Harmony Palos
Inspection history, citations, penalties and survey trends for this long-term care facility in Palos Heights, Illinois.
- Location
- 11860 Southwest Highway, Palos Heights, Illinois 60463
- CMS Provider Number
- 145893
- Inspections on file
- 30
- Latest survey
- March 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harmony Palos during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, and lung cancer developed a scattered rash on the arms, chest, and stomach that was later documented by a physician as possibly scabies, with a plan for treatment using permethrin cream and appropriate isolation. The MAR showed permethrin applications on two occasions, but there were no corresponding physician orders for contact isolation, no documentation of isolation on the infection control log, and no evidence the resident was ever placed on isolation or moved to a private room. Staff, including a CNA, former wound care coordinator, physician, and DON, all stated that residents treated for scabies should be placed on contact isolation with appropriate PPE, yet they either were unaware of this resident’s scabies treatment or did not recall any isolation being implemented, contrary to the facility’s infection prevention and control policy requiring transmission-based precautions when indicated.
A resident with multiple comorbidities and a documented high fall risk care plan fell from bed and sustained a displaced humerus fracture, head laceration, and facial contusions while receiving ADL care from an agency CNA. The CNA, caring for the resident for the first time, reported receiving no information about the resident’s history or fall risk and described providing in‑bed care with the resident on her side, without bed rails in place. The resident consistently stated that the CNA let go of her during changing, that the bed was high, and that there were no rails to prevent her from rolling out of bed, and denied reaching for any object or preferring to be at the bed’s edge. An LPN responding to the incident found the resident on the floor with active head bleeding, did not recall side rails being present, and stated she had not been told the resident was a fall risk. Another agency LPN also did not consider the resident a fall risk. When surveyors requested a fall prevention policy, the administrator produced only a fall occurrence policy, indicating the lack of a specific fall prevention policy and procedures for communicating fall risk and interventions to staff.
A resident with multiple comorbidities and a history of falls was assigned to an agency CNA whose competency in fall prevention and facility safety protocols had not been verified. During ADL care, the CNA, who had not been oriented to the resident’s fall risk, language needs, or specific care requirements, positioned the resident on her side while cleaning a large BM; the resident reached toward the bedside table, rolled from the bed, and sustained a right humerus fracture and a facial laceration. Facility orientation records for the CNA showed only a mass strike‑through over numerous training topics, including fall prevention, with no documented instructor validation, and an agency LPN reported receiving no in‑service training from the facility. The administrator could provide only a fall occurrence policy, and staff education materials addressed post‑fall procedures rather than proactive fall prevention.
A resident with multiple comorbidities, a history of falls, and documented high fall risk required extensive assistance for bed mobility and incontinence care per the care plan and MDS/CAA. An agency CNA, who had not previously cared for the resident and reported receiving no report on the resident’s care needs or fall‑prevention training, provided ADL care with the resident in a side‑lying position and removed stabilizing support while cleaning after a large BM, during which the resident reached toward the bedside table and rolled out of bed. The resident sustained a right humerus fracture and a laceration above the eye. Interviews with an LPN and an agency LPN showed they did not recognize the resident as a fall risk, were unaware of the high fall‑risk status, and reported no in‑service training from the facility on fall prevention, demonstrating a failure to implement and communicate the comprehensive fall‑risk care plan.
A resident with multiple chronic conditions and moderate cognitive impairment sustained a right femoral neck fracture during peri-care when a CNA inadvertently overturned her leg, causing her to partially roll out of bed. Although the x-ray confirmed the fracture the same day, the DON was not informed until several days later, resulting in the facility failing to report the major injury to IDPH within the required 24-hour period.
The facility failed to ensure a safe environment and adequate supervision for three residents at risk for falls. Staff did not consistently follow procedures for safe repositioning, reporting falls, or implementing individualized fall prevention interventions. One resident sustained a femoral neck fracture after falling from bed due to lack of proper assistance and equipment, while other residents experienced unsafe transfers and lacked access to functioning alarms or call lights.
