Greenfields Of Geneva
Inspection history, citations, penalties and survey trends for this long-term care facility in Geneva, Illinois.
- Location
- 0n801 Friendship Way, Geneva, Illinois 60134
- CMS Provider Number
- 146166
- Inspections on file
- 18
- Latest survey
- January 10, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Greenfields Of Geneva during CMS and state inspections, most recent first.
A resident with impaired mobility, osteoarthritis, and documented fall risk was dependent for toilet transfers and required assistance per the care plan and therapy notes, which described contact guard assistance but did not state that a gait belt was unnecessary. During an assisted toilet transfer, a CNA helped the resident stand and pivot without applying a gait belt, despite staff training and facility policy indicating gait belts should be used for transfers unless a mechanical lift is required. The resident later became lightheaded and fell in the bathroom, and was found on the floor without a gait belt in place, while other staff interviews confirmed inconsistent gait belt use and lack of clear documentation that this resident could be safely transferred without one.
Surveyors found that staff did not follow the facility’s Enhanced Barrier Precautions (EBP) policy or use appropriate PPE for several residents requiring device and wound care. An LPN discontinued and flushed a J‑tube feeding for a resident on ordered EBP while wearing only gloves, handling personal items and leaving the room with the same gloves. A resident with a sacral wound received a dressing change from an RN without a gown and without EBP signage or orders, despite facility policy requiring EBP and door signage for chronic wounds. Two other residents with chronic, full‑thickness wounds and moderate exudate had no EBP signage or PPE set up outside their rooms, and CNAs provided incontinence care and transfers without gowns and without performing required hand hygiene before or between glove use, while also stating that no residents on their hallway required EBP.
A resident with severe cognitive impairment, documented need for staff set-up/clean-up assistance at meals, and a care plan directing staff to anticipate her needs was observed eating pureed meals without a clothing protector on two occasions, resulting in repeated food spillage on her clothing. A CNA reported that this resident required prompting, cueing, and a clothing protector due to fatigue and unsteady utensil use, and the DON stated she expected staff to round during meals and provide clothing protectors to prevent spillage. This failure to provide a clothing protector during meals did not align with the resident’s assessed needs, care plan, or the facility’s Resident Rights policy requiring treatment with kindness, respect, and dignity.
Two residents were found with multiple medications stored at their bedsides and self-administering them without documented self-administration assessments, care plans, or appropriate physician orders for bedside use. One cognitively intact resident with age-related macular degeneration had PRN ophthalmic lubricant ordered but no order allowing bedside storage and no documented education on use. Another resident with multiple sclerosis, unsteadiness, and osteoarthritis, and with moderate cognitive impairment, kept and applied topical analgesic and antibiotic products that were not ordered on the POS and reported receiving no guidance on application amounts. The DON acknowledged that residents should be assessed for safe self-administration, demonstrate proper use, and have physician orders for medications kept at the bedside, as required by the facility’s self-administration policy.
Surveyors found that the facility did not reconcile or properly account for controlled substances for two discharged residents. During a Birch unit med cart observation with the DON, cards of Hydrocodone-Acetaminophen, Alprazolam, and Tramadol with remaining tablets were stored in the narcotic box with individual inventory sheets attached to the cards instead of being filed in the narcotic binder used for shift-change counts. The DON acknowledged that the inventory sheets were not kept in the binder because the residents had been discharged and stated that controlled count sheets should be in the binder for accurate counting and that narcotics should be destroyed upon discharge. Facility policy required end-of-shift controlled drug counts using narcotic records and reconciliation of controlled substance inventory to detect loss or diversion.
Surveyors found that two residents had unsecured medications left at their bedside, contrary to facility policy requiring drugs to be stored in locked compartments. A cognitively intact resident with COPD had two ordered inhalers left on her bedside table after a nurse administered one dose and failed to secure the inhalers, despite no bedside order. Another resident with dementia and moderate cognitive impairment had three tubes of a topical analgesic on her tray table, with no corresponding physician order or authorization for bedside medication storage.
