Fargo Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1512 West Fargo, Chicago, Illinois 60626
- CMS Provider Number
- 146169
- Inspections on file
- 28
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Fargo Health Care Center during CMS and state inspections, most recent first.
A resident with intact cognition and multiple behavioral and medical diagnoses was verbally and physically assaulted by another cognitively intact resident on the facility’s smoking patio after an argument over a lighter escalated without staff intervention. Both residents had signed out on independent pass and were smoking with a third resident when derogatory name calling began and one resident punched the other multiple times in the face, causing a comminuted right maxillary sinus fracture and a facial laceration requiring sutures and ED treatment. Surveyors confirmed through interviews and observations that no staff or security were present on the patio during the incident, that residents often smoked without direct supervision, and that monitoring relied on video cameras without audio. Staff, including an LPN, CNAs, the DON, the Administrator, security, and the psychiatric rehabilitation director, acknowledged that residents with behavioral issues can be aggressive, that the smoking area should be supervised, and that the facility is responsible for resident safety on its property. Facility policies on resident rights, abuse prevention, rounds, and smoking safety required prevention of abuse and regular monitoring, but these were not followed, and the facility’s investigation concluded that verbal and physical abuse occurred and caused harm.
The facility failed to properly justify and document involuntary discharges for two residents. One resident with depression, no documented history of aggressive behaviors, and a recent episode of self-harm after a family death was petitioned for involuntary discharge and not allowed to return, while the notice cited danger to others but the record lacked physician documentation or evidence of behaviors endangering other residents. Another resident with paranoid schizophrenia and repeated smoking in non-designated areas, profanity, and aggression was issued an involuntary discharge notice stating that the resident’s needs could not be met, yet the record contained no physician documentation explaining the discharge, what needs could not be met, or what services had been attempted beyond a smoking behavior contract.
A resident with intact cognition and multiple mental health diagnoses, including bipolar disorder and major depressive disorder, had a care plan calling for specialized mental health services such as psychotherapy and supportive counseling. Although several client-centered therapy sessions were documented initially, no further sessions occurred after a certain point, and the Social Service Director confirmed the resident did not participate in any ongoing structured groups or 1:1 psychosocial sessions, despite the availability of outside providers. The resident later reported feeling depressed over a sibling’s death, expressed a desire to go to the hospital, and disclosed self-harm by cutting the wrist, requiring hospital treatment and subsequent psychiatric evaluation, while a suicide/self-harm screening had identified a low to moderate risk and recommended supportive counseling.
Several residents were not provided with admission contract packets at the time of admission, with some waiting over a year to receive them. One resident with intact cognition reported being asked to sign a contract recently, expressing concerns about missing information and lack of time for review. Staff confirmed the facility was years behind in issuing these contracts, and an audit revealed multiple residents without them. The facility's policy did not address timely provision of admission packets.
The facility did not provide bread, Garlic Texas Toast, or appropriate bread substitutes during lunch meals as required by posted menus and dietary policies, affecting all residents receiving food from the kitchen. Multiple residents on regular, mechanical soft, and pureed diets did not receive these items, and staff interviews confirmed that bread had not been served at lunch for about a year without providing a substitute or informing the Registered Dietitian.
Surveyors found that kitchen staff did not consistently wear appropriate hair coverings, and multiple opened food items were not labeled or dated according to facility policy or manufacturer guidelines. Opened pre-thickened liquids and milk were not marked with opened or use-by dates, and some food items were not stored as directed by the manufacturer. These failures had the potential to affect all residents receiving food from the kitchen.
Staff failed to consistently bag soiled linen, transported clean linen in uncovered carts, and did not wear required PPE when providing care to a resident on enhanced barrier precautions for an indwelling catheter. The facility also did not track or report XDROs as required by state regulations, and the resident on EBP was not listed on the facility's EBP list.
Surveyors observed that nurses administered multiple medications to several residents outside the physician-ordered time frames, resulting in a medication error rate of 30%. Medications scheduled for specific times were given late, contrary to facility policy and physician orders, as confirmed by the DON and facility records.
Surveyors found that multi-dose inhalers for two residents were not dated after opening, despite pharmacy instructions to discard after a set period, and that a house stock Tubersol solution requiring refrigeration was stored at room temperature in a medication cart. Staff interviews and policy reviews confirmed that medications were not consistently dated or stored according to professional standards and facility policy.
Two residents were affected when staff failed to serve meals simultaneously to individuals seated at the same table, resulting in one resident waiting and observing another finish eating before receiving his own tray. Additionally, a resident with severe hearing impairment and no speech was not provided with accessible communication aids, and staff lacked training in sign language, relying instead on gestures. These actions did not align with facility policies on resident dignity and communication.
Two residents with limited ROM and physician orders for splint use were repeatedly observed without their prescribed splints in place. Despite care plans and orders specifying daily application, staff did not ensure splints were used as directed, and staff interviews confirmed knowledge of the orders and their purpose.
A resident was found keeping a cigarette accessible on a bedside table, contrary to facility policy requiring secure storage of smoking materials, while another resident with independent pass privileges left the facility without signing out and was not properly monitored or documented by staff. Staff interviews revealed inconsistent understanding and application of procedures for both smoking safety and resident monitoring during community leaves.
A resident with multiple diagnoses and a history of bladder incontinence was not provided with a restorative toileting program as required by facility policy. Staff confirmed that no such program was in place, and the resident reported using pullups and self-initiating restroom use without structured support.
A resident with chronic respiratory conditions was found to have a nebulizer mask and tubing improperly stored in a bedside drawer mixed with personal items and not dated, contrary to facility policy requiring proper storage and dating to prevent contamination. Both an LPN and the DON confirmed the equipment should have been stored in a clean, clear plastic bag and changed regularly.
Multiple incidents occurred in which residents were subjected to physical and verbal abuse by peers, including slapping, pushing, and threatening language. These events were confirmed through interviews and documentation, involving residents with various medical and psychiatric diagnoses. Staff and administrative personnel substantiated the abuse, indicating a failure to protect individuals from harm as required by facility policy and resident rights.
