Generations At Applewood
Inspection history, citations, penalties and survey trends for this long-term care facility in Matteson, Illinois.
- Location
- 21020 Kostner Avenue, Matteson, Illinois 60443
- CMS Provider Number
- 145781
- Inspections on file
- 41
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Generations At Applewood during CMS and state inspections, most recent first.
The facility failed to keep call lights accessible to several residents, contrary to its policy requiring functioning call lights to be within residents’ reach. One resident returning from dialysis was left in a reclining chair and had to shout for help because the call light cord was wedged behind the bed and a floor mat. Other residents lying in bed or seated in wheelchairs either had call light cords dangling from a wheelchair or positioned behind a wheelchair, and each reported not knowing where the call light was. In each case, the call light was not within easy reach of the resident.
A high fall-risk resident with impaired balance, intermittent confusion, and a history of recent falls was found on the floor near the bathroom after sliding while walking in regular socks instead of non-skid socks. The resident’s care plans documented the need for supervised transfers and fall prevention interventions, yet the resident was unsupervised for several hours and not using appropriate footwear. Staff reported the resident was not able to walk and typically self-transferred to a wheelchair and then to the toilet, but the positioning of the wheelchair and bedside table, along with lack of supervision and non-adherence to universal fall precautions outlined in the facility’s fall prevention policy, contributed to the fall and resulting leg injury.
A resident’s assigned call light was found wedged behind the head of the bed between the wall and a folded floor mat, leaving it inaccessible while the resident sat in a reclining chair needing assistance. When the DON provided the resident with this call light and asked the resident to press the button, the hallway light above the door did not activate on two attempts. When the resident was given the call light from the other bed in the room, that call light functioned properly and activated the hallway light. Facility policy required that a functioning call light be placed where it is accessible to the resident, but this was not done for this resident.
Two residents at risk for pressure injury developed multiple facility-acquired pressure ulcers, including a Stage 4 heel ulcer and unstageable coccyx/sacral and ischial wounds, after staff failed to consistently identify, document, and report early skin changes. One resident developed a new rear thigh pressure ulcer that was measured but not staged or fully described, and no physician treatment order or treatment documentation was found for this wound during the stay. For the other resident, staff reported performing weekly head-to-toe skin assessments and CNA skin checks during care, but there were no shower sheets or assessment records showing early skin alterations before the advanced pressure injuries were discovered. The DON acknowledged lapses in reporting by CNAs, and the wound care coordinator confirmed the absence of prior skin alteration documentation, while facility policies required daily/weekly skin checks, Braden risk assessments, prompt wound staging and description, and physician-ordered treatments for all pressure ulcers.
A resident with Multiple Sclerosis and muscle wasting, who was alert and able to communicate needs, fell inside a facility transport vehicle when the CNA driver braked, resulting in a right intertrochanteric femur fracture. The CNA reported that the wheelchair was locked and a seatbelt applied, and that the resident slid to the floor and initially denied pain before being assisted back into the wheelchair and taken to her room. The resident later reported that the wheelchair had not been strapped or properly secured, no seatbelt was used, and that both she and the wheelchair moved and tipped during the abrupt stop, with the chair striking her head. After arrival back at the facility, the CNA transferred the resident to bed despite her complaint of right leg pain, and only then was an RN notified and an assessment performed, which revealed right leg shortening, external rotation, and swelling. This sequence of events shows a failure to ensure proper securement during transport and to follow the facility’s fall management guideline requiring assessment before moving a resident after a fall.
The facility did not report allegations of abuse, neglect, or injuries of unknown origin to the State Survey Agency within the required two-hour timeframe for several residents. Incidents included family and staff reports of bruising, rough care by CNAs, inappropriate touching by a staff member, and a medication error. Although internal investigations were initiated, the mandated reporting deadlines were not met, contrary to the facility's abuse prevention policy.
Four residents identified as at risk for abuse did not have person-centered care plans developed or implemented, despite completed abuse risk assessments indicating care planning was required. Staff interviews revealed confusion over responsibility for initiating these care plans, and documentation was not present in the residents' medical records.
Three residents with pressure ulcers or high risk for skin breakdown did not receive appropriate prevention or treatment interventions. One resident developed a stage 4 knee ulcer without timely treatment or care plan updates, another was on an air mattress set incorrectly for their weight, and a third did not receive a recommended low air loss mattress. Staff interviews and documentation revealed gaps in following pressure ulcer prevention protocols.
A resident admitted on escitalopram for major depressive disorder did not have a documented attempt at gradual dose reduction (GDR) or a clinical contraindication for not attempting GDR, as required by facility policy. The DON confirmed the absence of GDR documentation in the medical record, despite policies mandating GDR attempts for residents on psychotropic medications.
A resident with urinary retention and an indwelling catheter did not have a care plan addressing catheter care, despite observations confirming catheter use and facility policy requiring comprehensive care planning. The ADON confirmed the absence of documentation or interventions related to the catheter.
A resident with hemiplegia and urinary incontinence did not receive timely incontinence care, resulting in prolonged exposure to wet and soiled bedding. The resident reported not being changed since early morning, and staff confirmed delays due to lack of assistance and busy schedules. The DON acknowledged the absence of a formal incontinence policy and stated that care should be provided every two hours or as needed.
A dependent, severely cognitively impaired resident with multiple complex medical conditions developed a large stool ball and was hospitalized for fecal impaction. Facility staff did not consistently monitor or document bowel movements or symptoms of impaction, despite the resident's inability to communicate and a care plan requiring such monitoring. Changes in the resident's condition were noted, but assessment and documentation were lacking.
The facility did not follow physician orders for urinary catheter care for two residents with indwelling catheters. One resident had multiple missed or undocumented catheter care shifts despite an order for care every shift, and also experienced recurrent UTIs with multidrug-resistant organisms. Another resident had a Foley catheter in place but lacked any physician orders for catheter care, size, or changes. Facility policy requires such orders and their implementation, but these were not met.
A resident who sustained a left femur fracture during a transfer did not receive timely follow-up with an orthopedic surgeon due to the facility's failure to arrange appointments, address insurance barriers, and document communication or transportation to appointments.
A resident with a physician order for double meat at lunch was served only one piece of meat, despite both the order sheet and diet card specifying the need for a double portion. The resident, who was alert and oriented, confirmed the discrepancy, and the dietary manager acknowledged that the therapeutic diet order was not followed.
A resident who suffered a left femur fracture during a transfer did not receive the ordered OT and PT services to address pain, mobility, and ADL limitations. Although therapy evaluations and plans of care were completed, no skilled therapy was provided due to issues with insurance authorization, and no further attempts were documented after an insurance change.
