Generations Oakton Pavillion
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Plaines, Illinois.
- Location
- 1660 Oakton Place, Des Plaines, Illinois 60018
- CMS Provider Number
- 145626
- Inspections on file
- 41
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Generations Oakton Pavillion during CMS and state inspections, most recent first.
A resident with a trach and ventilator dependence was observed using a visibly dirty ventilator circuit and a filter labeled with a change date more than 30 days prior, contrary to the facility’s Respiratory Care Equipment and Supplies policy. The resident and spouse reported that the vent circuit had not been changed monthly, and the RT confirmed the circuit and filters were due for 30-day changes but had delayed replacement until the start of the next month. The DON acknowledged that the vent circuit and filter should be changed per the policy, which requires ventilator circuits and air intake filters to be cleaned and replaced every 30 days.
A facility experienced a complete power loss when its emergency generator failed to activate, leaving all areas without electricity, including ventilators, tube feeding pumps, and other critical equipment. Fourteen ventilator-dependent residents were affected, and emergency (red) outlets remained without power until a portable generator was connected hours later. Maintenance records lacked evidence of required weekly inspections and monthly load-bank testing for the generator in the months before the outage. Nursing and respiratory staff did not initiate manual ventilation (ambu-bagging) as required by the facility’s Emergency Operations Plan, and an RN on duty reported not performing specialized respiratory interventions and focusing on only one ventilated patient. Two nurses on the ventilator unit did not know where backup ventilator batteries were stored, and the RN’s personnel file lacked documented competency in ventilator management and emergency respiratory procedures.
During a facility‑wide power outage when the emergency generator failed, ventilators and other electrical medical devices lost power for several hours, and the facility did not effectively implement its emergency plan requiring manual ventilation and continuous assessment of ventilator‑dependent residents. A resident with chronic respiratory failure and COPD, dependent on full mechanical ventilation via tracheostomy, had no documented respiratory assessments, ventilator checks, or clinical monitoring during the outage, and there was no evidence that manual ventilation was initiated when emergency outlets were found to be nonfunctional. Staffing consisted of one RT and two nurses for numerous ventilator and tracheostomy patients; one RN working a prolonged double shift reported performing minimal checks, not monitoring other residents due to limited staff, and not documenting care because of lack of computer power. The resident was later admitted to the hospital with an elevated lactic acid level and subsequently expired there with chronic respiratory failure and COPD listed as causes of death.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
A resident with necrotizing fasciitis and other comorbidities did not receive prescribed negative pressure wound therapy after independently removing the device and requesting assistance from multiple staff members. Despite repeated requests, staff failed to ensure the wound care nurse was notified or provided care, resulting in the resident waiting several hours without treatment and ultimately calling 911 for hospital transfer. Documentation confirmed no wound care was provided that day, and the resident presented to the hospital with a large, untreated wound.
A resident dependent on tube feeding was hospitalized due to dehydration after the facility failed to implement a registered dietitian's recommendation to increase fluid intake. The recommendation was not communicated effectively due to a transition in the electronic health record system, resulting in the resident receiving insufficient fluids and experiencing severe dehydration and related complications.
The facility failed to maintain cleanliness in the rooms and medical equipment of residents dependent on staff for care, as observed in four cases. Issues included visible dust and substances on oxygen machines, feeding tube monitors, and furniture. The Director of Nursing and Registered Nurse confirmed these observations, highlighting a collaborative effort needed for cleanliness. A staff shortage in housekeeping was noted, impacting daily cleaning routines.
The facility failed to follow physician orders for daily feeding tube site care for four residents dependent on enteral nutrition. Observations revealed undressed sites, outdated dressings, and improper documentation, indicating non-compliance with the facility's policy for daily gastrostomy tube care.
A resident with multiple diagnoses, including dementia and difficulty walking, was improperly transferred by a CNA, resulting in a neck fracture. The resident was wearing slippers instead of non-skid socks, and a gait belt was not used despite the care plan's requirements. The DON confirmed the need for a gait belt and appropriate footwear during transfers.
The facility failed to provide timely and appropriate catheter care for two residents, resulting in one resident's hospitalization for a severe UTI and sepsis. The facility did not obtain urine specimens promptly, failed to document catheter output, and neglected necessary catheter care. These deficiencies were compounded by incomplete documentation and inadequate response to residents' symptoms, such as altered mental status and poor appetite.
