Elevate Care South Holland
Inspection history, citations, penalties and survey trends for this long-term care facility in South Holland, Illinois.
- Location
- 16300 Wausau Street, South Holland, Illinois 60473
- CMS Provider Number
- 145671
- Inspections on file
- 38
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Elevate Care South Holland during CMS and state inspections, most recent first.
A resident with chronic ischemic heart disease, heart failure, renal dialysis, and pressure ulcers had a valid authorization and request for release of medical information submitted by the POA/HCR, but the facility did not provide the records in a timely manner. The medical records staff received the request and identification, determined additional documents were needed, and was unable to reach the POA by phone, yet did not send written notice or otherwise complete the process. This inaction conflicted with the facility’s own medical record policy requiring that resident records be accurately maintained and readily accessible.
Two residents’ individualized care plans were not revised and updated to reflect their current conditions and treatments. One resident with multiple chronic conditions was found receiving oxygen at 2L via nasal cannula without a corresponding physician order, without a dated label on the tubing, and without any care plan addressing oxygen therapy, as acknowledged by the DON and Administrator. Another high fall-risk resident with complex medical and psychiatric diagnoses had a fall care plan listing earlier interventions such as locked furniture, call light education, and bilateral floor mats, but later entries documented no new interventions after falls, despite the DON’s and Administrator’s expectations that care plans be updated after each fall with appropriate interventions.
A resident with multiple complex conditions, including ventilator dependence, prior left femur fracture, gait/balance problems, poor communication, decreased safety awareness, and behavioral issues, was assessed as high fall risk and care planned for bilateral floor mats and other fall interventions. After a prior fall resulting in an acute intertrochanteric fracture of the left femur, the care plan specified bilateral floor mats; however, during observation, only one mat was in place because the Assistant DON had removed the left-side mat to position a bedside table while the resident ate and then left the resident unsupervised. The DON later stated the resident should have been in a wheelchair in a highly visible area for monitoring due to high fall risk. The facility’s fall prevention policy requires implementation of appropriate safety interventions and communication of fall risk, but documentation after the fall showed entries with no new interventions added.
A resident with chronic respiratory failure, tracheostomy, liver transplant, G-tube, and seizure history had a physician order and care plan for continuous Nepro tube feeding at a specified hourly rate over 24 hours. The resident reported that the tube feeding had not been started that day and that he preferred it not run during meals. Staff interviews confirmed that the resident often refused tube feeding during meals but that feedings were expected to be administered at other times per order or adjusted by an NP if needed. Despite facility policy requiring EN to be delivered as ordered and closely monitored, the ordered continuous tube feeding was not administered as prescribed on the day observed.
A resident with multiple chronic conditions, including dementia, adult failure to thrive, type 2 DM, and chronic ischemic heart disease, was observed receiving oxygen at 2L via nasal cannula without a physician order or care plan in place. The oxygen tubing in use had no date label to show when it was last changed. The Wound Care Coordinator reported that tubing should be dated for infection control, and the DON confirmed that oxygen administration requires a physician order and dated tubing. This was inconsistent with the facility’s oxygen therapy policy, which requires verification of a physician order and adherence to an equipment change schedule for disposable oxygen delivery devices.
Two residents did not receive medications in accordance with prescriber orders and facility policy. One resident with complex medical conditions, including chronic respiratory failure, tracheostomy, liver transplant, G-tube, and seizures, reported not receiving morning medications, and an LPN admitted she was running late and had not administered them within the required 60-minute window, despite orders for continuous tube feeding and scheduled Keppra, metoprolol, and tacrolimus. A nurse practitioner stated these medications should be given as ordered and that combining morning and noon doses could cause GI upset and loose stools. Another resident with respiratory failure, ventilator and trach dependence, gastrostomy, fracture, hypertension, seizures, and multiple psychiatric and medical diagnoses was unsure if medications such as ferrous sulfate, valproic acid, and clonazepam had been given, and the assigned LPN acknowledged she failed to sign off the 9:00 a.m. medications immediately after administration, contrary to policy.
A resident with multiple chronic conditions and physician-ordered wound care to the sacrum, buttock, and heels received dressing changes during which the wound care nurse did not perform required hand hygiene between removing soiled dressings and applying clean dressings, contrary to the facility’s dressing change policy. The same resident was also observed receiving O2 at 2 L via nasal cannula with tubing that was not labeled with a change date, despite facility expectations and policy that O2 equipment be managed per an equipment change schedule and properly dated for infection control.
Surveyors identified that the facility did not follow wound care physician orders or manufacturer guidelines for Low Air Loss Mattresses (LALM) for three residents with pressure ulcers. LALMs were not set to the correct weight, some were malfunctioning, and excessive linen layers were used, impeding mattress function. Physician orders for wound care were not properly transcribed or followed, resulting in incorrect or omitted treatments, and care plan interventions were not consistently implemented.