A resident reported being verbally threatened by a former roommate, with the incident documented by security and later substantiated as abuse. Although the security guard informed the administrator and documented the event, the initial report to authorities was delayed, as the administrator did not recognize the urgency or nature of the allegation. Facility policy requires immediate reporting of abuse allegations, but this protocol was not followed, resulting in a deficiency for untimely reporting.
A resident with dementia was physically abused by her roommate, who had a history of aggressive behavior. Despite signs of verbal and physical aggression, staff failed to prevent the abuse, resulting in the resident sustaining a broken nose. The facility's investigation confirmed the abuse, but staff did not report the warning signs as required by the facility's policy.
A resident in an LTC facility suffered a bruise and skin tear on the left arm due to rough handling by a CNA during incontinence care. The resident, who is cognitively intact, reported the incident, leading to an investigation. The CNA initially denied the incident but later acknowledged seeing the injury. The facility failed to prevent and report the abuse, resulting in the CNA's termination.
The facility did not submit the final investigation report of a resident-to-resident altercation to IDPH within the required timeframe. The incident involved a verbal and physical altercation between two residents, who were separated immediately with no injuries noted. Although the initial report was sent, the final report's submission could not be confirmed by the current administrator.
A facility failed to protect residents from abuse, as evidenced by a CNA hitting a cognitively impaired resident and an unsupervised altercation between two residents over cigarettes. The incidents highlight deficiencies in staff supervision and monitoring, particularly in areas like the smoking area, where residents are vulnerable.
A resident fell from their bed and was injured after a CNA attempted to turn them alone, despite the resident's care plan requiring a two-person assist for bed mobility. The incident caused increased pain and psychosocial harm to the resident, who expressed ongoing fear and anxiety. The facility's policies on fall prevention and personal care services were not followed, leading to the deficiency.
The facility failed to ensure proper food storage, labeling, and dating practices in the kitchen, potentially affecting all 94 residents receiving an oral diet. Undated and expired food items were found in the walk-in cooler and dry storage area, and a staff member's drink was improperly stored in the freezer. The dietary manager acknowledged the importance of these practices to ensure food safety.
The facility failed to ensure that residents' call light devices were within reach, affecting four residents. Observations revealed that call light strings were often hanging from the wall switch and out of reach, despite care plans and facility policies requiring them to be accessible. The Director of Nursing confirmed the importance of having call lights within reach, but this was not consistently practiced.
The facility failed to have a Psychiatric Rehabilitation Services Coordinator (PRSC) to meet the individualized psychosocial and mental health needs of residents. Observations and interviews revealed that several residents with severe mental illness had not received counseling or therapy services, and the Social Services Director was unable to provide adequate support to all residents. The facility had not hired a full-time or part-time PRSC, despite efforts to do so.
The facility failed to provide individualized psychosocial and mental health services to residents with severe mental illness. Five residents were observed with flat affect and low mood, and reported not receiving counseling or therapeutic services. The Social Services Director was overwhelmed and unable to meet the needs of all residents, and additional PRSC positions had not yet been filled.
The facility failed to ensure that the air-conditioner in a resident's room was working, repair a broken wall heat vent cover, and clean and cover the air-conditioner air filter in residents' rooms. These deficiencies affected seven residents and were not reported or addressed by the maintenance staff.
The facility failed to document a resident's code status in the EMR upon admission, despite the resident being cognitively intact and having multiple diagnoses. The code status was only entered after the surveyor's request, highlighting a lapse in protocol.
The facility failed to provide a safe and functional environment for two residents. One resident's privacy curtain was soiled with a stool-like substance and remained uncleaned despite daily inspections. Another resident's room was missing a window screen, allowing flies to enter. Both residents expressed a desire for these issues to be addressed.
The facility failed to assist a resident with shaving facial hair, leading to discomfort. The resident, who has moderate impairment and various medical conditions, was supposed to be shaved but did not receive assistance due to a CNA being off-duty. The resident's care plan requires partial assistance with personal hygiene, and the facility's policy mandates well-groomed hair.
The facility failed to protect a resident from physical abuse by another resident with a history of aggressive behavior. Preventative measures were not in place, and care plans were not updated, leading to multiple injuries for the victim.
The facility failed to maintain an effective pest control program, leading to the presence of cockroaches in the kitchen. A resident reported finding a cockroach in her tray, and traps with cockroaches were found during an inspection. Pest control reports documented the presence of German roaches, but there was no documentation of staff reporting pest problems, and the facility's pest control policy was not effectively implemented.
Failure to Supervise Smoking Patio Resulting in Resident-on-Resident Assault and Facial Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by another resident and to follow its own abuse prevention and supervision policies. On the afternoon of 1/26/2026, two cognitively intact residents with independent community passes were on the facility’s smoking patio after signing out on pass. A verbal altercation began over a cigarette lighter, with both residents engaging in derogatory name calling. One resident (R3), who had a care plan noting potential for inappropriate behavioral problems and a need for supervised community access with restricted independent pass privileges, became agitated and punched the other resident (R2) multiple times in the right facial area. R2 and a witness (R5) both reported that there were no staff or security personnel present on the patio during the verbal escalation or the physical assault, and that no staff came outside to intervene. As a result of the assault, R2 sustained a laceration and a closed fracture of the right anterior maxillary sinus. R2’s hospital records documented an assault with loss of consciousness, a comminuted, mildly impacted fracture of the right anterior maxillary wall, soft tissue swelling, and a facial laceration repaired with sutures. Progress notes from the LPN on duty described R2 returning from the patio with a right facial laceration and minimal bleeding, calling the police, and being transported to the emergency department. Upon return, documentation confirmed the diagnoses of closed fracture of the right maxillary sinus and facial laceration with two sutures below the right eye and a scratch on the right eyebrow. R2’s medical history included schizoaffective disorder, epilepsy, anxiety disorder, insomnia, restlessness and agitation, chronic pain, sleep apnea, nicotine dependence, and other conditions, with an MDS BIMS score of 15 indicating intact cognition. Multiple staff interviews and observations showed that the facility did not provide active supervision of residents on the smoking patio, despite policies requiring resident monitoring and abuse prevention. On two separate observation dates, surveyors saw several residents smoking on the patio without any staff supervision. The security guard stated that supervised smokers should always have a staff member present on the patio, that unsupervised smokers with independent passes were mainly monitored by video cameras without audio, and that it would not be possible to hear verbal abuse or respond quickly enough to prevent a sudden physical assault. CNAs and nursing staff acknowledged that residents with behavioral issues could be aggressive or unpredictable and that someone should be supervising residents at all times to separate them before altercations escalate, but also stated that residents on the patio were not always supervised. The Psychiatric Rehabilitation Services Director, DON, Administrator, and Activity Director all confirmed that no staff witnessed the incident, that there was no supervising staff outside on the patio at the time of the altercation, and that the facility is responsible for residents while on facility property. Facility policies on resident rights, abuse prevention, rounds, and smoking safety required prevention of abuse, hourly monitoring of residents, and maintenance of a safe environment, but these were not followed, resulting in a founded conclusion of verbal and physical abuse of R2 by R3 and physical harm to R2. The facility’s abuse prevention policies defined abuse as the willful infliction of injury with resulting physical harm, including verbal and physical abuse, and required the facility to establish a resident-secure environment, supervise and monitor staff’s ability to meet residents’ needs, and correct inappropriate language or handling at the time situations occur. The Resident’s Rights policy affirmed residents’ right to be free from abuse. The Rounds Policy required daily rounds to ensure residents are monitored every hour or as needed, and the Smoking Safety Policy aimed to provide a safe and healthy living environment recognizing potential harm from careless smoking. Despite these written policies, the facility did not ensure that staff were physically present to supervise residents on the smoking patio, did not ensure that a resident with known behavioral risks and a care plan calling for supervised community access was appropriately supervised, and did not intervene during the verbal escalation that preceded the physical assault. The Administrator and other leaders acknowledged that the smoking patio should be monitored at all times and that staff presence could have de-escalated the situation and prevented the abuse, and the facility’s own final incident investigation concluded that abuse was founded.
