Hillcrest Retirement Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Round Lake Beach, Illinois.
- Location
- 1740 North Circuit Drive, Round Lake Beach, Illinois 60073
- CMS Provider Number
- 146130
- Inspections on file
- 23
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Hillcrest Retirement Village during CMS and state inspections, most recent first.
A resident reported that a CNA used a condescending tone of voice while providing care, which the resident perceived as discourteous. The administrator confirmed the resident’s complaint and documentation showed the CNA had previously received a disciplinary warning for discourteous behavior toward the resident. This reflects a failure to provide care and communication that support the resident’s dignity and right to a respectful, dignified existence.
A resident with dementia, depression, hallucinations, CKD, and multiple other comorbidities experienced a fall associated with catheter removal, but staff failed to document the fall event itself, including date, time, and location, in the EMR or risk management system. Although the resident’s care plan already identified a high fall risk related to hallucinations, psychotropic use, and self-lowering behaviors, it was not reviewed or revised after the fall. An LPN described the expected process for post-fall assessment and incident reporting, and the DON stated that care plans are to be updated after falls and that she is responsible for those updates, but she was unaware the fall had occurred. The facility’s fall policy requires incident documentation and immediate interventions for witnessed and unwitnessed falls, which were not completed in this case.
Surveyors found that kitchen staff did not maintain quaternary ammonium (quat) sanitizing solution at the required 200–400 ppm concentration or change it every 2 hours as required by facility policy, with test strips repeatedly reading 0 ppm despite staff acknowledging it should be effective for sanitizing food prep areas. During the same kitchen tour, surveyors observed a bag of hot dog buns on the bread cart that was dated beyond the facility’s 6‑day discard timeframe, contrary to the facility’s labeling and dating policy intended to control foodborne illness for all residents.
Surveyors found that multiple residents with G-tubes, indwelling urinary catheters, and chronic wounds had active orders for Enhanced Barrier Precautions (EBP), but their rooms lacked EBP signage and PPE availability at the doorway. One resident receiving enteral nutrition via gastrostomy tube, another with a long-term urinary catheter, and a third with a stage 4 pressure wound all had no posted EBP indicators or PPE outside their rooms. Additional residents sharing a room, one with G-tube bolus feedings and another with sacral wound treatments, also had no EBP signs posted. The facility’s infection prevention nurse and written EBP policy both specified that residents with these devices and chronic wounds should be on EBP and clearly identifiable as such.
A resident repeatedly reported feeling uncomfortable and upset due to her roommate’s jealous and inappropriate behaviors, especially when she had visitors, and stated she did not want to return to her room. Observations showed the roommate crying, calling out for the resident, and hovering over her while the resident attempted to rest, without staff intervention or redirection. The resident’s spouse reported that these behaviors were significantly affecting his wife, including multiple distressed phone calls, and voiced concerns to the DON and social services, who were aware of the situation but had only discussed, not implemented, a room change or other boundaries.
A resident with severe cognitive impairment and limited physical mobility, who required substantial/maximal assistance with personal hygiene per the MDS and care plan, was observed in a common area with prominent whiskers on her chin. CNAs and the Administrator stated that residents receive showers at least twice weekly and that shaving is included on shower days for both men and women. Despite a facility policy requiring staff to assist with grooming facial hair to maintain proper hygiene, the resident did not receive appropriate shaving assistance, resulting in visible facial hair.
Two residents at risk for pressure injuries did not receive ordered pressure-relieving interventions. One resident had an order for an air mattress to be on at all times, but surveyors twice observed the resident in bed with the air mattress pump unplugged and off, despite documentation of pressure-injury risk and a care plan listing an air mattress as an intervention. Another resident, dependent on staff for care and identified as at risk for pressure, was transferred to bed and provided incontinence care by CNAs without application of ordered protective boots, even though a sign above the bed and the care plan directed that cradle/protective boots be on at all times in bed. The facility’s pressure injury policy requires implementation of interventions for all residents assessed as at risk.