The facility failed to properly label, date, seal, and store food items, leading to potential contamination risks. Expired and improperly stored food items were found in the kitchen and dry storage areas, with small black flies present. Additionally, a server was observed with inadequate hair restraint, risking food contamination. These actions violated the facility's food safety and personal hygiene policies.
The facility failed to safely store medications for four residents who were not assessed or ordered to have medications at bedside. Medications were found in residents' rooms without proper authorization or assessment for self-administration. Staff interviews revealed that facility policies requiring physician orders and assessments for bedside storage were not followed.
A medication administration deficiency occurred when an RN failed to administer prescribed medications to a resident with COPD and hypertension, yet documented them as given. This resulted in a medication error rate of 6.67%, exceeding the acceptable threshold. The resident's care plan required these medications to manage their conditions, and the DON confirmed the importance of accurate documentation.
A resident was continued on antibiotics despite not meeting criteria for continued use according to the facility's antibiotic stewardship program. The resident was admitted from the hospital on antibiotics, but a McGeer's assessment showed no evidence of infection. Despite this, the resident received antibiotics for several days, and documentation from the Medical Director was lacking. A late entry note was provided during the survey, backdated to justify the antibiotic use, contrary to the facility's policies.
Failure to Use Gait Belt During Assisted Toilet Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly and safely transferred with the use of a gait belt, as required to prevent or minimize the risk of falls. The resident had a history that included right quadriceps strain, orthopedic aftercare, difficulty walking, osteoarthritis, and a prior fall, and was assessed as being at risk for falls. The resident’s MDS documented dependence for toilet transfers, meaning the helper does all the effort or two or more helpers are required, and the care plan identified fall risk and ADL self-care deficits related to limited mobility, weakness, and prior tendon tear and repair. The care plan interventions included assistance with toileting and, after a fall, specified use of a gait belt during transfers, but prior to the fall there was no documentation that a gait belt was not required. Therapy documentation showed that physical therapy recorded supervision or touching assistance with toilet transfers and occupational therapy documented toileting with “CGA,” later clarified by a therapist as contact guard assistance, indicating the resident still required some contact assistance. There was no documentation in the medical record or therapy notes stating that a gait belt was not required for this resident’s transfers. The facility’s Safe Resident Handling/Transfers policy stated that all residents require safe handling when transferred, that handling aides may include gait belts, and that lifting and transferring are to be performed according to the resident’s individual plan of care. On the night of the fall, staff heard a noise consistent with a fall and found the resident on the bathroom floor in an upright position with both legs extended, without a gait belt in place. The resident reported that an aide had assisted him to stand and pivot to the toilet and later to stand after toileting, and he did not recall a gait belt being applied before standing; he also reported becoming lightheaded and falling. The CNA who assisted the resident stated she did not put a gait belt on the resident, described him as a one-assist transfer, and acknowledged staff were supposed to use a gait belt with transfers unless the resident was independent, and that she had never been told this resident did not require a gait belt. Another CNA reported that if a gait belt was not available, he would still transfer a resident without one and just be extra careful. Other staff, including a CNA and a PT, stated that a gait belt should always be used with transfers unless a mechanical lift is used, and the DON stated that gait belt use depends on therapy recommendations, though no documentation existed that a gait belt was not required for this resident.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use for Device and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) and appropriate use of personal protective equipment (PPE) for multiple residents. One resident with dysphagia had a jejunostomy (J‑tube) with continuous tube feeding and an order for EBP related to the feeding tube. An LPN entered this resident’s room without a gown, wearing only gloves, moved the resident’s personal belongings with the same gloved hands, disconnected the J‑tube feeding, flushed the tube, covered the port, and then left the room still wearing the same gloves. The resident’s physician orders and care plan documented the need for EBP for the J‑tube, and the facility’s EBP policy required gown and gloves for device care, including feeding tubes. The facility also failed to post EBP signage and ensure EBP implementation for residents with chronic wounds. One resident with a sacral wound had no EBP sign on the door, and a wound care RN entered without a gown and performed a pressure dressing change. The physician orders for this resident did not include EBP, and the care plan did not address EBP, despite