The facility did not update care plans for three residents after falls, omitting new interventions such as assistive devices, increased monitoring, and floor mats, even though these were implemented following the incidents. These updates were required by facility policy and were not reflected in the residents' care plans.
A dependent resident with quadriplegia and multiple comorbidities, assessed as high risk for falls, was left unattended on his side in bed at a raised height while a CNA retrieved supplies. The resident fell from the bed, sustaining a laceration to the right eyebrow that required sutures and an ER visit. Facility staff and leadership confirmed that the resident was not positioned safely according to care plan and policy requirements, resulting in a failure to implement effective fall prevention interventions.
Two residents with a history of falls were admitted to a facility without adequate fall prevention measures, resulting in significant injuries. Despite known risks, necessary interventions such as bed alarms and caregiver supervision were delayed. The facility failed to incorporate family input and past medical history into care plans, leading to falls and injuries.
The facility failed to maintain sanitary conditions in food preparation, affecting all residents. Staff were observed changing gloves without hand hygiene, not sanitizing surfaces after cleaning, and using a wet food processor, violating facility policies. Hair was also improperly restrained, risking contamination.
The facility failed to implement proper infection control measures, including the use of PPE and catheter care. A CNA did not change soiled gloves during ADL care for a resident with hepatitis C. A resident's urinary catheter bag was improperly handled, dragging on the floor. Additionally, a podiatry assistant and podiatrist did not follow enhanced barrier and droplet precautions, failing to wear gowns or perform hand hygiene when moving between rooms of residents with gastrostomy tubes and COVID-19.
The facility failed to label insulin pens with access and discard dates for two residents and improperly disposed of expired medications. Insulin pens were found without necessary labeling, and expired stock medications were discarded inappropriately, contrary to facility policy. The ADON and DON confirmed these oversights, highlighting a breach in medication management protocols.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in care. One resident's care plan lacked necessary fall prevention interventions, another experienced delays in being assisted out of bed, and a third did not receive timely therapy for a hand contracture. Additionally, a resident's mood disturbances were not addressed in their care plan.
A resident with partial paralysis and dementia experienced a deficiency in care due to the facility's failure to provide timely restorative services for a contracted left hand. Despite the need for therapy being identified in the admission assessment, the resident did not receive necessary evaluations and treatment, leading to a deficiency in care.
A resident with COPD and dementia was found self-administering a Combivent inhaler and eyedrops without a proper assessment or physician's order. The facility's policy requires evaluation and authorization for self-administration, which was not followed, as confirmed by the DON.
A resident with a complex medical history sustained a clavicle fracture due to inadequate interventions for safe repositioning. Staff inconsistencies and lack of documentation regarding the resident's care needs contributed to the deficiency. The resident expressed fear of falling out of bed, and there was no documentation of a turning and repositioning program in the care plan.
A resident with a right clavicle fracture experienced untreated pain due to the facility's failure to conduct timely pain assessments and administer appropriate pain management. Despite the resident's complaints and a history of significant medical conditions, there were gaps in pain documentation and communication among staff, resulting in the resident's pain escalating to a constant severity of 10 out of 10.
A resident with multiple diagnoses, including a vertebra fracture and dementia, experienced an acute clavicle fracture, but the facility failed to document restorative assessments and interventions accurately. Despite being on a turning program, there was no record of it, and CNAs reported inconsistencies in assistance needed. The DON admitted the absence of an incident report, and pain assessments were not documented. The care plan was updated posthumously, and the facility's documentation policy was not provided.