A resident with an indwelling urinary catheter and a history of frequent UTIs was observed in a wheelchair with a leg drainage bag attached high on the thigh, positioned above bladder level and without slack in the tubing, preventing gravity-assisted drainage. A CNA acknowledged that catheter drainage bags should be kept below the waist to prevent UTIs/infections. The resident’s care plan and the facility’s catheter care policy both required that the catheter drainage bag and tubing be maintained below the level of the bladder to discourage backflow of urine, but this was not followed.
A resident with moderate dementia and anxiety exhibited escalating behaviors including yelling, crying, delusions, pacing, and intense preoccupation with a roommate, yet staff did not consistently intervene or document specific behavioral interventions during observed episodes. On one day, the resident loudly yelled and became agitated after a CNA delivered a meal tray; an RN attempted redirection but the resident remained distressed, and later that day two CNAs provided care to the roommate while the resident continued crying and calling out without staff engagement. Staff interviews and social services notes confirmed ongoing anxiety, hallucinations, and obsessive focus on the roommate, with acknowledged increases in behaviors after an antidepressant dose reduction, but progress notes lacked documentation of the observed behavioral incidents or targeted interventions, contrary to the facility’s dementia care policy requiring person-centered, non-pharmacological approaches and individualized care plan implementation.
A resident with COPD, whose principal diagnosis was COPD, had an order for an ipratropium-albuterol inhaler to be given four times daily, but two scheduled doses were not administered when the inhaler was not available at the time of medication pass. The MAR documented the missed doses and referenced notes indicating the medication was unavailable, and the resident reported missing two doses of the inhaler. An LPN later stated the inhaler was not in the med cart when she attempted to give it and was later found at the end of the resident’s bed, although it should have been stored in the cart. The DON confirmed the inhaler had been misplaced, despite the care plan and facility policy requiring medications to be administered as ordered.
Surveyors found that controlled medications and insulin were not managed according to facility policy. In one medication room, an LPN left the medication refrigerator unlocked while it contained a new box of Methadone Oral Concentrate, a Schedule II controlled substance, despite facility policy requiring locked storage. In a separate case, a resident with diabetes had a Humalog KwikPen labeled with an expiration date that had already passed, and an RN acknowledged it should have been discarded, while the facility’s insulin pen policy required disposal after 28 days.
A resident with documented oral/dental health problems did not receive routine or preventative dental care during more than two years in the facility. The resident’s spouse reported that no dental services had been provided and that he was only notified in writing much later that a dentist could see the resident if she was enrolled in a dental program. The Administrator confirmed the resident had never seen a dentist there and explained that, although eligible, she was not enrolled in the dental program. The DON stated there was no dental policy in place and acknowledged the resident was not offered enrollment in the dental plan at admission, noting she was Medicaid pending and was not informed about the program after Medicaid coverage began.
A resident with mobility issues and requiring mechanical lift assistance was found with a displaced left hip fracture after being put to bed early due to not feeling well. Despite staff reports of no falls or complaints of pain, the resident was discovered in pain with a hip deformity and cheek redness, suggesting a fall. The facility's investigation classified the injury as of unknown origin, highlighting a deficiency in supervision and monitoring.
A facility failed to supervise residents with a history of falls, resulting in injuries. One resident sustained a hip fracture due to lack of close supervision, while another suffered a head wound from improper transfer by a single CNA, against policy. A third resident's care plan was not updated after multiple falls, violating the facility's policy on monitoring and modification.
A facility failed to properly sanitize a blender pitcher used for pureed diets, affecting four residents. The dietary staff did not ensure the presence of sanitizer in the three-compartment sink, compromising the sanitization process. The dietary director confirmed the absence of sanitizer and corrected the issue, but not before the blender was used for meal preparation.
The facility failed to implement enhanced barrier precautions (EBP) for six residents with specific medical needs, such as urinary catheters, a urostomy, wounds, and a PEG tube. Observations revealed the absence of EBP signage and PPE stations outside residents' rooms. The Infection Control Nurse was unaware of the mandatory nature of EBP and admitted the facility lacked a policy on it.