the facility’s policy stating that EBP should be implemented for residents with chronic wounds and that clear signage indicating required PPE must be posted outside the room. The Infection Control Nurse stated that at that time they did not have wounds requiring EBP, and described EBP as needed for open wounds or pressure sores with significant exudate, while the written policy specified chronic wounds such as pressure ulcers and other long‑lasting wounds. Two additional residents with chronic, full‑thickness wounds and moderate serous exudate also did not have EBP signage or PPE set up outside their rooms. A CNA and another CNA assistant entered one resident’s room to provide incontinence care and transfer without performing hand hygiene before donning gloves, did not wear gowns, and one CNA changed gloves without hand hygiene before continuing care and using a mechanical lift. For another resident with a post‑surgical stump wound, a CNA provided incontinence care wearing gloves but no gown and did not perform hand hygiene before donning or after removing gloves. Both CNAs stated there were no residents on their hallway requiring EBP, while the DON stated that EBP is required for residents with chronic wounds present for more than 30 days and/or with biofilm, and the wound physician’s documentation showed both residents’ wounds had been present for more than 30 days with debridement of slough, biofilm, and devitalized tissue.
Failure to Provide Clothing Protector During Meals Compromising Resident Dignity
Penalty
Summary
Surveyors identified that staff failed to provide a clothing protector during meals to a resident with severe cognitive impairment, resulting in food spilling on her clothing. On the morning of 12/21/2025, the resident was observed in the dining room eating a pureed breakfast. She was severely cognitively impaired, fatigued, and had difficulty feeding herself, which led to multiple food residue spills on her shirt and pants. Despite this, she was not provided with a clothing protector. Later that day at lunchtime, the same resident was again observed in the dining room feeding herself pureed food with some unsteadiness using utensils, causing additional spillage on her shirt and pants, and again no clothing protector was provided. A CNA who routinely cared for the resident stated that the resident was able to feed herself but required prompting and cueing, especially when fatigued, and that she required the use of a clothing protector to protect her clothing from food spillage. The CNA also stated that due to the resident’s cognitive impairment, she was dependent on staff to provide a clothing protector at meals. The DON reported that she expected staff to provide resident-centered care during meals, including rounding and providing clothing protectors to prevent spillage on residents’ clothing. The resident’s MDS documented severe cognitive impairment and a need for staff set-up and clean-up assistance with meals, and the care plan indicated she was at risk for complications due to cognitive impairment, was dependent on staff for care, and that staff were to anticipate her care needs. The facility’s Resident Rights policy stated that employees shall treat all residents with kindness, respect, and dignity.
Failure to Assess and Authorize Resident Self-Administration of Medications at Bedside
Penalty
Summary
Surveyors identified that the facility failed to assess residents for self-administration of medications and failed to obtain physician orders for medications kept at the bedside. One resident had Systane lubricant eye drops and ointment on the bedside table and reported that no one at the facility had educated her on how to take the medications, stating she already knew how to use them and that they were always kept in her room. Her record showed a diagnosis of exudative age-related macular degeneration with active choroidal neovascularization and an MDS indicating she was cognitively intact. The POS contained an order for Systane ophthalmic gel to be instilled in both eyes every 24 hours as needed for dry eyes, but there was no order for the medication to be kept at the bedside. Her medical record contained no self-administration of medication assessment and no care plan addressing self-administration. Another resident had multiple tubes of topical analgesic and a topical antibiotic on the bedside table and stated she applied the analgesic to her knees for arthritis pain and the antibiotic to the sides of her nose where her eyeglasses rest, adding that the medications were always kept in her room and that no one had educated her on how much she could apply in a day. Her diagnoses included multiple sclerosis, unsteadiness on feet, and primary generalized osteoarthritis, and her MDS showed moderate cognitive impairment. The POS contained no orders for the topical analgesic or topical antibiotic, and her record lacked a self-administration of medication assessment and a care plan for self-administration. The DON stated that she did not currently have residents who self-administer medications, that nurses should assess residents and require them to demonstrate safe self-administration according to physician orders, and that there should be physician orders for medications to be kept at the bedside. The facility’s self-administration policy required IDT assessment of cognitive and physical abilities, documentation and care planning when self-administration is deemed safe, secure storage of self-administered medications, and turning over any unauthorized bedside medications to the nurse in charge.
