Elevate Care Waukegan
Inspection history, citations, penalties and survey trends for this long-term care facility in Waukegan, Illinois.
- Location
- 2222 Audrey Nixon Boulevard, Waukegan, Illinois 60085
- CMS Provider Number
- 145669
- Inspections on file
- 40
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Elevate Care Waukegan during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with ALS reported that a CNA attempted to damage and then turned off his oxygen concentrator and disabled his call light. The incident was reported internally to nursing supervisors and the Administrator, and the CNA was suspended during the investigation. However, the Administrator did not report the abuse allegation to the State Agency as required by facility policy.
Two residents who were dependent on staff for ADLs did not receive required oral care as ordered and outlined in their care plans. Both had visible debris and poor oral hygiene observed during the survey, despite staff statements that oral care is performed daily and facility policy requiring regular oral hygiene.
A resident with a history of stroke and on tube feeding experienced significant weight loss due to the facility's failure to monitor their weight as recommended. Despite being on a specific feeding regimen, the resident's weight was not recorded in December, leading to a 9.36% weight loss by January. The facility's policy required monthly weights and more frequent monitoring for those at nutritional risk, which was not followed.
The facility failed to provide palatable food, as observed during a lunch service where chicken was found to be hard, tough, and dry. Several residents reported dissatisfaction with the meal, and a test tray confirmed the chicken was overcooked. The Assistant Food Service Manager acknowledged the issue, stating that the chicken should be juicy.
A resident with chronic respiratory issues was observed self-administering a nebulizer treatment without the required assessment or physician's order. The facility's policy mandates an assessment and physician order for self-administration, but the resident's records lacked both. The Respiratory Therapy Manager provided the medication without knowing the requirement, and the resident's care plan did not address self-administration.
A resident was involved in a physical altercation with another resident, resulting in the resident being knocked out of her wheelchair. Both residents were alert and oriented, and the incident was witnessed by a CNA who intervened. The resident reported pain but refused further assessment. The facility's Administrator substantiated the abuse, and the involved resident was arrested and not allowed to return to the facility.
A facility failed to follow its abuse policy for a resident with a criminal history, leading to a deficiency. The resident's background check was delayed due to an error in recording race, and a HIT for domestic battery was not acted upon. The facility's policy required immediate fingerprinting, but this was not done, resulting in an incident with another resident. The admissions staff admitted to the error, and the necessary follow-up actions were not executed.
The facility failed to provide meaningful activities for two residents with dementia, leading to deficiencies in meeting their needs. One resident, who enjoys puzzles and arts, was left in bed without engagement, while another, who benefits from sensory activities, was not offered any activities and was repeatedly redirected to sit down. The lack of personalized activity offerings and insufficient staffing contributed to the residents' inactivity and dissatisfaction.
A resident with limited ROM was not evaluated for a brace and did not receive prescribed ROM exercises. Despite an order for evaluation dated in November, the resident had not been assessed for a splint by January, and documentation showed inconsistent delivery of ROM exercises.
The facility failed to supervise medication administration for two residents. One resident was found with an unconsumed Adderall pill, and another had multiple medications left at their bedside. Both instances lacked physician orders for self-administration, contrary to facility policy requiring nurse supervision during medication ingestion.
The facility failed to ensure proper PPE use and isolation signage for residents on isolation. A CNA entered a resident's room on contact isolation for ESBL without wearing required PPE. Additionally, two residents who tested positive for COVID-19 lacked isolation signs and PPE outside their rooms, as confirmed by an LPN and the Infection Preventionist. These actions violated the facility's infection control policies.
The facility failed to assess and administer influenza and pneumonia vaccinations to three residents, leading to a deficiency in their immunization practices. A resident received an influenza vaccine late, and two residents did not receive timely pneumonia vaccinations. The Infection Control Preventionist Nurse acknowledged the oversight and lack of documentation regarding communication attempts with a resident's POA.