A resident with psoriatic arthritis and other health issues was not provided with a necessary rheumatology consultation after her initial appointment was canceled due to insurance issues. Despite being in pain and expressing a desire to see a specialist, the facility did not reschedule the appointment, as confirmed by the DON.
Failure to Ensure Respectful and Dignified Communication During Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to a dignified existence, self-determination, communication, and exercise of rights. On 02/17/2026 at 9:50 AM, R1 was observed sitting in her room in an overstuffed reclining chair. Earlier that morning, at 9:31 AM, the Administrator (V1) stated that R1 reported disliking the tone of voice used by a CNA (V3) during care, describing it as condescending. R1 communicated this concern to the Administrator. Record review showed that V3 had received a Disciplinary Warning Notice dated 01/14/2026 for “discourteous behaviors to resident,” confirming that the CNA’s manner of interaction with R1 had been identified as inappropriate. This conduct reflects a failure to provide care and communication that support the resident’s dignity and quality of life.
Failure to Document Fall and Update Care Plan After Incident
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s fall and to update the resident’s care plan following that fall. Progress notes for the resident showed entries on one day indicating that the resident’s catheter had been dislodged and reinserted in the morning, and later that the catheter was removed during a recent fall, with another note stating the catheter was removed during a fall that evening. However, there was no documentation in the progress notes of the date, time, location, or any additional information related to the fall itself. The DON later confirmed that the nurse did not enter a note in the facility’s risk management system or any incident note in the electronic medical record about the fall, and that she was not aware the fall had occurred. The resident’s care plan, dated prior to the fall, identified the resident as being at risk for falls related to hallucinations, antidepressant use, and behaviors such as intentionally sliding out of a wheelchair to the floor when up longer than desired. Despite this identified fall risk and the documented references to a fall in the catheter-related notes, the care plan was not reviewed or revised after the fall. The DON stated that care plans are to be updated after a fall and that she is responsible for updating them, but acknowledged that the resident’s care plan was not updated because she was unaware of the fall. The facility’s fall policy requires the nurse to complete risk management documentation for witnessed or unwitnessed falls and to complete an incident note under progress notes at the time of the incident, as well as to initiate interventions immediately based on the resident’s specific needs, which did not occur in this case.
Improper Sanitizer Concentration and Failure to Discard Expired Bread
Penalty
Summary
Surveyors identified that the facility failed to maintain appropriate sanitizing solution levels for food contact surfaces in the kitchen. During an observation, the dietary manager tested the quaternary ammonium (quat) sanitizing solution in a bucket and the test strip registered a light orange color corresponding to a 0 ppm level, both after 10 seconds and again after approximately 20–30 seconds. The dietary manager stated the solution should be between 200–400 ppm and that the strip should turn dark blue to be effective for sanitizing food preparation areas. The dietary manager also stated the sanitizing solution was only effective for 2 hours and needed to be replaced. A dietary aide later reported that the sanitizing solution had been mixed at 6:00 AM and should have been replaced at 8:00 AM to remain effective, indicating it had not been changed in accordance with facility policy. Surveyors also found that the facility failed to discard expired bread products in the kitchen. During a kitchen tour, a bag of hot dog buns on the bread cart was observed with a date of 8/8/25. The dietary manager stated that all bread products were dated on the day of delivery and were to be discarded within six days, confirming that the buns should have been discarded by 8/15/25. The facility’s policies on manual sanitizing and on labeling and dating of foods documented that quat sanitizing solution must be maintained at 200–400 ppm and changed every 2 hours, and that food must be labeled with dates received, opened, and discard dates to decrease the risk of foodborne illness and provide the highest quality food. At the time of the survey, the CMS-671 form documented 126 residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions for Residents With Devices and Wounds
Penalty
Summary
Surveyors identified a failure to implement the facility’s Enhanced Barrier Precautions (EBP) policy for multiple residents who met criteria for these precautions. For one resident with a gastrostomy tube receiving enteral nutrition, there was a current physician order for EBP, but no EBP signage was posted on or near the room entrance and no PPE was available outside the room. Another resident with an indwelling urinary catheter in place for at least three months had current orders for EBP and for monthly catheter changes, yet the room lacked EBP signage and PPE outside the door. A third resident with a stage 4 pressure wound on the left lateral knee, receiving wound treatment and with a current EBP order, also had no EBP sign posted and no PPE located outside the room. Additional residents with qualifying conditions similarly did not have EBP implemented as required. One resident with an indwelling urinary catheter, whose drainage bag was changed to a leg bag during the day and who had current orders for EBP and monthly catheter changes, had no EBP signage or PPE outside the room. Two other residents sharing a room, one with orders for G-tube maintenance and bolus tube feeding and the other with orders for sacral wound treatments and dressings, had no EBP signs posted on or around their shared room. The facility’s own EBP policy stated that residents with medical devices such as catheters and feeding tubes, and residents with chronic wounds, must be on EBP precautions and that residents on EBP isolation must be identifiable as being on that status. The Infection Prevention Nurse confirmed that residents with chronic wounds, G-tubes, or indwelling urinary catheters should be on EBP.