Surveyors found that the ice scoop for the 2nd floor cooler box was being stored inside the cooler rather than in a separate container outside, contrary to facility policy. Both a CNA and the Director of Food Services confirmed the correct procedure was not followed, and a resident reported regularly finding the scoop inside the cooler when getting ice.
A resident in an LTC facility, who is severely cognitively impaired, was allegedly physically abused by an LPN. The incident was witnessed by a visitor who reported the LPN punching the resident twice, leading to the resident experiencing pain. The facility's response included assessing the resident for injuries and removing the LPN from duty. The actions of the LPN were deemed unwarranted and punitive, resulting in a deficiency in protecting the resident from abuse.
A resident with a history of hip issues experienced new-onset pain, and an x-ray revealed an acute fracture and dislocation of the right hip prosthesis. Despite these findings, the nurse did not assess the resident or take further action beyond informing the doctor, who did not provide new orders. The Director of Nurses later identified the fracture, but there was a five-day delay in transferring the resident to the hospital, resulting in increased pain.
A resident with severe cognitive impairment and high fall risk fell and fractured his hip during incontinence care. The CNA providing care moved back when the resident unexpectedly urinated, causing the resident to slip and fall. The resident was not wearing non-skid footwear, and there was nothing for him to hold onto for stability, leading to the fall and subsequent injury.
A resident experienced extreme pain due to the facility's failure to provide timely Hydrocodone-acetaminophen after a lumbar laminectomy. The resident's medication was not refilled in time, and despite requests for the specific pain relief, alternative medications were offered and refused. The pharmacy required a new prescription, which was sent, but the medication was not accessed, and necessary documentation was missing.
A facility was found to have forged a family member's signature on an admission contract without permission. The family member, who was the emergency contact and representative for a resident, received an admission packet via email containing her unauthorized signature. The admission coordinator admitted to electronically signing the name to meet a corporate deadline, acknowledging the wrongdoing and stating that the signed package was discarded, although a copy was automatically emailed to the family member.
A resident's urinary catheter drainage bag was not placed in a privacy bag, violating the facility's policy and compromising the resident's dignity. The LPN noted the CNA might have improperly positioned the bag, and the DON confirmed the requirement for privacy bags.
A facility failed to administer enteral feeding according to a physician's order for a resident. The resident's tube feeding was observed to be hanging but not connected or turned on as ordered. An LPN and the DON confirmed that the feeding should have been turned on at the specified time. The resident's medical records indicated a need for enteral feeding of Nepro at 55 ml/hour for 21 hours a day, starting at 9 AM.
A facility failed to label an oxygen humidifier bottle with the appropriate date for a resident using oxygen via nasal cannula. An LPN acknowledged the oversight, and the DON confirmed the requirement for weekly labeling and changing of the humidifier bottle. The resident had a history of COPD, acute respiratory failure with hypoxia, and anxiety disorder. Facility policy mandates labeling of all disposable respiratory equipment with the date when placed in use.
A facility failed to ensure proper infection control during a blood glucose monitoring procedure for a resident under Enhanced Barrier Precautions (EBP). An LPN did not wear the required PPE gown while performing the procedure, despite the presence of blood. The Director of Nursing confirmed that both gloves and a gown are necessary for infection control in EBP rooms. The resident had Type 2 Diabetes Mellitus and was under EBP due to enteral feeding, tracheostomy, and compromised skin integrity.
A resident with a stage three sacral pressure ulcer did not receive timely antibiotic treatment due to the facility's failure to notify the physician of a wound culture result indicating a high amount of bacteria. Despite the facility's policy requiring prompt reporting of test results, the culture findings were not communicated, leading to the resident's hospitalization with sacral osteomyelitis.
A resident with a history of substance abuse and significant physical impairments left a facility unauthorized due to inadequate supervision. The resident, who required supervised pass privileges, exited through the front lobby without staff intervention and was gone for fourteen hours. Staff failed to communicate effectively, and the receptionist did not recognize the resident, allowing them to leave without a pass.
A resident with dementia was left unsupervised during a transportation appointment, leading to a significant lapse in supervision. The facility also failed to adhere to fall prevention protocols for two residents, resulting in repeated falls and injuries. These deficiencies highlight systemic issues in supervision and fall prevention measures.
A facility failed to perform dressing changes and daily assessments of a resident's sacral wound as ordered, and did not address a foul odor in the wound, leading to an abscess/infection that required surgical drainage. The resident's wound care was not properly documented or managed, resulting in a decline in the wound's condition.
The facility failed to develop an effective care plan and provide adequate supervision for two high-risk residents, resulting in one resident suffering a pelvic fracture and another sustaining a head laceration during care. The lack of a documented monitoring schedule and improper handling during direct care contributed to these incidents.
