for the delays, and the DON confirmed the expectation for two-hour checks.
Surveyors found that multi-dose medications in one medication room were not labeled and discarded according to manufacturer and pharmacy instructions. An ophthalmic solution for a resident with primary open-angle glaucoma was open well beyond the labeled 6-week discard period, an insulin lispro vial for a resident with type 2 DM had no open date despite a 28-day discard requirement, and two open vials of Tuberculin PPD were undated even though labeling required discard after 30 days. An RN confirmed that all multi-dose medications should be dated when opened, and facility policy requires dating vials once the original seal is broken, including for multi-dose injectables and ophthalmic medications.
Surveyors identified that prepared cold sandwiches and juices stored in a cooler were not dated or labeled as required, and staff gave inconsistent accounts of when the items were prepared, despite facility policy mandating dating and labeling of non-immediate-use sandwiches. In addition, sanitizer solutions used in red buckets and the sanitizing sink were found to be below the manufacturer-recommended 200–400 ppm, and dishwashing test strips repeatedly failed to turn bright orange, indicating the dish machine was not reaching proper sanitizing temperature. These failures in food labeling and sanitization affected all residents receiving food trays from the kitchen.
A dependent, nonverbal resident with multiple complex medical conditions, including anoxic brain damage, chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, gastrostomy, colostomy, and a stage 4 sacral pressure ulcer, was observed with long, discolored fingernails containing black matter under the nails. During observations with wound care staff, it was confirmed that nail care is part of the ADL program and assigned to CNAs. The regular LPN for the resident reported she had not noticed the nail condition during rounds and stated that CNAs were responsible for nail care. The DON acknowledged that nail care, including daily cleaning and regular trimming, is required for residents dependent in ADLs, and the resident’s care plan and MDS documented total dependence for personal hygiene, yet facility policies on grooming and nail care were not followed for this resident.
Two residents with contractures and limited ROM were repeatedly observed without their ordered splints and braces in place, despite care plans and physician orders specifying use of a right-hand splint and right ankle orthosis for one resident and bilateral resting hand splints for the other. Nursing and restorative staff acknowledged that these devices were required to prevent further contracture and confirmed that restorative aides were responsible for applying them, yet documentation showed the splints were not applied daily and there was no record of resident refusal, contrary to facility policy and treatment orders.
Two residents receiving enteral nutrition experienced deficiencies in tube feeding management when staff did not follow physician orders and facility policy. For one resident, tube feeding was observed infusing at 55 ml/hr instead of the ordered 65 ml/hr of a 1.5 nutritional supplement, a discrepancy confirmed by an LPN and the DON. For another resident with a gastrostomy tube and dysphagia, the feeding was running at the ordered 50 ml/hr, but the feeding bag lacked any identification label, despite policy and staff statements that containers must be labeled with the resident’s name, date, time, rate, and volume to infuse.
A resident with a history of dementia and a previous femur fracture fell in the dining room and reported hip pain. Despite a STAT x-ray order, the x-ray was delayed, leading to a late hospital transfer where a hip fracture was confirmed. Nursing staff did not escalate the delay appropriately, resulting in a deficiency in care.
A resident with dementia and a history of falls was left unsupervised in the dining room, leading to a fall and hip fracture. The resident attempted to stand using a walker, which tipped over, causing the fall. Staff interviews revealed that the CNA was not present in the dining room, and the LPN was at the nurse's station, unable to see the dining room. The resident's care plan required supervision or touching assistance, which was not provided, resulting in the injury.
The facility failed to respond to residents' call lights in a timely manner, with reports of wait times up to two hours. Interviews and observations revealed that limited staff availability and lack of adherence to the call light policy contributed to the delays, affecting residents' care and services.
The facility failed to follow manufacturer's instructions for low air loss (LAL) mattresses by using additional linens, compromising their effectiveness for pressure ulcer prevention. Multiple residents, including those with high risk for skin impairment, were affected. Additionally, heel protectors were not properly applied as per physician orders, further impacting residents' care.
A resident identified as high risk for elopement left the facility without authorization due to inadequate monitoring and supervision. Additionally, medications and used syringes were found at residents' bedsides, posing safety risks. The facility staff failed to document the incidents and follow established policies, leading to deficiencies in resident care and safety.
A facility failed to ensure the privacy and dignity of a cognitively impaired resident who was observed exposed in bed, with an open door allowing visibility from the hallway and nurses' station. The resident, dependent on a ventilator and with multiple medical conditions, was not properly covered, despite the facility's policy emphasizing resident rights to privacy and confidentiality.
A resident with a history of elopement risk left the facility without proper discharge orders or a summary. The resident was documented as discharged to another facility, but had actually eloped the night before. The primary care physician was not informed, and the receiving facility did not receive necessary discharge instructions or belongings. The facility lacked a policy on discharge summaries.