A resident with a hand contracture suffered a foul odor and an open wound due to inadequate hand and nail care. Despite being dependent on staff for personal hygiene, the resident's fingernails were excessively long, causing a cut to the palm. Facility staff failed to follow policies for nail care and bathing, resulting in the resident's injury and requiring intervention by the wound care team.
A resident with a history of chronic conditions experienced a fall and subsequent pain, but the facility delayed X-ray reporting and treatment. The X-ray, revealing a fracture, was not reviewed until over 20 hours later, delaying hospital transfer. Staff interviews highlighted communication and procedural issues.
A resident at high risk for falls experienced an unwitnessed fall resulting in a right hip fracture due to inadequate supervision. Despite a care plan indicating high fall risk, the facility failed to continuously monitor and document the resident's condition post-fall, delaying hospital evaluation. The resident, previously ambulatory with assistance, required a total lift and non-weight bearing status after the incident.
A resident in a long-term care facility, who was a Full Code, did not receive immediate CPR due to staff's inability to quickly verify the code status. The resident was found unresponsive and pulseless, but the CNA and RN involved were unsure of the code status and had to check the electronic medical record, causing a delay. This delay contributed to the resident's death, highlighting a deficiency in the facility's process for identifying code status.
A resident experienced verbal abuse from a staff member, V12, who used profanity and inappropriate language during an altercation about an oxygen concentrator. Despite attempts by other staff to de-escalate the situation, V12 continued the confrontation at the nurses' station, witnessed by multiple staff members. The facility's investigation confirmed the incident as a violation of the resident's right to be free from abuse.
A resident was physically abused by another resident after wandering into their room and taking food. The incident resulted in a fall and injuries, including a laceration and bruising. A housekeeper witnessed the altercation and confirmed the push. The facility's policy requires such incidents to be reviewed as potential abuse.
A facility failed to monitor a resident for 72 hours after a fall where she hit her head. The resident was observed with discoloration on her forehead, and the DON confirmed that required post-fall procedures, including vital signs and neuro checks, were not completed. Initial vital signs were recorded, but further monitoring was not conducted as per policy.
The facility failed to ensure a resident room was free from cockroaches, despite multiple reports and observations of the pests. The Maintenance Director was aware of the issue but had not taken steps to seal the room or repair the hole in the bathroom wall where the pests were entering. The facility's Pest Control policy was not followed, and the problem persisted for weeks without resolution.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Abuse Allegation Involving Resident's Oxygen and Call Light
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by its own policy and regulatory standards. A male resident with Amyotrophic Lateral Sclerosis (ALS), who was alert and oriented, reported that a Certified Nursing Assistant (CNA) attempted to break his oxygen concentrator by hitting it, then turned it off, and also disabled his call light by pulling it out of the wall. The resident stated he informed a nurse about the incident, and an internal investigation was conducted. Multiple staff members, including the Administrator, DON, and nursing supervisors, were made aware of the allegations. The CNA involved was suspended during the investigation. Despite the seriousness of the allegations, including purposeful interference with life-sustaining equipment and communication devices, the Administrator decided not to report the incident to the Illinois Department of Public Health (IDPH), stating it was not considered a major abuse case. The facility's Abuse Prevention and Reporting Policy requires immediate reporting of any abuse allegations to the Department of Public Health, but this protocol was not followed in this case.
Failure to Provide Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate oral care to two residents who were dependent on staff for activities of daily living. For one resident with a history of poor oral hygiene and dental problems, physician orders and the care plan required oral care every eight hours. Despite this, observations revealed that the resident had visible white/yellow debris and a film on her teeth, and she confirmed that her teeth had not been brushed that morning. The resident's family also reported ongoing concerns about plaque and poor oral hygiene during recent visits. Staff interviews indicated that oral care should be performed daily, but the resident continued to have visible debris in her mouth during multiple observations. Another resident, who was nonverbal and had significant physical impairments including quadriplegia and a persistent vegetative state, also had physician orders for oral care every eight hours. A dental consult had previously documented poor general oral hygiene. During the survey, this resident was observed with yellowish debris between his teeth. The DON confirmed that morning care should include brushing teeth or using a sponge to remove debris, in accordance with the facility's oral hygiene policy. Despite these requirements, both residents did not receive the necessary oral care as ordered and outlined in their care plans.
