Elevate Care Windsor Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2649 East 75th St, Chicago, Illinois 60649
- CMS Provider Number
- 145970
- Inspections on file
- 43
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Elevate Care Windsor Park during CMS and state inspections, most recent first.
The facility failed to maintain adequate nurse and CNA staffing on multiple floors and shifts, resulting in delayed medication administration and delayed response to resident care needs. On several day and evening shifts, only one nurse or fewer nurses than scheduled were present at the start of the shift, causing 9:00 AM and 5:00 PM medications to be given outside the expected time windows. A resident with multiple comorbidities and intact cognition reported frequently receiving medications, including Gabapentin for leg pain, several hours late and described significant pain when doses were delayed. On high-census shifts, CNAs were assigned to care for 19–25 residents each, including many requiring total care and mechanical lifts, leading staff to prioritize basic rounds, incontinence care, call lights, and feeding while other tasks such as grooming, getting residents out of bed, and timely changes were not consistently completed. Staff, including the DON and an advanced practice nurse, acknowledged that these staffing levels were insufficient and that the facility lacked a formal staffing policy.
Nursing staff, including an RN and multiple LPNs, repeatedly failed to administer medications within the accepted one-hour before/after window of physician-ordered times for eight residents with conditions such as COPD, heart failure, diabetes, PVD, seizures, dementia, and chronic pain. Staff reported being the only nurse on a unit, covering extra assignments, arriving late, and being unable to complete 9:00 AM med passes on time. MARs and audit reports showed frequent late administration and some omitted doses of pain medications (e.g., Gabapentin, Lidocaine patch), psychotropics, anticonvulsants (e.g., Divalproex, Levetiracetam), antihypertensives (e.g., Metoprolol, Carvedilol), antidiabetics (e.g., Metformin, insulin), antibiotics (Bactrim), and respiratory meds (Advair, Albuterol, Symbicort). Cognitively intact residents reported not receiving medications as scheduled and experiencing significant pain, while the DON and NP confirmed that such late administration violates the facility’s policy and physician orders.
Two residents experienced repeated medication errors when nurses failed to administer multiple ordered medications within the facility’s required time window and, in some cases, did not administer them at all. One resident with diabetes, peripheral vascular disease, and respiratory issues repeatedly received late doses of Gabapentin, Advair, and Albuterol, and reported severe leg pain when Gabapentin was delayed. Another resident with COPD, heart failure, diabetes, and rheumatoid arthritis did not receive a scheduled lidocaine pain patch and had missing doses of Jardiance and Gabapentin during a late morning med pass, while still receiving other oral medications and an inhaler. Nursing staff and the DON acknowledged that medications are expected to be given within one hour before or after the ordered time and that late or omitted doses are not in accordance with physician orders, despite a facility policy requiring safe, timely administration and adherence to the five rights of medication administration.
A resident with hemiplegia and other comorbidities, who required a full-body mechanical lift for transfers and had intact cognition, was transferred from a shower bed to a mechanical lift in a hallway rather than in the room. A CNA used a sling that had been left under the resident from a prior shift and did not identify that its straps were worn before initiating the transfer. While the resident was suspended in the air near the bedroom doorway, the sling’s foot straps broke, causing the resident to fall to the floor, resulting in leg swelling, pain, and fear of subsequent transfers. An LPN who assisted confirmed the sling strap broke during the transfer, and facility leadership and the restorative nurse acknowledged that staff are trained and expected to inspect slings for wear and remove damaged equipment from use, consistent with facility policy and the lift manufacturer’s instructions.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with a history of repeated falls and cognitive impairment experienced an unwitnessed fall while pushing a wheelchair, resulting in transfer to the hospital. The fall was not reported to the DON or restorative nurse by the agency LPN involved, and as a result, no investigation or care plan update occurred. Staff responsible for the falls program were unaware of all the resident's falls, contrary to facility policy requiring post-fall investigations and care plan interventions.
A resident with significant immobility and incontinence was admitted with an unstageable sacral pressure ulcer and was identified as high risk for further skin breakdown. Despite physician orders for daily wound care and the use of a moisture barrier cream every shift, observations and record reviews showed that wound dressings were not changed as ordered and the moisture barrier was not consistently applied or documented. The wound increased in size and became infected, with cultures confirming the presence of multiple organisms.
A resident with a complex medical history, including a CRE-positive sacral wound, did not have contact isolation precautions implemented as required. Staff, including an LPN and a CNA, entered the room and provided care wearing only gloves and not gowns, and there was no signage or PPE supplies at the room entrance. Facility staff were aware of the wound culture results but did not ensure timely implementation of precautions, contrary to facility policy.
Two residents with histories of aggression engaged in a physical and verbal altercation during an unsupervised smoking break, resulting in one resident being struck and another having milk thrown at them. Staff were not present outside to supervise, and the incident was only addressed after it occurred, contrary to facility policy prohibiting abuse and neglect.
A facility failed to administer prescribed anticonvulsant medication, Dilantin, to two residents with seizure disorders, resulting in sub-therapeutic levels and missed doses. One resident experienced seizures after missing a dose, while another had their medication misplaced and not administered as ordered. The staff did not access the emergency medication supply, and the facility's policy for medication administration was not followed.
The facility failed to provide restorative services to four residents, including one with multiple sclerosis and another with rheumatoid arthritis, leading to emotional distress and unmet care needs. Despite assessments indicating the need for restorative care, residents did not receive consistent services due to a lack of scheduling and documentation.
A facility failed to provide proper oxygen therapy to residents, including one with misplaced nasal cannula leading to low oxygen saturation, another with undated oxygen tubing, and a third receiving incorrect oxygen concentration. These issues reflect non-compliance with physician orders and facility policies.
A resident was found to be receiving unnecessary psychotropic medications without documented gradual dose reductions or non-pharmacological interventions. The resident exhibited sedation and lethargy, with no documented behaviors justifying the medication use. The facility's psychiatric provider and pharmacy consultant acknowledged the inappropriate use of QUEtiapine for dementia-related behaviors, but the medication was not discontinued despite recommendations.
The facility failed to label food items in the refrigerator and freezer with storage and use-by dates, as observed during a survey. Four boxes of wild berry magic cup desserts and a package of cheese slices were found without proper labeling. The Director of Food Service confirmed that all kitchen staff are responsible for labeling food items to monitor their storage duration and prevent health risks to residents.
