Hillside Rehab & Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yorkville, Illinois.
- Location
- 1308 Game Farm Road, Yorkville, Illinois 60560
- CMS Provider Number
- 145609
- Inspections on file
- 25
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hillside Rehab & Care Center during CMS and state inspections, most recent first.
Two residents at high risk for falls, one cognitively intact with multiple comorbidities and a history of falls and another with vascular dementia and repeated prior falls, were not adequately supervised, leading to multiple unwitnessed falls with fractures. One resident, who required assistance with bathing, was left alone in a shower room, attempted to self-transfer, fell, and later was found to have an acute L1 compression fracture; CNAs assisted him from the floor but did not promptly notify an LPN, contrary to facility policy. The other resident, described as very impulsive with dementia and care-planned for alarms and visual monitoring, sustained several falls over time, including events that caused a tibia fracture, rib fractures, and a femur fracture, despite staff awareness that he often needed 1:1 support. These events reflect failures to implement and follow fall-prevention interventions and post-fall assessment procedures for high-risk residents.
Two residents at high risk for pressure ulcers did not receive appropriate wound care or preventive interventions. One resident's wounds worsened after staff failed to document, communicate, and follow provider orders for wound care consultation and treatment, resulting in hospitalization for sepsis and pressure injuries. Another resident with a coccyx ulcer was not regularly repositioned as required, and both lacked individualized care plans for skin or wound care.
A resident with multiple medical conditions repeatedly requested therapy medical records from the Director of Rehab and submitted a written request to the Administrator, seeking paper copies for her attorney. Despite these requests and documentation by the Business Office Manager, the records were not provided in a timely manner due to miscommunication and lack of follow-through among staff.
A resident with multiple complex medical conditions developed a new wound on the sacrum, which was documented and treated by an LPN, but the family/POA was not notified as required by facility policy. The family only learned of the wound during a subsequent hospital visit, and there was no documentation of any notification in the medical record.
A resident with a history of falls and muscle weakness, who required one-person assist and was identified as a fall risk, was not properly assisted during a transfer to a transport van. The CNA did not use a gait belt as required by facility policy and physical therapy recommendations, resulting in the resident's legs giving out during the transfer, causing bruising and pain. Therapy staff confirmed that a gait belt was necessary for this resident's safety during transfers and stair navigation.
The facility failed to maintain proper food safety and hygiene standards in the kitchen, affecting all residents receiving oral nutrition. Staff were observed not wearing hair coverings, and several food items were found opened and undated, violating facility policies. Additionally, the sanitation bucket lacked the required chemical levels, compromising sanitation standards.
The facility failed to update its Infection Control Policy and conduct infection surveillance, leading to inadequate infection prevention measures. Improper handling of linens, lack of PPE use, and failure to implement Enhanced Barrier Precautions for residents with medical devices or wounds were observed. These deficiencies increased the risk of infection spread among residents and staff.
The facility failed to provide adequate hygiene and grooming care to residents dependent on staff for ADL assistance. One resident was found with saturated undergarments due to a lack of timely incontinence care, while another expressed dissatisfaction with unaddressed grooming needs. Two residents did not receive scheduled showers, despite one having a portable oxygen tank for use during bathing. The DON confirmed that residents should receive regular care, but the facility's policies were not followed.
The facility failed to document essential information about pacemakers and defibrillators for three residents, including physician orders, manufacturer details, and monitoring frequency. The absence of this information was confirmed by the DON, who noted the lack of a relevant policy and the importance of having such details for emergency situations.
A facility failed to follow physician orders for a resident with severe contractures, as restorative devices were not applied to prevent worsening. The resident, who is nonverbal and in a comatose state, was observed without the necessary splints or carrots in her hands, contrary to her care plan and physician orders. The facility lacked a restorative nurse and aides, and there was no documentation of the resident's husband removing the devices, which was not care planned.
A resident with a history of UTIs and urinary retention was observed with a leg bag attached while in bed, contrary to the facility's policy requiring the drainage bag to be lower than the bladder. The DON confirmed this practice could lead to UTIs and improper drainage.
A facility failed to follow proper procedures for checking g-tube placement when administering medications to a resident. An RN used auscultation with air instead of aspirating stomach contents, contrary to the facility's policy and physician orders. The resident, with a history of dysphagia and other conditions, required specific methods for g-tube placement verification, which were not followed.
The facility failed to secure and contain respiratory equipment for four residents, leading to a deficiency in infection control. Nebulizer masks were left uncovered, and tubing was found on the floor, contrary to facility policy. Residents with significant respiratory conditions were not provided with bags for their equipment, as confirmed by their statements and the Director of Nursing.