A facility failed to provide a resident with a backup tracheostomy tube of the correct size at the bedside, necessary for emergencies like accidental extubation. The resident, with acute and chronic respiratory failure, required a 6.5 size tube, but a 7.5 size was found instead. The facility's policy mandates a backup tube of the same or smaller size be available, which was not adhered to.
A facility failed to follow its medication administration policy, allowing CNAs to apply Nystatin powder prescribed for one resident to another. The medication was found at the bedside of a resident with multiple health issues, and staff were unaware of the mix-up. The Wound Care Nurse confirmed using the correct medication but noted documentation was done by floor nurses, leading to a deficiency.
Two residents in a LTC facility did not receive timely assistance with activities of daily living. A resident dependent on staff for transfers remained in bed until 1:15 PM, despite preferring to be up earlier. Another resident, incontinent and at high risk for skin breakdown, was found with a leaking catheter and wet brief, having not been changed since 5:00 AM. Staff delays were attributed to prioritizing other residents and staffing shortages.
The facility failed to provide adequate staffing, resulting in delayed care for residents. On a day with only two CNAs for 37 residents, multiple residents reported not receiving timely assistance, particularly those requiring mechanical lifts. The facility's staffing schedule showed frequent understaffing, and grievances highlighted issues with call light response times and daily care. The scheduler admitted to challenges in covering staff call-offs, impacting resident care.
A resident with multiple medical conditions, including a recent fracture, did not receive the required two-person assistance for personal care, as per their care plan. A CNA provided a bed bath without a second staff member, leaving the resident in a raised bed and without an arm sling. Staff interviews confirmed the need for two-person assistance, but it was noted that staff sometimes do not wait for help, compromising the resident's safety.
A resident with PTSD did not receive Prazosin on time, with 14 doses administered late and two doses marked as 'Not Available'. Despite a 30-day supply being delivered, the medication was missing on two days. Staff acknowledged the issue, and the DON noted potential behavioral impacts due to missed doses.
A resident with multiple medical conditions missed an ophthalmology appointment due to the facility's failure to provide necessary assistance with ADLs. The resident, who requires help with transfers and daily activities, was not prepared in time by the assigned CNA, resulting in the transportation leaving without her. The facility's policy outlines CNA responsibilities, which were not met, leading to the missed appointment.
The facility failed to protect two residents from misappropriation of property. Surveillance footage showed a staff member, V14, stealing an iPad from one resident and using another resident's pre-paid cash card at vending machines. V14 was terminated for theft.
Failure to Provide Timely Incontinence and ADL Care, Including Hygiene and Grooming
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and adequate ADL and incontinence care, as well as grooming and hygiene, for two residents who were dependent on staff for these needs. One resident with Alzheimer’s disease, dementia, bowel and bladder incontinence, and significant cognitive and communication impairments was reported by a family member to be frequently found soiled with urine and feces, with feces on her hands, face, and hair. On observation, this resident was nonverbal, confused, and required total assistance with ADLs and transfers. When checked by the ADON and an LPN, her brief was found soiled with urine, and her sacral and buttocks area showed multiple superficial open wounds/excoriations, redness, and dark discoloration extending to the inner thighs, as well as bilateral heel redness, dry peeling skin, and a dark scab on the right heel. The assigned CNA stated she had not yet provided morning or incontinence care, although she had fed the resident, and there were no reports to the LPN about the skin issues. A second resident, on respiratory isolation for COVID-19 and with diagnoses including cerebral palsy, COPD, arthritis, and bowel and bladder incontinence, was found in a room lacking appropriate isolation supplies on the isolation cart and without an isolation waste bin inside the room. The resident reported she had not received a bath or shower since receiving ashes on her forehead several days earlier and stated she had not been provided morning care and was soiled. On observation, she had facial hair, long nails with black matter under them, and was lying on a low air loss mattress with the machine on the floor. When repositioned by an LPN and a CNA, her brief and bed linens were found soaked with urine, and incontinence care was then provided. The resident denied refusing care, and progress notes over several days documented no refusal of care. Staff interviews revealed confusion and inconsistency regarding CNA assignments and responsibilities for providing ADL care, including nail care and shaving. One CNA who assisted with incontinence care for the second resident stated she was not the assigned CNA and did not know who was assigned, while the LPN who made assignments stated that CNA was in fact assigned to the resident. Another CNA reported that for the second resident she routinely started rounds for incontinence care only after passing breakfast trays, and that she did not provide morning care or a bed bath, limiting care to incontinence care and changing the gown and bed sheets. The facility’s policies required incontinent residents to be checked periodically or every two hours and to receive perineal care after each episode, and described grooming tasks such as shaving and nail care as part of ADLs, but the facility had no separate policy on nail care and facial shaving for female residents.