Failure to Implement Contact Isolation for Resident Treated for Suspected Scabies
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of a resident being treated for suspected scabies. The resident, an older adult with dementia, Alzheimer’s disease, and lung cancer, had a scattered rash on both arms, chest, and stomach documented on 12/25/25, with some scabbing and no signs of itching. A physician note dated 1/13/26 documented that the rash was possibly scabies, with a plan to treat with permethrin cream and implement appropriate isolation. The Medication Administration Record for 01/2026 showed the resident received permethrin cream on 1/14/26 and 1/22/26 for a rash. However, review of the Physician Order Sheet from 12/21/25 to the present revealed no order for contact isolation related to rash or scabies, and the Infection Control Isolation Log for the last three months did not list the resident as having been on isolation. Staff interviews further demonstrated that isolation precautions were not implemented for this resident while being treated for suspected scabies. A CNA reported the resident had a rash on the arms, chest, and back a couple of months prior and stated that residents treated for scabies are supposed to be placed on isolation immediately, but the CNA was not aware this resident had been treated for scabies and denied ever seeing the resident on isolation, noting it was the nurse’s responsibility to enter isolation orders and inform staff. The former Wound Care Coordinator stated that when scabies is suspected, nurses contact the physician for orders and residents should be placed on contact isolation and moved to a private room because the condition is very contagious. The medical physician confirmed that residents treated with topical ointment for suspected scabies should have contact isolation ordered, and the DON stated that residents treated for scabies should be placed on isolation and moved to a room alone, but did not recall this resident being on isolation in the prior couple of months. The facility’s Infection Prevention and Control policy required provision of transmission-based precautions, including contact precautions with gown and glove use, when indicated, but these measures were not documented or implemented for this resident.
Failure to Communicate High Fall Risk and Implement Fall Prevention During ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at high risk for falls was free from accident hazards and received adequate supervision and assistive devices during care. The resident is an alert and oriented, predominantly Polish‑speaking older adult with multiple comorbidities including type II diabetes, COPD, atrial fibrillation, hypertension, anxiety disorder, history of falls, and prior humeral fracture. The resident’s care plan, dated 5/12/25, identified her as at high risk for falls due to history of falls, impaired mobility, weakness, and multiple comorbidities, with interventions including keeping the bed in a low position, encouraging slow transfers and position changes, frequent toileting, having commonly used items within reach, and use of a low bed. Despite this, on observation on 1/2/26, the resident was seen in bed with the bed raised to waist height and no fall mats or other fall prevention measures in place. On the date of the fall, an agency CNA provided ADL care to the resident for the first time without being oriented to the resident’s high fall risk status or specific care needs. According to the facility’s incident report, the CNA had the resident lying on her left side, with one hand on the resident’s rib cage to stabilize her while washing with the other hand, when the resident began to roll out of bed; the CNA attempted but failed to stop the fall. The resident consistently reported in interviews, including through a Polish‑speaking surveyor and in a post‑fall statement interpreted by a staff member, that the CNA let go of her while changing her, that there were no side rails in place, and that she then rolled out of the bed and fell. The resident denied reaching for any object or preferring to be at the edge of the bed or using the nightstand for support, and the care plan contained no documentation of such preferences, contradicting the facility’s later assertion that the resident’s own positioning preferences contributed to the fall. Staff interviews further demonstrated a lack of communication and understanding of the resident’s fall risk status and fall prevention measures. The agency CNA stated that no one told her anything about the resident’s history or that she was a high fall risk, that it was her first time caring for the resident, and that she did not recall receiving fall prevention training at the facility. She also confirmed there were no bed rails in place and that she did not understand the resident because the resident did not speak English. The LPN on duty at the time of the incident reported finding the resident on the floor with active head bleeding and stated that the CNA told her the resident fell when she was turned too far during cleaning; the LPN did not recall any side rails being present and stated that if there had been side rails, the resident might not have rolled out of bed. This LPN also stated she did not consider the resident a fall risk and had never been told the resident was high risk for falls. An agency LPN caring for the resident later also stated she did not consider the resident a fall risk and could not describe facility fall prevention measures, indicating she relied on agency training. When surveyors requested a fall prevention policy, the administrator provided only a Fall Occurrence policy focused on assessment and care planning after falls, and confirmed that was the only policy, indicating the absence of a documented fall prevention policy and procedure for communicating fall risk and interventions to staff. The fall resulted in the resident sustaining a displaced fracture of the right humerus, a head laceration above the right eye with active bleeding requiring Steri‑Strips, facial contusions, and a hematoma and bruising of the right eye and right side of the face, as confirmed by hospital records and NP documentation. The resident reported ongoing pain in both shoulders and difficulty holding objects after the fall. The facility’s investigation notes and staff statements attempted to attribute the fall to the resident’s actions or preferences, but these claims were not supported by the care plan, resident interviews, or contemporaneous staff accounts. Overall, the deficiency centers on the facility’s failure to orient agency staff to the resident’s high fall risk, failure to implement and communicate care‑planned fall prevention interventions (including bed position and assistive devices such as side rails), and failure to maintain an environment free from accident hazards, which directly preceded the resident’s fall and injuries.