The facility failed to secure medications for three residents, leading to a deficiency in medication management. One resident kept several medications at her bedside without orders, expressing distrust in staff. Another resident had prescription Nystatin powder on her overbed table, using it without recalling the proper application frequency. A third resident had fluticasone nasal spray in a bag attached to his wheelchair. The facility's policy requires medications to be stored securely and accessed only by authorized personnel, which was not followed.
A resident's surgical procedure was rescheduled due to the facility's failure to follow physician orders to hold a blood thinner. Despite the resident's awareness and attempts to communicate the need to hold the medication, the facility did not document or implement the order, resulting in the medication being administered within the preoperative timeframe. The oversight was attributed to a lack of communication and documentation among staff.
The facility failed to complete quarterly MDS assessments within the required timeframe for five residents, with delays ranging from 123 to 140 days. The MDS Coordinator attributed the delays to assisting the acting DON, causing her to fall behind on her duties.
The facility failed to provide proper peri-care and catheter care, leading to potential risks of UTIs for several residents. Instances included inadequate cleaning of the inner labia and urethra, unsecured catheter tubing causing pulling during transfers, and improper hygiene practices during incontinence care. These deficiencies were observed in residents requiring extensive assistance or total dependence on staff for toileting hygiene.
The facility failed to follow standard infection control practices, including hand hygiene and gloving, during perineum and catheter care. Staff members were observed changing gloves without sanitizing hands and handling soiled items improperly, compromising infection control protocols.
A facility failed to notify the physician, obtain treatment orders, and update the care plan for a resident with a new skin wound. Despite the wound being observed by a hospice CNA, it was not properly documented or communicated to the facility nurse or physician, leading to a lack of timely treatment.
The facility failed to assess and provide proper adaptive devices to a resident with multiple medical diagnoses, leading to ineffective hand rolls and lack of documented rehabilitation evaluation, raising concerns about potential hand contractures.
The facility failed to document the reason for the use of an antipsychotic medication and develop interventions for dose reduction for a resident with multiple medical diagnoses. Despite being on Risperidone, there was no documentation justifying its use, and the care plan did not include any targeted behavior. Staff interviews indicated the resident experiences forgetfulness but no aggressive or unusual behaviors.
The facility failed to follow the standardized recipe for pureed butternut squash during meal preparation for two residents on pureed diets. The cook used incorrect amounts of broth and thickener, resulting in a watery mixture that required additional thickener. The dietitian confirmed that not following the recipe could compromise nutrient values.
The facility failed to serve pureed braised beef in the desired consistency for two residents on pureed diets. The cook prepared the beef, but the resulting product had shreds and appeared granular, requiring chewing. The Dietary Manager acknowledged the inconsistency, and the Dietitian confirmed that pureed products should be smooth and pudding-like. The residents' meal tickets indicated they were on pureed diets for chewing or swallowing difficulties.
Failure to Supervise High-Risk Residents Resulting in Falls and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for residents at high risk for falls, resulting in falls with fractures for two residents. One resident (R1), who had diagnoses including CHF, shortness of breath, Type 2 DM, morbid obesity, anxiety disorder, and a prior wedge compression fracture of the first lumbar vertebra, required one‑person assistance with bathing and had a care plan noting a history of multiple falls. On the day of his fall, R1 went to the shower room in his wheelchair with clean clothes. He reported that while in the bathroom he finished and told a CNA (V3) he was ready to get up, but she told him to wait; he stated he had already been sitting for 25 minutes and did not want to wait, so he attempted to transfer himself to his wheelchair and fell. R1 stated that V3 was on the phone, that she and another CNA (V20) helped him up, and that V3 did not report the fall to the nurse. Nursing and CNA statements and documentation show inconsistent but related accounts of the same event, all indicating that R1 was not properly supervised in the shower room and that the fall was not promptly reported to nursing for assessment. The LPN (V4) on duty saw R1 pass the nurses’ station with clean clothes, later saw the shower room call light and confirmed V3 was in the room with R1, and then saw V3 wheel R1 back to his room. R1 then told V4 he had fallen in the shower room, had severe back pain, and wanted to go to the hospital. V4 documented that V3 had not informed him of the fall and that when questioned later, V3 said she was going to tell him and that she had told R1 not to remove his rubber shoes. V3’s own written statement said she told R1 not to take his shoes off in the shower and that he stood up and slipped; another CNA (V20) stated that V3 had told R1 to go to the shower room alone, that she knew he could not shower independently, and that V3 later asked her to help get him up after he fell. The facility’s incident report and hospital records confirm that R1 slipped and fell in the shower, was not with a CNA at the time of the fall per the final investigation addendum, and was later found to have an acute compression fracture of L1. The second resident (R3) also experienced multiple falls with serious injuries in the context of high fall risk and inadequate supervision. R3 had diagnoses including vascular dementia, major depressive disorder, Type 2 DM, and right knee pain, and his care plan identified him as at risk for falls due to vascular dementia, with interventions including chair and bed alarms and keeping him in visual