Failure to Implement MASD and Pressure Ulcer Prevention and Monitoring for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered wound and skin care interventions and to monitor and report skin changes for a resident at high risk for skin impairment with MASD and a history of a right heel pressure ulcer. The resident, who has Alzheimer’s disease, dementia, bowel and bladder incontinence, and an ADL self-care deficit, is nonverbal, confused, and requires total care. During observation, the resident was found on a low air loss mattress with a soiled brief, no sacral dressing, no heel dressings, and no heel boots, despite active physician orders and a care plan requiring MASD treatment to the sacrum/buttocks/perineum/thighs, foam dressings to the sacrum/buttocks, and heel dressings three times weekly with offloading devices. The sacrococcygeal area showed multiple clustered superficial open wounds/excoriations, redness over the sacral/buttocks area, and dark discoloration extending to the inner thigh, with no barrier or treatment cream residue present. Staff interviews revealed that the LPN on duty was unaware of the resident’s superficial open wounds and heel condition, stating she had not received any report from the prior nurse or CNA. The wound care coordinator also reported he was not aware of the new superficial open wounds on the sacral area or the dark scab on the right heel and stated he had not been notified of these skin changes by CNAs or floor nurses. The CNA assigned to the resident acknowledged she had not yet provided morning or incontinence care that day, although she had fed the resident, and the ADON stated CNAs are expected to check residents for incontinence every two hours and report any skin changes. The regular nurse for the resident, who had cared for her the previous day, also reported she was not aware of any sacral skin impairment and had not seen the sacral area, indicating that skin inspection and reporting were not occurring as required. Record review showed that the resident’s care plan and physician orders required keeping the skin clean and dry, monitoring skin during care and reporting changes, offloading heels with protective devices, and ongoing wound assessment for deterioration or improvement. The most recent wound report prior to the survey documented MASD to the sacrum/buttocks/perineum with 100% non-blanchable erythema and a healed right heel pressure ulcer with intact skin, but on the survey date the sacral area measured 4 cm x 4 cm as a clustered superficial open wound and the right heel showed dry scaly skin with scab formation and blanchable redness. Facility policies on skin condition assessment and pressure ulcer prevention required daily skin observation by CNAs during care, prompt reporting of changes to the charge nurse, several-times-daily skin inspection during hygiene and repositioning, timely linen changes when soiled, and use of positioning devices to reduce pressure and friction. These policy expectations were not followed, as evidenced by the resident being found soiled, without ordered dressings or barrier creams, and with unreported and unassessed skin breakdown.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The facility failed to follow its Incontinence Care Guidelines by not providing timely incontinence care to residents who were dependent on staff for toileting hygiene. Three residents, all dependent on staff for incontinence care as documented in their Minimum Data Set (MDS) assessments, experienced delays in receiving care. One resident reported being changed only at specific times and sometimes having to wait extended hours if missed by the morning shift. Another resident was observed with a soiled brief and linens after not being changed since the start of the CNA's shift, despite the facility's policy to check every two hours. The third resident also experienced delays, with staff acknowledging the need to notify the assigned CNA and the resident remaining in a wet brief for an extended period. Observations, interviews, and record reviews confirmed that staff did not consistently check and provide incontinence care every two hours as required by the facility's guidelines and individual care plans. Staff cited being occupied with other duties, such as passing meal trays, as reasons for the delays. The Director of Nursing confirmed the expectation for two-hour checks, and the facility's written guidelines also specified this standard. Despite these policies, the care provided did not meet the documented requirements for timely incontinence care for dependent residents.
Improper Labeling and Dating of Multi-Dose Medications
Penalty
Summary
Surveyors identified a failure to ensure multi-dose medications were labeled and discarded according to manufacturer and pharmacy instructions in one of two medication rooms reviewed. During an observation of the second-floor medication room with a registered nurse, an open bottle of Latanoprost ophthalmic solution for a resident with primary open-angle glaucoma was found with an open date of 08/01/2025, despite the pharmacy label directing that any remaining drug be discarded 6 weeks after first use. The resident’s order for Latanoprost had been in place since 2019. Additionally, an insulin lispro vial for a resident with type 2 diabetes mellitus was found without an open date, even though the pharmacy label instructed that any remaining medication be discarded 28 days after first use. Further observation in the same medication room revealed two open, undated vials of Tuberculin Purified Protein Derivative. The vial label stated that once entered, the vial should be discarded after 30 days, and accompanying medication literature specified that vials in use more than 30 days should be discarded due to possible oxidation and degradation affecting potency. In an interview, the registered nurse confirmed that all multidose medications and vials should be labeled with an open date once opened. Review of the facility’s “Storage of Medications” policy showed that medications and biologicals are to be stored safely and properly, and that when the original seal of a manufacturer’s container or vial is initially broken, the container or vial must be dated, including for multi-dose injectables and ophthalmic medications or items with a specified usable life after opening.