Failure to Monitor Weight in Tube-Fed Resident
Penalty
Summary
The facility failed to ensure that a resident receiving tube feedings had their weight monitored, resulting in significant weight loss. The resident, identified as R112, had a history of difficulty swallowing due to a stroke and was on a gastrostomy tube feeding regimen. The Physician Order Sheet indicated that R112 was to receive Glucerna 1.5 at 60 ml per hour for 10 hours daily, supplemented by a general diet of mechanical soft with nectar thick fluids. Despite recommendations from the dietitian to monitor the resident's weight weekly, no weights were recorded for December 2024, and the resident experienced a weight loss from 173 pounds in November 2024 to 156.6 pounds in January 2025, a 9.36% decrease. The dietitian, V13, noted that R112's food intake was poor in November 2024 and had reinstated the tube feeding order with an increased rate of 75 ml per hour. However, the resident's weight was not monitored as recommended, and the December weight was not recorded. The facility's policy required monthly weights and more frequent monitoring for residents at nutritional risk, but this was not adhered to. The physician, V25, confirmed that weight monitoring should be done at least monthly for tube-fed residents, and weekly if weight loss is detected. The lack of timely weight monitoring led to the resident's significant weight loss, highlighting a deficiency in the facility's adherence to its weight monitoring policy.
Facility Fails to Ensure Palatable Food for Residents
Penalty
Summary
The facility failed to ensure that food was palatable for resident consumption, affecting four residents in the sample. During a lunch service, the cooked chicken was observed on the steam table and required reheating in the oven before being served. Several residents reported that the chicken was hard, tough, dry, and overdone, with one resident unable to eat it and another only consuming half of the portion. A test tray provided to surveyors confirmed that the chicken appeared dry and overcooked, with a tough texture. The Assistant Food Service Manager acknowledged that the food should not be hard or dry, indicating that chicken should be juicy on the inside.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
The facility failed to assess and approve a resident for self-administration of medications, specifically nebulizer treatments. A male resident, who was admitted with chronic respiratory failure, tracheotomy, and chronic obstructive pulmonary disease, was observed self-administering a nebulizer treatment without an assessment or physician's order. The resident reported that the respiratory therapist provided him with the medication ampule, and he initiated the treatment himself. The Director of Nursing confirmed that an assessment and physician order are required for residents to self-administer any medication, including nebulizer treatments. The Respiratory Therapy Manager, who provided the medication to the resident, was unaware of this requirement. The resident's medical records lacked an assessment for self-administration and did not include a physician's order for the nebulizer treatment. Additionally, the resident's care plan did not address self-administration of medications, contrary to the facility's policy, which mandates an assessment and physician order for self-administration requests.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. An incident occurred where a resident, identified as R84, was involved in a physical altercation with another resident, R166. Both residents were described as alert and oriented with no cognitive impairments. The altercation began as a verbal disagreement in R166's room, which escalated to R84 being knocked out of her wheelchair onto the floor. A Certified Nursing Assistant (CNA), V15, witnessed the incident and intervened to prevent further harm. R84 reported pain in her left lower extremity and right arm but refused a full body assessment and any diagnostic tests. Following the incident, R84 expressed a desire to press charges against R166, leading to police involvement and R166's arrest. The facility's Administrator, V1, substantiated the abuse after an investigation, noting that R166 had a clenched fist directed at R84, although no further physical harm was inflicted. R84 was granted an order of protection against R166, who was not allowed to return to the facility. The facility's Abuse Prevention and Reporting policy, last revised in 2022, emphasizes that residents should be free from all forms of abuse, including physical and verbal abuse.