The facility failed to maintain proper coverage of outside trash dumpsters, as observed by a surveyor. Two dumpsters had missing parts of their lids, which are necessary to prevent trash from escaping and to deter animals. The Dietary Aide was unaware of who was responsible for maintenance, while the Director of Food Service indicated it was the housekeeping department's responsibility. The Director of Environmental Services acknowledged the issue and had previously informed the disposal service. The facility's policy requires dumpsters to be covered and the area to be litter-free.
The facility failed to maintain infection control by improperly storing a clean linen cart in the restroom of residents on Enhanced Barrier Precautions and not securely tying soiled linen bags before chute conveyance. Observations showed the cart was uncovered, and bags burst open in the laundry area, risking contamination. Staff confirmed these actions were against policy, highlighting the need for proper linen handling to prevent infection spread.
The facility failed to conduct care plan conferences, preventing residents and their families from participating in care plan development. This affected four residents with varying cognitive impairments, who were not invited to meetings or involved in their care plans. Documentation showed missing interdisciplinary team members and non-compliance with the facility's policy requiring quarterly reviews.
A facility failed to assist a resident with grooming, as observed when the resident had long fingernails with brown matter underneath. The resident, who has dementia and moderate cognitive impairment, expressed a desire for trimmed nails but did not receive the necessary assistance, contrary to the facility's policy on activities of daily living.
The facility failed to ensure Low Air Loss Mattresses were set correctly for several residents, affecting pressure ulcer prevention. Observations revealed discrepancies between residents' weights and mattress settings, despite guidelines requiring settings to match patient weights. This deficiency impacted residents with pressure ulcers and those at risk for skin integrity issues.
The facility failed to monitor personal refrigerator temperatures in residents' rooms, leading to expired food items and unsafe temperature levels. Staff interviews confirmed that maintenance and housekeeping were responsible for daily checks, but logs were outdated or missing, and temperatures were not within the safe range. This posed a risk of foodborne illness for cognitively intact residents.
The facility failed to maintain functional call lights, affecting four residents, including one who was visually impaired. Residents reported non-responsive call lights, requiring them to yell for assistance or pull cords from walls, posing safety risks. The Maintenance Director was unaware of the issues until informed by staff and surveyors, and the system was found to be old and malfunctioning.
A facility failed to obtain informed consent for a resident prescribed QUEtiapine Fumarate for dementia with behavioral disturbance. The consent form, dated months after the medication order, incorrectly listed the dosage and lacked necessary details. Staff interviews confirmed the requirement for informed consent before administering psychotropic medications, highlighting a lapse in adherence to facility policy.
The facility failed to store a bottle of lorazepam according to the manufacturer's instructions, affecting a resident. The lorazepam, which should have been refrigerated, was found in the medication cart's narcotics drawer. The LPN acknowledged the storage error upon observing the sticker indicating refrigeration was required. The facility's policy mandates that medications needing refrigeration be stored at specific temperatures, with controlled substances in a lock box within a refrigerator.
A resident with a history of falls and abnormal medication levels fell in the dining room, resulting in a hip fracture. The facility failed to implement its fall prevention policy, as staff did not provide adequate supervision or assistive devices. Despite being aware of the resident's high fall risk due to abnormal phenytoin and valproic acid levels, the staff did not monitor the resident closely, leading to the fall and subsequent injury.
The facility failed to maintain clean and functional shower rooms, affecting 195 residents. Observations showed broken tiles, missing fixtures, and cluttered spaces, despite staff claims of regular cleaning and maintenance. Interviews revealed a disconnect between policy and practice, with maintenance issues not promptly addressed.
The facility failed to provide adequate clean bed linen for its 197 residents due to a shortage of new linens and a malfunctioning washing machine. Observations showed empty linen carts and rooms across multiple floors, and staff interviews confirmed the lack of linens. The Administrator noted that a large order of sheets had not arrived, and the facility struggled to maintain linen stock. Facility policies on linen handling and equipment maintenance were not effectively followed.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a stage 3 pressure ulcer, leading to a deficiency. The resident was not placed on EBP upon admission, and there was no EBP signage or PPE available outside the room. The occupational therapist and other staff were unaware of the wound, and the infection preventionist confirmed the absence of EBP measures. The Director of Nursing acknowledged the lapse in policy adherence, as the resident's condition was not included in the EBP list, and no EBP care plan was in place.
A resident with a stage 3 pressure ulcer was found lying on a low air loss mattress set at 280 lbs, higher than their actual weight of 182.2 lbs. This incorrect setting was confirmed by staff and contradicted the facility's policy, which requires mattress settings to match the resident's weight to prevent further skin damage.
The facility failed to maintain a properly functioning nurse call system, affecting four residents who required substantial assistance. Despite activating their call lights, the signals were not visible outside their rooms or at the nurses' station, leading to delays in receiving help. The maintenance director identified that the system needed updating, as the lights would not illuminate if the bathroom call light was accidentally bumped.
A facility failed to investigate and report an alleged incident of mental abuse involving a resident and a staff member. The resident reported feeling demeaned and that staff were ganging up against her after an interaction with a CNA. The facility administrator did not investigate further or report the incident to the IDPH, believing it was not reportable since the resident cursed at the staff first. This action violated the facility's abuse prevention procedures.