Improper Food Labeling and Inadequate Sanitization in Dietary Services
Penalty
Summary
The deficiency involves failures in food labeling and dating, as well as improper use and monitoring of sanitizing solutions and dishwashing temperatures in the dietary department. Surveyors observed 15 cold sandwiches and 4 juices stored in a cooler without any dates or labels, and staff provided inconsistent information about when the items were prepared. Both the night supervisor and another staff member acknowledged that all prepared food items and beverages should be dated and labeled, and facility policy on sandwiches requires cold sandwiches made for non-immediate use to be dated, labeled with the food item, date made, and use-by date, and stored appropriately in the refrigerator. Surveyors also found that sanitizing solutions and the dishwashing machine were not maintained or monitored according to manufacturer and facility policy. Testing of a red bucket sanitizing solution showed 0 ppm, despite the manufacturer’s requirement of 200–400 ppm, and review of the sanitizing sink chemical log showed recorded levels of 100 ppm on multiple dates, below the recommended range. Dishwashing test strips applied to utensils and run through the dish machine repeatedly failed to change to the bright orange color required to indicate proper sanitizing temperature, instead remaining faded black/gray on several documented meal services. Facility policies require sanitizer solutions to be checked and logged before meal preparation and dish machine sanitizing parameters to be tested and logged before washing dishes from each meal, but the observations and records showed these standards were not met for the 146 residents receiving food trays from the kitchen.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide nail care as part of activities of daily living (ADLs) for a dependent resident. On 11/19/25 at 8:56 AM, the resident was observed lying on a low air loss mattress, awake but nonverbal, with total dependence on staff for ADLs and transfers. The resident had a tracheostomy connected to a ventilator, a gastrostomy tube connected to an enteral feeding pump, and bilateral arm contractures. During an observation with the Wound Care Coordinator and Wound Care Nurse, the resident was noted to have long, discolored fingernails on both hands with black matter under the nails. Both wound care staff stated that nail care is part of the ADL program and that CNAs are responsible for providing this care. Later that morning, the regular LPN for the resident was shown the resident’s hands with long, discolored fingernails containing black matter and stated she had not noticed this condition during her rounds, reiterating that CNAs are responsible for the resident’s nail care. The DON acknowledged that residents unable to perform ADLs independently should receive services necessary to maintain grooming and personal hygiene, and that nail care is part of ADLs, including daily cleaning and regular trimming. The resident’s comprehensive care plan documented an ADL self-care performance deficit, and the MDS quarterly assessment indicated the resident was dependent for personal hygiene. Facility policies on ADLs and nail care required maintaining personal hygiene, including self-manicure and observing and trimming nails for cleanliness, length, and condition, but these standards were not met for this resident, resulting in the observed deficiency in nail care.
Failure to Apply Ordered Splints and Braces for Residents With Contractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered splints and braces were applied for residents with contractures and limited range of motion. One resident with a history of stroke, hemiplegia affecting the right dominant side, major depressive disorder, hypertensive heart disease without heart failure, and osteoarthritis was observed on multiple occasions without the prescribed right-hand splint and right ankle orthosis in place. On one morning observation, the resident was lying in bed with a right-hand contracture and no splint on, and later the same day was again observed without the right-hand splint or right ankle orthosis. The LPN present acknowledged that both devices should have been on and stated they were used to prevent the resident’s contractures from worsening. The restorative nurse confirmed that the resident was on a ROM exercise program and splint program for the right upper extremity and right ankle orthosis, that the restorative aide was responsible for applying them, and that failure to apply them created the potential for further contracture. The care plan specified that the right-hand resting splint was to be worn for 6–8 hours with a defined on/off schedule, and the DON stated the expectation that staff carry out orders as prescribed, confirming the splint and orthosis should have been applied. A second resident with anoxic brain damage and gait and mobility abnormalities was also found without ordered hand splints. This resident was observed in bed without hand splints on both hands and was unable to fully open either hand. A subsequent observation the same day again found the resident without the bilateral hand splints. The LPN stated that restorative aides were responsible for applying the splints, and the restorative nurse stated that the resident should have splints on both hands to prevent further development of contractures. The physician order required resting hand splints to bilateral hands daily after morning care for six hours as tolerated, and the care plan indicated the resident would benefit from splints/braces due to actual contracture and limited ROM. Documentation survey reports for October and November showed that the resting hand splints were not being applied daily and did not document any refusals by the resident. The facility’s policy on application of splints required proper application per physician order and documentation of use, but this was not consistently carried out for this resident.