A resident was found with a soiled, discolored, and lifting midline IV dressing that had not been changed within the facility's required 5-7 day interval. Staff interviews revealed uncertainty about responsibility and policy adherence, and the dressing was not dated. The facility's policy requires dressings to be changed at specific intervals or when soiled, but this was not followed.
A resident with multiple risk factors for pressure ulcers did not receive timely or documented pressure ulcer prevention and care interventions, including delays in providing a low air loss mattress, missed and undocumented dressing changes, and incomplete daily skin assessments. The sacral wound was not properly identified or documented upon return from the hospital, and the wound progressed to a stage 4 ulcer with infection due to these lapses.
The facility did not follow its controlled substance policy, resulting in multiple instances where hydrocodone doses were signed out for two residents but not documented as administered on the MAR. Despite physician orders for as-needed pain management, the required documentation was missing, and one resident reported not requesting the medication as frequently as recorded. The DON confirmed that controlled substances should be documented after administration, highlighting a lapse in accurate recordkeeping.
A resident with significant weakness and mobility issues fell from bed during incontinence care when a CNA turned away, leaving the resident near the edge. The resident required partial to moderate assistance and was identified as a fall risk, but was not adequately supervised or positioned safely, leading to the fall.
A resident developed a stage 4 pressure ulcer on the sacrum due to the facility's failure to provide adequate care and prevention. Despite having a history of pressure ulcers and orders for weekly skin assessments, the resident's condition worsened without timely intervention. Observations showed the resident was left unchanged and without proper wound dressing, and there was a lack of communication and follow-up by the wound care team, leading to hospitalization for infection treatment and surgical debridement.
Two residents under enhanced barrier precautions were affected by staff's failure to use proper PPE and adhere to hand hygiene protocols. A resident received wound care without staff wearing gowns or performing hand hygiene between glove changes, while another resident received incontinence care without staff wearing gowns. The facility's policies on hand hygiene and enhanced barrier precautions were not followed.
A facility failed to provide adequate hygiene care for a dependent resident with severe cognitive impairment. The resident was found with long, jagged fingernails and actively bleeding scratch marks, indicating a lack of proper grooming. A CNA noted that nails are cut during scheduled showers, but the resident's tendency to scratch herself led to frequent changes of her sheets. The facility's policy requires necessary services to maintain good grooming and hygiene for residents unable to perform activities of daily living independently.
Two residents in a LTC facility did not receive prescribed medications and topical treatments due to unavailability. One resident with severe cognitive impairment and skin conditions missed multiple applications of creams, while another resident with multiple diagnoses missed doses of oral and topical medications. The facility's failure to reorder and ensure medication availability led to these deficiencies.
A resident with severe cognitive impairment and multiple medical conditions received inadequate incontinence care from two CNAs, who failed to spread the resident's legs for proper cleaning, reused the same washcloth, and did not change gloves or perform hand hygiene. The DON expected staff to follow proper procedures to prevent infection, as outlined in the facility's policy.
A resident with significant medical conditions, including a right above-knee amputation, was improperly transferred without a mechanical lift, resulting in a fracture. Despite the resident's request for the lift, a CNA proceeded with a manual transfer, assisted by another CNA unfamiliar with the resident's needs. The facility's policy requiring mechanical lifts for such transfers was not followed, leading to the resident's injury.
The facility failed to provide necessary admissions paperwork, including notice of rights and responsibilities, to three residents upon admission. The admissions packets lacked signatures and dates verifying receipt and agreement. The Admissions Director did not document all attempts to complete the packets, and in some cases, packets were not returned or signed by family members. The facility's policy requires that residents receive an admission agreement at the time of admission, but this was not consistently followed.
The facility failed to implement effective fall prevention measures for three residents, leading to multiple falls and one resident being hospitalized with a femoral fracture. Despite being identified as high fall risks, necessary interventions such as bilateral floor mats and low bed positions were inconsistently applied, contrary to the residents' care plans and the facility's fall prevention policy.
A resident with chronic health conditions did not receive anti-embolism stockings as ordered by the physician, leading to observed swelling in the lower extremities. The RN admitted difficulty in applying the stockings due to the resident's mobility, and the DON acknowledged the need to follow physician orders. The facility's policy on elastic stockings was not adhered to.
A resident with a history of CVA and limited range of motion was not provided with a prescribed hand splint and sling, as per physician orders and care plan interventions. The resident was observed without the splint, and the restorative nurse was unaware of the order, indicating a failure to follow the facility's policy on restorative programming and splint assistance.
The facility failed to serve coffee at a safe temperature, leading to a resident sustaining burns. Another resident rolled out of bed during a linen change due to inadequate supervision, resulting in multiple injuries. Additionally, the facility did not develop adequate fall prevention interventions for a resident with a history of falls and severe cognitive deficits.
The facility failed to provide adequate feeding assistance for two residents with visual deficits, leading to significant unplanned weight loss. One resident lost 8.99% of her weight in one month, while another lost 10.6% over four months. Despite care plans indicating the need for feeding assistance, staff did not regularly provide the necessary support.
The facility failed to follow their hot beverage policy by serving coffee at 145 degrees Fahrenheit and not logging temperatures, resulting in a resident with multiple sclerosis and Alzheimer's disease suffering full-thickness burns after spilling hot coffee on her lap.
The facility failed to notify the family and hospice in a timely manner of a fall incident involving a resident with Dementia and other conditions. The resident was found on the floor in a praying position, and the facility's policy mandates notification of any change in the resident's condition or status.
The facility failed to follow their abuse policy by not investigating or determining how a resident's injury of unknown origin occurred. A resident was found with a bruise on her hand, and despite the policy requiring immediate reporting and investigation, no action was taken.
The facility failed to supervise an impulsive, confused resident with an unsteady gait, resulting in the resident getting into bed with another resident, causing distress. Despite known aggressive behaviors and the need for constant observation, the resident was not adequately monitored, leading to the incident.
Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to follow its call light policy requiring a functioning call light to be placed where it is accessible to the resident, resulting in multiple residents not having call lights within reach. During observation on 2/13/26 at 9:45 AM, one resident was heard shouting for help from his room and reported being uncomfortable in a reclining chair after returning from dialysis at 5:00 AM and wanting to go back to bed; his call light cord was found by the DON wedged between the wall and a folded floor mat behind the head of the bed, and he stated he could not find it. Later that morning, another resident lying in bed had a call light cord observed dangling on a wheelchair positioned at the side of the bed and stated not knowing where the call light was. A third resident sitting in a wheelchair next to her bed had a call light cord located behind the wheelchair and not within reach, and also stated not knowing where the call light was. A fourth resident sitting in a wheelchair next to her roommate’s bed similarly stated she did not know where her call light cord was, and her call light was observed not to be within reach. These observations and resident interviews showed that four residents did not have accessible call lights as required by the facility’s policy. The deficiency centers on the inaccessibility of call light cords for these residents, as evidenced by their inability to locate or reach the call lights when they needed assistance, and the physical placement of the cords behind furniture or on equipment rather than within the residents’ immediate reach.