Inadequate Nurse and CNA Staffing Leading to Delayed Medications and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff to ensure resident needs were met in a timely manner and medications were administered as ordered. On multiple occasions, nurse and CNA staffing on various floors and shifts fell below the facility’s usual staffing framework, resulting in delayed medication administration and delayed response to resident care needs. On one day shift, an LPN assigned to the first floor arrived around 10:14 AM to cover a 7-3 shift, causing some 9:00 AM medications on her assignment to be given after 10:00 AM. A registered nurse working that same day reported being the only nurse on the first floor at the start of the shift after another nurse called off, and stated that residents on the second set of rooms did not receive their 9:00 AM medications within the 8:00-10:00 AM window because of short staffing. A resident with diagnoses including chronic upper respiratory disease, congenital tracheal malformation, type 2 diabetes mellitus, morbid obesity, peripheral vascular disease, seizure disorder, schizophrenia, bipolar disorder, and anxiety reported often not receiving medications as scheduled, sometimes three hours late, and described one day when no medications were received until early afternoon. This resident, who receives Gabapentin for bilateral lower leg pain and has an intact cognition per MDS, stated that on a Saturday when the unit was short staffed and there was an emergency with another resident, his Gabapentin was not given on time and his pain level was eight out of ten. The RN confirmed that this resident’s standing 9:00 AM Gabapentin dose was administered around 11:15 AM and documented in the eMAR, outside the stated 8:00-10:00 AM window for 9:00 AM medications. The facility also failed to maintain adequate CNA staffing on several shifts. On one 7-3 shift with a census of 81 residents, only four CNAs worked on the second floor instead of the usual six, resulting in one CNA caring for approximately 19-20 residents, about half of whom required total care and three required a mechanical lift. That CNA reported prioritizing initial rounds, incontinence care, answering call lights, feeding residents, and passing out ice water, and stated that charting, nail care, shaving, and getting some residents who required a mechanical lift dressed or out of bed might not have been completed. Another resident with multiple comorbidities including partial traumatic amputation of the left lower leg, chronic venous hypertension with inflammation of both lower extremities, complex regional pain syndrome, dietary folate deficiency anemia, long-term insulin use, type 2 diabetes mellitus, long-term anticoagulant use, and chronic kidney disease, and who requires assistance with toileting, bathing, and transfers, reported that on a Saturday day shift there were only four CNAs working and that she had to wait a longer time for staff to respond to her call light and to be changed because staff were very busy. Additional staffing shortfalls occurred on other units and shifts. On one 3-11 shift on the third floor, only two nurses worked instead of the expected three, and an LPN reported that although all residents eventually received their 5:00 PM medications, some were administered outside the 4:00-6:00 PM timeframe due to the reduced staffing and the higher acuity of the dementia unit. On a separate 11-7 shift on the third floor, three CNAs worked instead of the usual four, with one CNA caring for 24-25 residents on the dementia unit and reporting that residents who wander and are at risk for falls could not all be watched and that residents had to wait longer to be changed if wet or soiled. On another morning, an LPN assigned to approximately 24 residents on the second floor arrived at 9:35 AM for a shift where 9:00 AM medications were to be given between 8:00-10:00 AM; by 10:01 AM she still had not completed the medication pass for all assigned rooms and acknowledged she would not be able to finish before 10:00 AM. The Director of Nursing and an advanced practice nurse both stated that inadequate staffing can delay medication passes, nursing assessments, accuchecks, and timely ADL care, and that CNA-to-resident ratios such as 1:20 and nurse shortages on heavier units like the locked dementia floor are problematic. The administrator reported that the facility does not have a staffing policy.
Widespread Failure to Administer Medications According to Physician-Ordered Times
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for timely medication administration for eight residents, resulting in repeated late or omitted doses. Nursing staff, including LPNs and RNs, reported being the only nurse on a unit, covering additional assignments, arriving late for shifts, and being unable to complete 9:00 AM medication passes within the accepted 8:00–10:00 AM window. One LPN stated that some 9:00 AM medications were given after 10:00 AM and acknowledged that late medications could mean residents’ pain or blood pressure were not well controlled. Another LPN reported arriving at 9:30 AM with no medications yet passed for her assignment and stated she would not be able to complete all 9:00 AM medications within the one-hour before/after window. Multiple residents experienced late administration of scheduled medications across several days, as documented in the MARs and medication audit reports. One resident with intact cognition and diagnoses including PVD, seizures, schizophrenia, COPD-related conditions, and diabetes reported often not receiving medications as scheduled, sometimes three hours late, and described a day when all medications were delayed until early afternoon. This resident’s records showed repeated late administration of Gabapentin for neuropathic pain, Advair and Albuterol for tracheal stenosis and shortness of breath, with doses scheduled for morning, afternoon, and evening frequently given several hours after the ordered times. Another cognitively intact resident with COPD, heart failure, diabetes, and rheumatoid arthritis did not receive a prescribed 6:00 AM Lidocaine patch and reported shoulder pain rated 8/10; the patch was not observed in place. The same resident’s 9:00 AM medications, including Bactrim DS for UTI, Hydroxychloroquine, Metformin, Symbicort, and Gabapentin, were administered after 11:00 AM, and some medications such as Empagliflozin and Gabapentin were not available and therefore not given. Additional residents with intact or impaired cognition and multiple chronic conditions also had late medication administration documented. One resident receiving psychotropic medications (Risperidone and Benztropine) and a bowel regimen had doses scheduled for 9:00 AM and 6:00 PM given several hours late on multiple days. Another resident with diabetes, hypertension, CKD, and anemia had Metoprolol, Metformin, Ferrous Sulfate, and Humalog insulin repeatedly administered beyond the ordered times, including insulin given well after the scheduled pre-meal time. A resident with neuropathic pain had Gabapentin doses scheduled three times daily administered late on several dates. Residents with seizure disorders and cardiovascular conditions had anticonvulsants (Divalproex, Levetiracetam), antihypertensives (Carvedilol), muscle relaxants (Baclofen), and other medications administered outside the one-hour before/after window, including one evening Levetiracetam dose given in the early morning of the following day. The DON and NP both stated that nurses are expected to follow the five rights of medication administration, that medications should be given within one hour before or after the ordered time, and that administration beyond this window is considered late and not following the physician’s order, consistent with the facility’s medication administration policy. The facility’s own policy on administration procedures for all medications, dated 10/25/14, requires medications to be administered in a safe and effective manner, with review of the five rights and checking the MAR for orders. Interviews with the DON and NP confirmed that medications given more than one hour outside the ordered time are considered late and not in accordance with physician orders. Despite this, the documented MARs and audit reports for all eight residents show a pattern of late administration and, in some cases, omitted doses due to unavailability of medications, affecting pain medications, psychotropics, anticonvulsants, antihypertensives, antidiabetics, antibiotics, and respiratory medications. These actions and inactions by nursing staff, combined with staffing and scheduling issues described by the nurses, led directly to the failure to provide pharmaceutical services in accordance with physician orders for the affected residents.