Failure to Reconcile and Account for Controlled Substances After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to reconcile and properly account for controlled substances after residents were discharged. During a medication cart storage observation on the Birch unit with the DON, surveyors found a card of Hydrocodone-Acetaminophen 5-325 mg containing 30 tablets for resident R67 stored in the narcotic box with its individual controlled inventory sheet attached to the card rather than maintained in the cart’s controlled inventory binder. The DON stated that R67’s inventory sheet was not kept in the binder for counting because the resident had been discharged. Record review showed R67 had an as-needed order for Hydrocodone-Acetaminophen that started on 12/03/2025 and was discontinued on 12/08/2025, and the EMR documented that R67 was discharged on 12/16/2025. In the same observation, the Birch unit medication cart also contained a card of Alprazolam 0.25 mg with 14 tablets and a card of Tramadol HCL 50 mg with 15 tablets for resident R68 stored in the narcotic box, each with individualized controlled inventory sheets attached to the cards instead of being in the narcotic binder. The DON explained that R68’s inventory sheets were not maintained in the binder for count because the resident had also been discharged, and stated that individual controlled count sheets should be in the narcotic binder so all stored narcotics are accounted for during shift-change counts and that narcotics should be destroyed per policy when a resident discharges. EMR review showed R68 was discharged on 12/20/2025 and had as-needed orders for Alprazolam 0.25 mg and Tramadol HCL 50 mg. The facility’s controlled substances policy required nursing staff to count controlled medication inventory at the end of each shift using narcotic records to reconcile counts and to monitor and reconcile controlled substance inventory to identify loss or potential diversion.
Unsecured Medications Left at Bedside for Two Residents
Penalty
Summary
Surveyors identified a failure to secure and properly store medications when a cognitively intact resident admitted with chronic obstructive pulmonary disease was found with two inhalers on her bedside table. The resident reported she had been admitted the previous day and that both the Breztri Aerosphere and Airsupra inhalers had been in her room since admission. She stated a nurse had administered the Airsupra inhaler and then left it in the room, and that the Breztri inhaler was awaiting approval by the respiratory therapist. The resident’s physician orders included both inhalers but did not include any order for medications to be kept at the bedside. Facility policy required all medications and biologicals to be stored in locked compartments, and the DON stated that medications brought from home should be given directly to the nurse and not left in resident rooms. In a separate instance, surveyors observed three tubes of a brand name topical analgesic 1% on the tray table of another resident who had moderate cognitive impairment and diagnoses including unspecified dementia, cognitive communication deficit, and major depressive disorder. This resident was unable to comment on the medication due to impaired cognitive function as documented in her care plan. The resident’s physician orders did not contain any order for the topical analgesic or for any medication to be kept at the bedside. These observations showed that medications were not secured in locked storage as required by facility policy and accepted professional principles.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and storage protocols, as observed during a kitchen inspection. Several food items in the facility's kitchen were found improperly labeled, dated, and stored. For instance, packages of Canadian bacon and ground beef were past their expiration dates, with the latter leaking juices onto the cooler floor. Additionally, various food items, including chicken thighs, shrimp, and sauces, were not labeled, dated, or sealed, posing a risk of contamination. Expired items such as mozzarella slices, goat cheese, and smoked roasted bacon were also found in the walk-in cooler. In the dry storage area, small black flies were observed, and several food containers were improperly sealed or left open, exposing contents to potential contaminants. Sticky and expired items, such as a bottle of browning and season sauce and a gallon of apple cider vinegar, were noted, with flies present on some items. Dishes were stored improperly, right side up and dusty, increasing the risk of contamination. Additionally, dented cans, which pose a risk for botulism, were found on the circulation rack. The facility's staff also failed to comply with personal hygiene standards. A server was observed serving meals with a hairnet that did not fully cover her hair, risking contamination of the food. The facility's policies clearly state the need for proper labeling, dating, and sealing of food items, as well as the use of hair restraints to prevent contamination. However, these protocols were not followed, leading to the deficiencies noted during the inspection.