Failure to Properly Justify and Document Involuntary Discharges
Penalty
Summary
The deficiency involves the facility’s failure to ensure that involuntary transfers and discharges were not based solely on residents’ conditions at the time of transfer to acute care and to obtain and maintain required physician documentation supporting the reasons for involuntary discharge. For one resident (R1), who had a diagnosis of depression and no documented history of physical, verbal, or other behavioral symptoms on the most recent MDS, the facility initiated an involuntary transfer and discharge after the resident expressed depression over a sister’s recent death, stated a desire to go to the hospital, and cut her own wrist with scissors. Progress notes show the resident was sent to the hospital via 911, returned the same day with stitches, and was placed on 1:1 observation before being petitioned for involuntary discharge to another hospital for psychiatric evaluation and not allowed to return. The administrator and DON both stated that the resident was not a danger to other residents and that the self-harm incident was more like a cry for help, yet the facility issued a Notice of Involuntary Transfer or Discharge citing endangerment to the safety of individuals in the facility. The notice for R1, addressed to the resident and the legal guardian and signed by the former social services director, documented the regulatory reason as endangerment to the safety of individuals in the facility under 483.15(c)(1)(i)(C). However, the electronic health record contained no physician documentation explaining how the resident endangered the safety of individuals in the facility or supporting the stated regulatory basis for the involuntary discharge. The record also lacked documentation of behaviors that endangered other residents, and the DON and administrator both acknowledged that the resident was not aggressive and did not pose a threat to others. The legal guardian reported being informed by the facility that the resident could not return because she needed 24-hour care and might again use scissors to harm herself, and also reported being satisfied with the resident’s care and wishing the resident could have returned. For another resident (R4), who had paranoid schizophrenia and a history of smoking in non-designated areas, profanity, and aggressive behaviors toward staff and peers, the facility initiated an involuntary transfer and discharge after staff observed the resident smoking in a non-designated area, becoming verbally aggressive, and refusing redirection. Progress notes described the resident as a threat and harmful to self and others and noted that nursing staff contacted the physician, who recommended further evaluation, after which the resident was petitioned and sent to the hospital. The social services director completed and signed a Notice of Involuntary Transfer or Discharge citing that the resident’s welfare and needs could not be met by the facility under 483.15(c)(1)(i)(A), stating that the facility could not accommodate the resident’s smoking schedule and supervision needs and that the resident had violated the smoking policy multiple times. However, the electronic health record lacked physician documentation of the reason for the proposed discharge, did not specify what services the facility was unable to provide to meet the resident’s needs, and did not document what the facility attempted beyond a smoking behavior contract, resulting in a failure to support the regulatory basis for the involuntary discharge in the clinical record.
Failure to Provide Ongoing Behavioral Health Services and Implement Psychosocial Care Plan
Penalty
Summary
The facility failed to implement a care plan for psychosocial and mental well-being and to provide necessary behavioral health services for a resident with multiple mental health diagnoses, including bipolar disorder (current episode depressed), major depressive disorder, restlessness and agitation, and a history of seizures and chronic pain. The resident’s MDS showed intact cognition, and the care plan identified a need for specialized rehabilitation, support, counseling, and/or psychotherapeutic services, including mental health services such as psychotherapy, life skills training, and substance abuse services. Interventions in the care plan included obtaining consent, assisting the resident in locating an appropriate treatment provider, making initial appointments, and arranging transportation as necessary. The record showed that client-centered therapy sessions occurred on several documented dates, with the last session indicating the therapist would continue individualized biweekly therapy for six months, but no further therapy sessions were documented after that date. The Social Service Director reported that the facility had outside providers who came twice weekly for support groups and 1:1 sessions, and another provider offering intensive outpatient group therapy off-site, but she was not aware that the resident participated in any of these services and could not provide documentation of the resident’s participation in structured group or individualized mental health sessions. She also stated that the facility’s Social Services Department did not conduct any therapy groups or individualized sessions to address residents’ mental health needs. Progress notes later documented that the resident stated being depressed due to a sister’s death, expressed a desire to go to the hospital, and reported self-harm by cutting the right wrist with scissors, with bleeding observed. The resident was sent to the hospital via 911, returned the same day with stitches and was placed on 1:1, then was petitioned for involuntary discharge for psychiatric evaluation and was issued an involuntary discharge, not being allowed to return. A suicide/self-harm screening documented the resident as presenting a low to moderate risk for self-harmful behavior and recommended integration with structure, direction, and supportive counseling. The facility’s Social Services policy stated that it is the policy to provide a competent variety of psychological programming and therapeutic recreation opportunities to meet each resident’s mental and psychosocial well-being needs.