Failure to Ensure Timely and Complete Medication Administration for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically repeated late and omitted medication administrations for two residents with intact cognition and multiple chronic conditions. One resident reported frequently receiving medications up to three hours after scheduled times and described a day when all medications were delayed until early afternoon. This resident, admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, peripheral vascular disease, and other conditions, stated he receives Gabapentin for bilateral lower leg pain and reported experiencing pain at a level of eight out of ten when his Gabapentin was delayed. A registered nurse confirmed that on one day she was the only nurse on the unit due to another nurse calling off, and that she administered this resident’s 9:00 AM Gabapentin dose at approximately 11:15 AM, outside the facility’s stated 8:00–10:00 AM window for 9:00 AM medications. Record review for this resident’s physician orders, MARs, and medication audit reports showed multiple instances of late administration of respiratory and pain medications. On several dates, Advair inhaler doses ordered for 9:00 AM and 6:00 PM were given hours late, including a 6:00 PM dose administered at 10:50 PM. Albuterol tablets ordered three times daily were repeatedly given several hours after the ordered times, such as a 9:00 AM dose given at 12:06 PM and a 1:00 PM dose given at 4:19 PM. Gabapentin 600 mg ordered three times daily for neuropathy was also administered late on multiple occasions, including a 9:00 AM dose given at 12:13 PM, a 1:00 PM dose given at 4:19 PM, and doses ordered for 11:00 AM and 4:00 PM given in the mid-afternoon and late evening. The nurse practitioner stated that medications not given within one hour before or after the ordered time are considered late and not following the doctor’s order, and that pain medications not given as ordered could result in residents being uncomfortable and having mobility affected. A second resident, admitted with diagnoses including COPD, sleep apnea, hypertensive heart disease with heart failure, heart failure, type 2 diabetes mellitus, and rheumatoid arthritis, also experienced medication administration issues. During observation, an LPN who had arrived late for her shift stated that none of the medications on her set had been passed yet and acknowledged she would not be able to complete all 9:00 AM medications within the 8:00–10:00 AM window. During a medication pass, the LPN prepared and administered multiple oral medications and an inhaler to this resident but stated that Empagliflozin (Jardiance) and Gabapentin were not available and therefore were not given. The resident, alert and oriented, reported not receiving her ordered 6:00 AM lidocaine pain patch to the left shoulder and rated her shoulder pain as eight out of ten; observation confirmed there was no pain patch in place. Review of this resident’s MAR and physician orders showed scheduled medications including a daily lidocaine patch at 6:00 AM, Bactrim DS twice daily for UTI, Hydroxychloroquine, Metformin, Symbicort inhaler twice daily, and Gabapentin three times daily for pain. The DON and nursing staff stated that medications are expected to be given within one hour before or after the ordered time, that late administration beyond this window is considered not following the doctor’s order, and that pain, hypertensive, diabetic, and antibiotic medications must be given timely as ordered. The facility’s policy on administration procedures for all medications, dated 10/25/14, states that medications are to be administered in a safe and effective manner, with review of the five rights and checking the MAR for orders. Despite this policy, the documented late administrations, missed doses due to unavailability, and failure to apply an ordered pain patch demonstrate that the facility did not consistently follow ordered times and the five rights of medication administration for these residents. Staff interviews, resident statements, and medication records collectively show that the facility did not ensure residents were free from significant medication errors related to timing and omission of ordered medications.
Failure to Inspect Mechanical Lift Sling Leads to Resident Fall During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer using a mechanical lift and to follow its fall prevention and transfer policies for one resident. The resident had medical diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, essential hypertension, type 2 diabetes mellitus, obesity, and peripheral vascular disease, and required a full-body mechanical lift for transfers. The resident’s cognition was intact, with a BIMS score of 15. On the day of the incident, the resident was transferred from a shower bed to a mechanical lift in the hallway outside the resident’s room, rather than in the room, after receiving a shower. According to progress notes and staff interviews, a CNA placed the resident in the mechanical lift and began the transfer toward the resident’s bed. The CNA reported that the resident had been on a sling that was already under the resident from an earlier shift and that she did not realize the sling was defective. The CNA stated she did not notice the worn-out strap before attempting the transfer. While the resident was suspended in the air on the mechanical lift near the doorway to the resident’s room, the foot straps of the mechanical lift sling broke, causing the resident to fall to the floor on her buttocks and one leg. A nurse who came to assist reported that the resident was already on the lift when she arrived, that the sling strap broke during the transfer, and that she did not know whether the CNA had assessed the sling for wear and tear before use. The resident reported that the CNA told her the room was too congested and that the transfer to the lift would be done in the hallway. The resident stated that after being lifted, the CNA said something did not feel right and sought help, at which point an LPN came to assist, and then the sling strap broke and the resident fell. The resident described falling on one leg and her buttock, experiencing swelling in her left leg and ongoing pain after the fall, and feeling frightened whenever staff transfer her. The restorative nurse stated that staff are trained to inspect mechanical lift slings for wear and tear and that the sling should have been inspected prior to placing it under the resident and before the transfer. The DON stated that a quick inspection of the mechanical lift sling could have prevented the fall and confirmed that the mechanical lift is for transfers and not for transporting residents, and that moving the resident from the hallway to the bed in this manner would be considered transporting. The facility’s policies and the lift manufacturer’s manual require inspection of slings for damage and removal of malfunctioning equipment from service, which was not done in this case, resulting in the resident’s fall from the mechanical lift.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Investigate Resident Fall and Update Care Plan
Penalty
Summary
The facility failed to investigate a fall experienced by a resident with a history of repeated falls and spinal stenosis, who also had some cognitive impairment as indicated by a BIMS score below 10. The resident was able to answer surveyor questions appropriately during the survey. According to progress notes, the resident fell in the hallway while pushing a wheelchair, and the fall was unwitnessed. The resident was transferred to the hospital per physician's request, with no observable injuries except for redness on areas impacted by the fall. The resident reported having had four falls at the facility, with the most recent occurring in the bathroom with staff present but unable to prevent the fall. The resident recalled a fall in June but could not remember exact dates. Interviews with facility staff revealed that the restorative nurse and DON, who oversee the falls program, were only aware of two falls, not the third fall documented in the progress notes. The restorative nurse stated that fall investigations are conducted and care plans updated with interventions after each fall, but was unaware of the third fall until reviewing the notes during the survey. The DON confirmed that the agency LPN who documented the fall did not notify either the DON or the restorative nurse about the incident, and described the LPN as substandard and no longer permitted to work at the facility. Facility policy requires fall risk assessments and investigations after each fall, with interventions to be added to the care plan, but this process was not followed for the resident's fall on the specified date.