A resident with multiple sclerosis and other conditions was not provided a recliner wheelchair after hospice services ended, despite expressing a desire to get out of bed. The facility's staff, including a CNA and RN, were unaware of the resident's lack of a wheelchair, which was contrary to the facility's policy of meeting residents' needs.
A high-risk resident fell from an unlocked wheelchair in an unsupervised dining room, sustaining facial injuries requiring hospital evaluation. The resident, with a history of dementia and other conditions, was left unsupervised after an activity aide failed to lock both wheelchair wheels. Staff interviews revealed inadequate training on wheelchair use and supervision, contributing to the incident.
A facility failed to follow physician orders for transmission-based precautions for a resident with multiple infections. Despite clear signage, a CNA entered the resident's room without PPE or hand hygiene, misunderstanding the necessity of these precautions. The RN and Infection Prevention Nurse confirmed the requirement for PPE to prevent infection spread, highlighting a deficiency in infection control practices.
The facility failed to protect a resident from abuse, resulting in another resident punching him in the face, causing injuries. The incident occurred when a CNA found the injured resident bleeding and reported it to the nurse. The aggressor admitted to the act, and both residents were transferred to the hospital. The facility's investigation confirmed the abuse, and the aggressor was discharged.
A high-risk resident fell from a wheelchair at the nurse's station due to inadequate supervision, resulting in a laceration that required hospital evaluation and sutures. Despite being identified as a high fall risk, the resident was left unsupervised, leading to the incident.
Failure to Follow 30-Day Ventilator Circuit and Filter Change Policy
Penalty
Summary
Failure to provide safe and appropriate respiratory care occurred when the facility did not follow its Respiratory Care Equipment and Supplies policy for changing ventilator circuits and filters. A male resident with intact cognition, admitted with tracheostomy, ventilator dependence, and neuromuscular dysfunction of the bladder, was observed in bed with a ventilator/tracheostomy setup and cough assistance, using a visibly dirty ventilator circuit and a filter labeled with a change date of 2/20. During observation, the resident and his spouse reported that the facility was not changing the ventilator circuit every month and stated that the last change was on February 20th, which they believed was overdue. The respiratory therapist acknowledged that the resident’s ventilator circuit and filters were due to be changed every 30 days per policy and admitted waiting until the first of the next month instead of following the 30‑day schedule. The DON also confirmed that the ventilator circuit and filter should be changed according to the facility’s policy, which specifies that ventilator circuits and air intake filters must be cleaned and replaced every 30 days, indicating that this schedule was not followed for this resident.
Generator Failure and Inadequate Emergency Response for Ventilator-Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency generator functioned during a widespread power outage and to document required weekly and monthly testing of the generator. On the evening of 09/20/25, the primary utility power failed, and the facility’s emergency generator did not engage as designed. The Administrator reported arriving to find the building dark, with the Maintenance Director already on-site attempting to troubleshoot the generator and having contacted the generator contractor. The Administrator stated that the root cause, as relayed by the generator service company, was that condensation in the gasoline tank may have caused water and gas to mix, which then burned out the generator wiring that activates the unit. Review of maintenance records revealed no evidence of weekly generator inspections or monthly load-bank testing for the three months preceding the outage. During the outage, all areas of the facility lost electrical power, including power to mechanical ventilators, tube feeding pumps, air mattresses, mechanical lifts, and other electrically powered equipment. Fourteen ventilator-dependent residents were affected when the emergency generator failed to provide power to life-sustaining devices. The Maintenance Director confirmed that emergency outlets (red plugs) remained without power until a portable generator was obtained and connected at 12:41 AM the following morning. Staff attempted to plug ventilators and other equipment into the red emergency outlets, but nursing staff reported that there was no power to those outlets and that the unit was in total darkness. Nursing and respiratory staff actions during the outage did not follow the facility’s Emergency Operations Plan. The plan states that if a ventilator battery does not continue operating or power is lost, manual ventilation (Ambu-bagging) must be initiated immediately, and that nursing and respiratory staff will ensure medical equipment is energized via red emergency outlets and will continually or continuously assess residents. One RN reported working a double shift and remaining on duty into the early morning hours, stating that he did not initiate manual ventilation or conduct specialized respiratory monitoring for ventilator patients, explaining that he “didn’t do anything to the ventilator patient, it’s not my thing,” and that he focused primarily on one ventilated resident and did not monitor other residents. Another nurse confirmed that manual ventilation was not performed for any of the 14 ventilator-dependent residents during the outage and that she had to call the respiratory therapist when she noticed the ventilators were dark, after which she brought oxygen cylinders to several patients. Staff also demonstrated a lack of knowledge regarding backup ventilator batteries. Two nurses working on the ventilator floor stated they did not know where backup batteries for the ventilators were stored in case of power failure. Personnel file review showed that the RN who was on duty during the outage lacked documented competency evaluation for ventilator management or emergency respiratory procedures such as Ambu-bagging. The combination of the generator’s failure to activate, the absence of documented generator testing, the lack of power to emergency outlets, and the failure of nursing and respiratory staff to implement the facility’s emergency procedures for ventilator-dependent residents led to the cited deficiency and was determined to constitute Immediate Jeopardy to resident health and safety.