Failure to Provide Timely Admission Contracts to Residents
Penalty
Summary
The facility failed to provide admission contract/agreement packets in a timely manner to five residents, as evidenced by observations, interviews, and record reviews. One resident, who had been living in the facility for over two years and had an intact cognitive status, reported only recently being asked to sign a contract for services. The resident expressed dissatisfaction with the process, noting that the contract contained blank areas, missing pages, and insufficient time was given for review. The resident also described being called to a meeting by the administrator, who accused him of discouraging others from signing the contract, which the resident denied. The resident was concerned that the contract could alter his living arrangements and expressed reluctance to sign it. Staff interviews confirmed that the facility was three years behind in providing admission contracts to residents already in the facility, prompting the hiring of a consultant to address the issue. The Director of Social Services acknowledged that the admission contract, which outlines policies, regulations, resident rights, and payment terms, should be provided at the time of admission. An audit conducted by the administrator revealed that several residents had not been offered admission contracts, with most affected residents lacking these documents for over a year after admission. The facility's admission policy, dated January 2025, did not include procedures for providing the admission packet or contract during or at the time of admission.
Failure to Serve Menu-Required Bread Items During Meals
Penalty
Summary
The facility failed to follow its posted menus, spreadsheets, and standardized recipes, resulting in residents not receiving all required food items during meal service. Observations on multiple occasions showed that residents on various diets, including regular, mechanical soft, and pureed, did not receive bread, Garlic Texas Toast, or appropriate bread substitutes as listed on the menu and required by the facility's dietary policies. Residents expressed dissatisfaction, noting that they would have liked to receive the missing bread items and that meal portions felt insufficient. Interviews with dietary staff revealed that the cook did not serve bread or bread substitutes at lunch, despite these items being listed on the menu and spreadsheets. The dietary manager confirmed that bread was not being served at lunch for about a year, based on instructions from a previous administrator, and that no menu substitute was provided. The Registered Dietitian was unaware that bread was being omitted and stated that all menu items should be served as planned to ensure nutritional adequacy. The facility's own policies and menu documents required bread or bread equivalents to be served at specific meals, and recipes for these items were available in the kitchen. Record review confirmed that all residents had dietary orders specifying their required diets, and the menu spreadsheets detailed the bread or bread substitute to be served for each diet type. The failure to provide these items was not discussed with the Resident Council, and the Registered Dietitian was not informed of the change. The deficiency affected all 93 residents receiving food from the facility's kitchen, including those on specialized diets such as pureed or thickened liquids.
Failure to Follow Food Safety and Sanitation Standards in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food safety and sanitation practices. A dietary aide was seen in the food preparation area without a beard or mustache covering, despite having facial hair. The dietary manager confirmed that all facial hair should be covered and that beard protectors were available, but the aide had not used one upon entering the kitchen. Later, the same aide was observed wearing a beard protector that did not fully cover his mustache while preparing lunch trays. During a tour of the walk-in refrigerator, several opened containers of pre-thickened liquids and milk were found without any opened or use-by dates labeled by staff. Although the manufacturer’s printed best-by dates were visible, the containers also included instructions to use the product within seven days of opening, which was not being followed due to the lack of labeling. The dietary manager acknowledged that without an opened date, it was impossible to determine how long the items had been stored, and that the facility was not adhering to the manufacturer’s guidelines for use after opening. Additionally, an expired bottle of ground cloves was found, and a container of soy sauce that required refrigeration after opening was being stored at room temperature, contrary to manufacturer instructions. Interviews with the dietary manager and registered dietitian confirmed that the facility’s policy requires all food items to be labeled with the date received, the date opened, and the discard or use-by date, and that manufacturer guidelines for storage and use should be followed. The failures to properly label, date, and store food items, as well as to ensure appropriate use of hair restraints, had the potential to affect all residents receiving food from the kitchen. No residents were reported as NPO at the time of the survey.
Failure to Implement Infection Control Measures and Track XDROs
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures in several key areas. During a survey, it was observed that staff did not consistently bag or secure soiled linen and resident clothing before sending them down the laundry chute, resulting in loose items falling into collection bins. Additionally, clean linen and resident clothing were transported in uncovered carts, contrary to facility policy. Interviews with the laundry attendant and infection preventionist confirmed that these practices were not always followed, and staff acknowledged that linen should be bagged or covered during transport to prevent contamination. The facility also failed to track and report cases of extensively drug-resistant organisms (XDROs) as required by state regulations. The infection preventionist and director of nursing both stated that they had not been tracking or reporting XDROs to the appropriate registry, despite regulatory requirements and facility policy. This lack of tracking and reporting was confirmed through interviews and review of facility documentation. Furthermore, staff did not adhere to enhanced barrier precautions (EBP) for a resident with an indwelling suprapubic catheter. Two certified nursing assistants were observed transferring the resident without wearing the required gown and gloves, despite clear signage and physician orders indicating the need for EBP. The infection preventionist and LPN confirmed that staff should have worn appropriate PPE during high-contact care activities for residents on EBP. The resident's care plan and physician orders documented the need for these precautions, but the facility's EBP list did not include the resident, indicating a lapse in communication and documentation.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 30% error rate during observed medication administration for four residents. Surveyors observed registered nurses and licensed practical nurses administering medications outside the physician-ordered time frames. Specifically, medications scheduled for 8:00 AM were administered between 9:31 AM and 10:03 AM, exceeding the facility's policy of administering medications within one hour before or after the scheduled time. The errors involved multiple medications, including Levetiracetam, Valproic acid, Lamotrigine, Gabapentin, Eliquis, Diltiazem, Metformin, Namenda, and Depakote, all given later than ordered. The Director of Nursing confirmed that the facility's protocol requires medications to be administered within one hour of the scheduled time and acknowledged that administration outside this window is considered a medication error. The facility's medication administration policy, dated January 2024, also specifies this timing requirement. The survey findings were based on direct observation, interviews, and review of physician orders and medication administration records, all of which confirmed that the medications were not given according to the prescribed times.