Failure to Provide and Document Ordered Pressure Ulcer Care
Penalty
Summary
A resident with a history of hemiplegia, aphasia, dysphagia, acute respiratory failure, and an unstageable sacral pressure ulcer was admitted to the facility and identified as high risk for pressure wounds, with a Braden Score of 12. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. The care plan included the use of a moisture barrier cream with zinc after each incontinent episode and daily wound treatments as ordered by the physician. Despite these orders, observations and record reviews revealed that wound care and dressing changes were not performed as prescribed. On observation, the resident's wound dressing was found to be dated four days prior, despite a daily dressing change order. The wound was noted to have increased in size and showed signs of infection, with cultures later confirming the presence of Proteus mirabilis and CRE. The Treatment Administration Record (TAR) showed multiple dates where the application of the moisture barrier cream was not documented as completed, indicating missed treatments. Interviews with nursing staff, the wound care director, the nurse practitioner, and the wound physician confirmed that wound care and dressing changes were not consistently performed or documented as required. Staff acknowledged that failure to provide and document these treatments could lead to wound deterioration and infection, which was observed in this case as the resident's wound worsened and became infected.
Failure to Implement Contact Precautions and Provide PPE for Resident with CRE-Positive Wound
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for a resident with multiple complex medical conditions, including a sacral pressure ulcer that tested positive for CRE (Carbapenem-resistant Enterobacteriaceae) and other organisms. Despite the resident's wound culture result indicating the need for contact isolation precautions, there was no order for transmission-based precautions or contact isolation in the physician order sheet, and enhanced barrier precautions were only noted for wounds and G-tube care. Observations revealed that the resident's room lacked required signage for transmission-based precautions, and there was no isolation setup or PPE supplies accessible at the room entrance. Staff members, including an LPN and a CNA, were observed entering the resident's room wearing only gloves and not donning gowns as required for contact precautions. The CNA provided direct care, including changing an incontinence brief and repositioning the resident, without proper PPE. Interviews with facility staff, including the infection preventionist and the director of nursing, confirmed awareness of the wound culture results and the necessity for contact isolation precautions, but these measures were not implemented in a timely manner. The infection preventionist acknowledged that the resident should have been transferred to a single room and that proper signage and PPE should have been in place immediately upon receipt of the culture results. The facility's own infection precaution guidelines require the use of transmission-based precautions, including contact precautions for residents with infections that can be transmitted by direct or indirect contact. The guidelines also specify the need for signage and PPE availability at the room entrance. The failure to follow these protocols resulted in staff providing care to the resident without proper PPE and without clear communication of the required precautions, creating the potential for cross-contamination among other residents assigned to the same staff.
Failure to Prevent Resident-to-Resident Abuse During Unsupervised Smoking Break
Penalty
Summary
Two residents were involved in a physical and verbal altercation during a smoking break on the facility's patio. Both residents have documented histories of aggression and combative behavior, as indicated in their care plans and abuse risk reviews. During the incident, one resident hit the other in the face, and the other retaliated by throwing an open milk carton, resulting in milk being spilled. Both residents exchanged insults and physical contact, with no staff present outside at the time to supervise the interaction. The altercation was only addressed after it had occurred, when a psychosocial aide/social service assistant intervened. The incident was not reported to the police, and one of the residents was sent to the hospital for evaluation. Both residents have intact cognition, as shown by their BIMS scores, and have diagnoses including schizophrenia, major depressive disorder, chronic obstructive pulmonary disease, and end stage renal disease. The facility's policy affirms residents' rights to be free from abuse and neglect, but the lack of staff supervision during the smoking break allowed the altercation to occur without immediate intervention.
Failure to Administer Anticonvulsant Medication
Penalty
Summary
The facility failed to provide prescribed anticonvulsant medication, Dilantin, to a resident diagnosed with a seizure disorder, resulting in sub-therapeutic levels and missed doses. Resident R444, who is cognitively intact, reported missing a dose on the night of 3/1/25 due to the facility running out of the medication, which led to two seizures the following morning. The emergency medication supply had doses available, but the staff did not access it, and the nurse on duty did not have access to the emergency medication dispenser. Additionally, another resident, R15, who also has a seizure disorder, did not receive their prescribed Phenytoin suspension as the medication was not located in the cart. The medication was found on the resident's dresser, and the nurse confirmed it was prescribed for R15. The resident's Phenytoin levels were consistently low, and the medication was not administered as ordered, leading to sub-therapeutic levels. The facility's policy requires medications to be administered as prescribed and to contact the pharmacy or use the emergency kit if a medication is unavailable. However, the staff failed to follow these procedures, resulting in missed doses and low therapeutic levels for both residents, increasing the risk of seizures.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide necessary restorative services to four residents, leading to a deficiency in maintaining or improving their range of motion and mobility. Resident R445, who is cognitively intact and diagnosed with multiple sclerosis and other conditions, expressed emotional distress due to the lack of therapy or restorative services since her admission two weeks prior. Despite being assessed for restorative services, R445 was not added to the restorative list, and there was no schedule in place to ensure she received the necessary care. Resident R59, with diagnoses including rheumatoid arthritis and contractures, reported not receiving passive range of motion exercises for about a week. The restorative aide, V29, mentioned that R59 seemed to be in pain during exercises, but R59 clarified that she never refused exercises due to pain. The lack of consistent restorative services was further highlighted by the absence of a structured schedule and documentation of services provided. Resident R88, who requires assistance for range of motion exercises, and R85, who was recently discharged from therapy to restorative care, also experienced lapses in receiving restorative services. R85, in particular, noted that restorative staff did not accommodate his dialysis schedule, resulting in missed exercises. The facility's policy mandates individualized restorative programs with documented interventions, but the lack of documentation and adherence to care plans contributed to the deficiency.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide continuous supplementary oxygen to a resident, resulting in an oxygen saturation level of 89%. The resident, who has chronic obstructive pulmonary disease and other serious health conditions, was found with a nasal cannula hanging from their ear instead of being properly placed in the nostrils. This incident occurred despite the resident's care plan requiring continuous oxygen at 3 liters per minute. The resident expressed difficulty in breathing and had attempted to call for help, indicating that the nasal cannula had been misplaced for some time. Another resident was found with oxygen tubing that was not dated, contrary to the facility's policy which requires labeling of respiratory equipment with the date of use. The resident's physician order required continuous oxygen at 4 liters per minute, and the facility's policy mandates weekly changes of oxygen tubing to prevent infection. However, the Director of Nursing admitted that the tubing was not dated due to a lack of space for writing the date, although the water canister was dated. Additionally, a third resident was receiving oxygen at a higher concentration than prescribed. The resident's physician order specified oxygen at 2 liters per minute, but the oxygen concentrator was set to deliver 4 liters per minute. The Director of Nursing was unsure of the correct setting and the resident confirmed that they did not adjust the oxygen themselves. This discrepancy highlights a failure to adhere to physician orders and facility policies regarding oxygen delivery.