Failure to Implement Fall Prevention Measures and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify, evaluate, and eliminate fall hazards and to provide adequate supervision for a high fall-risk resident. The resident was found lying on his right side on the floor near the bathroom, wearing regular socks instead of non-skid socks. His wheelchair was positioned at the head of the bed with the bedside table in front of it, and he reported that he slid while walking to the bathroom because of the socks he was wearing. A nurse responded to the surveyor’s call for assistance, obtained vital signs, and performed a head-to-toe assessment, identifying an open area on the resident’s right lateral lower leg. Multiple CNAs stated that the resident was not able to walk and that his usual pattern was to self-transfer to his wheelchair, self-propel into the bathroom, and then self-transfer onto the toilet. Record review showed that the resident’s admission fall risk assessment documented a history of falls in the past three months, intermittent confusion, chairbound status, and incontinence. The falls care plan identified the resident as high risk for falls related to gait and balance problems, with interventions including anticipating and meeting his needs. The ADL care plan documented an ADL self-care performance deficit related to impaired balance and specified that transfers required supervision by one staff member to move between surfaces. Despite these identified risks and care plan interventions, the resident was not wearing appropriate non-skid socks and did not receive the supervision required for transfers, as his assigned CNA reported last rounding on him several hours earlier. The facility’s fall prevention and management policy called for universal fall precautions, standardized assessment of fall risk factors, and implementation of a fall risk care plan to address universal precautions and individual risk factors, which were not effectively implemented in this case.
Inaccessible and Nonfunctional Call Light for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident’s bathroom and bedside call light system in good working condition and accessible to the resident. During observation, the resident was seated in a reclining chair next to the bed closest to the door, and the call light cord for that bed was found between the wall and a folded floor mat behind the head of the bed, out of the resident’s reach. When asked if he could use the call light for assistance, the resident stated he could not find it. The DON was called to the room and located the call light cord behind the head of the bed, then handed the call light button to the resident. When the resident pressed the call light button, the hallway light above the door did not activate, and a second attempt also failed. The resident was then given the call light cord from the other bed in the room, and pressing that button successfully activated the hallway light. The facility’s call light policy, reviewed 06/2024, states that a functioning call light will be placed where it is accessible to the resident, but in this instance the resident’s assigned call light was both inaccessible and nonfunctional.
Failure to Prevent and Treat Facility-Acquired Pressure Injuries in At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent facility-acquired pressure injuries in residents at risk and to initiate appropriate wound treatment once new pressure ulcers were identified. One resident was admitted with multiple wounds and was assessed as being at moderate risk for pressure ulcers using the Braden Scale, with a score of 13. During the stay, this resident developed a new pressure ulcer on the rear left thigh that was documented with measurements but without staging or descriptive details of the wound. The wound nurse later confirmed that the documentation lacked staging and other required descriptors and, based on a photograph, would have staged the wound as unstageable. For this same resident, review of the Treatment Administration Record and Physician Order Sheet with the wound nurse showed that there was no treatment order for the newly acquired rear left thigh pressure ulcer from the date it was first documented until the resident’s discharge. The wound nurse confirmed the absence of any treatment order, and the wound physician stated that it is important to have treatment for a wound as soon as it is identified, although he suggested that lack of an order did not necessarily mean no treatment was given. The facility’s own policies require that residents with pressure ulcers have a physician’s order for treatment, that wounds be described and documented weekly, and that licensed nurses document treatment on the Treatment Administration Record. A second resident, admitted with intact skin and assessed as at risk for pressure injury with Braden scores of 17 on two separate assessments, developed three facility-acquired pressure injuries: a right heel wound initially documented as a diabetic ulcer and later classified as a Stage 4 pressure injury, an unstageable coccyx/sacrum pressure injury, and an unstageable rear left thigh (ischial) pressure injury described as a deep tissue injury. The wound care coordinator stated that CNAs are expected to check skin during care and report changes to nurses, who then refer to the wound care team, but confirmed there was no documentation of skin alterations prior to the identification of these pressure injuries. The wound physician’s notes documented the right heel as a Stage 4 pressure injury with nonviable tissue and necrosis, and the sacrum and left ischium wounds as unstageable due to necrosis or deep tissue injury. Nursing staff reported that weekly head-to-toe skin assessments are performed, often during bathing or changing, and that any redness or skin changes should be promptly reported and documented for the wound care team to provide treatment orders. However, documentation review revealed no shower sheets or assessment records indicating that the second resident’s skin was assessed during showers or care before the wounds were discovered. The DON acknowledged a lapse in reporting skin conditions, stating that CNAs may have assumed nurses were already aware of the wounds and did not notify the wound care team, and agreed that a Stage 4 pressure ulcer could not develop overnight and that earlier signs should have been reported. Facility policies require daily skin checks, weekly documented skin checks, timely risk assessments, individualized care plans, and immediate treatment orders and wound descriptions for residents with pressure ulcers, but these processes were not followed for the residents involved, leading to the development and progression of multiple facility-acquired pressure injuries without timely identification and treatment. The record for the second resident also showed that the right heel pressure injury became infected, with a wound culture positive for ESBL and subsequent IV antibiotic treatments ordered and administered for the infected heel wound. Despite nurse interviews describing routine and thorough skin assessments and prompt reporting expectations, there was no supporting documentation of early skin changes or interventions prior to the development of the Stage 4 and unstageable pressure injuries. The facility’s documented failures included not preventing facility-acquired pressure injuries in residents identified as at risk, not staging and fully describing a newly acquired pressure ulcer, not obtaining or documenting physician treatment orders for a new pressure ulcer, and not documenting or acting on early skin alterations as required by the facility’s pressure ulcer prevention and treatment policies.