Failure to Accommodate Resident’s Needs and Preferences Regarding Roommate Behaviors
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences regarding her roommate’s behaviors. During an initial tour, one resident in a wheelchair reported she was having problems with her roommate, stating the roommate became jealous when she had visitors and made inappropriate comments, leading her to say she did not want to return to her room. Later the same day, the resident again expressed discomfort, stating that although the facility had discussed moving rooms, she felt she should not have to move because she liked her room and felt uncomfortable when her roommate exhibited behaviors toward her. Further observations showed the roommate lying in bed crying while the resident sat next to her, holding her hand. When CNAs entered to transfer and provide care to the resident, the roommate repeatedly called out for the resident, asking her not to leave, while crying. The resident attempted to rest in her bed, but the roommate continued calling out, and the CNAs did not intervene or redirect the roommate. The resident’s spouse reported to management that the roommate’s behaviors were affecting his wife, including multiple upset phone calls about the roommate issues. The DON acknowledged that the spouse reported the roommate was “driving” the resident “insane” and that a room change had been discussed but not implemented due to concerns the roommate might follow her. Social services also stated that the roommate hovered over the resident, causing her to become upset, and that the spouse wanted more boundaries and limits to protect his wife.
Failure to Assist Dependent Resident With Facial Hair Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) by not ensuring a female resident was shaved and free of facial hair. On one observation, the resident was seen in the dining room with prominent whiskers covering her chin. Certified Nursing Assistants (CNAs) reported that all residents receive showers at least twice a week and that shaving for both men and women is included on shower days, and the Administrator confirmed that shaving occurs on shower days. The resident’s care plan documented an ADL self-care performance deficit and limited physical mobility, and her Minimum Data Set (MDS) indicated severe cognitive impairment and a need for substantial/maximal assistance with personal hygiene, including shaving. The facility’s policy on grooming a resident’s facial hair states that staff are to assist residents with grooming facial hair to maintain proper hygiene, but this was not carried out for this resident as evidenced by the observed facial hair. This deficiency is based on observation, staff interviews, and record review showing that the resident, who required significant assistance with personal hygiene due to cognitive and physical limitations, did not receive the grooming care outlined in her care plan and the facility’s grooming policy.