Failure to Timely Provide Resident Medical Record to Legal Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s medical record to the resident’s Power of Attorney/Healthcare Representative (POA/HCR) in a timely manner after a formal request was made. The medical records staff member (V5) acknowledged receiving a request from the resident’s POA in October 2025, along with a completed application and identification. V5 stated that additional documents were needed to process the request and that attempts to reach the POA by phone were unsuccessful. Despite this, no certified letter or other documented follow-up was sent to inform the POA of the missing documents, resulting in the requested records not being provided. The resident’s admission record dated 1/20/2026 shows diagnoses including chronic ischemic heart disease, heart failure, renal dialysis, and pressure ulcers. The record also reflects a State of Illinois compliant authorization for release of patient information dated 10/1/2025 and a request for information dated 1/20/2026. The facility’s Medical Record Policy states that an organized, accurate, and complete written record will be maintained for each resident in accordance with applicable state and federal guidelines and that records are to be readily accessible. Despite this policy, the resident’s records were not made accessible to the POA/HCR as requested, leading to the cited deficiency.
Failure to Revise and Update Individualized Care Plans for Oxygen Use and Fall Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure ongoing revision and updating of individualized care plans in accordance with residents’ conditions and treatments. For one resident with diagnoses including Alzheimer’s disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease, surveyors observed the resident lying in bed with oxygen in use at 2L via nasal cannula. The oxygen tubing had no label with a date, there was no physician order for oxygen administration in the active orders, and there was no care plan addressing oxygen use. The DON acknowledged that oxygen use should have a physician’s order and that the tubing should be labeled with a date, and the Administrator was informed that there was no care plan for the oxygen therapy. Another resident, an older adult with multiple diagnoses including chronic respiratory failure with hypoxia, tracheostomy and ventilator dependence, gastrostomy, left femur fracture with routine healing, essential hypertension, seizure disorder, anxiety disorder, depressive disorders, generalized edema, left hip pain, diaphragmatic hernia, and delirium, was identified as being at high risk for falls per a Fall Risk scale. The resident’s fall care plan, initiated for high fall risk with problems such as gait/balance issues, poor communication/comprehension, decreased safety awareness, and adverse behaviors, contained dated interventions such as keeping furniture locked, educating the resident to use the call light, and bilateral floor mats. However, on subsequent dates, entries of 11/29/25 and 12/1/25 documented “no intervention” instead of updated fall-prevention measures after falls. The DON stated that the fall care plan should be updated after each fall with appropriate interventions, and the Administrator stated that his expectation is that care plans be updated after appropriate interventions are discussed, indicating that this did not occur as required by facility policy for comprehensive care plans.
Failure to Maintain Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention measures for a resident identified as high risk for falls. The resident is an adult with multiple complex medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, gastrostomy, a prior displaced intertrochanteric fracture of the left femur with routine healing, essential hypertension, seizure disorder, anxiety disorder, adjustment disorder with depressed mood, major depressive disorder, generalized edema, left hip pain, diaphragmatic hernia, and delirium due to a known physiological condition. A facility incident report shows that on 10/21/25 the resident was found lying on the floor on the left side, reported left lower extremity pain, and an x‑ray revealed an acute intertrochanteric fracture of the proximal left femur, after which the physician ordered transfer to the hospital. The resident’s fall risk scale dated 10/26/25 identifies the resident as high risk for falling, and the care plan dated 2/27/25 documents high fall risk related to gait/balance problems, poor communication/comprehension, decreased safety awareness, and adverse behaviors, with interventions including keeping furniture locked, educating the resident to use the call light, and bilateral floor mats added on 10/21/25. On 1/20/26 at 1:00 PM, the resident was observed in bed with only one floor mat on the right side of the bed and no floor mat on the left side, despite the care plan intervention for bilateral floor mats. At that time, the Assistant DON stated she had moved the left-side floor mat to place the bedside table so the resident could eat lunch and that she would return after the resident finished eating, leaving the resident in the room unsupervised. Later that day at 2:42 PM, the DON acknowledged that the resident should have been out of bed in a wheelchair in a highly visible area for monitoring because of the high fall risk. The facility’s Fall Prevention Program policy, revised 11/21/17, requires assessment of fall risk, implementation of appropriate safety interventions, and incorporation of fall interventions into the care plan, including informing nursing personnel of residents at risk and maintaining safety interventions for those residents. The record review also shows that after the addition of bilateral floor mats on 10/21/25, entries dated 11/29/25 and 12/1/25 list “no intervention,” indicating no documented changes or additions to fall interventions following the resident’s fall.