Failure to Implement Gradual Dose Reductions for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R58, was free from unnecessary psychotropic medication use and did not complete gradual dose reductions (GDR) as required. This failure resulted in harm to R58, who exhibited symptoms of sedation. Observations noted that R58 was difficult to arouse, appeared lethargic, and had unclear speech. The resident's care plan did not document any non-pharmacological interventions attempted prior to the administration of psychotropic medications, and there was no evidence of targeted behaviors that would justify the use of such medications. R58 was prescribed QUEtiapine Fumarate for dementia with behavioral disturbance and Sertraline for hypersexuality. However, the facility's records did not document any abnormal or targeted behaviors from October 2025 to March 2025. The facility's psychiatric provider, V34, acknowledged that QUEtiapine is not approved for dementia-related psychosis and that the medication can have sedative effects. Despite this, the provider continued the prescription, citing a lack of alternative treatments for dementia-related aggression. The facility's pharmacy consultant, V31, confirmed that the use of QUEtiapine for dementia with behaviors and hypersexuality was inappropriate and had recommended discontinuation of the medications, which was denied by the provider. The facility's policy on psychotropic medication and GDR was not followed, as evidenced by the lack of documented attempts to reduce the medication dosage. The failure to adhere to these protocols resulted in R58 experiencing sedation and being at increased risk of adverse effects from the medication.
Failure to Label Food Items in Storage
Penalty
Summary
The facility failed to ensure that food items stored in the refrigerator and freezer were labeled with the date they were placed into storage and a use-by date. During an observation of Walk-in Freezer #1, four boxes of wild berry magic cup desserts were found without any labeling indicating when they were stored or their use-by date. Similarly, in the walk-in refrigerator, a package of yellow pasteurized process American cheese slices was observed without any date labeling. These labeling omissions were noted during a survey conducted in the presence of the Director of Food Service. The Director of Food Service acknowledged that all kitchen staff are responsible for labeling food items with the date of storage and a use-by date, as per the facility's expectations. The purpose of this practice is to monitor the storage duration of food items and ensure they are consumed or discarded in a timely manner to prevent potential health risks to residents. The facility's policy on food storage, although lacking a letterhead, mandates that all food items be labeled with the name of the food and the date by which it should be sold, consumed, or discarded. The Director of Food Service's job description includes supervising the receiving and storage of food, highlighting the importance of adherence to these labeling practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the outside trash dumpsters were properly covered, as observed by a surveyor on March 4, 2025. The facility has two green-colored outside trash dumpsters, each with a black plastic lid divided into three parts. It was noted that the first part of the black plastic lid was missing on both dumpsters. The Dietary Aide, V38, confirmed that the lids are necessary to prevent trash from flying out and to deter animals from accessing the dumpsters. However, V38 was unaware of who was responsible for maintaining the dumpsters. The Director of Food Service, V4, indicated that the housekeeping department was responsible, while the Director of Environmental Services, V18, acknowledged the missing lids and stated that they had informed the disposal service about the issue some time ago. The facility's policy requires outdoor trash receptacles to be covered and the surrounding area to be free of litter.
Infection Control Deficiencies in Linen Handling
Penalty
Summary
The facility failed to maintain proper infection control practices by storing a clean linen cart inside the restroom of residents on Enhanced Barrier Precautions (EBP). Observations revealed that the cart, containing washcloths, fitted sheets, and adult diapers, was uncovered and placed inside the restroom of two residents, one of whom was cognitively intact and the other moderately impaired. The facility's policy dictates that clean linen carts should be kept in hallways and covered to prevent contamination, as entering a resident's room or restroom renders the linens contaminated. Staff interviews confirmed that the presence of the cart in the restroom was against policy and posed a risk of contamination. Additionally, the facility failed to ensure that soiled linen bags were securely tied before being conveyed via a chute to the laundry department. During an interview and observation, it was noted that a bag of soiled linen burst open upon landing in the laundry area, spilling its contents onto the floor. Further inspection revealed that some bags were not tied, and a towel was found outside of a bag. The Director of Nursing acknowledged the issue and indicated a need for staff reeducation on securely tying bags to prevent contamination during transport. The facility's Linen Handling Principles emphasize the importance of securely tying soiled linen bags to prevent the spread of microorganisms. The failure to adhere to these guidelines resulted in potential contamination risks, as the air in the laundry area could become contaminated, affecting all residents who receive linens from the facility. The report highlights the need for proper handling and containment of both clean and soiled linens to maintain infection control standards.
Failure to Conduct Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences, which resulted in residents and their families not being able to exercise their right to participate in the development and implementation of their care plans. This deficiency affected four residents, each with varying levels of cognitive impairment. For instance, one resident with mild cognitive impairment expressed a desire to discharge from the facility but was unaware of any discharge plan within their care plan. This resident, along with others, denied being asked to participate in the development of their care plans or being invited to care plan conferences. The facility's documentation revealed that care plan meetings were not held as required, and key interdisciplinary team members were absent from the meetings that did occur. The facility's policy mandates that residents and/or their representatives be invited to review the care plan with the interdisciplinary team at least quarterly, but this was not adhered to. The facility's failure to follow its comprehensive care planning policy was acknowledged by the Director of Nursing, who admitted that care plan conferences were not being completed according to policy, and no documentation of corrective action was provided.
Failure to Assist Resident with Grooming Needs
Penalty
Summary
The facility failed to provide necessary assistance with grooming for a resident, identified as R46, who was unable to perform this activity of daily living independently. On March 3, 2025, it was observed that R46 had long fingernails with brown matter underneath them. R46 expressed a preference for shorter nails and a desire to have them trimmed. Despite this, the facility did not provide the required assistance, which is a failure to adhere to the resident's care plan and the facility's policy on activities of daily living. R46 was admitted to the facility with multiple diagnoses, including dementia, which contributed to a self-care performance deficit. The resident's Minimum Data Set indicated moderate cognitive impairment, necessitating supervision or assistance with most activities of daily living. The facility's policy aims to promote residents' independence and includes grooming as a key component. However, the facility did not fulfill this policy requirement for R46, leading to the observed deficiency.