Failure to Verify Agency Staff Competency and Provide Fall Prevention Training
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received care from staff with documented competency and training, particularly in fall prevention and resident-specific safety needs. An agency CNA was assigned to provide ADL care to an alert and oriented, predominantly Polish‑speaking resident with multiple diagnoses including type II diabetes, right humerus fracture history, COPD, atrial fibrillation, hypertension, anxiety disorder, and a history of falls. During incontinence care, the CNA positioned the resident on her side with one hand on the resident’s rib/shoulder area and the other hand cleaning a large bowel movement. The resident then reached toward the bedside table or an item on it, rolled out of the bed, and fell to the floor. The CNA reported there were no bed rails, that she did not understand the resident due to the language barrier, that it was her first time caring for the resident, and that no one had given her any information about the resident’s care needs or fall risk status. Following the fall, the resident complained of right shoulder pain and had a laceration above the right eye, was sent to the ED, and returned with a diagnosed right humerus fracture and a laceration treated with Steri‑strips. Record review showed that the facility’s orientation documentation for the agency CNA consisted of a form listing over two dozen training topics, including fall prevention and safety protocols, all marked only with a single continuous vertical strike‑through line and the CNA’s signature, without instructor initials, dates of completion, or evidence of observed competency by facility leadership. The CNA stated she did not recall receiving fall prevention training. An agency LPN caring for the same resident reported receiving no in‑service training from the facility, only from the agency, and incorrectly stated that the resident was not a fall risk despite being aware of a prior fall. When the surveyor requested a fall prevention policy, the administrator provided only a Fall Occurrence policy that addressed assessment and interventions after falls and confirmed there was no separate fall prevention policy. Review of the facility’s education modules showed staff were trained only on the fall occurrence policy, not on a proactive fall prevention framework. As a result, the agency CNA was assigned to a high‑risk resident without verified competency in the facility’s safety standards or resident‑specific fall prevention needs.
Failure to Implement and Communicate High Fall-Risk Care Plan During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to implement an established comprehensive care plan for a resident identified as high risk for falls and dependent for toileting hygiene and bed mobility. The resident, an alert and oriented, predominantly Polish‑speaking older adult with multiple comorbidities including a history of falls and fractures, had a care plan and MDS/CAA documentation indicating high fall risk and a need for extensive assistance of at least one staff member for bed mobility and incontinence care. Care plan interventions included maintaining the bed in a low position, encouraging slow transfers and position changes, frequent toileting, and keeping commonly used items within reach. Despite this, on the date of the incident, an agency CNA provided incontinence/ADL care with the resident in a side‑lying position, using one hand to stabilize the resident and the other to clean her after a large bowel movement. The CNA reported that the resident reached toward the bedside table and then rolled out of the bed, and the CNA was unable to prevent the fall. Following the fall, the nurse assessed the resident, who complained of right shoulder pain and had a laceration above the right eye; the resident was sent to the ED and returned with a diagnosed right humerus fracture and a laceration treated with Steri‑strips. Interviews revealed that the agency CNA had not previously cared for the resident, did not receive any report or endorsement about the resident’s care needs, did not know the resident was a fall risk, and reported not receiving fall‑prevention training from the facility. Additional interviews with an LPN and an agency LPN showed they did not consider the resident to be a fall risk, were unaware of the resident’s high fall‑risk status, and one LPN stated the resident had never fallen out of bed and that she was never told the resident was high risk for falls. Staff also reported there were no side rails on the bed and no communication board in use, and the agency LPN stated she did not receive in‑service training from the facility and could not describe fall‑prevention measures for this resident. These findings demonstrate that the facility failed to implement and communicate the resident’s comprehensive fall‑risk care plan and required level of assistance during bed mobility and ADL care, resulting in a fall with significant injury.