Failure to Properly Label and Store Medications and Biologicals
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications and biologicals in accordance with professional standards. Specifically, opened multi-dose inhalers for two residents were not dated, despite pharmacy labels indicating a required discard date after opening. Multiple inhalers were found opened without dates, and staff interviews confirmed that inhalers should be dated upon opening to ensure proper tracking of expiration. Additionally, a vial of Tubersol solution, labeled as house stock and requiring refrigeration, was found stored in a medication cart at room temperature rather than in a refrigerator. Staff were unsure of the delivery date and acknowledged that the solution should be refrigerated to maintain potency. Record review showed that the affected residents had physician orders for the medications in question, and facility policies required dating of opened medications and proper storage according to manufacturer and pharmacy guidelines. The facility's own policies specified that medications with shortened expiration dates after opening must be dated, and that certain biologicals, such as Tubersol, must be refrigerated whether opened or unopened. These deficiencies were identified during inspection of medication carts and rooms, and were confirmed through staff interviews and review of facility policies.
Failure to Ensure Resident Dignity and Effective Communication
Penalty
Summary
The facility failed to ensure that residents' rights to dignity, self-determination, and effective communication were upheld, as evidenced by two separate incidents involving two residents. In the first incident, a resident with multiple medical diagnoses, including schizophrenia, COPD, and malnutrition, was observed sitting at a dining table with another resident. While the other resident received his meal promptly, this resident waited for approximately nine minutes without being served, despite inquiring about his meal. Staff continued to serve other residents before eventually providing the meal, resulting in the resident watching his tablemate finish eating before he received his own tray. Facility policy and the Director of Nursing both confirmed that residents seated at the same table should be served at the same time to maintain dignity and a homelike environment. In the second incident, a resident with highly impaired hearing and absence of speech was not provided with effective and accessible means of communication. The resident's care plan indicated the need for communication aids such as cue cards and a communication board, but these were not available or accessible in the resident's room. Staff interviews revealed that none of the staff had received training in sign language, and most relied on gestures or facial expressions to communicate. The communication board was found attached to the wall and could not be detached for use, and cue cards were not present. The resident confirmed that he did not use the communication board or cue cards. Facility policies required that meals be served in a manner that respects residents' dignity and that communication aids be made available for residents with communication needs. Despite these policies and recent in-service training for staff on meal service and seating arrangements, the facility did not ensure that these standards were met for the affected residents, resulting in a failure to honor their rights to dignity and effective communication.
Failure to Apply Splints as Ordered for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to ensure that splints were applied as ordered by the physician for two residents with limited range of motion. One resident with a history of a right distal radius fracture and diagnoses including paroxysmal atrial fibrillation, osteoporosis, and osteoarthritis, was observed multiple times without the prescribed right wrist splint in place. The resident reported that staff had previously applied the splint but could not recall the last time it was used. The physician order and care plan specified that the splint should be applied daily, with removal only for bathing, sleeping, writing, or physical therapy, yet observations confirmed the splint was not in use during the review period. Another resident with left-sided hemiplegia following cerebrovascular disease and a left hand contracture was also observed multiple times without the ordered left arm/hand splint. The care plan and physician order required daily application of the splint, with removal at bedtime and for skin checks. Staff interviews confirmed awareness of the orders and the importance of splint use to prevent contractures, but the splints were not applied as directed. The facility's contracture prevention policy required contracture prevention appliances to be applied as ordered, but this was not followed for these residents.
Failure to Safely Store Smoking Materials and Monitor Residents on Independent Pass
Penalty
Summary
The facility failed to ensure that smoking materials were safely stored and not accessible to other residents, as observed with one resident who kept a cigarette on top of the bedside table in a shared room. The resident, who had a history of smoking and multiple medical diagnoses including chronic obstructive pulmonary disease and schizophrenia, stated he kept his lighter and cigarette with him, although he had lost his lighter. Staff interviews confirmed that smoking materials are not supposed to be kept by residents and should be stored securely to prevent access by others, especially those not assessed as safe to smoke or who wander. Additionally, the facility did not adequately monitor or document the whereabouts of a resident who had independent community pass privileges. The resident left the facility without signing out, and there was no documentation of when the resident left or returned. Staff were unable to provide information on the resident's departure, and there was no evidence that required procedures, such as notifying supervisors or filing a missing person report, were followed when the resident did not return as expected. The facility's policies did not clearly outline staff responsibilities for residents on short community leaves without medications, nor did they specify actions to take when residents failed to sign out or return on time. The lack of proper supervision and adherence to facility policies regarding both smoking materials and independent community passes resulted in unsafe conditions and inadequate monitoring of residents. Staff interviews revealed gaps in knowledge and inconsistent practices related to the facility's procedures for resident safety in these areas.
Failure to Provide Restorative Toileting Program for Bladder Continence
Penalty
Summary
The facility failed to provide a restorative toileting program to maintain bladder functioning for one resident who was reviewed for bowel and bladder continence. The resident had diagnoses including major depressive disorder, bipolar disorder, asthma, and seizure, and was documented as frequently incontinent on the Minimum Data Set (MDS), though another MDS assessment indicated bladder continence. During interviews, the resident reported using pullups, getting up to use the restroom as needed, and not receiving any bladder toileting restorative program. Facility staff confirmed that there was no bladder toileting restorative program in place, and that certified nursing assistants were expected to encourage the resident to use the bathroom and offer help if needed. The facility's policy required comprehensive assessment and placement into an incontinence toileting program for residents demonstrating incontinence, but this was not implemented for the resident in question.