Failure to Implement Ordered Pressure-Relieving Interventions for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure-relieving interventions for residents identified as at risk for pressure injuries. For one resident (R5), the Medication Review Report dated 8/26/25 showed an order for an air mattress to be on at all times. Observations on 8/25/25 at 2:06 PM and on 8/26/25 at 1:42 PM found the resident in bed with the air mattress pump hanging at the foot of the bed, with the lights off and the pump unplugged on both occasions. On 8/27/25 at 9:01 AM, an LPN (V13) confirmed that an air mattress pump is a pressure-relieving intervention. R5’s Braden Scale dated 8/18/25 indicated the resident was at risk for pressure injuries, and the care plan revised 8/19/25 documented potential for skin impairment with an air mattress listed as an intervention. The deficiency also includes failure to apply ordered protective boots for another resident (R30) at risk for pressure injuries. On 8/25/25 at 1:35 PM, two CNAs (V10 and V11) transferred R30 to bed with a mechanical lift and provided incontinence care, then positioned the resident’s feet on the mattress without applying the protective boots. A bright-colored sign above the bed displayed a turning schedule and directed that cradle boots be on at all times when the resident was in bed. On 8/26/25 at 12:33 PM, an RN (V8) stated that R30 is at risk for pressure, dependent on staff for care, and should have protective boots applied when in bed. R30’s current care plan documented potential impairment to skin integrity related to fragile skin, with interventions including an air mattress, wheelchair cushion, and protective boots while in bed. The facility’s Pressure Injury Prevention and Management Policy states that interventions will be implemented for all residents assessed and considered at risk.
Improper Positioning of Indwelling Catheter Drainage Bag
Penalty
Summary
Surveyors identified a deficiency in catheter care when a resident with an indwelling urinary catheter and a history of frequent UTIs was observed sitting in the dining room in a wheelchair with a leg drainage bag attached high on the top of the thigh, positioned above the level of the bladder and without slack in the tubing, which did not allow gravity to aid urine drainage. On a subsequent interview, a CNA stated that urinary catheter drainage bags should be kept below the waist to prevent UTIs/infections. The resident’s care plan indicated the presence of an indwelling urinary catheter and the need for the drainage bag and tubing to be maintained below the level of the bladder, and the facility’s catheter care policy likewise stated that drainage bags should be located below the level of the bladder to discourage backflow of urine. Despite these documented requirements, the drainage bag was not maintained below bladder level for this resident.
Failure to Implement and Document Dementia-Related Behavioral Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document individualized interventions and services for a resident with dementia and anxiety who was exhibiting escalating behavioral and emotional distress. The resident had documented diagnoses of unspecified dementia (moderate) with anxiety, anxiety, hypertension, and muscle weakness, and her care plan indicated moderately impaired cognition and dependence on staff for emotional, intellectual, physical, and social stimulation. Despite a dementia care policy requiring person-centered, non-pharmacological approaches and care plan interventions related to each resident’s symptomatology, the resident’s increased anxiety, crying, yelling, delusions, and preoccupation with her roommate were not consistently addressed with observable interventions or documented in the clinical record. On one observed day, the resident was initially sleeping when a CNA delivered her meal tray, after which she began loudly yelling statements such as “Stay out of my life” and “Get out of it.” The CNA left to notify an RN, and the resident continued to yell and appear agitated. The RN attempted redirection but the resident remained distressed; the RN reported that the resident had earlier accused staff of trying to kill her and believed she might have a urinary tract infection. Later that day, the resident was observed crying in bed, repeatedly calling out to her roommate not to leave her, while the roommate attempted to console her. Two CNAs entered to provide care and transfer assistance to the roommate but did not approach or intervene with the crying, anxious resident, who remained tearful and asking for a kiss when the surveyor left the room. On the following day, the resident was observed wandering, pacing, and appearing restless in her room. Multiple staff interviews confirmed that the resident frequently cries, hallucinates, worries, misses her family, and becomes very anxious and nervous, particularly in relation to her roommate, over whom she “hovers” and becomes preoccupied. Staff, including CNAs, an LPN, the DON, and Social Services, acknowledged that the resident has ongoing behavioral symptoms, including delusions and emotional lability, and that her behaviors had increased after a decrease in antidepressant medication at family request. Social Services documentation noted her anxiety and preoccupation with the roommate and with the roommate’s spouse. Despite these ongoing and escalating behaviors, the progress notes contained no documentation on the day of the observed increased behaviors regarding the episodes or any interventions implemented, and the existing care plan interventions remained general (e.g., consults, encouragement of activities, monitoring) without evidence of being actively implemented during the observed episodes of distress.