Failure to Administer Ordered Continuous Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s ordered continuous enteral tube feeding was administered as prescribed. During an observation, the resident reported having a tube feeding and stated that he did not want the tube feeding running while he was eating, but also reported that the nurse had not started his tube feeding at all that day. The admission record documented that the resident had chronic respiratory failure, a tracheostomy, a history of liver transplant, a gastrostomy tube, and seizures. An order summary for enteral feeding directed Nepro 1.8 at a rate of 45 ml/hour for 24 hours, with a total volume of 1,080 ml, and the care plan included an intervention to administer tube feeding as ordered. Interviews with facility staff confirmed expectations that tube feedings be administered according to the physician’s order or adjusted by the nurse practitioner if needed to accommodate resident preferences. One staff member stated that all tube feedings were expected to be given as ordered or adjusted by the nurse practitioner, and another staff member acknowledged that the resident refused tube feeding during meals but stated that the feeding was expected to be administered when the resident was not eating by mouth. The facility’s enteral nutrition policy required nursing staff to follow enteral nutrition guidelines, ensure continuous drip feedings were administered appropriately, and closely monitor tube feeding tolerance and intake to ensure nutritional goals were met, including confirming that enteral nutrition was delivered as ordered by the physician. Despite these policies and orders, the resident’s tube feeding was not initiated as ordered on the day observed.
Failure to Follow Physician Orders and Oxygen Therapy Policy
Penalty
Summary
Surveyors identified that a resident with diagnoses including Alzheimer's disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease was receiving oxygen therapy without a corresponding physician order or care plan. On observation, the resident was found lying in bed with oxygen running at 2 liters via nasal cannula, and the oxygen tubing lacked a date label indicating when it had been changed. During interviews, the Wound Care Coordinator stated that oxygen tubing should be labeled with the date to ensure cleanliness and for infection control, and the DON acknowledged that oxygen administration requires a physician order and that tubing should be dated. The facility’s oxygen therapy policy, last revised 12/1/2021, requires verification of a physician order prior to oxygen administration and directs staff to discard disposable masks, cannulas, and tubing after use in accordance with an equipment change schedule, which was not followed in this instance. The deficiency centers on the facility’s failure to follow its own oxygen therapy policy and physician order requirements, resulting in oxygen being administered to the resident without an active physician order, without a documented care plan for oxygen use, and with unlabeled oxygen tubing that did not comply with the facility’s infection control and equipment change procedures.
Failure to Administer and Document Medications as Ordered for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician for two residents. One resident with chronic respiratory failure, tracheostomy, liver transplant, G-tube, seizures, and other conditions reported around midday that he had not received his morning medications, stating the nurse had told him they would be given with his noon medications, but as of after 12:30 p.m. he still had not received them. The LPN responsible stated she was running late and had not had a chance to administer the morning medications, acknowledging they should be given within one hour before or after the scheduled start time and that she would notify the nurse practitioner of the late administration. The nurse practitioner stated that this resident’s medications, including continuous Nepro tube feeding, Keppra, metoprolol, and tacrolimus, should be administered as ordered and that administering both morning and noon medications together could cause gastrointestinal upset, loose stools, and abnormal medications. The resident’s care plan directed staff to administer medications as ordered, and the facility’s medication administration policy required medications to be given in accordance with prescriber orders and within 60 minutes of the scheduled time. For a second resident with multiple diagnoses including chronic respiratory failure with hypoxia, tracheostomy and ventilator dependence, gastrostomy, left femur fracture, hypertension, seizures, anxiety disorder, depressive disorders, generalized edema, hip pain, diaphragmatic hernia, and delirium, there were concerns regarding documentation of medication administration. This resident had orders for ferrous sulfate in the morning, valproic acid oral solution twice daily, and clonazepam three times daily, with a care plan to give medications as ordered. Around midday, the resident was in bed and stated he was unsure if he had received his medications, although he usually did. The LPN assigned to this resident later stated she was supposed to sign off medications immediately after administering them and could not explain why she had not documented administration when she reported giving the medications at 9:00 a.m. This conflicted with the facility’s policy requiring proper and timely documentation of medication administration.
Failure to Follow Infection Control Practices During Wound Care and Oxygen Use
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices during wound care and oxygen administration for a resident with multiple chronic conditions, including Alzheimer’s disease, dementia, adult failure to thrive, type 2 diabetes mellitus, and chronic ischemic heart disease. The resident had active physician orders for wound care to the right buttock, sacrum, and both heels, specifying cleansing with normal saline or wound cleanser, patting dry, applying betadine where ordered, and covering with appropriate dressings, as well as use of a low air loss mattress. During an observation of wound care, the wound care nurse (V3) cleansed the sacral wound area and then applied a clean dressing without performing hand hygiene in between steps. V3 then changed the dressing on the right heel, again without performing hand hygiene between tasks, contrary to the facility’s Dressing Change (Clean/Non-Sterile) policy, which requires removal of soiled gloves, handwashing or use of alcohol-based hand gel, and then application of clean gloves before proceeding. In addition, the resident was observed lying in bed with oxygen in use at 2 L via nasal cannula, and the oxygen tubing had no label indicating the date it was changed. V3 stated that oxygen tubing should have a label with the date to indicate when it was changed for infection control purposes. The DON (V2) acknowledged that hand hygiene is required between wound dressing changes and that oxygen use should have a physician’s order and the tubing should be labeled with the date, consistent with the facility’s Oxygen Therapy policy, which requires disposable cannulas and tubing to be discarded after use in accordance with an equipment change schedule. These observations demonstrate that the facility did not follow its own infection control and treatment policies during wound care and oxygen administration for this resident.