Failure to Safely Store Medications at Bedside
Penalty
Summary
The facility failed to ensure safe storage of medications for residents who were not assessed or ordered to have medications kept at bedside. This deficiency was observed in four residents who had medications stored in their rooms without proper authorization or assessment. Resident R24 had eye drops on his bedside table for cataract surgery, but there was no physician order or assessment for self-administration or bedside storage. Similarly, Resident R13 had various topical medications on his side table, including a discontinued Chlorhexidine solution, without orders for bedside storage or self-administration. Resident R7 had a bottle of Phenol oral spray in her room, which she used sporadically without a physician's order or assessment for self-administration. The spray was initially on her tray table and later found in her dresser drawer. Resident R19 had an unopened tube of hydrocortisone cream in her room, which she was unaware of how it got there. There was no order for bedside storage, and the cream was later removed from her room. None of these residents had assessments in their electronic medical records to indicate they were safe to self-administer medications or store them at bedside. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that the facility's policy required a physician's order and an assessment for residents to self-administer medications or store them at bedside. However, these procedures were not followed for the residents in question. The facility's policies on medication and treatment, as well as medication labeling and storage, were not adhered to, leading to the observed deficiencies.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 6.67%, which exceeds the acceptable threshold of 5%. During a medication pass observation, a registered nurse (RN) did not administer the prescribed medications, fluticasone-salmeterol and Metoprolol Succinate, to a resident with multiple diagnoses including COPD, asthma, and hypertension. Despite this, the RN documented in the electronic medical record that the medications were administered. The resident involved was admitted with conditions such as a fracture of the left femur, hyperlipidemia, hypertension, anxiety, obstructive sleep apnea, COPD, and asthma. The resident's care plan included interventions to manage these conditions, such as administering bronchodilators and anti-hypertensive medications as ordered. The Director of Nursing confirmed that medications should not be documented as administered if they were not given, and highlighted the potential outcomes of missing these medications, such as elevated heart rate or blood pressure and increased wheezing or shortness of breath.
Failure to Discontinue Unnecessary Antibiotics
Penalty
Summary
The facility failed to discontinue an antibiotic for a resident who did not meet the criteria to continue antibiotics, as part of their antibiotic stewardship program. The resident, identified as R242, was admitted to the facility from the hospital on antibiotics on October 9, 2024. The resident had started Augmentin 875-125 MG on September 28, 2024, while in the hospital. Upon admission, a McGeer's assessment was completed, which indicated that the resident did not meet the criteria to continue the antibiotics, as there was no evidence of infection and cultures were negative. Despite this, the resident continued to receive antibiotics until October 14, 2024. The facility's records showed that the resident received multiple doses of the antibiotic from October 10 to October 14, 2024. The Infection Preventionist, V8, noted that there was no evidence of infection and that the resident did not meet McGeer's criteria for antibiotic stewardship. However, there was a lack of documentation from the Medical Director, and a late entry note was provided during the survey, backdated to October 10, 2024, by the Infectious Disease Nurse Practitioner. This note stated that antibiotics were to be completed as per hospital discharge paperwork, despite the lack of evidence supporting the need for continued antibiotic use. The facility's policies on antibiotic stewardship and unnecessary drugs emphasize the importance of discontinuing medications when conditions have resolved, which was not adhered to in this case.
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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