Missed COPD Inhaler Doses Due to Misplaced Medication
Penalty
Summary
The facility failed to provide ordered pharmaceutical services when a resident with chronic obstructive pulmonary disease (COPD), whose principal diagnosis was COPD, did not receive two scheduled doses of an ipratropium-albuterol inhaler. The resident’s medication review showed an order for the inhaler to be administered four times daily for COPD, and the August medication administration record documented that the 3:00 PM and 8:00 PM doses on 8/18/25 were not given, with a code directing to progress notes. The corresponding progress notes stated the medication was not available for those doses. The resident reported missing two doses of the inhaler about a week prior and did not know why. A nurse stated that when she attempted to administer the inhaler at the scheduled time, it was not in the medication cart, resulting in the missed doses, and that the inhaler was later found at the end of the resident’s bed, although it should have been stored in the medication cart. The DON confirmed the inhaler had been misplaced and should have been kept in the medication cart, and the resident’s care plan and the facility’s medication administration policy both required that medications be administered as ordered.
Failure to Secure Controlled Drugs and Remove Expired Insulin Pen
Penalty
Summary
The facility failed to ensure controlled medications were secured with a dual lock system and failed to discard an outdated insulin pen. During an observation of the 100-200 hall medication room, an LPN opened the medication room and the resident medication refrigerator was found with an open lock hanging on the latch, leaving it unlocked. Inside the unlocked refrigerator was a new box of Methadone Oral Concentrate, a Schedule II controlled substance, for a resident who had a physician’s order for Methadone 10 mg/ml, 4 ml by mouth once daily for pain. The DON confirmed that the medication room refrigerator should be locked. The facility’s Medication Storage Policy stated that all drugs and narcotics must be stored in a locked storage area with limited access by authorized personnel. In a separate incident, a resident’s Humalog KwikPen insulin was observed with a written expiration date that had already passed. An RN stated that the insulin pen should have been thrown away and explained that nurses label insulin with a “use by” date 30 days from when it is opened. The resident’s records showed a diagnosis of diabetes and an active order for Humalog KwikPen to be administered before meals and at bedtime per a sliding scale. The facility’s Insulin Pen Policy specified that insulin pens should be disposed of after 28 days, indicating that the insulin pen in use was outdated according to the facility’s own policy.
Failure to Provide Routine Dental Care and Enrollment in Dental Program
Penalty
Summary
The facility failed to ensure that a resident received routine dental care despite documented oral/dental health problems and over two years of residency. The resident’s husband reported on 8/25/25 that the resident had been in the facility for more than two years and had not received any preventative dental care, and later stated he was notified in writing in early July 2025 that a dentist would come to the facility and see the resident if he enrolled her in the program, but she had not seen a dentist since admission. The admission record dated 8/25/25 shows the resident was admitted on an earlier date, and the current care plan indicates the resident has oral/dental health problems. The Administrator confirmed on 8/27/25 that the resident had not seen a dentist since admission, explaining that although she was eligible for the dental program, she was not enrolled and therefore did not receive dental care. The DON stated on 8/27/25 that the facility had no dental policy and acknowledged that the resident was not offered enrollment in the dental plan upon admission, noting she was Medicaid pending and should have been informed about the program after Medicaid coverage began. These actions and omissions resulted in the resident not receiving routine or preventative dental services during her stay, despite eligibility for a dental program and identified oral/dental health needs.
Resident Safety Lapse Leads to Hip Fracture
Penalty
Summary
The facility failed to ensure the safety of a resident, resulting in a displaced left hip fracture. The resident, who had diagnoses including osteoarthritis, dementia, and unspecified abnormalities of gait and mobility, required substantial assistance for mobility and was typically transferred using a mechanical lift. On the evening of the incident, the resident was put to bed early due to not feeling well, and throughout the night, staff reported no falls or complaints of pain. However, during the morning medication pass, the resident was found with an internally rotated left hip and was in immense pain, leading to an emergency hospital transfer. The hospital records confirmed a comminuted fracture in the left hip, suggesting a fall might have occurred, although staff denied any falls. The paramedic noted a hip deformity and redness on the resident's cheek, which appeared bruised, raising suspicions of a fall. Despite an investigation by the facility, the injury was classified as of unknown origin, and abuse was ruled out. The lack of clear documentation or observation of a fall indicates a deficiency in supervision and monitoring, contributing to the resident's injury.