Improper Low Air Loss Mattress Settings for Residents
Penalty
Summary
The facility failed to ensure that the Low Air Loss Mattresses (LALM) for pressure ulcer prevention were set at the correct weight settings for several residents. This deficiency was identified through observation, interviews, and record reviews, affecting five residents out of nine reviewed for pressure ulcer prevention and treatment. The facility had a list of 33 residents on LALM, with weights recorded on March 3, 2025. However, discrepancies were found between the recorded weights and the mattress settings for multiple residents. One resident, admitted with multiple pressure ulcers and severe cognitive impairment, was observed with a mattress setting significantly lower than their recorded weight. Despite the care plan specifying the need for appropriate mattress settings, the setting was not adjusted correctly. Another resident, with a history of dementia and other health issues, had a mattress setting at zero while not in bed, contrary to the requirement for settings to match or be below the resident's weight. Similarly, other residents had mattress settings that did not align with their documented weights, indicating a systemic issue in maintaining proper mattress settings. The facility's guidelines and in-service training emphasized the importance of setting air mattresses to the patient's weight and not altering the settings. However, observations revealed that these guidelines were not consistently followed, leading to improper mattress settings that could compromise pressure ulcer prevention. The failure to adhere to these guidelines and ensure correct mattress settings for residents at risk of skin integrity issues represents a significant deficiency in care provision.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of personal refrigerator temperatures in residents' rooms, which is crucial to prevent foodborne illnesses. Observations revealed that temperature logs were either missing or outdated for several residents, and expired food items were found in the refrigerators. For instance, in one resident's room, the temperature log was absent, and expired food items were discovered. Another resident's refrigerator had a temperature log from a previous year, and expired milk was found inside. The facility's procedure requires daily temperature checks and logging, but these were not consistently performed. Interviews with staff, including an LPN and the Assistant Director of Nursing, confirmed that the maintenance and housekeeping departments were responsible for monitoring refrigerator temperatures. However, the logs were not up-to-date, and temperatures were not within the safe range of 38F to 41F, with one refrigerator registering at 60F. The residents involved were cognitively intact, as indicated by their BIMS scores, but the lack of proper temperature monitoring posed a risk of foodborne illness. The facility's guidelines stipulate that outdated food should be discarded, and any temperature deviations should be reported immediately, but these protocols were not followed, leading to the deficiency.
Non-Functional Call Lights Affect Resident Safety
Penalty
Summary
The facility failed to ensure that residents' call lights were functional and in good working order, affecting four residents. During observations, interviews, and record reviews, it was found that several residents, including one who was visually impaired, experienced non-functional call lights. One resident reported that no staff responded to his call light for several days, requiring him to yell for assistance. Another resident had to pull the call light cord out of the wall to get it to work, which was acknowledged by a Licensed Practical Nurse (LPN) as a potential safety risk. The facility's policy requires that call lights be available and accessible to residents at all times, and defects should be promptly reported to maintenance. The Maintenance Director was unaware of the call light issues until informed by staff and surveyors. The facility did not maintain a maintenance logbook at the nursing station, and staff were expected to call maintenance directly. The Maintenance Director later confirmed that the call light system was old and malfunctioning, requiring repairs. The facility's policy emphasizes the importance of responding to residents' requests in a timely manner, but the lack of a functional call light system hindered this process, leaving residents without a reliable means to request assistance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication for a resident, identified as R58, who was prescribed QUEtiapine Fumarate (Seroquel) 12.5 mg at bedtime for dementia with behavioral disturbance. The physician's order for this medication began on 9/17/2023, but the informed consent form, dated 1/11/2024, incorrectly documented the dosage as 25 mg and lacked details on diagnosis, benefits, targeted behaviors, and alternatives. This discrepancy was noted during a survey, and no other consent forms were provided for review. Interviews with facility staff, including the Nursing Supervisor (V20) and the Director of Nursing (V3), confirmed that informed consent is required before administering psychotropic medications. V20 acknowledged the inconsistency in the dosage listed on the consent form and was unaware of why the consent was not obtained timely, as the order was initiated before their tenure. V3 emphasized the importance of obtaining informed consent to ensure residents are aware of the risks and benefits of their medications. The facility's policy on psychotropic medication also mandates obtaining informed consent prior to administration.
Improper Storage of Lorazepam
Penalty
Summary
The facility failed to store a bottle of lorazepam in accordance with the manufacturer's instructions, affecting one resident in a sample of 65. The resident had a physician's order for Lorazepam 2mg/mL concentrate, which was discontinued on December 20, 2024. On March 4, 2025, a Licensed Practical Nurse (LPN) was observed withdrawing the resident's bottle of lorazepam from the medication cart's narcotics drawer. The bottle had a sticker indicating it should be stored in the refrigerator, which the LPN acknowledged. The manufacturer's instructions specify that lorazepam oral concentrate should be protected from light and stored at temperatures between 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit). The facility's policy on medication storage, dated May 1, 2018, also requires medications needing refrigeration to be stored at these temperatures, with controlled substances stored within a lock box in the refrigerator or a locked refrigerator near the nurses' station or in a locked medication room.
Failure to Implement Fall Prevention Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement its fall prevention policy, resulting in a resident, identified as R1, experiencing a fall that led to a closed fracture of the neck of the left femur. R1's clinical record indicated a history of falling, epilepsy, dementia, and other medical conditions, and R1 was assessed as a high fall risk. Despite this, the facility did not provide adequate supervision or assistive devices, and R1 fell while attempting to stand in the dining room, leading to hospitalization and surgical repair of the fracture. The report highlights that R1's phenytoin levels were supratherapeutic, and valproic acid levels were low, contributing to gait instability and the fall. The nursing staff was aware of R1's abnormal medication levels, which increased the risk of falls, yet failed to monitor R1 closely or provide necessary interventions. Interviews with staff and family members revealed that R1's medication levels had been problematic before, and the staff was aware of the need for close monitoring when levels were abnormal. The facility's fall prevention program was not effectively implemented, as evidenced by the lack of supervision and failure to communicate R1's high fall risk to all staff members. The report indicates that the nursing staff did not follow established safety regulations, and there was a lack of leadership in directing nursing assistants to monitor R1 closely. This oversight led to R1's fall and subsequent injury, highlighting deficiencies in the facility's fall prevention measures.