Removal Plan
- The facility has an emergency policy and procedure system in place on what to do if the facility's electrical system is affected.
- The emergency policy and procedure affecting the facility's electrical system is reviewed upon hire during orientation and educated on annually.
Failure to Provide Respiratory Monitoring and Care During Power Outage
Penalty
Summary
The deficiency involves the facility’s failure to provide specialized respiratory care and continuous clinical monitoring to ventilator‑dependent residents during a total facility power loss. An area‑wide electrical outage occurred, the facility’s emergency generator failed to activate, and all electrical power to the ventilator unit and other medical devices was lost for approximately 3 hours and 15 minutes. During this time, the facility’s Emergency Operations Plan for loss of electrical power, which required initiation of manual ventilation with Ambu‑bags and continuous assessment of residents by nursing and respiratory staff, was not effectively implemented. All ventilator‑dependent residents were ultimately evacuated to the hospital to maintain their health and safety. One resident, identified as having chronic respiratory failure and COPD and requiring full mechanical ventilation via tracheostomy, had no documented respiratory assessments, ventilator checks, or clinical monitoring in the EHR from the afternoon prior to the outage through shortly after midnight, encompassing the period of the power failure. The respiratory therapist on duty at the start of the outage did not document any respiratory assessments or monitoring for this resident, and the facility could not provide documentation that manual ventilation was initiated once staff realized the red emergency outlets were nonfunctional. Hospital admission records for this resident showed an elevated lactic acid level, which the report notes can be a marker of tissue hypoxia and metabolic stress during respiratory compromise. Staff interviews revealed additional gaps in care and monitoring during the outage. There was one respiratory therapist on site for 14 ventilator‑dependent and 6 tracheostomy residents, and the ventilator unit was staffed with two nurses and two aides. One RN reported working a double shift exceeding 14 hours and stated that he did not perform interventions on ventilator patients beyond checking if a resident was breathing or in distress, did not monitor other residents due to limited staffing, and did not document his actions because the computers had no power. Another nurse reported that the outage began around 9:00–9:30 PM, that ventilator power cords were moved to emergency outlets, and that oxygen cylinders were brought to some patients, but there was no documented evidence that the required manual ventilation and continuous respiratory assessments were carried out for the ventilator‑dependent residents during the generator failure.
Removal Plan
- Updated emergency power outage plan.
- Updated staffing plan for emergencies.
- Updated command list for key personnel outlining responsibilities of responsible individuals.
- Created plan to monitor and track maintenance of life maintaining equipment.
- Created QA tool to monitor compliance.