Failure to Timely Report Major Injury to State Agency
Penalty
Summary
The facility failed to follow its Incident Reporting Policy by not reporting a major injury to the Illinois Department of Public Health (IDPH) within the required 24-hour timeframe. A female resident with multiple diagnoses, including congestive heart failure, stage 3 sacral pressure ulcer, chronic kidney disease, seizures, lymphedema, and pulmonary hypertension, and a BIMS score indicating moderate cognitive impairment, sustained an acute right intertrochanteric femoral neck fracture. The injury occurred when a CNA, while providing peri-care in bed, inadvertently overturned the resident's right leg, resulting in the resident partially rolling out of bed. The resident complained of right hip pain following the incident, and an x-ray ordered by the attending physician confirmed the fracture. Despite the x-ray result being available on the evening of 5/9/25, the Director of Nursing (DON) was not made aware of the fracture until 5/13/25. The facility reported the incident to IDPH only after the DON became aware of the injury, exceeding the 24-hour reporting requirement. The facility's policy mandates that any serious injury, such as a fracture, must be reported to the state agency within 24 hours of discovery, but this protocol was not followed in this case.
Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement fall prevention interventions for three residents reviewed for falls. Staff did not consistently follow policy and procedures for turning and repositioning dependent residents, reporting falls, or ensuring that staff were aware of and implemented individualized fall prevention interventions. Equipment intended to prevent falls, such as alarms and assistive devices, was not always in place or functioning properly. One resident with significant medical conditions, including congestive heart failure and chronic kidney disease, was assessed as high risk for falls and dependent on staff for repositioning. During care, staff failed to use an assistive device or a two-person assist as required, resulting in the resident falling from bed and sustaining an acute femoral neck fracture with significant pain. Documentation and staff accounts of the incident were inconsistent, and the care plan was not updated to reflect necessary interventions. Staff were also unclear about the resident's fall prevention measures, and required equipment was not observed in use during the survey. Other residents with histories of falls and impaired mobility were also not provided with appropriate interventions. One resident, dependent on staff for transfers, experienced multiple falls and was observed being transferred unsafely by a single staff member without proper equipment, despite care plan requirements. Another resident, also at high risk for falls and with severe cognitive impairment, was left without accessible call light assistance and was not provided with required transfer devices or functioning alarms. Staff were observed not responding promptly to requests for assistance, and fall prevention interventions outlined in care plans and facility policy were not consistently implemented.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise and update comprehensive care plans for three residents following fall incidents, as required by policy and regulation. For one resident, after a fall occurred during peri-care when a CNA inadvertently overturned the resident's leg, the care plan was not updated to include the use of an assistive device in bed, despite this intervention being noted in the incident report. The resident's risk for falls care plan did not reflect the most recent fall or the new intervention. Another resident experienced a fall when attempting to get into bed independently after a CNA left to retrieve supplies. The care plan was not updated to include the fall or the preventive interventions implemented after the incident until the survey entrance date. A third resident, who had a pressure ulcer and was visually impaired, rolled off the bed, prompting the addition of bed rails, a bed alarm, and floor mats as immediate interventions. However, the care plan did not reflect the most recent fall or the addition of floor mats. These omissions occurred despite facility policy requiring that fall interventions be added to the care plan and revised as necessary.