Failure to Follow Wound Care Orders and LALM Guidelines
Penalty
Summary
The facility failed to adhere to its own policies and procedures, as well as manufacturer guidelines, regarding the use and maintenance of Low Air Loss Mattresses (LALM) and the implementation of physician-ordered wound care interventions for three residents with pressure ulcers. Observations revealed that LALMs were not set to the correct weight settings based on resident weights, with one resident's mattress set at 250 pounds despite weighing only 121.1 pounds. Additionally, another resident's LALM was found to have a malfunctioning static mode, and alternating pressure was not observed as required. Multiple layers of linen and a disposable brief were used on top of the LALM for one resident, contrary to manufacturer instructions, potentially impeding the mattress's effectiveness. Record reviews and staff interviews indicated that physician orders for wound care were not consistently transcribed into the Physician Order Sheets (POS) and Treatment Administration Records (TAR), resulting in treatments not being administered as prescribed. For example, one resident's order for cleaning a sacral wound with Dakin's solution was omitted, and another resident did not receive the prescribed Calcium Alginate for wound care. In some cases, discontinued treatments such as Collagen were still being applied to healed wounds, and appropriate dressings like foam island or hydrocolloid were not used as ordered. Care plans for residents with pressure ulcers included interventions such as ensuring LALMs were functioning properly and set to appropriate settings, but these interventions were not consistently implemented. Staff interviews confirmed a lack of awareness or adherence to current physician orders and manufacturer guidelines. The deficiencies were identified through direct observation, interviews with wound care nurses, and review of medical records, highlighting failures in following established protocols for pressure ulcer prevention and treatment.
Improper Storage of Ice Scoop in Cooler Box
Penalty
Summary
Surveyors observed that the ice scoop for the cooler box on the 2nd floor was stored inside the cooler box rather than in a separate container outside the box, as required by facility policy. This was confirmed during observations with both a Certified Nursing Assistant and the Director of Food Services, who each acknowledged that the scoop should be kept outside the cooler box to prevent contamination. Additionally, a resident reported consistently finding the scoop inside the cooler when retrieving ice. Review of the facility's policy indicated that the ice scoop should be cleaned daily and stored outside the ice bin, either covered or in a holder on the side of the bin. The failure to follow this procedure was directly observed and confirmed by staff and a resident.
Resident Abuse by LPN in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by an employee. A severely cognitively impaired resident was allegedly physically assaulted by an LPN, resulting in the resident experiencing pain. The incident was witnessed by a visitor who reported seeing the LPN punch the resident twice. The visitor attempted to record the incident but only captured the aftermath. The LPN was removed from the facility following the report. The resident involved is an elderly female with a diagnosis of unspecified dementia, among other conditions. Her cognitive impairment was severe, as indicated by a BIMS score of 3. At the time of the incident, the resident was in the common area and reportedly interfered with another resident's oxygen tubing, which led to the alleged physical altercation with the LPN. The resident later reported pain in her right scapula, which was a new complaint following the incident. The facility's response included assessing the resident for injuries, which showed no visible signs of harm, although the resident did report pain. The facility's abuse prevention policy emphasizes the prohibition of abuse and the importance of creating a secure environment for residents. However, the actions of the LPN, as described, were deemed unwarranted and punitive, failing to adhere to the facility's policy and resulting in a deficiency in protecting the resident from abuse.
Failure to Transfer Resident After Acute Fracture Diagnosis
Penalty
Summary
The facility failed to transfer a resident to the hospital after a new onset of pain and abnormal x-ray results indicated an acute fracture. The resident, who had a history of osteoarthritis, syncope episodes, radiculopathy, Raynaud's syndrome, and a previous fall with a right hip fracture, experienced new-onset pain in the right hip. An x-ray revealed a poster superior dislocation of the right prosthetic femoral head with an acute fracture of the posterior right acetabular wall. Despite these findings, the nurse who received the x-ray results did not assess the resident or take further action beyond relaying the results to the medical doctor, who did not provide new orders at that time. The Director of Nurses later reviewed the x-ray results and recognized the acute fracture, but there was a delay in transferring the resident to the hospital for five days. During this period, the resident experienced increased pain. The medical doctor eventually instructed the facility to send the resident to the hospital after being informed of the x-ray results and the possibility of a new fracture. The resident was transferred to the hospital for evaluation of the right hip prosthesis dislocation and increasing pain, but the delay in response to the x-ray findings and the resident's condition constituted a deficiency in care.