Inadequate Supervision and Safety Measures Lead to Resident Injuries
Penalty
Summary
The facility failed to adequately supervise and ensure the safety of residents with a history of falls, resulting in significant injuries. One resident, with a history of falls and moderate risk for falling, sustained a right hip fracture. Despite being known for attempting to get up on his own and having impaired cognitive function, the resident was not provided with close supervision as indicated in his care plan. The incident was not witnessed, and there were no documented signs of pain or abnormal behavior prior to the discovery of the injury, indicating a lack of proper monitoring and intervention. Another resident, identified as high risk for falls, suffered a head wound due to improper transfer procedures. The resident was transferred using a mechanical sling lift by a single CNA, contrary to the facility's policy requiring two staff members for such transfers. This lapse in protocol led to the resident falling forward and sustaining a wound on the forehead. The CNA involved acknowledged the deviation from the standard procedure, which was confirmed by the Director of Nursing. A third resident, also at high risk for falls, experienced multiple unwitnessed falls without subsequent revision of their care plan. Despite having a care plan focus on fall risk due to conditions like Parkinson's disease and confusion, the interventions were not updated following the falls. The facility's policy on monitoring and modification of care plans was not adhered to, as there was no evaluation or adjustment of interventions after the incidents, highlighting a systemic issue in addressing fall risks effectively.
Improper Sanitization of Blender Pitcher for Pureed Diets
Penalty
Summary
The facility failed to ensure proper sanitization of a blender pitcher used for preparing pureed diets for residents. On the morning of September 23, 2024, a dietary aide filled the three compartments of the sink, and shortly after, a cook began pureeing couscous for lunch. After finishing, the cook washed the blender pitcher and lid in the three-compartment sink, allowing them to air dry. However, the sanitization process was compromised as the test strip used to check the concentration of the sanitizer solution in the third sink did not register any sanitizer, indicating that the sink lacked the necessary sanitizing solution. The dietary director confirmed the absence of sanitizer in the sink and subsequently refilled it with a pre-diluted sanitizer and water mixture, achieving the correct concentration. This deficiency affected four residents who were on pureed diets, as the blender used for their meals was not properly sanitized according to the facility's policy. The facility's manual sanitizing policy requires utensils and equipment to be sanitized in the third sink by immersion in a chemical sanitizing solution used according to the manufacturer's instructions.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for six residents who required them due to their medical conditions. During an initial tour, it was observed that residents with urinary catheters and a urostomy did not have EBP signs on their doors. Additionally, a resident with wounds on his toes also lacked appropriate signage. The Infection Control Nurse admitted to being unaware that EBP was mandatory and acknowledged the absence of a facility policy on EBP. Further observations revealed that a resident with an indwelling catheter had their catheter bag visibly exposed, and there was no EBP signage or personal protective equipment (PPE) station outside their room. Another resident receiving nutrition through a PEG tube also lacked EBP signage and a PPE station. These oversights indicate a systemic failure in the facility's infection prevention and control program, as evidenced by the lack of EBP implementation for residents with specific medical needs.
Failure to Schedule Rheumatology Consultation
Penalty
Summary
The facility failed to provide necessary care and services to a resident who required a rheumatology consultation. The resident, a female with multiple diagnoses including age-related osteoporosis, psoriatic arthritis, and protein-calorie malnutrition, was observed to be in pain and expressed a desire to see a rheumatologist. Despite having an appointment scheduled for July 24, 2024, it was canceled because the provider did not accept her insurance, and no follow-up appointment was made. The Director of Nursing confirmed that the resident is alert, oriented, and in discomfort due to her arthritis, and acknowledged that a new appointment was not scheduled after the cancellation.
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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