Failure to Secure Resident During Transport and Inadequate Post-Fall Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly secured while being transported in the facility’s private vehicle and to follow post-fall assessment procedures before moving the resident. The resident had diagnoses including Multiple Sclerosis and muscle wasting and atrophy, was alert and oriented with a BIMS score of 13, and was able to make her needs known. During transport back from a medical appointment, the CNA driver reported that the resident’s wheelchair was locked in place with a seatbelt secured, and that when the CNA applied the brakes at a red light, the resident slid out of the wheelchair onto the floor of the vehicle, landing on her buttocks. The CNA stated the resident denied pain at that time, was assisted back into the wheelchair, and then transported back into the facility. Upon return to the facility, the resident reported right leg pain. The CNA assisted the resident to bed and notified a nurse of the incident and the complaint of pain. The nurse assessed the resident and observed external rotation and shortening of the right lower extremity, as well as swelling from the right hip to the right thigh. The nurse practitioner’s note documented that the resident reported slipping out of her wheelchair and hitting her head, denied headache, but complained of right hip pain, with the right hip appearing shortened and externally rotated and pain elicited with abduction and adduction. Hospital records later indicated the resident sustained a right intertrochanteric femur fracture requiring surgical repair with intramedullary nailing of the right proximal femur. The resident’s account of the incident conflicted with the CNA’s description of safety measures during transport. The resident stated that the CNA abruptly pressed the brake, causing her to fall forward to the vehicle floor, and reported that her wheelchair was not strapped or properly secured and that no seatbelt was applied. She stated she was sure the wheelchair was not secured because as she fell forward, the wheelchair also moved, tipped over, and hit her on the head. The facility’s Clinical Guideline for Falls Management requires that, prior to moving a resident after a fall, staff assess for injury, perform a pain assessment and physical assessment, and activate emergency response as required, particularly for potential head injury. The Director of Nursing stated that the expectation and facility policy for fall incidents is to report the fall and not move the resident without assessment, especially if the resident is complaining of pain. Despite this, after the fall in the vehicle and the resident’s subsequent complaint of pain, the CNA moved and transferred the resident back to bed before a nurse assessment, contributing to the identified deficiency in accident prevention and post-fall response.
Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse prevention policy by not notifying the State Survey Agency within the required two-hour timeframe after becoming aware of allegations of abuse, neglect, or injury of unknown origin for six residents. In multiple instances, staff became aware of allegations or observations of potential abuse, such as bruising, rough care, inappropriate touching, and medication errors, but the initial reports to the State Survey Agency were delayed, ranging from over two to more than forty-eight hours after the incidents were known. Documentation and interviews confirmed that staff recognized these events as reportable and initiated internal investigations, but did not meet the mandated reporting timeframe. Specific cases included family members and staff reporting bruising, allegations of rough handling by CNAs, inappropriate contact by a staff member, and a medication error. In each case, the facility's own records and staff interviews confirmed the time the allegation was known and the time the report was sent, showing delays beyond the policy requirement. The facility's abuse prevention policy, revised in October 2022, requires immediate reporting, but not more than two hours after the allegation is known, which was not followed in these cases.
Failure to Develop Abuse Risk Care Plans for At-Risk Residents
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents identified as at risk for abuse. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for initiating and updating abuse risk care plans. The social services director stated that social services is responsible for care plans related to behaviors, mood, and cognitive status, but not for abuse risk care plans, and was unaware of who should complete them. The interim DON indicated that nurses are responsible for nursing-related care plans and believed social services should initiate abuse risk care plans, while the social service assistant reported that abuse risk assessments are completed but not followed by specific abuse care plans, with documentation instead placed under other care plan categories. Record review showed that each of the four residents had completed abuse risk assessments indicating they were at risk for abuse or neglect and that care planning was required. The assessments cited reasons such as physical and mental dependence, impaired mobility, lack of safety awareness, non-verbal communication deficits, and cognitive fluctuations. Despite these findings and the explicit notation that care planning was required, none of the residents had an at risk for abuse care plan initiated in their medical records.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to develop and implement adequate pressure ulcer prevention interventions for three residents with significant risk factors and existing pressure ulcers. For one resident with multiple comorbidities including Alzheimer's Disease, chronic kidney disease, and diabetes, a stage 4 pressure ulcer developed on the left knee while in the facility. Despite documentation of the wound as early as March, there was no treatment ordered or documented for the knee until over a month later, and the care plan did not address the knee ulcer or include specific interventions for the knees. Staff interviews revealed a lack of awareness regarding avoidable/unavoidable risk assessments for pressure ulcers, and documentation of prevention measures was incomplete or missing. Another resident with stage 3 and stage 4 pressure ulcers and functional quadriplegia was found on an air loss mattress set at a weight far above their actual weight, contrary to facility policy and staff training, which requires mattress settings to match the resident's weight for effective pressure ulcer prevention. A third resident, who had a wound doctor’s recommendation and family request for a low air loss mattress, was observed on a regular mattress instead of the prescribed pressure-relieving mattress. Facility policy states that such recommendations must be followed, but this was not done, and the resident did not receive the recommended intervention.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving a psychotropic medication, specifically escitalopram 10mg daily for major depressive disorder, had a documented attempt at gradual dose reduction (GDR) or a clinical contraindication for not attempting GDR. The resident was admitted on this medication and transferred from another LTC facility, with continued use of the same dosage. Upon review, the DON confirmed there was no documentation in the resident's medical record indicating that a GDR had been attempted for the escitalopram. Facility policy requires that residents on psychotropic drugs receive GDRs and behavioral interventions, with attempts at GDR in two separate quarters within the first year of admission on such medications.
Failure to Develop and Implement Urinary Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who was admitted with a diagnosis of urinary retention and required an indwelling urinary catheter. During the survey, the resident was observed with a urinary catheter in place on multiple occasions, but a review of the resident's care plan revealed no documentation or interventions related to catheter care. The Assistant Director of Nursing confirmed that there was no care plan addressing the urinary catheter and was unable to explain the omission. Facility policy requires a comprehensive, person-centered care plan with measurable objectives and timeframes, including interventions for areas of potential risk, but this was not followed for the resident in question.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with diagnoses of obesity, hemiplegia, and hemiparesis following a cerebral infarction, who was assessed as cognitively intact and always incontinent, did not receive timely incontinence care. On the day in question, the resident was observed with the call light on, reporting that she was wet and had not received incontinence care since 4:00am. The resident's bed sheets were visibly soiled with urine, and there was a strong odor of urine present. The resident expressed feeling bad about not being provided care. The assigned CNA confirmed that she had not provided incontinence care to the resident until late in her shift, citing the need for assistance and staff being busy as reasons for the delay. Both the CNA and another staff member observed that the resident's brief and bed sheets were saturated with urine. The DON stated that the facility did not have an incontinence policy but expected residents to be checked and changed every two hours or as needed.