Failure to Follow Abuse Policy for Resident with Criminal History
Penalty
Summary
The facility failed to adhere to its abuse policy for a resident, identified as R166, who was admitted with a criminal history that included a HIT for domestic battery. The initial criminal history background check was initiated on 5/28/24, but due to an error in recording the resident's race, the process was delayed. A second report dated 6/27/24 confirmed the HIT, but the facility did not act on this information. The administrator and assistant administrator were unaware of the HIT until after an incident on 11/1/24, when R166 was involved in a physical altercation with another resident, R84. The facility's policy required immediate fingerprinting upon identifying a HIT, but this step was not taken. The admissions staff, V28, admitted to the error in recording the resident's race and the subsequent delay in processing the background check. V28 was not present when the final background check results were received, and the necessary follow-up actions, such as notifying social services for fingerprinting, were not executed. The facility's abuse policy mandates requesting background checks within 24 hours of admission and taking all necessary steps to ensure resident safety while awaiting fingerprint results. However, these procedures were not followed, leading to the deficiency identified in the report.
Failure to Provide Meaningful Activities for Dementia Residents
Penalty
Summary
The facility failed to provide meaningful activities to two residents with dementia, leading to deficiencies in meeting their needs. Resident R70, who enjoys activities such as bingo, puzzles, and arts and crafts, was observed in bed multiple times without any activities being offered. Despite being part of the Activity on Wheels (AOW) program, R70 expressed boredom and a lack of engagement. The Activity Assistant, V8, was unaware of R70's preferences and only offered activities that R70 did not enjoy, such as music. This lack of personalized activity offerings contributed to R70's inactivity and dissatisfaction. Similarly, Resident R111, who benefits from sensory activities and enjoys watching movies and TV shows, was observed in her wheelchair without any activities being offered. Staff repeatedly redirected her to sit down without providing engaging activities. The Activity Assistant, V8, admitted to not seeing R111 due to leaving early and noted that R111 was often asleep. The facility's policy requires activities to meet the interests and preferences of each resident, but the lack of available sensory items and insufficient staffing on the dementia unit contributed to the failure to provide appropriate activities for R111.
Failure to Evaluate and Provide ROM Exercises for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) was properly evaluated for a brace and received the necessary ROM exercises. The resident's care plan, initiated in October 2022, indicated the need for an active assisted ROM program 3-7 days a week. However, an order for restorative nursing to evaluate the resident's left wrist and finger contractures for a splint was not acted upon. This order was dated November 26, 2024, but by January 14, 2025, the resident had not been evaluated for a possible splint, and the resident reported not receiving routine ROM exercises. Observations and interviews revealed that the resident's left wrist was contracted at about 90 degrees, and the resident was unable to move the wrist and index finger. The resident mentioned requesting a brace from a doctor over a month ago, but no action had been taken. The restorative nurse was unaware of the evaluation order and confirmed that the resident had not been evaluated for a splint. Documentation showed that the resident did not receive ROM exercises 3-7 days a week for several weeks, with multiple instances of missing documentation or notes indicating that ROM was not applicable, meaning it was not done.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for two residents. In the first instance, a resident was found with an orange pill, identified as Adderall, on their bedside stand. The resident admitted to not taking the medication because they did not want to stimulate their system further. The resident's Physician Order Summary (POS) indicated an active order for Adderall to be administered twice daily, but there was no order permitting self-administration. The nurse responsible for administering the medication believed the resident had taken it, highlighting a lapse in supervision. In the second instance, another resident was found with two plastic medication cups containing approximately 18 medications. The resident stated that the medications were left with them to take later with food. The Director of Nursing confirmed that no residents had orders to self-administer medications, and nurses were required to supervise medication ingestion. The resident's POS did not include an order for self-administration, and the Medication Administration Summary showed a scheduled administration of 16 pills that morning. The facility's policy mandates supervision during medication administration, which was not adhered to in these cases.