Failure to Implement Effective Fall Interventions for High-Risk Dependent Resident
Penalty
Summary
A dependent resident with functional quadriplegia, atrial fibrillation, bradycardia, and hypertensive heart disease was assessed as high risk for falls and required staff assistance for all activities of daily living. The resident's care plan included interventions such as keeping needed items within reach, maintaining the bed in a low position, ensuring furniture was locked during care, and keeping the call light accessible. Despite these interventions, the resident experienced a fall resulting in a laceration to the right eyebrow that required sutures and an emergency room visit. On the night of the incident, a CNA was providing incontinence care to the resident, who was positioned on his side in bed. The CNA left the resident briefly to retrieve additional linen from a cart located by the door, leaving the resident unattended. During this time, the resident fell from the bed. The CNA reported that the bed was not in the lowest position but at about hip level, and no bed rails were in use. The resident was found on the floor, alert and oriented, with a wound on the right eyebrow and complaints of pain in both arms. The nurse on duty confirmed that the bed was waist high and that the resident had no bed rails. The nurse also stated that, for safety, the resident should have been placed on his back and the bed lowered before leaving the room, especially given the resident's quadriplegia. Interviews with facility leadership, including the DON and Administrator, revealed that staff are expected to ensure residents are left in a safe position before stepping away, which includes centering the resident in bed and lowering the bed. Both leaders agreed that, for a resident with quadriplegia, the safest position when left briefly would be on the back. Facility policies require individualized fall prevention interventions and safe positioning during care, but these were not consistently implemented in this case, leading to the resident's fall and injury.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement established fall prevention interventions for two residents, leading to significant injuries. One resident, a male with a history of frequent falls and multiple medical conditions, was readmitted to the facility without the necessary fall interventions in place. Despite recommendations for bed and chair alarms, caregiver supervision, and a toileting schedule, these measures were not implemented until after the resident experienced falls. The resident's care plan did not initially include these interventions, which were only added after subsequent falls occurred. Another resident, also a male with a complex medical history including cirrhosis, emphysema, and a history of falls, was admitted to the facility without adequate fall prevention measures. Upon admission, the resident was placed in a room far from the nurses' station and without bed sensors or railings. The resident experienced a fall resulting in a femur fracture shortly after admission. The facility did not incorporate information from the resident's family regarding his fall risk into his care plan, and necessary interventions such as bed alarms and side rails were not implemented until after the fall. Interviews with facility staff revealed that initial fall assessments were not adequately conducted, and personalized fall interventions were not tailored to the residents' needs. The Director of Nursing acknowledged that past medical history and family input should have been considered in the care plans. The facility's policies on fall risk assessment and care planning were not followed, resulting in a lack of timely and appropriate interventions for residents at high risk of falls.
Sanitation Deficiencies in Food Preparation
Penalty
Summary
The facility failed to adhere to its policies and procedures for maintaining sanitary conditions in food preparation, affecting all 96 residents. During an observation in the kitchen, several staff members, including the cook and the food service director, were seen changing gloves without performing necessary hand hygiene. This was a direct violation of the facility's hand hygiene policy, which mandates hand washing or the use of alcohol gel after removing gloves. Additionally, the cook was observed with hair exposed from the back of her hairnet, and a dietary aide had hair exposed from the sides of her hairnet, contrary to the facility's kitchen policy requiring full hair coverage to prevent contamination. Further observations revealed that surfaces were not sanitized after being cleaned with soapy water, and the food processor was not adequately dried before use. The food service director acknowledged that surfaces should be sanitized immediately after cleaning and that the food processor should be allowed to drain to prevent contamination. However, the food processor was used with noticeable water remaining, which could alter the consistency of pureed food and introduce contamination. These lapses in following established procedures highlight significant deficiencies in maintaining sanitary conditions in the facility's kitchen.