Improper Storage of Nebulizer Equipment
Penalty
Summary
A deficiency was identified when a resident's nebulizer mask and tubing were found improperly stored inside a bedside nightstand drawer, mixed with personal items, and not dated. The resident, who had been living in the facility for over a year, was alert and oriented, and reported periodic use of nebulization treatments. Observation confirmed that the nebulizer equipment was not stored according to infection control protocols. The LPN acknowledged that the storage was improper upon inspection. Further review revealed that the facility's policy required nebulizer masks and tubing to be changed at least every three days, dated when changed, and stored in a clean, clear plastic bag to prevent contamination. The DON confirmed these requirements during an interview. The resident's medical history included chronic respiratory conditions such as malignant neoplasm of the lung and COPD, and physician orders documented regular and as-needed nebulizer treatments. Medication administration records showed the treatments were being given as ordered, but the storage and dating of the equipment did not comply with facility policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by other residents, as evidenced by three separate incidents involving multiple individuals. In the first incident, one resident with hypertension, hemiplegia, and a history of cerebral infarction was slapped in the face by another resident diagnosed with hypertension, anxiety disorder, schizophrenia, and bipolar disorder. The altercation began after a dispute over a TV remote, with the aggressor becoming agitated and physically striking the other resident. Staff and administrative interviews confirmed the physical abuse, and documentation indicated that the incident was substantiated. In a second event, a resident with extrapyramidal and movement disorder and schizophrenia was pushed and scratched by another resident with schizoaffective disorder and chronic pain. The altercation occurred in a common area after a verbal exchange escalated, resulting in one resident being pushed, falling, and sustaining a minor injury. Both residents were found to be cognitively intact, and the incident was confirmed as physical abuse through staff interviews and medical record review. The third incident involved verbal abuse, where a resident verbally threatened another following a disagreement about bathroom use. The aggressor confronted the other resident on the porch, using explicit language and making a direct threat of physical harm. Both parties acknowledged the incident, and the administrator confirmed that verbal abuse had occurred. Facility policies and residents' rights documents were referenced, outlining the definitions and expectations regarding abuse prevention, but the incidents demonstrated a failure to uphold these standards.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported to the appropriate authorities within the mandated timeframe. A resident (R5), who was cognitively intact and had diagnoses including diabetes, hypertension, restlessness, and agitation, reported that her former roommate (R6), also cognitively intact with diagnoses of bipolar disorder and schizophrenia, verbally threatened her in a confrontational manner. The incident involved R6 approaching R5 on the porch and stating, 'I'll beat your mother f*****g a**,' which R5 perceived as a vicious and unprovoked verbal assault. Following the incident, R5 reported the threat to the facility's security guard (V6), who documented the event in the Security Report and stated he informed the administrator (V1) and a nurse on the first floor. However, both the LPN (V7) and CNA (V8) working that shift denied being informed of any unusual events or allegations of verbal abuse. The administrator (V1) acknowledged receiving a call from security but did not recognize the urgency or nature of the report as verbal abuse at that time. The initial report to the state agency was not made until several days later, after V1 received the information in real time, rather than immediately as required by facility policy and regulation. Documentation confirmed that the incident was later substantiated as abuse, with both internal and external reports indicating that the verbal threat constituted verbal abuse. Facility policy requires immediate reporting of any abuse allegations to the Department of Public Health within 24 hours, but this protocol was not followed in this case, resulting in a delay in the mandated reporting process.
Failure to Protect Resident from Roommate Abuse
Penalty
Summary
The facility failed to protect a resident, R2, from abuse by her roommate, R3, resulting in R2 sustaining a broken nose. R2, an elderly resident with dementia and other health issues, was struck by R3, who has a history of aggressive behavior and mental health diagnoses. The incident was reported by a CNA who found R2 with facial injuries during breakfast. R2 indicated that she was hit by 'the little lady,' referring to R3. Another resident, R7, who shared the room with R2 and R3, reported hearing R2 scream and witnessing R3's intimidating behavior towards R2. Despite these signs, the staff failed to prevent the abuse. Interviews with staff and residents revealed that R3 had a pattern of verbal and physical aggression towards R2, which was known to some staff members. R7 reported that R3 would often yell at R2 and had expressed a wish for R2's death. The facility's Director of Nursing was unaware of R3's behavior towards R2, and the staff did not report the signs of abuse as required by the facility's abuse policy. The facility's investigation confirmed the abuse, but the failure to act on the warning signs and protect R2 from R3's aggression led to the deficiency.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R3, from physical abuse, resulting in a bruise and skin tear on R3's left arm. The incident occurred when a CNA, identified as V11, allegedly handled R3 roughly during incontinence care, causing the injury. R3, who is cognitively intact with a BIMS score of 15, reported that V11 dug her fingers into R3's arm and flipped R3 over, leading to the skin tear and bruising. R3 expressed fear and stated that V11 had been mean to R3 for some time. The incident was first noticed by another CNA, V14, who observed the injury and reported it to the LPN, V3. V3 assessed the injury and informed the DON, V2, who then conducted an investigation. During the investigation, V11 initially denied causing the injury but later acknowledged seeing the skin tear after being confronted with statements from other staff. V11 failed to report the injury to the nurse on duty, which was a violation of the facility's abuse prevention policy. The facility's administrator, V1, and the DON, V2, suspended and subsequently terminated V11 following the investigation. The incident was reported to the local police, and R3's physician was notified, who confirmed that R3 has fragile skin due to chemotherapy. The physician emphasized that staff should not use their nails to reposition residents, as it can cause injury. The facility's failure to prevent and properly report the abuse led to the deficiency being cited.
Failure to Submit Final Investigation Report to IDPH
Penalty
Summary
The facility failed to submit the final investigation of an alleged abuse incident to the Illinois Department of Public Health (IDPH) within the required five-day timeframe. This deficiency affected two residents involved in a resident-to-resident altercation. On the day of the incident, one resident reported a verbal and physical altercation with another resident, which resulted in both residents being separated immediately, and no injuries were noted. Although the initial incident was reported to IDPH on the same day, the final investigation report was not confirmed as submitted. The current administrator, who was not employed at the time of the incident, could not find any confirmation that the final report was sent, despite locating a final incident investigation report. The facility's abuse policy mandates that a complete written report of the investigation's conclusion be sent to the Department of Public Health within five working days after the occurrence.