Infection Control Deficiencies in PPE Use and Isolation Signage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and signage for residents on isolation, leading to deficiencies in infection control. In one instance, a Certified Nursing Assistant (CNA) entered the room of a resident on contact isolation for extended-spectrum beta-lactamases (ESBL) without wearing the required gown and gloves. The resident's care plan and the facility's contact precautions policy both indicated the necessity of these protective measures, yet they were not followed. This oversight was observed during a survey, highlighting a lapse in adherence to infection control protocols. Additionally, the facility did not display isolation signs or provide PPE outside the rooms of two residents who tested positive for COVID-19. A Licensed Practical Nurse (LPN) confirmed the absence of necessary signage and PPE, which should have been in place following the residents' positive test results. The Infection Preventionist acknowledged the oversight, noting that the signs were not moved after room changes. The facility's infection prevention manual mandates isolation with signage and PPE for residents testing positive for COVID-19, but these measures were not implemented as required.
Failure to Assess and Administer Vaccinations
Penalty
Summary
The facility failed to properly assess and administer vaccinations for influenza and pneumonia to three residents, leading to a deficiency in their immunization practices. Resident 27, who was over the age of 65, received an influenza vaccine on January 14, 2025, but it was noted that the vaccine should have been offered at the start of the flu season. The Infection Control Preventionist (ICP) Nurse, V24, attempted to contact the resident's Power of Attorney (POA) but was unsuccessful and did not document the communication attempt. Resident 23, also over the age of 65, had received a Prevnar 13 dose on April 21, 2024, but was due for another pneumonia vaccine dose, which had not been administered. Resident 17 had received a Pneumovax dose in 2018, but there was uncertainty about which dosage was administered, and no follow-up was conducted to verify this information. The facility's policy, revised on April 21, 2022, states that residents should be educated about the benefits and side effects of immunizations upon admission, and once consent is given, the influenza vaccine should be administered annually. Additionally, residents should be offered influenza immunizations from October 1 through March 31 annually and pneumococcal immunizations per CDC recommendations. However, the facility failed to adhere to these policies, as evidenced by the lack of timely vaccination and follow-up for the residents in question. The ICP Nurse acknowledged these oversights, indicating a lapse in the facility's vaccination assessment and administration processes.
Neglect in Hand and Nail Care Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate hand and nail care to a dependent resident with a hand contracture, resulting in a foul odor and an open wound on the resident's palm. The resident, who has a history of encephalopathy, traumatic subdural hemorrhage, and other significant medical conditions, was dependent on staff for activities of daily living, including personal hygiene. Despite the care plan indicating the need for active assistive range of motion and monitoring of skin integrity, the resident's hand care was neglected. Observations revealed that the resident's fingernails were excessively long, with one nail causing a cut to the palm of the contracted hand. The resident's room had a foul odor, and there was a noticeable build-up of debris on the resident's hand. Interviews with staff indicated that hand care should be performed daily for residents with contractures, but this was not done for the resident in question. The facility's policies for nail care, morning/nighttime care, and bed baths were not followed, as evidenced by the lack of documentation and the condition of the resident's hands. The Director of Nursing and other staff acknowledged the oversight, noting that the resident's nails should have been trimmed and hand care provided regularly. The wound care team had to intervene to treat the open wound caused by the long fingernail. The facility's failure to adhere to its own policies and procedures for resident care led to the resident's injury and the need for immediate medical attention.