Infection Control Deficiencies in PPE Use and Catheter Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several observed deficiencies. A Certified Nurse Assistant (CNA) was seen providing activities of daily living (ADL) care to a resident with chronic viral hepatitis C without changing soiled gloves between tasks, such as wiping the resident's face and cleaning the genital area. This practice risks cross-contamination and violates standard infection control protocols. Another deficiency was observed with a resident who had an indwelling urinary catheter. The resident's urine bag was not kept in a privacy bag and was seen dragging on the floor as the resident moved in a wheelchair. This improper handling of the catheter and urine bag increases the risk of contamination and infection, as confirmed by a Registered Nurse (RN) who acknowledged the need for the catheter and tubing to be kept off the floor. Additionally, a podiatry assistant and podiatrist failed to adhere to enhanced barrier precautions and droplet precautions while providing care to residents. They did not wear gowns or perform hand hygiene when moving between rooms of residents with gastrostomy tubes and active COVID-19 infection. This lack of adherence to infection control measures, such as wearing appropriate personal protective equipment (PPE) and performing hand hygiene, further highlights the facility's failure to prevent the transmission of infectious agents.
Medication Labeling and Disposal Deficiency
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and disposal of medications, specifically insulin pens and expired stock medications. During an inspection, a surveyor observed that insulin pens for two residents, R14 and R5, were not dated when first accessed, nor were they labeled with a discard date. The insulin pens, which had been previously accessed, were found in the medication carts without the necessary labeling, contrary to the facility's policy that requires insulin pens to be dated upon opening and discarded within a specified period. Additionally, the surveyor found seven expired bottles of house stock medications in the medication carts, which were not disposed of according to the facility's procedures. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the oversight regarding the insulin pens and the improper disposal of expired medications. The ADON was initially unsure of the duration insulin pens remain viable after opening but later confirmed they should be discarded after 28 days. The DON reiterated that insulin pens should be dated upon first use and that expired medications should not be discarded in trash bins on medication carts, as this poses a risk of contamination and potential harm. The facility's policy mandates that expired medications be removed from circulation and disposed of using a drug buster or returned to the pharmacy, which was not followed in this instance.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in care. For one resident, R7, the facility did not include necessary interventions in the care plan despite a history of frequent falls and recommendations from the interdisciplinary team. The care plan lacked interventions such as bed/chair alarms and a toileting schedule, which were only implemented after the resident experienced falls at the facility. Another resident, R16, experienced delays in being assisted out of bed, which was not addressed in her care plan. Despite grievances and family reports about the need for a get-up schedule, the care plan did not include this intervention. The resident was often left in bed for extended periods, and staff cited her weight as a reason for the delay in using the mechanical lift. For resident R45, the care plan did not address the need for therapy services for a hand contracture, despite a physician's note and family concerns. The resident's care plan lacked timely evaluation for a hand splint, which was only ordered months after admission. Additionally, resident R56's care plan did not include interventions for mood disturbances, despite documented symptoms of depression and family concerns about the lack of social services support.
Failure to Provide Timely Restorative Services for Contracture
Penalty
Summary
The facility failed to provide necessary restorative nursing program services to a resident, leading to a deficiency in care. The resident, a male with a history of partial paralysis following a stroke, dementia, and a history of falling, was observed with a contracted left hand. Despite the resident's admission restorative assessment indicating a need for referral to physical and occupational therapy, the facility did not ensure timely evaluation and treatment for the contracture. The resident's care plan, initiated upon admission, required assistance with activities of daily living and included interventions for skilled rehabilitation therapy evaluation and treatment. However, it did not address the treatment for the left-hand contracture. The resident's family member reported being informed that therapy services were not provided due to insurance coverage issues, despite the resident having multiple medical insurances. The facility's Director of Nursing acknowledged that the resident should have been evaluated for a hand splint much sooner, as delays could lead to further deterioration and worsening of the contracture. The facility's policy mandates comprehensive nursing and restorative needs assessments upon admission, with appropriate services provided based on the resident's functional needs. However, the resident's contracture management, specifically the need for a splint, was not timely addressed, resulting in a deficiency.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess and evaluate a resident for self-administration of medications, specifically inhalers and eyedrops, and did not obtain a physician's order for the eyedrops. The resident, a male with a history of pulmonary embolism, COPD, chronic respiratory failure with hypoxia, and unspecified dementia, was observed with a Combivent inhaler and two bottles of eyedrops at his bedside. The resident reported using the inhaler and eyedrops independently, despite the absence of a formal assessment or physician's order for self-administration. The facility's policy requires an interdisciplinary team to evaluate a resident's ability to self-administer medications safely and to obtain a physician's order for medications to be kept at the bedside. However, the Director of Nursing confirmed that the resident was not supposed to self-administer medications and that no assessment or physician's order was in place. This oversight indicates a failure to adhere to the facility's policies regarding medication administration and physician orders.