Failure to Follow Enteral Feeding Orders and Label Feeding Containers
Penalty
Summary
The deficiency involves failure to administer enteral tube feeding according to physician orders and failure to label an enteral feeding container per facility policy. One resident’s tube feeding was observed infusing at 55 ml/hr in the morning and again at midday, while the physician’s order specified a rate of 65 ml/hr of a 1.5 nutritional supplement every shift. The LPN confirmed that the rate should have been set at 65 ml/hr per the order, and the DON later stated that staff are expected to carry out orders as prescribed and that the rate should have been 65 ml/hr. This resident is an 80-year-old male with a history including malignant neoplasm of the prostate, Parkinson’s disease without dyskinesia, multiple rib fractures, and gait and mobility abnormalities, and had an active order for enteral feeding at 65 ml/hr. A second resident with a gastrostomy tube and diagnoses including diffuse traumatic brain injury with loss of consciousness, encounter for attention to gastrostomy, and unspecified oropharyngeal dysphagia was observed in bed with enteral feeding running at 50 ml/hr, consistent with the physician’s order for 1.5 nutritional supplement at 50 ml/hr for 21 hours or until 1050 ml total volume infused. However, the enteral feeding bag in use had no visible identification label. The Wound Care Coordinator stated that feeding bags should be labeled with the resident’s name, date, start time, rate, and volume to infuse per the physician’s order before administration. The DON also stated that enteral feeding containers should be labeled for identification and proper administration. The facility’s “Gastrostomy Tube – Feeding and Care” policy requires the licensed nurse to review the physician’s order for formula type, concentration, rate, and method, and to label the container with the resident’s name, flow rate, date, and time.
Failure to Timely Complete STAT X-ray After Resident Fall
Penalty
Summary
The facility failed to follow a provider order for a STAT x-ray for a resident who had fallen, resulting in a delay in transferring the resident to the hospital for evaluation and treatment of a fractured hip. The resident, an elderly female with a history of right femur fracture, dementia, and mild cognitive impairment, fell in the dining room and was found on the floor by a Licensed Practical Nurse (LPN). The resident reported pain in her right hip, and a Nurse Practitioner (NP) ordered a STAT x-ray of the right hip and bilateral shoulders. However, the x-ray was not completed in a timely manner, leading to a delay in the resident's transfer to the hospital. The report details the actions and inactions of the nursing staff following the fall. The LPN who first assessed the resident after the fall ordered the x-ray as instructed by the NP and informed the facility administrator. However, the x-ray company did not provide a specific timeframe for when the x-ray would be conducted. The Registered Nurse (RN) on the subsequent shift followed up with the x-ray company but did not receive a definitive time for the x-ray and did not escalate the issue further. The RN noted the resident's pain and applied a Lidocaine patch and administered Tylenol but did not notify the doctor of the resident's pain. The delay continued into the overnight shift, where another LPN observed swelling and external rotation of the resident's leg, prompting immediate action to send the resident to the hospital. The Director of Nursing (DON) and the resident's Power of Attorney (POA) were notified, and the resident was transferred to the hospital, where a hip fracture was confirmed. The facility's policy on STAT x-rays was not adhered to, as the x-ray was not completed within the expected timeframe, and the resident's condition was not reassessed promptly to ensure timely intervention.
Failure to Provide Adequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident, R1, during a sit-to-stand transfer, as outlined in her care plan and assessments. R1, a female resident with a history of dementia, cognitive impairment, and a previous femur fracture, was involved in a fall incident in the dining room. The incident occurred when R1 attempted to stand using her walker, which tipped over, resulting in her fall and subsequent hip fracture. At the time of the incident, R1 was in the dining room with another resident, R2, and there was no staff member present to provide the necessary supervision or touching assistance as required by her care plan. Interviews with staff revealed that the CNA, V7, was not in the dining room but was instead standing by a nearby room, supervising the unit. The LPN, V8, was at the nurse's station and responded to the commotion after hearing residents yelling. The dining room was not visible from the nurse's station, and V8 confirmed that there was usually someone monitoring the residents in the dining room, but it was unclear if the CNA was present at the time of the fall. The Director of Nursing, V2, and the Administrator, V1, acknowledged that R1 required supervision due to her high fall risk, but they believed her ambulation was generally safe without one-to-one supervision. R1's care plans and assessments indicated she was at high risk for falls and required supervision or touching assistance for transfers and ambulation. Despite this, the facility did not ensure that staff were present to provide the necessary supervision, leading to R1's fall and injury. The facility's failure to adhere to R1's care plan and provide adequate supervision resulted in a significant injury that required surgical intervention.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to adhere to its call light policy, resulting in delayed responses to residents' call lights. This deficiency was observed in three residents, who reported waiting times ranging from one to two hours for assistance. One resident, who is cognitively intact, reported waiting several hours to be changed, while another resident observed staff taking a long time to attend to others. A third resident, also cognitively intact, stated that he had waited more than two hours for his call light to be answered, indicating a systemic issue with call light response times. Interviews with staff revealed that there were only two CNAs and one nurse available for approximately 22 residents on the floor, which may contribute to the delayed response times. The call light system at the nurse's station indicates how long a call light has been on, with staff reporting seeing wait times as long as 50 minutes. Despite the facility's policy requiring all staff to assist in answering call lights, observations showed that call lights were not promptly answered, even when staff were present at the nurse's station. The Director of Nursing acknowledged the challenge of answering call lights promptly when staff are engaged in other duties, such as medication administration or patient care.