Failure to Prevent and Monitor Fecal Impaction in Dependent Resident
Penalty
Summary
The facility failed to prevent a dependent resident from developing a large stool ball, resulting in hospitalization for fecal impaction. The resident had multiple diagnoses, including respiratory failure, tracheostomy status, anemia, seizures, hemiplegia, metabolic encephalopathy, and aphasia, and was identified as severely cognitively impaired and dependent on staff for all care. The resident was also frequently incontinent of bowels. Hospital records indicated the presence of a large stool ball in the rectum with mass effect on the bladder, requiring an enema. Facility staff noted changes in the resident's condition, including copious drainage from a sacral wound, increased pitting edema, decreased alertness, and lack of usual responsiveness. Interviews with facility staff revealed that symptoms of impaction, such as decreased bowel movements, discomfort, pressure, or bloating, were not effectively assessed or documented for this resident, who was unable to communicate. The care plan included monitoring and documenting signs of constipation or fecal impaction, but there was no evidence that this was consistently done. The nurse practitioner confirmed that the facility would not have known about the impaction unless daily tracking of bowel movements was performed, which was not documented in this case.
Failure to Provide and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to follow physician orders for providing urinary catheter care every shift for residents with indwelling catheters, as well as failed to obtain and document a diagnosis in the physician's orders for an indwelling catheter. For one resident with a chronic indwelling catheter, there were multiple documented instances across several months where catheter care was not recorded as provided on various shifts. This resident had a history of urinary tract infections, including infections with multidrug-resistant organisms, and received antibiotic treatments as a result. The treatment administration record showed numerous days and shifts with missing documentation of catheter care, despite an active physician order for care every shift. Another resident was admitted with a Foley catheter in place, but there were no physician orders documented regarding catheter care, catheter size, or catheter changes. Facility staff confirmed that such orders should have been present but were unable to locate them. Facility policies require that all medications and treatments, including catheter care, be ordered by a physician and implemented by staff, but these requirements were not met for the residents reviewed.
Failure to Arrange and Document Follow-Up Orthopedic Care
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident in scheduling and attending follow-up appointments with an orthopedic surgeon after the resident sustained a fractured left femur during a transfer from bed to wheelchair. The resident reported wearing a knee immobilizer since the fall and stated that no follow-up appointment with an orthopedic surgeon was made. Documentation in the medical record indicated attempts to schedule an appointment were hindered by the resident's insurance not being accepted by local orthopedic offices. The facility staff noted efforts to contact the local county Health Systems and to schedule a primary care provider appointment to obtain a referral, but there was no documentation confirming that referrals were sent or that the resident was transported to scheduled appointments. Further, the facility was unable to provide documentation of communication with the resident's insurance provider, attempts to schedule appointments, or records confirming that the resident was seen by an orthopedic surgeon. The lack of documentation and follow-through on arranging necessary medical appointments and transportation resulted in the resident not receiving timely follow-up care after a significant injury.
Failure to Provide Physician-Ordered Double Meat Portion at Lunch
Penalty
Summary
The facility failed to follow a physician's prescribed diet order for a resident who required double portions of meat at lunch. The resident's physician order sheet and diet card both specified a regular texture, thin diet with double meat at lunch. However, during observation at lunchtime, the resident was served only one piece of meat instead of the ordered double portion. The resident, who was alert and oriented, confirmed receiving only one piece of meat. The dietary manager later verified that a double portion should have consisted of two pieces of meat and acknowledged that therapeutic diet orders must be followed. The facility's policy also states that therapeutic diets are to be prescribed by the attending physician.
Failure to Provide Ordered Skilled Therapy After Resident Fracture
Penalty
Summary
A resident sustained a left femur fracture after falling during a transfer from bed to wheelchair. Following the fall, the resident experienced significant pain and required a left knee immobilizer. Physician orders were written for both occupational therapy (OT) and physical therapy (PT) evaluations and treatments, specifying the frequency and duration of therapy sessions to address the resident's pain, mobility limitations, and activities of daily living (ADL) needs. The OT and PT plans of care outlined the necessity for skilled therapy to improve the resident's independence, manage pain, and reduce fall risk. Despite these orders and documented clinical needs, there was no evidence in the medical record that the resident received any OT or PT services after the initial evaluations. The rehabilitation director confirmed that therapy had not been provided, citing difficulties in obtaining insurance authorization and a change in the resident's insurance provider. No attempts to secure authorization from the new insurance were documented, resulting in the resident not receiving the required skilled rehabilitative services.
Failure to Timely Change Soiled Central Venous Catheter Dressing
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy regarding the timely changing of a central venous catheter dressing for one resident. The resident was observed with a soiled, discolored, and lifting dressing on a midline IV site, and was unsure how long it had been in place or the cause of the discoloration. Staff interviews revealed confusion about responsibility and policy for dressing changes, with the Infection Preventionist needing to check the policy and the Director of Nursing stating that dressings should be changed weekly or when soiled or not intact. Record review showed the midline was inserted 12 days prior, exceeding the facility's policy of changing dressings every 5 to 7 days or as needed if soiled, wet, or not intact. The dressing was not dated, and staff could not explain why it had not been changed as required. The facility's policy, dated 10/25/14, specifies that central venous catheter dressings must be changed at specific intervals or when soiled, wet, or not intact to prevent infection, but this was not followed for the resident in question.
Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement and document appropriate pressure ulcer prevention and care interventions for a resident with multiple risk factors and existing wounds. Upon the resident's return from the hospital, there was no documentation of a sacral wound during the initial evaluation, and staff were unable to specify when or under what condition the sacral wound was first identified. The wound care team, including the Wound Care Coordinator, Wound Care Technician, and Wound Care Physician, could not recall or provide documentation regarding the initial discovery or staging of the sacral wound. Additionally, there was a lack of timely notification and documentation to ensure that appropriate interventions were initiated promptly. The resident, who had diagnoses including stage 3 pressure ulcer of the right hip, deep tissue injury to the foot, dysphagia, failure to thrive, heart failure, and COPD, was at high risk for pressure ulcers as indicated by a Braden Scale score of 11. The care plan and physician orders required the use of a low air loss mattress, daily skin checks, and specific wound dressing changes. However, after hospice services were revoked and the hospice-provided air mattress was removed, there was a delay in ordering and providing a replacement low air loss mattress. Documentation shows the mattress was not ordered until several days after the resident's return, and staff were unaware of the resident's hospice status change for about a week. There were multiple missed and undocumented dressing changes and daily skin assessments as ordered. The Treatment Administration Record (TAR) showed gaps in documentation for both wound care and skin checks, with several days where required interventions were not recorded as completed. The sacral wound progressed from an unstageable or early-stage wound to a stage 4 pressure ulcer with necrosis and infection, as documented by the wound care physician. The facility's own policy required daily or at least weekly skin checks and prompt documentation and intervention for new skin alterations, which were not consistently followed in this case.
Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to follow its controlled substance policy and ensure that hydrocodone 5-325 mg was properly documented and accounted for in the cases of two residents. For both residents, the control drug receipt/record/disposition forms indicated that hydrocodone doses were signed out on multiple dates and times. However, a review of the Medication Administration Records (MAR) for the same periods showed no documentation that these doses were actually administered. The physician orders for both residents specified hydrocodone/APAP to be given as needed for pain, with one resident having orders for different dosages based on pain severity. During interviews, the Director of Nursing confirmed that controlled substances should be signed out on the MAR after administration, in accordance with facility policy, which requires accurate accountability of all controlled drugs at all times. One resident stated that her pain medication was as needed and that she did not request or take the medication multiple times during the month in question. The discrepancies between the control drug records and the MARs, along with the lack of resident requests for medication, demonstrate a failure to maintain accurate records and accountability for controlled substances as required by facility policy.
Resident Falls from Bed During Incontinence Care
Penalty
Summary
The facility failed to ensure the safety of a resident during incontinence care, resulting in the resident falling out of bed. The resident, who has a history of heart failure, end-stage renal disease, weakness, lack of coordination, and muscle wasting, was being attended to by a CNA. During the care, the CNA turned away to grab a new pad, leaving the resident near the edge of the bed. The resident, who was weak and unable to maintain balance, rolled out of the bed and fell to the floor. Interviews and records indicate that the resident required partial to moderate assistance with bed mobility due to significant weakness and deconditioning. The CNA acknowledged that the resident was positioned too close to the edge of the bed and that they were unable to reposition the resident to the center of the bed due to the resident's size. The CNA admitted to taking their eyes off the resident, which contributed to the fall. The incident was documented in the nursing notes and fall report, and the resident was subsequently taken to the emergency department for evaluation. Although no injuries were noted, the incident highlights a failure in providing adequate supervision and safe positioning during care. The facility's assessments and care plans identified the resident as a fall risk, yet the necessary precautions were not effectively implemented during the incident.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in the development of a stage 4 pressure ulcer on the sacrum, which required hospitalization for infection treatment and surgical debridement. The resident, a female with a history of multiple medical conditions including existing pressure ulcers, was admitted to the facility with orders for weekly skin assessments. However, these assessments were not documented, and the resident's condition worsened without timely intervention. Observations revealed that the resident was left unchanged and without proper wound dressing for extended periods, contributing to the deterioration of her condition. The resident reported feeling wet and not being changed, and staff confirmed that her incontinence brief was stained with wound drainage. Despite the presence of a wound care team, there was a lack of communication and follow-up, leading to the resident's sacral wound being left uncovered and untreated for significant periods. The facility's pressure injury prevention protocol and skin assessment policy were not adhered to, as evidenced by the lack of documented weekly skin checks and the failure to identify and address the resident's worsening condition promptly. The wound care team was unaware of the sacral wound until it had significantly progressed, highlighting a gap in communication and protocol adherence that contributed to the resident's severe pressure ulcer and subsequent hospitalization.
Inadequate PPE Use and Hand Hygiene in Infection Control
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and adherence to hand hygiene protocols, affecting two residents under enhanced barrier precautions. A female resident with a history of local skin infection, pressure ulcers, and other medical conditions was observed receiving wound care without the staff wearing gowns or performing hand hygiene between glove changes. The LPN involved admitted to not noticing the enhanced barrier precaution sign and was unaware of the requirement to perform hand hygiene between glove changes, as per her previous training. Additionally, a male resident with a history of acute and chronic respiratory failure and other medical conditions was observed receiving incontinence care without the staff wearing gowns, despite the enhanced barrier precaution sign on the door. The staff involved were unsure of the last time the resident was changed and did not adhere to the facility's policy requiring gown use during high-contact care activities. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, as staff failed to perform hand hygiene before and after care and did not wear gowns during high-contact activities. The Director of Nursing acknowledged the expectations for hand hygiene and PPE use but did not intervene during the surveyor's presence.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to ensure proper hygiene care for a dependent resident, identified as R2, who was unable to perform activities of daily living independently. R2 was admitted with multiple diagnoses, including severe cognitive impairment, and was dependent on staff for all care. During an observation, R2 was found in bed with wet and bloody sheets, and actively bleeding scratch marks on her hips, buttocks, and thighs. R2's fingernails were long, jagged, and had debris underneath, indicating a lack of proper grooming. A CNA stated that nails are typically cut during scheduled showers, but R2's tendency to scratch herself led to frequent changes of her sheets during incontinence care. The facility's policy mandates that residents unable to perform activities of daily living independently should receive necessary services to maintain good grooming and hygiene, which was not adhered to in this case.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident received prescribed oral medication and topical creams, resulting in deficiencies for two of the three residents reviewed. One resident, identified as R2, was admitted with multiple diagnoses including dysphagia, thrombocytopenia, and severe cognitive impairment, and was dependent on staff for care. Observations revealed that R2 had extremely dry, flaking skin with areas actively bleeding due to scratching. Despite having physician orders for Ammonium Lactate, Cetaphil, and Triamcinolone creams to manage her skin conditions, R2 missed numerous applications due to the unavailability of these medications. Progress notes indicated that the creams were often on order or awaiting delivery, and the Director of Nursing confirmed the absence of these medications in the facility. Another resident, R1, with diagnoses including hemiplegia, Type 2 Diabetes, and major depressive disorder, also experienced medication administration issues. R1's prescribed medications included Venlafaxine, Metformin, Lotrimin AF cream, and Nystatin powder. The eMAR showed that R1 missed several doses of Venlafaxine and other topical treatments due to unavailability. Progress notes corroborated these findings, indicating that medications were not on the cart or unavailable for administration on multiple occasions. The facility's policy on the administration of drugs, revised in May 2017, states that medications should be administered as prescribed by the attending physician. However, the failure to reorder and ensure the availability of medications led to missed doses and incomplete treatment for both residents. The Director of Nursing expressed expectations for timely reordering and communication with the pharmacy, but these procedures were not effectively followed, contributing to the deficiencies observed.