Delayed X-ray Reporting and Treatment After Resident Fall
Penalty
Summary
The facility failed to ensure timely completion and reporting of an X-ray and delayed treatment for a resident who experienced a fall. The resident, who had a history of chronic kidney disease, hemiplegia, and vascular dementia, was found on the floor by a nursing supervisor. Despite the resident's complaints of pain and visible discomfort, the X-ray order was not marked as urgent, leading to a delay in obtaining and reviewing the results. The X-ray, which revealed an acute intertrochanteric fracture of the right femur, was completed and signed by the radiologist on the evening of the fall. However, the results were not reviewed by the facility's staff until the following afternoon, resulting in a delay of over 20 hours before the resident was transferred to the hospital for emergency care. During this time, the resident continued to experience pain, and there was a lack of documentation regarding ongoing monitoring of the resident's condition. Interviews with facility staff revealed communication breakdowns and procedural lapses. The Director of Nursing acknowledged that the X-ray should have been ordered as STAT and that the results should have been monitored more closely. The Nurse Practitioner, who ordered the X-ray, was not informed of the results until the next day, which contributed to the delay in the resident receiving appropriate medical attention.
Inadequate Supervision Leads to Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to provide adequate supervision for a resident at high risk for falling, resulting in an unwitnessed fall and a right hip fracture. The resident, who had a history of moderate cognitive impairment, hemiplegia, and was at high risk for falls, was found on the floor by a nursing supervisor during rounds. The resident was unable to recall the details of the fall and complained of pain in the right leg. An X-ray confirmed an acute intertrochanteric fracture of the proximal right femur. The resident's care plan indicated a high risk for falls due to confusion and gait/balance problems, yet there was a lack of continuous monitoring and documentation of the resident's condition following the fall. The nursing staff did not document any progress notes from the time of the fall until the resident was sent to the hospital the next day. The resident was in pain and had decreased mobility, but the facility delayed sending her to the hospital for evaluation and treatment. Interviews with staff revealed that the resident was previously able to ambulate with a walker and minimal assistance but required a total lift and non-weight bearing status after the fall. The facility's fall prevention program aimed to ensure resident safety by assessing fall risks and implementing appropriate interventions, but these measures were not effectively executed in this case, leading to the resident's injury.
Failure to Quickly Identify Code Status Delays CPR
Penalty
Summary
The facility failed to have an effective process in place for staff to quickly identify a resident's code status, leading to a delay in providing cardiopulmonary resuscitation (CPR) to a resident who was found unresponsive and pulseless. The resident, who was a Full Code according to their POLST form and physician orders, did not receive immediate CPR due to staff's inability to quickly verify the code status. This delay contributed to the resident's death in the facility. The incident involved a cognitively impaired resident with diagnoses including dementia, cerebral infarction, dysphagia, and schizophrenia, who was dependent on staff for care. On the evening of the incident, a Certified Nursing Assistant (CNA) found the resident unresponsive in their room but did not check for a pulse or call for help immediately due to uncertainty about what to do. The CNA sought assistance from a Registered Nurse (RN), who also did not know the resident's code status and had to leave the room to check the electronic medical record, further delaying the initiation of CPR. Interviews with facility staff revealed that there was no quick method to verify a resident's code status, as it required checking the electronic medical record or DNR lists in binders on crash carts. The facility's CPR policy required immediate assessment and initiation of CPR for Full Code residents, but staff were not adequately prepared to follow this protocol, resulting in a critical delay in emergency response for the resident.
Removal Plan
- Social Services Director and Director of Nursing completed full facility audit of DNR status to ensure all POLST forms are in place and match code status in PCC.
- Facility staff were educated on where resident code status is available via PCC as well as POLST binders located at each crash cart on each unit to quickly identify a resident's CPR/code status.
- Staff educated on facility's Code Blue Policy and process on what to do should a resident be found unresponsive and pulseless to ensure no delay in CPR.
- Education on Code Blue policy and POLST binders location on each crash cart to quickly identify code status has been included in facility new hire orientation process and annually for all staff.
- Education has been provided to all RNs, LPNs, and CNAs staff currently present in the facility and all staff not present in the facility, have been in-serviced over the phone and will be re-inserviced before the start of their next shift.