Improper Use of LAL Mattresses and Heel Protectors
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for using low air loss (LAL) mattresses, which are crucial for pressure ulcer prevention and management. Observations revealed that multiple residents, including R62, R100, R104, R112, and R208, were not properly positioned on their LAL mattresses. Instead of having only a flat sheet as recommended, additional linens such as cloth pads and towels were used, which could compromise the effectiveness of the LAL mattresses. This oversight was acknowledged by the Nursing Supervisor, V15, who confirmed that only a flat sheet should be used. Additionally, the facility did not comply with physician orders and care plan interventions regarding the use of heel protectors for residents at high risk of skin impairment. For instance, R208, who has a stage 4 pressure ulcer and is at very high risk for further skin integrity issues, was observed without properly placed heel protectors. One protector was found on the floor, and the other was improperly positioned, contrary to the care plan's directive to offload heels using protective devices. The facility's policies on pressure ulcer prevention and wound management were not followed, as evidenced by the improper use of LAL mattresses and the failure to apply heel protectors as ordered. The facility's policy, revised in 2018, specifies the use of a cotton sheet over LAL mattresses to reduce friction, and the wound management policy mandates treatment according to physician orders. These lapses in adherence to established guidelines and care plans contributed to the deficiencies observed during the survey.
Failure to Monitor Elopement Risk and Medication Safety
Penalty
Summary
The facility failed to adequately monitor and supervise a resident identified as high risk for elopement, resulting in the resident leaving the facility without authorization. The resident, who had a history of unauthorized departures and was identified as an elopement risk, was not properly monitored despite being placed on an elopement watch. The resident was found missing on the night of 9/30/24, and the facility staff did not document the incident or notify the appropriate authorities in a timely manner. The resident was eventually found by a friend and taken to another facility without a proper discharge order from the attending physician. Additionally, the facility failed to ensure that medications and used syringes were not left at residents' bedsides, posing a safety risk. Observations revealed that medications belonging to one resident were found at another resident's bedside, and used syringes were left on a resident's bedside counter. The nursing staff acknowledged that medications should not be left at the bedside and that used syringes should be disposed of in sharps containers immediately after use. The lack of communication and documentation among the interdisciplinary team contributed to the deficiencies. Staff members were unaware of the resident's elopement risk status and did not document monitoring efforts. The facility's policies on missing residents and medication safety were not followed, leading to lapses in resident safety and care.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the resident's right to privacy and dignity for a totally dependent and cognitively impaired resident. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure with hypoxia, dependence on a ventilator, hemiplegia, and hemiparesis, was observed lying in bed exposed from the abdomen to the lower extremities. The resident was wearing a gown and disposable brief, with a folded linen sheet left unused at the corner of the bed. Additionally, the resident's left heel protector was on the floor, and the right heel protector was improperly placed. The resident was also wearing bilateral hand mittens, and the door to the room was open, making the resident visible to anyone passing by in the hallway, including staff at the nearby nurses' station. The nursing supervisor, upon being shown the situation, acknowledged that the resident should have been covered for privacy and dignity and proceeded to cover the resident with the linen. The facility's policy on resident rights, reviewed in 2019, emphasizes the importance of promoting the exercise of rights for each resident, including privacy and confidentiality. Despite this policy, the facility did not ensure the resident's privacy and dignity, as evidenced by the resident's exposure and the open door, which allowed visibility from the hallway and nurses' station.