Resident Falls During Incontinence Care Due to Unsafe Environment
Penalty
Summary
The facility failed to provide a safe environment during incontinence care, resulting in a resident falling and sustaining a left hip fracture. The resident, who has severe cognitive impairment and is at high risk for falls due to decreased mobility and balance, was standing next to his bed when a CNA was providing incontinence care. The CNA removed the resident's adult brief and began cleaning, during which the resident unexpectedly urinated. The CNA moved back to avoid the urine, and the resident, wearing only socks, attempted to walk towards the CNA but slipped in the urine and fell. The incident report and subsequent interviews reveal that the resident was found on his back near the bed, with a wet floor identified as a predisposing environmental factor. The resident was not wearing non-skid footwear, and there was nothing for him to hold onto for stability. An x-ray confirmed an acute nondisplaced left femoral intertrochanteric fracture, requiring surgical intervention. The facility's fall preventive program emphasizes the use of professional standards of practice to ensure resident safety, which was not adhered to in this instance.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required Hydrocodone-acetaminophen PRN, resulting in the resident experiencing extreme pain for about one day. The resident, who was cognitively intact and had undergone a lumbar laminectomy, reported being in severe pain for two to three days without relief from a pain patch and muscle relaxant. The resident's pain was not alleviated because the nurse did not refill the Hydrocodone-acetaminophen prescription when there were only five pills left, leading to a lapse in medication availability. The pharmacy required a new prescription for the medication, which was received and a thirty-day supply was sent to the facility. However, the medication was not removed from the nexus, and the Control Drug Receipt/Record form with the nurse's signatures was not available. Despite the resident's complaints of pain and requests for Hydrocodone-acetaminophen, the facility failed to administer the medication, and the resident refused alternative medications offered. The facility's Pain Assessment Policy indicates that medication should be administered at the patient's request, but this was not adhered to in this instance.
Unauthorized Signature on Admission Contract
Penalty
Summary
The facility was found to have committed a deficiency by forging a family member's signature on an admission contract without permission. This incident involved a resident's family member, who was the emergency contact and representative for the resident. The family member reported receiving an admission packet via email that contained her unauthorized signature. The admission coordinator admitted to electronically signing the family member's name on the admission contract to meet a corporate deadline, acknowledging the wrongdoing and stating that the signed package was discarded, although a copy was automatically emailed to the family member.
Failure to Ensure Privacy for Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to adhere to its policy regarding the placement of a urinary catheter drainage bag in a privacy bag, compromising the dignity of a resident. The incident involved a resident diagnosed with benign prostatic hyperplasia, chronic heart failure, and urine retention. During an observation, the resident's urinary catheter drainage bag was found not placed in a privacy bag and was visible to anyone entering the room. The LPN acknowledged that the CNA might have improperly positioned the drainage bag, which should have been either placed in a privacy bag or moved to a less visible location. The Director of Nursing confirmed that the facility's policy requires urinary catheter drainage bags to be placed in privacy bags to prevent exposure.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to administer enteral feeding according to the physician's order for a resident requiring tube feeding. During an observation round, it was noted that the resident's tube feeding was hanging but not connected or turned on as per the physician's order, which specified that the feeding should be on at 9 AM. A Licensed Practical Nurse (LPN) confirmed that the feeding should have been turned on. The Director of Nursing (DON) also acknowledged that the tube feeding should have been administered according to the physician's order. The resident's admission record indicated a diagnosis requiring attention to gastrostomy, with an order for enteral feeding of Nepro at 55 ml/hour via pump for 21 hours a day, starting at 9 AM. The facility's policy on medication administration requires that medications, including enteral feedings, be administered as prescribed by the physician.
Failure to Label Oxygen Humidifier Bottle
Penalty
Summary
The facility failed to ensure that the oxygen humidifier bottle used by a resident was labeled with the appropriate date. During an observation, it was noted that a resident using oxygen via nasal cannula with a portable concentrator had an undated humidifier bottle attached. A Licensed Practical Nurse (LPN) acknowledged that the humidifier bottle should be labeled with the date to inform staff when it needs to be changed. The Director of Nursing (DON) confirmed that the oxygen humidifier bottle should be labeled with the date and changed weekly. The resident involved had a medical history of Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with Hypoxia, and an Anxiety Disorder. The facility's policy requires that all disposable respiratory equipment be labeled with the date when placed in use, and the humidifier bottle should be changed weekly and as needed.