- Emergency QA meeting conducted with facility Medical Director.
- The Director Of Nursing/DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure staff is able to state facility's Code Blue Policy, how to quickly identify a resident's code status, and immediately initiate CPR as/when indicated.
- The DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure they are aware of the POLST binders located on each crash cart in the facility for quick identification of code status.
- Social Services will conduct audits of POLST binders, 2 times a week for 3 months, to ensure the binders are up to date with the latest POLST information.
Verbal Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a resident and a staff member. The incident began when a resident, concerned about their brother's oxygen concentrator, approached a staff member for assistance. The staff member, identified as V12, responded inappropriately by using profanity and expressing frustration. This interaction escalated when the resident reported the issue to other staff members at the nurses' station, and V12 continued to use inappropriate language and behavior towards the resident. Multiple staff members, including nurses and a CNA, witnessed the altercation at the nurses' station. Despite attempts by other staff to de-escalate the situation, V12 persisted in using profanity and refused to step back when instructed. The facility's camera footage corroborated the accounts of the staff, showing V12 approaching the resident and engaging in a verbal confrontation. The resident expressed feeling unsafe when V12 was present, indicating the impact of the verbal abuse on their sense of security. The facility's investigation concluded that V12's behavior was unprofessional and constituted verbal abuse. The facility's policy affirms the right of residents to be free from abuse, and this incident was a clear violation of that policy. The report includes interviews with the involved parties and witnesses, as well as a review of the facility's camera footage, which all supported the finding of verbal abuse by V12.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, as evidenced by an incident involving two residents. Resident 1 (R1) wandered into another resident's room and began taking food from trays. During this interaction, Resident 2 (R2) pushed R1, causing her to fall and sustain a small laceration on her right eyebrow. The incident report did not initially identify R2 as the resident who pushed R1. The facility's preliminary investigation noted an allegation of physical abuse involving R1 and R2. Observations and interviews conducted on 5/20/24 revealed that R1 had a scabbed laceration on her right eyebrow and bruising on her forehead and shoulder. R1 reported being pushed by a man, which caused her to fall and injure her right leg. A housekeeper, V8, witnessed the incident and confirmed that R2 pushed R1 with significant force, resulting in R1 hitting her head on the floor. The facility's abuse prevention policy requires that resident-to-resident altercations be reviewed as potential abuse situations, especially when they result in physical injury.
Failure to Monitor Resident Post-Fall
Penalty
Summary
The facility failed to adequately assess and monitor a resident for 72 hours following a fall in which the resident hit her head. This deficiency was identified for one resident in a sample of eight reviewed for quality of care. On May 8, 2024, the resident experienced a fall in front of her bathroom door and reported hitting her head. The Director of Nursing confirmed that post-fall procedures, including vital signs and neurological checks, were not completed for the required 72-hour period following the incident. The resident's fall report documented initial vital signs, but subsequent monitoring and documentation were not conducted as per the facility's policy, which mandates 72 hours of documentation by all three shifts after an incident.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to ensure a resident room was free from pests, specifically cockroaches, for one of the residents reviewed. On multiple occasions, staff and residents reported the presence of cockroaches in the room, with one resident showing the surveyor a hole in the bathroom wall where the pests were entering. Despite claims of spraying, the infestation persisted, and no efforts were made to seal the room or repair the hole. The Maintenance Director acknowledged awareness of the issue but had not taken steps to address it or communicated the problem effectively with other staff members. The facility's Pest Control policy, last revised on 9/1/22, mandates that employees promptly report pest observations and ensure all building openings are tight-fitting and free of breaks. However, this policy was not followed, as the maintenance request book did not contain recent reports of the roach problem, and the issue remained unresolved for weeks. The resident affected by the infestation had not been offered relocation to another room, and the problem continued to impact their living conditions.
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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