- Reviewed and updated staffing plan.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Provide Timely Wound Care Following Physician Orders
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders for wound care for a resident with necrotizing fasciitis, sepsis, type II diabetes, polyneuropathy, and anxiety disorder. The resident was cognitively intact and had a physician order for negative pressure wound therapy (NPWT) to be applied to the right foot on specific days and as needed. On the day of the incident, the resident independently removed the NPWT device after showering and wrapped her foot in a towel due to a strong odor. She repeatedly requested assistance from various staff members, including a CNA, nurse, social service director, and front desk staff, to have the wound care nurse attend to her wound, but her requests were not acted upon or communicated effectively to the wound care nurse. Multiple staff members, including the CNA, nurse, social service director, and front desk staff, either assumed the wound care nurse would see the resident during rounds or did not follow up after initial attempts to contact the wound care nurse. The wound care nurse reported not receiving any requests or reports about the resident needing wound care after her initial morning encounter. The facility's protocol required staff to call the wound care nurse directly if a resident requested wound care, but this was not done. Documentation for the day showed no record of wound care being provided, and the only progress note indicated the resident was non-compliant with prescribed wound care, had removed her wound vac, and was upset, eventually insisting on hospital transfer. The resident waited approximately five hours without receiving wound care, ultimately calling 911 herself and being transported to the hospital. Upon EMS arrival, the resident and her husband reported that she had been requesting wound care and pain management for several hours without response. EMS documented a large, deep, weeping wound on the right foot, and hospital records confirmed the resident presented with pain, erythema, and exposed tendon, with no wound care provided that day. The facility's grievance and policy documents further confirmed the lack of adherence to physician orders and wound care protocols.
Failure to Ensure Adequate Hydration for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on tube feeding for nutrition, received the recommended amount of fluids. This deficiency was identified for a resident who was hospitalized with dehydration, high blood sodium, and hypotension. The resident, a male with a complex medical history including brain damage, epilepsy, and acute kidney failure, was admitted to the facility and was receiving enteral nutrition via a feeding tube. The care plan for the resident included interventions for potential impaired nutrition and required the registered dietitian to assess fluid needs and report any signs of dehydration. The registered dietitian recommended an increase in the resident's enteral flush from 30ml to 200ml every four hours to provide adequate hydration. However, the facility continued to administer only 30ml flushes as per the existing physician order, which was not updated to reflect the dietitian's recommendation. The resident's progress notes did not document any communication with the physician regarding the recommended increase in fluids, and the resident was subsequently hospitalized with severe dehydration and related complications. The Director of Nursing reported that the registered dietitian's recommendation was not communicated effectively due to a transition in the electronic health record system. The recommendation was entered into an inactive system and was not transferred to the active system, resulting in the facility being unaware of the need to increase the resident's fluid intake. The failure to communicate and implement the dietitian's recommendation led to the resident not receiving the necessary amount of fluids, contributing to his hospitalization.
Facility Fails to Maintain Cleanliness in Resident Rooms and Equipment
Penalty
Summary
The facility failed to adhere to its housekeeping policy and procedure, resulting in unclean and unsanitary conditions in the rooms and medical equipment of residents who are entirely dependent on staff for care. This deficiency was observed in four residents, each with significant medical needs, including brain damage, epilepsy, pressure ulcers, and feeding tube use. The observations revealed multiple instances of visible dust, particles, and substances on medical equipment such as oxygen machines and feeding tube monitors, as well as on furniture and other surfaces within the residents' rooms. For one resident, the oxygen machine and respiratory equipment were found with visible dust, and a brown substance was observed on the feeding tube monitor and pole. Uncovered syringes were also noted on the dresser, and the refrigerator had visible dust and residue. Another resident's room had similar issues, with dust on the oxygen machine and respiratory equipment, stained mats, and uncovered syringes. The resident's care plan indicated complete dependence on enteral feeding due to conditions like dementia and renal disease. The facility's Director of Nursing and Registered Nurse confirmed the observations and acknowledged the responsibility of nursing and respiratory staff in maintaining the cleanliness of medical equipment. The Housekeeping Supervisor noted that housekeeping staff are responsible for cleaning the rooms daily, but a staff shortage due to illness had impacted this routine. Despite the collaborative effort required to maintain cleanliness, the deficiency persisted, affecting the residents' environment and potentially their care.