Deficiencies in Resident Protection and Supervision
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving a Certified Nurse Assistant (CNA) identified as V9, who was reported to have hit a resident, R5, on the head. R5, who is cognitively impaired with a BIMS score of 0, was unable to provide a statement. However, another resident, R6, witnessed the incident and reported it. The facility's investigation substantiated the claim, leading to the termination of V9. R5's medical history includes conditions such as hemiplegia, schizophrenia, and dementia, which contribute to his vulnerability. In another incident, two residents, R2 and R3, engaged in a verbal and physical altercation in the patio/smoking area, resulting in injuries. R2, who has a BIMS score of 15, and R3, with a BIMS score of 13, both have cognitive impairments. The altercation began over a disagreement about cigarettes, leading to R3 striking R2 and R2 scratching R3. The facility's investigation confirmed the occurrence of the altercation, and it was noted that no staff were present during the incident, which occurred outside of the usual smoking time. The facility's abuse prevention program, dated 10/2022, outlines the commitment to protecting residents from abuse and establishing a resident-sensitive environment. However, the incidents involving R5, R2, and R3 highlight failures in staff supervision and monitoring, particularly in areas where residents are known to congregate, such as the smoking area. The lack of staff presence during the altercation between R2 and R3, and the failure to prevent the physical abuse of R5 by V9, demonstrate deficiencies in the facility's ability to ensure a safe environment for its residents.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a resident's fall from the bed to the floor, despite the resident being assessed as requiring a two-person assist for bed mobility. The incident occurred when a Certified Nursing Assistant (CNA) attempted to turn the resident alone, resulting in the resident falling face-first onto the floor. The resident, who has a history of idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, and other significant health issues, experienced increased pain and psychosocial harm from the fall. The resident expressed feelings of fear and anxiety following the incident, which were discussed with the facility's psychiatrist and Director of Nursing (DON). The resident's care plan indicated a high fall risk and required substantial/maximal assistance for bed mobility, specifically noting the need for two-person assistance. However, on the night of the incident, the CNA did not follow this protocol and attempted to turn the resident alone. The CNA admitted to not ensuring the resident was in the middle of the bed and not seeking assistance from another staff member. The bed was also not positioned against the wall, which was different from the resident's previous room setup, contributing to the fall. The facility's policies on fall prevention and personal care services were not adhered to in this case. The CNA's failure to follow the care plan and the facility's safety protocols directly led to the resident's fall and subsequent injury. The incident highlights a lapse in staff training and adherence to established safety precautions, resulting in harm to the resident and a failure to provide adequate supervision to prevent accidents.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and dating practices in the kitchen, which could potentially affect all 94 residents receiving an oral diet. During a tour of the kitchen, the surveyor observed undated bowls of apple sauce, deli meat cheese sandwiches, and a block of cheese in the walk-in cooler. Additionally, seven packages of premium sliced ham were found to be expired. The dietary manager acknowledged the importance of labeling, dating, and discarding expired foods to ensure food safety and prevent illness. In the freezer, a water bottle containing a dark liquid, identified as belonging to staff, was found, which the dietary manager admitted could contaminate food products. In the dry storage area, a container of navy beans was found to be expired. The facility's policies on food storage and labeling were not followed, as evidenced by the undated and expired food items. The dietary manager's job responsibilities include inspecting food storage areas to ensure they are maintained in a clean, safe, and sanitary manner, which was not upheld in this instance.
Failure to Ensure Call Light Devices Were Within Residents' Reach
Penalty
Summary
The facility failed to ensure that residents' call light devices were within reach, affecting four residents. On multiple occasions, residents were observed with their call light strings hanging from the wall switch and out of reach. For instance, one resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and schizophrenia, was unable to locate or reach the call light string. Another resident, who was cognitively intact but had diagnoses such as schizophrenia and dementia, also had their call light string out of reach and confirmed they could not access it when needed. Additionally, a resident with severe cognitive impairment and a history of falls was observed with their call light string hanging towards the floor and out of reach. This resident's care plan specifically mentioned the need for the call light to be within easy reach to prevent falls. Another resident, who was cognitively intact and had multiple diagnoses including pulmonary embolism and acute respiratory failure, also had their call light string positioned out of reach, despite their care plan indicating the need for assistance. The Director of Nursing confirmed that call light strings should be positioned within residents' reach, typically attached to the pillow, to ensure they can call for help when needed. The facility's policy and job descriptions also mandate that call lights must be within easy reach of residents. However, observations and interviews revealed that this was not consistently practiced, leading to the deficiency noted in the report.
Failure to Provide Psychiatric Rehabilitation Services Coordinator
Penalty
Summary
The facility failed to have a Psychiatric Rehabilitation Services Coordinator (PRSC) to meet the individualized psychosocial and mental health needs of residents. This deficiency was identified through observations, interviews, and record reviews. The facility census was reported as 96 residents, with 68 residents diagnosed with severe mental illness (SMI). Several residents were observed with flat affect and low mood, and multiple residents reported not having seen a counselor or therapist recently. The Social Services Director, who recently started working at the facility, was responsible for providing psychosocial services to all 96 residents, including those with SMI. However, the Director admitted that a therapist only comes twice a week to conduct group sessions, and no PRSC was observed interacting with residents during the survey period. The facility's policy and job description for the PRSC indicate that the role is essential for planning, developing, organizing, implementing, evaluating, and directing social service programs to meet the emotional and social needs of residents. Despite this, the facility had not hired a full-time or part-time PRSC, as confirmed by the Administrator, who stated that efforts were being made to fill these positions. The lack of a PRSC has the potential to affect all residents requiring psychosocial support, particularly those with severe mental illness, as the current staffing levels are insufficient to meet their needs.
Failure to Provide Individualized Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate person-centered and individualized psychosocial and mental health services to meet the needs of residents diagnosed with mental disorders or psychosocial adjustment difficulties. This deficiency affected five residents who were observed with flat affect and low mood, and who reported not receiving any counseling or therapeutic services. Despite being cognitively intact, these residents had not interacted with a counselor or Psychiatric Rehabilitation Services Coordinator (PRSC) recently, as required by their care plans. The facility's social services staff, specifically the Social Services Director/PRSD, was responsible for providing psychosocial services to all 96 residents, including 68 with severe mental illness (SMI). However, the PRSD admitted to being overwhelmed and unable to meet the individualized needs of all residents. The facility had advertised for additional PRSC positions but had not yet filled them. Observations and interviews with nursing staff confirmed the lack of PRSC presence and interaction with residents on the nursing units. The care plans for the affected residents detailed specific psychosocial and mental health interventions that were not being implemented. For example, one resident with schizophrenia was supposed to receive encouragement to verbalize thoughts and feelings and learn stress management techniques. Another resident with major depressive disorder and anxiety was to be encouraged to verbalize feelings. The facility's policies and job descriptions outlined the responsibilities of the PRSC, which included providing assessments, group interventions, and one-on-one support, but these services were not being adequately provided.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure that the air-conditioner in a resident's room was working, failed to repair a broken wall heat vent cover, and failed to clean and cover the air-conditioner air filter in residents' rooms. These deficiencies were observed on the third floor and had the potential to affect seven residents. Specifically, in one room, the wall heat vent cover was hanging and almost falling off, and the window shades were torn and worn out. In another room, a resident complained about the heat, and the air-conditioner was observed blowing warm air with a non-functional on/off button. Additionally, in four other rooms, the air-conditioner air filters were found without vent covers and had a thick layer of accumulated dust. The maintenance staff was notified of these issues, but the maintenance log did not show that staff had reported the problems or that maintenance staff was in the process of repairing them. The facility's job description for the Director of Maintenance outlines the responsibility to ensure that the facility is maintained in a safe and comfortable manner, which was not followed in this instance. The deficiencies were identified through observation, interview, and record review, highlighting a failure to maintain a safe and comfortable environment for the residents.