Inadequate PPE Use During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper infection control practices during a blood glucose monitoring procedure for a resident under Enhanced Barrier Precautions (EBP). On 12/10/2024, an LPN entered a resident's room, which had signage indicating EBP, and performed hand hygiene before putting on gloves. However, the LPN did not wear the required PPE gown while conducting the blood glucose check, during which blood was visibly present. After completing the procedure, the LPN removed her gloves, performed hand hygiene, and exited the room. The LPN acknowledged that both gloves and a gown should have been worn during the procedure. The Director of Nursing confirmed that in EBP rooms, the required PPE includes gloves and a gown, and emphasized the importance of using both during blood glucose monitoring for infection control. The resident involved had a diagnosis of Type 2 Diabetes Mellitus without complications and was under EBP due to enteral feeding, tracheostomy, and compromised skin integrity. The facility's policy on EBP, dated 1/15/2024, mandates the use of PPE, including gowns and gloves, for high-risk activities where contact with blood, bodily fluids, skin breakdown, or mucous membranes is expected.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician or nurse practitioner of a sacral wound culture result indicating a high amount of bacteria, specifically greater than 100,000 pseudomonas aeruginosa, for a resident with a stage three sacral pressure ulcer. This oversight affected one of the three residents reviewed for notification of abnormal lab results. As a result, the resident did not receive any antibiotic treatments and was hospitalized two weeks later with a diagnosis of sacral osteomyelitis. The resident was admitted with multiple diagnoses, including sepsis, a stage three sacral pressure ulcer, quadriplegia, anemia, muscle wasting, and adult failure to thrive. A wound assessment documented signs of infection, and a wound culture was ordered. However, the results were not communicated to the appropriate medical personnel. Interviews with staff revealed a lack of clarity and follow-up regarding the culture results, with several staff members, including the wound care coordinator and infectious disease nurse practitioner, unaware of the results. The facility's policy required that test results be reported to the ordering physician to ensure prompt and appropriate action. Despite this, the culture results were not communicated, and no new antibiotic treatments were documented for the resident after the culture was reported. The resident's condition worsened, with the pressure ulcer progressing to stage four, and the resident was eventually diagnosed with sacral osteomyelitis, highlighting the failure to act on the abnormal lab results.
Unauthorized Resident Exit Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, resulting in the resident leaving the facility unauthorized. The resident, who had a history of substance abuse and alcohol use, was assessed to have supervised pass privileges and was not deemed capable of unsupervised outside pass privileges. Despite this, the resident exited the facility through the front lobby entrance without staff intervention and was gone for approximately fourteen hours without staff knowledge of their whereabouts. The incident occurred when the resident, who was non-weight bearing on the right lower extremity and had significant physical impairments, was last seen ambulating in the hallway with a walker. Staff members, including a CNA and an RN, noted the resident's absence during routine checks and medication pass. The resident was seen on camera leaving the facility with a male companion, who was carrying the resident's belongings. The receptionist, who was supposed to monitor the front desk, did not recognize the resident and failed to stop them from leaving. Interviews with staff revealed a lack of communication and urgency regarding the resident's absence. The RN and Social Service Coordinator did not express concern when the resident was reported missing, and the receptionist was unaware of the resident's identity. The facility's policy required a doctor's order for a resident to leave on a pass, which was not obtained in this case. The resident's departure was not reported to public health as an elopement, as the facility considered the resident cognitively intact and not at risk for elopement.
Inadequate Supervision and Fall Prevention Failures
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with dementia, resulting in the resident being left unsupervised during a transportation appointment. The resident, who had a BIMS score of 5 indicating cognitive impairment, was dropped off by a transportation company without a staff escort, despite being identified as not capable of unsupervised outside pass privileges. The resident was later found by family members attempting to navigate a street in a wheelchair, highlighting a significant lapse in supervision and communication between the facility, transportation service, and family. The incident was compounded by a lack of immediate action from facility staff when the resident's absence was reported. The unit clerk, who was aware of the situation, did not notify the appropriate nursing staff or management, delaying the implementation of the facility's missing resident protocol. This inaction contributed to the resident being unsupervised for an extended period, increasing the risk of harm. Additionally, the facility failed to adhere to its fall prevention protocols for two residents, resulting in one resident sustaining a laceration requiring sutures after falling from a wheelchair. The facility did not complete accurate fall risk assessments or implement individualized interventions based on the root causes of falls. This oversight led to repeated falls for the residents, indicating a systemic issue in the facility's fall prevention measures.
Removal Plan
- R1 reassessed without any adverse negative outcome.
- R1's appointment has been rescheduled.
- All facility contracted Medi-car and ambulance companies were contacted and reviewed facility's expectations during transportation, including ensuring the resident is safely transferred and reported to the receiving appointment staff.
- All residents with scheduled appointments have the potential to be affected by the alleged deficiency.
- The facility has conducted a comprehensive review to identify any other residents with scheduled appointments and has established corresponding staff escorts.
- The facility has conducted a comprehensive review to identify residents with a BIMS under 11 and those which cannot safely access the community independently, additionally, each resident is reviewed for additional factors such as behaviors, physical challenges and assistive devices as appointments arise to ensure a facility escort is assigned.
- The Unit Clerk will communicate upcoming appointments 72 hours prior to appointment date with confirmed staff escort name to nursing staff during morning meeting utilizing the appointment communication log.
- Emergency QA meeting conducted.
- Residents with upcoming scheduled appointments will be evaluated by nursing and social service departments to ensure resident is cognitively appropriate for independent community access.