Failure to Obtain Discharge Orders and Provide Summary
Penalty
Summary
The facility failed to obtain discharge orders from the physician and provide a discharge summary for a resident being transferred to another facility. The resident, identified as having a risk of elopement, was admitted with diagnoses including cellulitis, unsteadiness, anemia, and long-term antibiotic use. Despite being on elopement watch, the resident left the facility without proper discharge documentation or physician orders. On the day of the incident, the resident was noted to be out on pass and later documented as discharged to another facility, although the resident had actually eloped the previous night. The social service staff documented the discharge as if the resident was present in the facility, without obtaining a physician's discharge order. The primary care physician was unaware of the resident's elopement and subsequent transfer, and the receiving facility did not receive discharge instructions or personal belongings. The facility lacked a policy on discharge summaries, and the Director of Nursing stated that discharge narratives should include clinical condition, vital signs, medications, and other relevant information. However, this was not done for the resident in question, leading to a deficiency in the discharge process.
Failure to Provide Appropriate Backup Tracheostomy Tube
Penalty
Summary
The facility failed to provide a resident with a backup tracheostomy tube of the appropriate size at the bedside, which is necessary for emergency situations such as accidental extubation. The resident, identified as R111, was admitted with conditions including acute and chronic respiratory failure with hypoxia, a tracheostomy, gastrostomy, and anoxic brain damage. The active physician order sheet specified the use of a 6.5 size tracheostomy tube, and the comprehensive care plan required an additional tracheostomy tube of the same size to be kept at the bedside for emergencies. During an observation, it was noted that the spare tracheostomy tube at the resident's bedside was size 7.5, not the required 6.5. The respiratory therapist, V8, confirmed that the resident should have a trach size of 6.5 at the bedside, along with a downsized tube for emergency situations. The facility's policy on accidental extubation mandates that a backup tube of the same size or one size smaller than the prescribed size should always be kept at the bedside. This oversight was communicated to the Director of Nursing, V2, highlighting the facility's failure to adhere to its own policy and the standard of care required for managing tracheostomy care in emergencies.
Unauthorized Medication Administration and Misuse
Penalty
Summary
The facility failed to adhere to its medication administration policy by allowing unauthorized personnel to administer treatment medication and by using medication prescribed for one resident on another. This deficiency was observed in the case of a resident who was admitted with multiple diagnoses, including Type 2 Diabetes Mellitus with diabetic neuropathy, morbid obesity, and respiratory failure. The resident had an active physician order for Nystatin powder to be applied topically every 12 hours for Moisture Associated Skin Disease. However, the Nystatin powder found at the resident's bedside was labeled for a different resident, and it was being applied by Certified Nurse Assistants (CNAs), who are not authorized to administer medication. The issue was brought to the attention of various staff members, including the Nursing Supervisor, Registered Nurse, Licensed Practical Nurse, Director of Nursing, and Wound Care Coordinator. All acknowledged that medication should not be left at the resident's bedside and that CNAs are not permitted to administer medication. Despite this, the CNAs admitted to applying the Nystatin powder at the resident's request, unaware that it belonged to another resident. The Wound Care Nurse confirmed administering the correct Nystatin powder from the treatment cart but noted that documentation was typically handled by floor nurses. This practice led to a lapse in proper medication administration and documentation, contributing to the deficiency identified by the surveyors.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living for two residents, R2 and R3. R2, who is cognitively intact and dependent on staff for bed-to-chair transfers, was observed still in bed at 12:05 PM, despite expressing a preference to be up between 10:00 to 11:00 AM. R2 reported that the delay was due to staff prioritizing dialysis residents. R2 was eventually assisted into her motorized wheelchair by 1:15 PM, just in time for a scheduled activity. R3, who is always incontinent of stool and dependent on staff for toileting and hygiene, was found with a leaking catheter and a wet incontinence brief at 9:58 AM. R3 reported being last changed at 5:00 AM. A registered nurse acknowledged the issue but continued with other duties, and R3 was not changed until 10:39 AM. The care plan for R3 indicates a high risk for skin breakdown due to incontinence, emphasizing the importance of keeping the skin clean and moisturized.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, as evidenced by observations and interviews with residents and staff. On a particular day, only two nurses and two CNAs were observed working on the second floor, which housed 37 residents. Multiple residents reported delays in receiving care due to staffing shortages. One resident expressed frustration about not being able to get out of bed on weekends due to insufficient staff. Another resident, who required assistance with a mechanical lift, was left in bed until the afternoon because the staff prioritized dialysis patients. The CNAs on duty confirmed that they were short-staffed and struggled to meet the needs of all residents, especially on days when there were call-offs. The facility's staffing schedule revealed that the second floor was frequently understaffed, with only two CNAs working on 19 out of the last 32 days. The facility's grievance records also showed multiple complaints about call light response times and daily living care. The scheduler acknowledged the staffing issues, noting that the second floor required more staff due to the high dependency of the residents. Despite these challenges, the facility was unable to find coverage for staff call-offs, leading to inadequate care for the residents.