Failure to Follow Feeding Tube Care Protocols
Penalty
Summary
The facility failed to adhere to its policy and procedures for feeding tube care by not following physician orders for daily cleansing and dressing of feeding tube sites for residents dependent on enteral nutrition. This deficiency was observed in four residents, each with significant medical histories requiring enteral feeding. The facility's policy mandates daily gastrostomy tube care, which was not consistently performed, as evidenced by missing documentation and observations of improper site care. One resident, a male with a history of brain damage, epilepsy, and other severe conditions, was found with a feeding tube site that lacked a dressing and had a noticeable scab. The registered nurse acknowledged that the site should have been cleaned and dressed nightly, as per the physician's orders. Another resident, a female with partial paralysis and dysphagia, had a feeding tube site with an outdated dressing and visible staining, indicating that the site had not been properly cleaned and redressed as required. Additional observations included a female resident with Alzheimer's disease and dysphagia, whose feeding tube site was found without a dressing and with old drainage. The licensed practical nurse confirmed that the site should have been dressed nightly. Similarly, another female resident with a history of stroke and dysphagia had a feeding tube site with an undated dressing and signs of crust and dry drainage. The Director of Nursing confirmed that the night shift was responsible for changing the dressings, and missing entries in the Treatment Administration Record suggested that the required care was not administered.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to properly transfer a resident, resulting in the resident being hospitalized with a neck fracture. The resident, an elderly female with multiple diagnoses including dementia and difficulty walking, was being transferred from a wheelchair to a shower chair by a Certified Nursing Assistant (CNA). During the transfer, the resident began to slide and was lowered to the floor. The resident was wearing slippers at the time, which were not appropriate for transfers, and a gait belt was not used despite the care plan indicating its necessity. The CNA involved in the transfer stated that the resident could transfer independently and did not require a gait belt, contrary to the care plan and Minimum Data Set (MDS) which indicated the need for maximum assistance and a gait belt during transfers. The Director of Nursing confirmed that the resident should have been wearing non-skid socks and a gait belt should have been used. The incident led to the resident sustaining an acute C7 spinous process fracture, as confirmed by hospital records.
Deficient Catheter Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide timely and appropriate care for residents with indwelling catheters, leading to severe health consequences. For one resident, the facility did not obtain a urine specimen from the catheter in a timely manner, failed to document catheter output, and did not provide necessary catheter care. This resident, who had a history of UTIs and other significant health issues, showed signs of increased confusion and distress, which were not adequately addressed by the staff. Despite orders for a urinalysis, the specimen was not collected promptly, and the resident was eventually hospitalized with a severe UTI and sepsis. The facility's documentation was incomplete and inconsistent, with missing entries for urine output and catheter care in the Medication Administration Record (MAR). The resident's care plan included monitoring for signs of UTI and providing catheter care, but these interventions were not effectively implemented. The staff failed to recognize and respond to the resident's symptoms, such as altered mental status and poor appetite, which were indicative of a UTI. The lack of timely intervention and communication with healthcare providers contributed to the resident's deterioration and subsequent hospitalization. Another resident also experienced issues with catheter care, as evidenced by the presence of sediment in the catheter tubing and missing documentation of urine output and catheter care. This resident had a history of frequent UTIs and was on antibiotic therapy for a positive urine culture. The facility's failure to adhere to its own policies and procedures for catheter care and monitoring contributed to the deficiencies observed by the surveyors.
Failure to Provide Recliner Wheelchair for Resident
Penalty
Summary
The facility failed to provide a recliner wheelchair to a resident, identified as R12, who expressed a desire to get out of bed and interact with the environment. R12, who is [AGE] years old, was admitted to the facility with diagnoses including multiple sclerosis, a sacral ulcer, chronic anemia, and protein energy undernutrition. The Minimum Data Set (MDS) indicated that R12 uses a wheelchair for mobility. However, during facility rounds, R12 was observed in bed and stated a desire to get out but was unable to do so due to the lack of a wheelchair. The resident mentioned not remembering the last time they got up and had asked nursing assistants for assistance but was told there was no chair available. The deficiency was further highlighted when a Certified Nursing Assistant (CNA) confirmed that R12 had been using a recliner wheelchair provided by hospice services, which was removed after hospice care was discontinued. The CNA admitted to not having gotten R12 out of bed since the hospice service ended. A Registered Nurse and the Assistant Director of Nursing were unaware of the lack of a recliner wheelchair for R12, despite the facility's policy stating that residents should have reasonable arrangements to meet their needs. The Director of Nursing expected all residents to have a wheelchair upon admission or as needed, but no wheelchair was available for R12 during the surveyor's checks.