Deficient Shower Room Conditions in LTC Facility
Penalty
Summary
The facility failed to provide a home-like environment and maintain clean and sanitary shower rooms, potentially affecting 195 residents. Observations revealed multiple issues in the shower rooms across different floors, including wet and used towels on the floor, broken floor tiles, missing shower fixtures, and cluttered spaces with equipment obstructing pathways. These conditions were observed despite staff claims that shower rooms are cleaned daily and after each use. Interviews with various staff members, including LPNs, CNAs, and the Director of Environmental Services, indicated that there is a system in place for reporting and addressing maintenance issues. However, the maintenance director acknowledged that repairs depend on the availability of parts and that monthly equipment rounds do not include checking shower rooms. Despite signs indicating some showers were temporarily out of service, staff stated that all shower rooms were still in use, and residents continued to use them despite the broken and cluttered conditions. The facility's policies and job descriptions for the Director of Environmental Services and Maintenance Director emphasize maintaining a clean, safe, and comfortable environment. However, the observations and interviews suggest a disconnect between policy and practice, as the shower rooms remained in disrepair and unclean. The facility's assessment tool highlights the importance of maintaining physical resources and equipment to ensure resident safety and comfort, yet the observed conditions indicate a failure to meet these standards.
Inadequate Linen Supply Due to Equipment Malfunction and Stock Shortage
Penalty
Summary
The facility failed to ensure the availability of adequate clean bed linen for its 197 residents due to an inadequate supply of new bed linens and a malfunctioning laundry machine. Observations on multiple floors revealed that clean linen carts and linen rooms were devoid of sheets. The basement supply storage room also lacked new bed linens, and one of the three washing machines in the laundry room was not functioning, contributing to the shortage of clean linens. Interviews with staff, including CNAs, the Housekeeping Manager, and the Laundry Aide, confirmed the absence of linens on the floors and the lack of new stock. The Administrator acknowledged the issue, stating that a large order of sheets had not yet been delivered and that the facility had been experiencing difficulties maintaining an adequate stock of linens. The facility's policy on Preventative Maintenance Laundry and Linen Handling Principles was not effectively implemented, as evidenced by the failure to maintain adequate linen supplies and ensure timely repairs of laundry equipment.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to implement their Enhanced Barrier Precaution (EBP) policy and procedures by not placing a resident with a pressure wound on EBP, which is intended to prevent the potential spread of multidrug-resistant organisms. This deficiency was identified during a survey when a resident, who had a stage 3 pressure ulcer on the sacral region, was not placed on EBP upon admission. The resident was readmitted to the facility, and despite having a documented wound, there was no EBP sign or personal protective equipment (PPE) available outside the resident's room. The occupational therapist, who interacted with the resident, was unaware of the wound and did not observe any EBP signage or PPE bin, indicating a lapse in communication and procedure adherence. The wound care nurse and infection preventionist confirmed the absence of EBP measures, acknowledging that the resident should have been placed on EBP due to the presence of a wound. The infection preventionist noted that the process involves checking new admissions for EBP requirements, but this was not done in a timely manner for the resident in question. The Director of Nursing confirmed that the facility's policy requires residents with wounds to be on EBP, with appropriate signage and PPE readily available. However, the resident's condition was not included in the EBP list, and there was no EBP care plan in place for the resident. This oversight resulted in a delay in implementing necessary precautions, as the enhanced barrier precaution was ordered three days after the resident's admission.
Improper Low Air Loss Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set appropriately for a resident with a pressure ulcer. During an observation, it was noted that the mattress was set at 280 lbs, which was higher than the resident's actual weight of approximately 182.2 lbs. This discrepancy was confirmed by a Certified Nursing Assistant and an Agency RN, who both verified the incorrect setting. The Wound Care Nurse explained that the mattress setting should be adjusted to the resident's weight to prevent further skin damage, and a higher setting could make the mattress firmer, increasing pressure on the resident's skin. The resident in question had a documented diagnosis of a stage 3 pressure ulcer in the sacral region and was assessed as having a moderately impaired mental status. The facility's pressure injury prevention policy emphasized the importance of setting the low air loss mattress to the appropriate weight to prevent skin breakdown. Despite this policy, the resident's mattress was not set correctly, potentially compromising the effectiveness of the pressure-relieving device intended to aid in the resident's care.
Deficiency in Nurse Call System Functionality
Penalty
Summary
The facility failed to ensure that the nurse call system was properly functioning for four residents, leading to a deficiency in the availability of a working call system in each resident's bathroom and bathing area. During the investigation, it was observed that the call lights for these residents were not illuminating outside their rooms or at the nurses' station, despite being activated. This issue was noted for residents who required substantial assistance with daily activities, including toileting, dressing, and transferring. For instance, one resident was found sitting in bed crying out for help, and although the call light was activated, it was not visible outside the room or at the nurses' station. The maintenance director later identified that the call light system required updating, as the lights outside the bedrooms and at the nurses' station would not illuminate if the bathroom call light had been accidentally bumped. This malfunction resulted in residents being unable to effectively communicate their need for assistance, as evidenced by multiple residents expressing their need for help and medication without receiving timely responses. The facility's policy mandates that call lights be answered promptly and any defects reported to maintenance, but this was not adhered to, contributing to the deficiency.
Failure to Investigate and Report Alleged Mental Abuse
Penalty
Summary
The facility failed to investigate and report an alleged incident of mental abuse involving a resident (R1) and a staff member (V8). R1, who has intact cognitive function as indicated by a BIMS score of 15/15, reported feeling demeaned and that staff were ganging up against her after an interaction with V8. R1 requested assistance from V8 to clean her back, but V8 responded in a manner that R1 perceived as mean and dismissive. R1 felt demeaned and cursed at V8. The facility administrator (V7) acknowledged the incident but did not investigate further or report it to the Illinois Department of Public Health (IDPH), as she believed the incident was not reportable since R1 cursed at the staff first. The facility's policy on abuse prevention requires all incidents to be documented and investigated, with a final investigation report submitted within five working days. However, V7 did not follow this policy, as she did not conduct a thorough investigation or report the incident to the appropriate authorities. Instead, the incident was only logged in the concerns log. Additionally, V7 attempted to address R1's distress by involving a family member in a call, but this did not resolve the issue, and R1 remained upset. The facility's failure to investigate and report the alleged mental abuse is a clear violation of their own abuse prevention procedures.
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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