Failure to Ensure Safe Repositioning Leads to Resident Injury
Penalty
Summary
The facility failed to develop appropriate interventions to safely turn and reposition a resident who expressed fear of rolling out of bed during repositioning. This deficiency resulted in the resident sustaining an acute clavicle shaft fracture. The resident had a complex medical history, including vertebra fracture, cognitive communication deficit, history of falling, dementia, depression, anxiety, and osteoarthritis. On a specific date, the resident complained of shoulder pain, and an X-ray revealed an acute clavicle fracture. Interviews with staff revealed inconsistencies in the care provided to the resident. A Licensed Practical Nurse (LPN) was notified by a hospice nurse about the resident's shoulder appearing swollen and reddened, prompting an X-ray. The resident reported pain during repositioning, and staff members had varying accounts of the assistance required for turning the resident. Some staff mentioned the resident's fear of falling out of bed and the lack of grab bars or rails, while others noted the resident's need for assistance from one or two persons during repositioning. However, there was no documentation of a turning and repositioning program in the resident's care plan. The facility's documentation and communication regarding the resident's care needs were inadequate. The Director of Nursing (DON) and other staff members were unsure of the level of assistance required for the resident's bed mobility. The resident's care plan lacked follow-up interventions to prevent reoccurrence of injury during repositioning. Additionally, the Medication Administration Record and hospice records indicated discrepancies in pain management and documentation, further highlighting the facility's failure to ensure adequate supervision and safety measures for the resident.
Failure to Conduct Timely Pain Assessment and Management
Penalty
Summary
The facility failed to conduct a comprehensive pain assessment for a resident after the new onset of pain persisted for more than 12 hours. This oversight affected a resident who had a right clavicle fracture, resulting in their pain escalating from intermittent to constant, with a severity rating of 10 out of 10. The resident's medical history includes vertebra fracture, cognitive communication deficit, symptoms involving the nervous system, history of falling, dementia, depression, anxiety, and osteoarthritis. Despite the resident's complaints of shoulder pain and the presence of a sling, the facility did not perform timely pain assessments or administer appropriate pain management. Interviews with staff revealed that the resident experienced significant discomfort when repositioned, yet there was a lack of communication and documentation regarding the resident's pain levels. The Director of Nursing acknowledged that pain should be assessed every shift and that a new onset of pain should prompt a call to the physician and a pain assessment. However, records show gaps in pain assessments and medication administration, with no pain scale ratings documented for several days. The hospice nurse had instructed the facility nurse to assess and administer medication as needed, but this was not consistently followed, leading to the resident enduring untreated pain for nearly 24 hours.
Incomplete Documentation and Lack of Incident Reporting for Resident Injury
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and accurately documented, particularly concerning restorative assessments and interventions to address care plan needs. The resident, who had multiple diagnoses including vertebra fracture, dementia, and osteoarthritis, complained of shoulder pain, which was later identified as an acute clavicle fracture. Despite being on a turning and repositioning program, there was no documentation of this program in the resident's records. Interviews with CNAs revealed inconsistencies in the assistance required for turning the resident, and there was no documentation of these observations in the resident's chart. The Director of Nursing acknowledged the absence of an incident report for the resident's injury and stated that the IDPH reportable served as documentation, which was not part of the resident's chart. A pain assessment was not documented, and there were no additional interventions recorded to prevent similar injuries. The restorative assessments were incomplete and were only filled out after the surveyor's inquiry. The care plan was updated to include the clavicle fracture after the resident's death, and the facility's policy for documentation was not provided upon request. The facility's policy required an incident report for all incidents, including injuries of unknown source, which was not adhered to in this case.
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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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