Failure to Document Resident's Code Status in EMR
Penalty
Summary
The facility failed to ensure that a resident's code status was documented under the physician's order in the electronic medical record (EMR). This deficiency affected one resident (R11) who had multiple diagnoses including paranoid schizophrenia, epilepsy, essential hypertension, asthma, type 2 diabetes, and chronic obstructive pulmonary disease. Despite being cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14, R11's code status was not entered into the physician's order sheet upon admission. The code status was only documented after the surveyor requested the resident's advance directives orders, indicating a lapse in the facility's protocol for documenting code status upon admission. Interviews with the Social Service Director (V16) and the Director of Nursing (V2) revealed that the admitting nurse is responsible for entering the resident's code status order upon admission. Both V16 and V2 acknowledged the importance of having a code status order to ensure the resident's wishes are honored and to provide appropriate care. The facility's policy dated 01/01/17 also mandates that all residents be provided with information on advance directives upon admission and be treated as full code if no advance directive is provided. However, in this case, the policy was not followed, resulting in the deficiency noted by the surveyor.
Failure to Maintain a Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe and functional environment for two residents who were cognitively intact and had various medical diagnoses, including schizophrenia, essential hypertension, and major depression. One resident's privacy curtain was observed to be soiled with a brown stool-like substance, and the resident expressed a desire for it to be cleaned. Despite the housekeeping supervisor's statement that privacy curtains should be inspected and cleaned daily, the curtain remained soiled upon re-inspection the following day. The housekeeping supervisor acknowledged the importance of clean privacy curtains to prevent smells, germs, and to maintain a clean environment. Another resident's room was observed to be missing a window screen, which allowed flies to enter the room. The resident confirmed that the window had never had a screen and expressed a desire for one. The maintenance director, responsible for checking and maintaining window screens, was unaware of how long the screen had been missing and stated that window screens are important to prevent flies and mosquitoes from entering the facility. Despite this, the window remained without a screen upon re-inspection the following day.
Failure to Assist Resident with Shaving
Penalty
Summary
The facility failed to ensure that residents receive assistance with shaving facial hair, affecting one resident (R12) who was reviewed for personal hygiene and care. R12, who has diagnoses including inflammatory polyneuropathy, age-related osteoporosis, essential hypertension, and hyperlipidemia, was observed with facial hair and reported that she was supposed to be shaved the previous day but did not receive assistance. R12 expressed discomfort due to the facial hair and indicated that she could shave herself if provided with a razor, although the facility typically performed the shaving for her. A CNA confirmed that she usually shaves R12 on weekends but was off during the past weekend, leading to the missed shaving. The CNA acknowledged that R12 could likely shave herself with minimal assistance. The Director of Nursing stated that facial hair on residents should be cut as it could be irritating and undesirable. R12's care plan indicated that she requires partial/moderate assistance with personal hygiene, including shaving, and should be provided with training to promote her highest level of independent performance. The facility's policy on personal care services mandates that each resident's hair should be kept clean, neat, and well-groomed.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident (R1) from physical abuse by another resident (R2). R2, who had a history of physical, verbal, and sexually inappropriate behavior, physically assaulted R1, causing multiple injuries. The facility did not have preventative measures in place for R2, nor did they update R1's care plan to address potential abuse before and after the incident. This lack of action led to R2 physically assaulting R1, resulting in multiple bruises and scratches on R1's body. R2 had a documented history of aggressive behavior, including incidents of physical, verbal, and sexually inappropriate actions towards both staff and residents. Despite this, R2's care plan did not address these behaviors, and there were no psychiatric or medical notes documenting any interventions. R2's progress notes detailed multiple incidents of aggression and inappropriate behavior, yet the facility failed to implement measures to ensure the safety of other residents. The facility's abuse prevention policy required staff to identify residents with increased vulnerability to abuse and to incorporate security measures into the care plans of identified offenders. However, the facility did not follow these procedures for R2. Additionally, the Social Service Director admitted to being unaware of the need to care plan for abuse incidents and the guidelines for protecting victims from perpetrators. This lack of knowledge and failure to follow established protocols contributed to the deficiency in protecting residents from abuse.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to have an effective pest control program and did not monitor and log pest issues related to the presence of cockroaches in the kitchen. This deficiency was identified through observations, interviews, and review of records. A resident reported finding a cockroach in her tray, and during an inspection of the kitchen, two traps containing cockroaches were found under the three-sink compartment and the deep freezer. Pest control reports from March and April 2024 documented the presence of German roaches in the main kitchen area, including equipment, stoves, and preparation tables. Despite these reports, the Maintenance Director (V3) stated that there were no complaints of pests since February 2024 and admitted that there was no documentation of staff reporting pest problems in the kitchen. The facility's policy for pest control, which was not dated, requires routine checks and monitoring by maintenance and housekeeping staff, with a log maintained of pest issues. However, this policy was not effectively implemented, as evidenced by the ongoing presence of cockroaches and the lack of documentation. The Maintenance Director acknowledged the need to call pest control again due to the persistent problem but was unable to provide pest monitoring logs. This failure to maintain an effective pest control program has the potential to affect all 98 residents' food preparation and consumption due to the presence of cockroaches in the kitchen.
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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