Failure to Lock Wheelchair and Supervise Resident Leads to Fall
Penalty
Summary
The facility failed to ensure the wheelchair locking mechanism was engaged and failed to supervise a high-risk resident, resulting in the resident falling out of an unlocked wheelchair in an unsupervised dining room. The resident sustained bruising to the left side of the face and a cut above the left eye, requiring hospital evaluation and four sutures. The incident occurred when the activity aide transported the resident to the dining room and did not lock both sides of the wheelchair. The resident was left unsupervised, and the fall occurred shortly after. The resident involved in the incident had a history of dementia with other behavioral disturbances, anemia, anxiety disorder, major depressive disorder, essential hypertension, heart failure, glaucoma, osteoarthritis, and vertigo. The resident was assessed as high risk for falls, with a care plan indicating the need for the wheelchair to be locked at all times and for the resident to be placed in supervised areas when out of bed. Despite these precautions, the resident was left unsupervised in the dining room, leading to the fall. Interviews with staff revealed that the activity aide was not adequately trained on the use of wheelchairs and the importance of locking both wheels. The aide admitted to locking only one side of the wheelchair and was unaware of the need for supervision in the dining room. The facility's policies on fall prevention and wheelchair safety were not effectively communicated or enforced, contributing to the incident.
Failure to Follow Isolation Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to physician orders for transmission-based precautions for a resident diagnosed with multiple infections, including Klebsiella in the urine and MRSA in the nares. The resident was placed on contact and droplet isolation precautions due to their neutropenic status, as documented in their care plan. Despite clear signage indicating the need for PPE and isolation precautions, a CNA entered the resident's room without performing hand hygiene or donning any PPE, collected a meal tray, and continued to other rooms without following proper infection control protocols. The CNA admitted to not wearing PPE because they believed it was unnecessary if they did not touch the resident. This misunderstanding was corrected by the RN and the Infection Prevention Nurse, who both confirmed that PPE must be worn by anyone entering the room to prevent the spread of infection. The facility's infection control policy, revised in May 2024, outlines the necessity of PPE and hand hygiene to prevent the transmission of infectious agents, but these protocols were not followed in this instance, leading to a deficiency in infection control practices.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident (R4) from abuse, resulting in R3 punching R4 in the face, causing discoloration to the right eye and bleeding from the nose and mouth. The incident occurred on 12/12/2023 when a Certified Nursing Assistant (CNA) found R4 bleeding and reported the situation to the nurse. R3 admitted to punching R4 because R4 was coughing and allegedly did so on purpose after R3 asked him to stop. R4's care plan indicated a risk for abuse due to dementia and behavioral disturbances, while R3's care plan noted a risk of abuse due to schizophrenia and a history of provoking others. Both residents were transferred to the hospital for further evaluation, and the police were notified, but no criminal charges were pursued due to the mental diagnoses of both residents. The facility's investigation confirmed that R3 hit R4, and R3 was subsequently discharged from the facility. The facility's abuse prevention policy affirms the right of residents to be free from abuse, neglect, and exploitation. The deficiency was corrected on 12/15/2023.
Inadequate Supervision of High-Risk Resident
Penalty
Summary
The facility failed to adequately supervise a high-risk resident (R2) for falls, resulting in R2 falling out of his wheelchair and sustaining injuries. R2, who has a history of falls and multiple medical conditions including Orthostatic Hypotension, Major Depressive Disorder, and Mild Cognitive Disorder, was left unsupervised at the nurse's station. Despite being identified as a high fall risk, R2 was allowed to fall asleep in his wheelchair and subsequently fell forward onto the floor, causing a laceration on the bridge of his nose that required hospital evaluation and sutures. Interviews with staff revealed that R2 was being moved around by a CNA (V9) to prevent him from falling out of bed. However, R2 was left at the nurse's station while the CNA attended to another resident. The LPN (V10) at the nurse's station was not closely monitoring R2 at the time of the fall, as she was engaged in other tasks and conversations. Multiple staff members, including V8 and V17, confirmed that they did not witness the fall but heard a loud noise and found R2 on the floor. The Director of Nursing (V2) acknowledged that R2 had a history of falls and that the facility was aware of his high fall risk. Despite this, the facility did not have a specific policy on monitoring high fall risk residents, relying instead on general supervision practices. Observations by the surveyor also noted a lack of supervision in the dining room, where residents were left unattended, further highlighting the facility's inadequate supervision practices.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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