Failure to Provide Adequate Assistance for Resident with Fracture
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R2, by not providing the required two staff members for personal care, as per the resident's care plan. R2 has multiple medical conditions, including a wedge compression fracture, hemiplegia, and dementia, which necessitate substantial assistance from staff for activities of daily living (ADLs) such as toileting and bathing. The care plan specifically indicates that R2 requires the assistance of two or more helpers due to her cognitive impairment and physical limitations, including a recent non-displaced fracture of the right humerus. During an observation, a Certified Nurse Assistant (CNA), identified as V16, was seen providing a bed bath to R2 without the assistance of a second staff member. R2's bed was raised, and she was undressed without her arm sling, which was removed by V16 for the bath. V16 rolled R2 onto her injured side to change linens, despite R2's inability to assist with her right arm. The CNA left R2 unattended in a raised bed position to fetch a gown and comb, further compromising R2's safety. Another CNA, V28, later assisted V16 in repositioning R2, but V16 admitted to not knowing how to properly apply the sling. Interviews with staff, including the Director of Nursing (V2) and a Registered Nurse (V14), confirmed that R2 requires two-person assistance for ADLs, especially after her fracture. Despite this, it was noted that staff sometimes do not wait for a second person to assist, as required by R2's care plan. The physician (V22) highlighted the risk of further injury due to R2's atrophied condition, emphasizing the need for careful handling. The deficiency was attributed to inadequate supervision and failure to adhere to the care plan, which mandates two-person assistance to prevent accidents and ensure resident safety.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medications were available and administered on time, specifically affecting one resident who was reviewed for medication management. The resident, who has PTSD and relies on Prazosin as a sleep aid to prevent nightmares, reported that the medication was frequently given late and was not administered on two occasions. The resident expressed concerns about the impact of not receiving the medication as scheduled, noting that it could cause him to feel disoriented. The resident's medical records confirmed the absence of Prazosin administration on two specific dates, with the medication marked as 'Not Available'. The facility's records showed that a 30-day supply of Prazosin was delivered, which should have been sufficient to cover the period in question. However, the medication was not available on two days, and there were 14 instances where the medication was administered more than an hour late. The facility's staff, including registered nurses, acknowledged the issue, with one nurse noting that the medication was not in the medication cart or room, prompting a reorder. The pharmacist confirmed that the medication should be administered within an hour of the scheduled time and noted that missing doses could cause psychological distress for the resident. The Director of Nursing (DON) acknowledged the facility's policy to administer medications within one hour of the scheduled time and recognized the issue of late doses for the resident. The DON noted the potential for behavioral issues or trouble sleeping due to missed or delayed administration. Despite the facility's policy and procedures for medication administration, documentation in the Medication Administration Record (MAR) and progress notes was insufficient to explain the late doses and missing medication, highlighting a gap in adherence to the facility's medication management system.
Failure to Assist Resident with ADLs for Medical Appointment
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to a resident, identified as R4, in preparation for an outside medical appointment. R4, a resident with multiple medical diagnoses including chronic kidney disease, congestive heart failure, and hemiplegia, requires assistance with transfers and ADLs due to mobility impairments and cognitive challenges. On the day of the scheduled ophthalmology appointment, R4 was not prepared in time by the assigned CNA, resulting in the resident missing the appointment. The resident expressed that the CNA did not get her ready on time, and by the time the staff realized the situation, the transportation had already left. The Director of Nursing confirmed that the CNA responsible for R4's care on that day no longer works at the facility due to poor attendance. The Medical Records Coordinator, who coordinates transportation, mentioned that R4 had missed previous appointments due to personal refusals, but on this occasion, the resident was not ready despite having enough time to prepare. The facility's policy outlines the responsibilities of CNAs in assisting residents with ADLs, including dressing and grooming, which were not adequately provided to R4, leading to the missed appointment.
Misappropriation of Property by Staff Member
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of property, affecting two residents. Resident R9 reported her iPad missing, and surveillance footage showed a staff member, V14, entering her room at 2:46 AM and exiting with an object resembling the iPad under his scrub top. The administrator confirmed the theft after reviewing the footage and contacting the police, who later identified V14 as a suspect in a theft case in another state. R9, who is non-verbal and on a ventilator, confirmed the theft by shaking her head when asked about the missing iPad. Resident R10 reported a missing pre-paid cash card, and surveillance footage showed V14 entering and exiting R10's room multiple times. V14 was later seen using a black card at the vending machines and emptying snacks and drinks into his personal bag. The administrator confirmed the transactions on R10's card matched the time V14 was at the vending machines. V14 was terminated for theft, and it was noted that he had a waiver for writing bad checks on his background check before being hired.
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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