Inadequate Incontinence Care Leading to Cross-Contamination
Penalty
Summary
The facility failed to provide incontinence care in a manner that prevents cross-contamination for one resident with severe cognitive impairment and multiple medical conditions, including dysphagia, thrombocytopenia, and chronic kidney disease. During an observation, two CNAs were providing incontinence care to the resident. The CNAs did not spread the resident's legs to properly clean the perineal area and used the same washcloth multiple times without changing gloves or performing hand hygiene. The washcloth was left between the resident's legs, and stool was observed on the washcloth after cleaning the buttocks. The Director of Nursing (DON) stated that staff should have all necessary supplies and follow proper procedures to clean, rinse, and dry the resident to prevent infection and skin conditions. The facility's policy requires using a clean surface of the washcloth for each wipe, rinsing if necessary, and drying the resident with a clean towel. The CNAs did not adhere to these guidelines, as they did not change gloves or wash their hands during the care process.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to perform a safe transfer for a resident (R2) who was dependent on staff for transfers, resulting in an acute mildly displaced fracture of the distal femoral diaphysis on the resident's left leg. On the day of the incident, R2 was being transferred to a dialysis chair by a CNA without the use of a mechanical lift, despite R2's request for it. The CNA, V9, stated there was no time to retrieve the mechanical lift and proceeded with a manual transfer with the help of another CNA, V10, who was unfamiliar with R2's transfer needs. During the transfer, R2 slid down and had an assisted fall, leading to the injury. R2's medical history includes conditions such as Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 5 Chronic Kidney Disease, Peripheral Vascular Disease, and a Right Above the Knee Amputation. R2 was dependent on renal dialysis and had been assessed as requiring a mechanical lift for transfers since July 2024. The facility's records indicated that R2 was non-weight bearing and required a full body mechanical lift for transfers. Despite this, the staff did not use the mechanical lift, and R2 was transferred manually, which was against the facility's policy and R2's care plan. The incident occurred because the staff did not follow the established procedure for transferring R2, which required the use of a mechanical lift. The CNAs involved in the transfer did not ensure the availability of a lift pad, and V9 admitted to having transferred R2 without a mechanical lift in the past. The facility's policy required that if a lift pad was not available, staff should notify the on-call person, but this was not done. The failure to adhere to the transfer protocol and the lack of communication among staff members contributed to the unsafe transfer and subsequent injury to R2.
Removal Plan
- Inservices for safer transfers began at the facility.
- Competency by return demonstration of safe transfer training.
- Safe transfer audits are being completed.
- QA meeting held with administrator, DON, and medical director to discuss improvement plan.
- Interviews with staff regarding transfer status knowledge.
- DON said there was 90% staff training completed on initial inservicing. There were 4 CNAs left to train. They are PRN (as needed) staff.
- The CNA who performed the improper transfer had not returned to work because she refused to come to the facility for training.
Failure to Provide Admission Paperwork to Residents
Penalty
Summary
The facility failed to ensure that residents received necessary admissions paperwork, including notice of rights, rules, and responsibilities, either prior to or upon admission. This deficiency was identified in three out of four residents reviewed for residents' rights. Specifically, the admissions packets for these residents were missing signatures and dates that would verify receipt and agreement to the information contained within. The residents involved included a male with a history of quadriplegia and other serious health conditions, a female with multiple sclerosis and dementia, and a male with Down syndrome and epilepsy, all of whom were admitted to the facility at different times. Interviews and record reviews revealed that the Admissions Director had not documented all attempts to complete and upload the admissions packets to the electronic health record. In one case, a family member was uncomfortable completing the packet electronically, and a hard copy was provided but never returned. Another resident's packet was initiated but not given to the family member for signing. The facility's Admission Agreement Policy requires that residents or their representatives receive an admission agreement at the time of admission, outlining services covered and any additional services requested. However, this process was not consistently followed, leading to the deficiency.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective interventions to reduce the risk of falls for three residents, resulting in one resident being hospitalized with a femoral fracture. Resident R80, identified as a high fall risk, was observed with only one floor mat instead of the required two. Despite multiple falls and injuries, including a femur fracture, interventions were inconsistently applied or absent. The resident's care plan indicated a need for bilateral floor mats and a low bed position, but these measures were not consistently in place. Resident R69, also at high risk for falls, was found in a precarious position in bed without the necessary floor mats on both sides and the bed not in the lowest position. The staff acknowledged the need for these interventions, yet they were not consistently implemented. The resident's care plan highlighted the necessity of these precautions due to cognitive and physical impairments, but observations showed lapses in adherence to the plan. Similarly, Resident R58 was observed with only one floor mat and the bed not in the lowest position, contrary to the fall prevention plan. The resident's care plan required bilateral floor mats and a low bed position due to a high risk of falls from various health conditions. Despite the facility's fall prevention policy, these safety measures were not consistently applied, indicating a systemic issue in implementing fall prevention strategies.
Failure to Apply Anti-Embolism Stockings as Ordered
Penalty
Summary
The facility failed to apply anti-embolism (TED) elastic stockings to a resident, identified as R73, as ordered by the physician. This deficiency was observed during a survey when R73 was seen sitting in a wheelchair with swollen bilateral ankles. R73, who is alert and oriented, reported that staff elevate her legs when she is in bed but do not apply the anti-embolic stockings. She was unaware of the need to wear these stockings during the day and remove them at bedtime, as per the physician's orders. The Registered Nurse (RN), identified as V14, acknowledged the physician's order for the stockings to be applied every morning and removed at bedtime but admitted to not applying them because R73 is often up and about, making it difficult to catch her in bed. The Director of Nursing (DON), identified as V2, was informed of the observation and confirmed that treatments should be implemented as ordered by the physician. R73 was readmitted with multiple diagnoses, including chronic diastolic congestive heart failure and chronic kidney disease, and had an active physician order for anti-embolism stockings. The facility's policy on elastic stockings, revised in May 2017, outlines the procedure for applying them, which was not followed in this case.