- Family members of residents with upcoming scheduled appointments who require an escort, will be contacted to, optionally, assist with escorting/accompanying residents during transport if available. If family is not available, the facility will ensure a staff escort will accompany residents for all non-contracted transportation companies for residents who have been determined to require an escort.
- The Director of Nursing or designee educated the facility transportation coordinator/unit clerk on communicating upcoming appointments 72 hours prior to appointment date, including the name of the confirmed staff escort communicated to nursing staff during morning meeting utilizing the appointment communication log.
- Facility has developed a Transportation Communication Form which is being provided to all transportation companies at the time of scheduled resident appointments, which communicates pertinent transportation information, including resident drop off points, contact information for physician office and facility, to ensure resident safety.
- The Director of Nursing or designee educated the facility staff on the new Transportation Communication Form to be provided to transportation drivers at the time of resident pick-ups for scheduled appointments.
- The Director of Nursing or designee educated the facility staff who may accompany residents on appointments that Escort must call the facility to inform/confirm resident's arrival to appointment location office/Suite with Unit Clerk immediately to verify safe arrival. Knowledge check to be completed with staff escort prior to leaving the facility for verification/clarification.
- The Director of Nursing or designee educated the facility staff on immediately implementing the missing resident policy and procedure once a resident has been identified as missing.
- Staff, including agency, not present in the facility will be educated prior to starting their next shift. This training will be ongoing for new hires in the orientation process and has been added to the agency staff orientation folder.
- The Director of Nursing or designee will audit 3 random residents with scheduled appointments twice a week for 3 months or until compliance has been determined thereafter, to ensure safe transport and delivery of cognitively impaired residents to scheduled appointments.
- The Director of Nursing or designee will audit 3 random staff, twice a week for 3 months, for knowledge checks of previous education related to missing resident policy and Transportation Communication Form to ensure safe transport and delivery of residents who have been determined to require a staff escort to scheduled appointments.
- Findings of the quality review audits will be brought to the facility QA meeting until such time as the committee has determined substantial compliance has been achieved and recommends ongoing monitoring.
Failure to Perform Dressing Changes and Address Wound Odor
Penalty
Summary
The facility failed to perform dressing changes and daily assessments of a resident's sacral wound as ordered for two days and did not address a foul odor in the wound for six days. This resulted in an abscess/infection forming behind the sacral wound, which required surgical drainage while the resident was hospitalized. The sacral wound developed a foul odor that was not identified at the facility, affecting one of three residents reviewed for pressure sore prevention and treatment. The resident, who had multiple diagnoses including urinary tract infection, peripheral vascular disease, hemiplegia following a cerebral infarction, and chronic ischemic heart disease, had a care plan that included monitoring and treating a sacral pressure ulcer. Despite the care plan, the facility did not perform the required dressing changes on specific dates and failed to document or address the foul odor emanating from the wound. The wound, initially documented as stable and showing no signs of infection, eventually declined, growing in size and developing necrotic tissue. Interviews with the wound care nurse, wound physician, and other nursing staff revealed that the dressing change frequency was revised based on family requests, and there was a lack of awareness and documentation of any signs of infection. The facility's policy required daily checks of dressings for signs of infection and proper documentation, which were not followed. The resident was eventually sent to the hospital, where a CT scan revealed abscess formation, necessitating surgical intervention and a course of IV antibiotics.
Failure to Prevent Falls and Ensure Safe Bed Mobility
Penalty
Summary
The facility failed to develop an effective plan of care for a dementia resident (R1) assessed to be at high risk for falls. Despite being identified as a high fall risk, there was no documentation of the specific monitoring required for R1. This lack of monitoring led to R1 suffering a right-sided pelvic fracture after attempting to self-ambulate to the bathroom and falling. The incident was only reported by another resident (R3) a couple of days later, and staff were unable to determine the exact circumstances of the fall due to R1's severe cognitive impairment and confusion. Interviews with staff revealed that R1 was impulsive, had poor safety awareness, and often attempted to get up without assistance, but there was no set monitoring schedule documented for high fall risk residents like R1. Another resident (R2) also experienced a fall resulting in a laceration to the head that required hospital treatment. R2, who had spinal stenosis, weakness, and lack of coordination, fell off the bed while being changed by a CNA. The CNA admitted to holding R2 with one hand while attempting to provide pericare with the other, which led to R2 sliding off the bed and hitting their head on the floor. The incident report and interviews with staff confirmed that R2 needed substantial assistance with bed mobility and could not turn over in bed without help. The fall occurred because R2 was positioned too close to the edge of the bed during care. The facility's failure to ensure adequate supervision and safe bed mobility practices for these high-risk residents resulted in significant injuries. The lack of a documented monitoring schedule for high fall risk residents and improper handling during direct care contributed to these incidents. The facility's fall prevention program policy stated that residents should be checked approximately every two hours or as per the care plan, but this was not effectively implemented for R1 and R2, leading to their injuries.
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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