Failure to Implement Splint Program for Resident with Limited ROM
Penalty
Summary
The facility failed to follow physician orders and implement care plan interventions for a resident with limited range of motion due to a history of cerebrovascular accident (CVA). The resident, identified as R86, was observed without a hand splint despite having a physician's order for a left-hand splint and sling to be used when up in a chair. The care plan also indicated the need for these devices to prevent contractures. However, the resident was not on the splint program, and the restorative nurse, V21, was unaware of the order for the splint and sling. This oversight was noted during an observation and interview with the registered nurse, V14, who confirmed the resident's contractures and flaccid left arm. The resident's medical records revealed a lack of a restorative assessment upon readmission, with the most recent assessment indicating no risk for contractures and no use of a splint. The facility's policy on restorative programming requires assessments upon admission and with any significant change in condition, but this was not adhered to in R86's case. The restorative nurse, V21, later assessed the resident and found severe joint mobility issues, indicating the resident would benefit from the splint. The facility's policy on splint/brace assistance outlines the need for a scheduled program of applying and removing splints, which was not followed, leading to the deficiency.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure that coffee was served at a safe temperature below 140-degrees Fahrenheit, leading to a resident spilling hot coffee on herself and sustaining full thickness burns to her thighs. The resident, who had severe cognitive impairment and a history of impulsive behaviors, was given hot coffee by an activity aide who did not wait for the coffee to cool down. Despite the resident's known behaviors of throwing items when upset, the staff did not take adequate precautions to prevent the incident, resulting in significant injuries to the resident's thighs. Another deficiency involved a resident who rolled out of bed while a CNA was changing the bed linens. The resident, who required partial assistance for bed mobility and had a bed support safety rail on only one side of the bed, was not properly positioned or supervised during the linen change. The CNA did not ensure that the resident grabbed the bed support safety rail before proceeding, leading to the resident falling and sustaining a laceration to the left eyebrow, a subarachnoid hemorrhage, and a nondisplaced patella fracture. The facility also failed to develop adequate fall prevention interventions for a resident with a history of falls, severe cognitive deficits, dementia, and restless agitation. The resident had multiple incidents of attempting to get out of bed or a chair, resulting in falls. Despite these behaviors, the facility did not implement sufficient monitoring or environmental modifications to prevent further falls, leading to the resident being found on the floor on multiple occasions.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance for residents with visual deficits, leading to significant unplanned weight loss for two residents. One resident, diagnosed with dementia, was observed struggling to feed herself without assistance, resulting in an 8.99% weight loss in one month. Despite the resident's care plan indicating the need for 1:1 feeding assistance, staff only provided setup assistance and did not intervene until prompted by the surveyor. The resident's weight had been steadily declining over the past six months, with the lowest weight recorded being 79 pounds in May 2024. Another resident, diagnosed with dementia, glaucoma, intraocular lens, and multiple sclerosis, also experienced significant weight loss, losing 10.6% of her body weight over four months. This resident was observed attempting to feed herself with a spoon held backward and expressed difficulty in feeding herself. Despite her care plan indicating the need for assistance due to visual impairment and impaired coordination, staff did not regularly provide the necessary feeding assistance. The resident's weight had been declining each month, with a dietary note indicating that her oral intake was insufficient for weight maintenance. The facility's weight maintenance policy requires monitoring and investigating significant or trending weight changes, but these protocols were not adequately followed for the two residents. The policy outlines steps to determine the cause, plan of action, and notify the physician and responsible party, but these measures were not effectively implemented, resulting in the residents' unplanned weight loss and inadequate nutritional support.
Failure to Follow Hot Beverage Policy Results in Resident Burns
Penalty
Summary
The facility failed to follow their hot beverage policy by not ensuring coffee was below 140 degrees Fahrenheit and not logging coffee temperatures prior to each service. This deficiency was observed when coffee temperatures were measured at 145 degrees Fahrenheit in the common dining area. The Dietary Manager confirmed that coffee should be served at a temperature between 130-140 degrees Fahrenheit and acknowledged that temperatures were checked weekly but not logged. This failure affected a resident who had multiple sclerosis, Alzheimer's disease with late onset, major depressive disorder, and anxiety, and who had severe cognitive impairment as indicated by a mental status score of 5/15 on the Minimum Data Set. The incident occurred when the resident requested coffee from an activity aide, who served it without allowing it to cool down. The resident spilled the hot coffee on her lap, resulting in full-thickness burns on her thighs. The wound doctor documented significant burn injuries, including fluid-filled blisters. The facility's hot beverage policy required that all hot beverages be served at a safe temperature and that temperatures be logged prior to each meal service, but these procedures were not followed, leading to the resident's injury.
Failure to Notify Family and Hospice of Resident's Fall
Penalty
Summary
The facility failed to follow their change in condition policy by not notifying the family (responsible party) and hospice in a timely manner of a fall incident involving a resident diagnosed with Dementia with behavior disturbance, general anxiety disorder, restlessness, and agitation. The hospice referral paperwork required notification of falls or injuries. On the specified date, the resident was found on the floor in a praying position after attempting to get out of bed. The Assistant Director of Nurses (ADON) confirmed that the family was not notified because they were out of town, and the Hospice Director confirmed that hospice was not notified of the incident. The facility's policy mandates notification of the resident, attending physician, and representative of any change in the resident's condition or status.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow their abuse policy by not investigating or determining how an injury of unknown origin occurred for one of the residents. The incident involved a resident (R2) who was found with a bruise on the back of her right hand. The hospice nurse inquired about the bruise with a new staff nurse (V36), who denied any knowledge of a fall or injury. Despite the facility's policy requiring immediate reporting and investigation of such injuries, no notification or investigation was initiated for R2's bruise. The Director of Nurses (V2) confirmed that the administrator should have been notified and an investigation should have been started, but this did not happen. V36, who was on orientation, was informed to report any bruising or marking on a resident to the administrator. The facility's abuse policy mandates that any suspicious bruises or injuries of unknown origin be reported immediately and documented on a facility incident report. However, this protocol was not followed in the case of R2, resulting in a failure to investigate the cause of the injury.
Failure to Supervise Impulsive Resident
Penalty
Summary
The facility failed to supervise an impulsive, confused resident (R2) with an unsteady gait, resulting in R2 getting into bed with another resident (R1). This incident caused R1 to scream, cry, and feel nervous. R1 was found gripping a butter knife but was not aiming it towards R2. R1's diagnoses include Dementia, Anxiety, Adjustment Disorder with Mixed Anxiety, Weakness, History of Transient Ischemic Attack, and Osteoporosis. R2's diagnoses include Diabetes Mellitus, Heart Failure, Vascular Dementia, and Major Depressive Disorder. Staff interviews revealed that R2 had a history of aggressive behavior, including hitting staff and other residents, and required frequent monitoring and redirection, especially during the evening when her behaviors worsened. On the night of the incident, a CNA heard yelling and found R2 on top of R1 in R1's bed. R1 was calling for help and was visibly upset. Staff noted that R2 had a behavior of crawling on the floor and was often verbally and physically aggressive. Despite these known behaviors, R2 was not adequately supervised, leading to the incident. The Director of Nursing and Social Service Director were not aware of the extent of R2's aggressive behaviors or the issues between R1 and R2, indicating a lack of communication and proper documentation within the facility. R2's care plan documented her need for constant or near-constant observation due to her impulsive behaviors and lack of safety awareness. However, this level of supervision was not provided, as evidenced by the incident. R1's care plan noted her impaired vision and cognitive decline, making her particularly vulnerable. The failure to provide adequate supervision and address the known behavioral issues of R2 directly led to the distressing event for R1.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