range of floor staff. His records show a fall resulting in a right tibia fracture, two additional falls on the same later date that led to two separate ED visits and rib fractures, and another fall on a subsequent date where he was found on the floor on his left side outside his room, reporting pain to his back, left shoulder, and left hip. The facility’s serious injury incident report for that later fall states that the final investigation determined he sustained a left femur fracture. The administrator and an RN both described R3 as very impulsive, with dementia, and noted that he needed 1:1 support and that staff tried to keep him with someone or provide 1:1 “as much as they could,” but they were not able to provide continuous 1:1 care. Despite his repeated falls, documented cognitive impairment, and identified need for close supervision, he continued to experience falls with fractures, indicating that the planned interventions and supervision were not effectively implemented to prevent these events. The facility’s own falls management policy requires that residents identified as high risk have fall prevention addressed on the plan of care and that when a resident falls, reports falling, or is suspected of falling, staff must assess for injury, provide treatment, and document in the EHR. In R1’s case, the resident was left alone in the shower room despite requiring assistance with bathing and having a history of falls, and the CNAs who assisted him from the floor did not immediately notify the nurse, contrary to policy. In R3’s case, although his care plan called for alarms and keeping him within visual range, he was repeatedly found on the floor after unwitnessed falls, including outside his room, despite staff awareness of his impulsivity and dementia. These actions and inactions demonstrate a failure to provide adequate supervision and to consistently follow the facility’s fall prevention and post‑fall assessment procedures for residents at high risk for falls.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to follow a nurse practitioner's order to consult a wound care doctor for a newly acquired wound and did not implement appropriate pressure ulcer prevention and care for two residents. One resident, who had multiple significant medical diagnoses including encephalopathy, end stage renal disease, and dementia, was identified as high risk for pressure ulcers and required substantial assistance for repositioning. Upon readmission, redness was noted on the resident's buttocks and heels, but the heel assessment was not documented, and only the buttocks redness was communicated to the next shift. When an open area was later found, the nurse notified the doctor via a messaging system but did not enter any orders or document the wound in wound rounds. The nurse practitioner's directive to consult wound care was not entered into the system, resulting in no treatment or wound care consult being provided. The resident's care plan lacked any skin or wound care interventions, and the resident was not listed among those with facility-acquired wounds, despite clear evidence of wound progression and subsequent hospitalization for sepsis and pressure wounds. Another resident, with diagnoses including rhabdomyolysis and chronic kidney disease, was also at risk for pressure ulcers and required maximal assistance for repositioning. This resident developed a coccyx ulcer, which was first identified by a wound doctor over a month after it appeared on the facility's wound list. Observations showed the resident remained in the same position for extended periods, contrary to the facility's policy requiring repositioning every two hours for bedbound residents. Staff stated the resident was kept on her right side to avoid pressure on the coccyx ulcer, but there was no evidence of regular repositioning or a care plan addressing skin or wound care. Both residents lacked individualized care plans for skin or wound care, and the facility did not follow its own wound management and repositioning policies. The failures included lack of documentation, communication, and follow-through on provider orders, as well as absence of preventive and treatment interventions for residents at risk for or experiencing pressure ulcers.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with requested medical records in a timely manner. The resident, who had diagnoses including myopathy, inflammatory and immune myopathies, leg pain, anxiety, atherosclerotic heart disease, and a history of falls, made multiple requests to the Director of Rehab for therapy medical records. Despite assurances from the Director of Rehab that the records would be provided, the resident did not receive them. The resident also submitted a written request for medical records to the Administrator, who did not fulfill the request after being informed by the Business Office Manager that the resident allegedly no longer needed the paperwork. Further interviews revealed that the Business Office Manager had spoken with the resident, who clarified that she wanted paper copies of her medical records to provide to her attorney and did not wish to review them with staff. The Business Office Manager documented this request and communicated it to the Administrator, but was waiting for the Administrator to provide the records. The Director of Rehab, after consulting with her supervisor, deferred the request to the facility and did not inform the resident of the proper procedure. As a result, the resident's request for medical records was not fulfilled in a timely manner.
Failure to Notify Family/POA of New Wound
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's family or Power of Attorney (POA) of a new wound that developed on the resident's sacrum. The resident, who had multiple significant medical diagnoses including encephalopathy, malignant melanoma, end stage renal disease, epilepsy, chronic congestive heart failure, and dementia, was found to have skin breakdown with redness and open areas on the buttocks, as documented by an LPN in the progress notes. The wound was treated and documented in the medical record, but there was no evidence that the family or POA was informed of this new condition. The resident's family member and POA later stated that they were not notified of the wound and only became aware of it during a hospital visit. The LPN who discovered and documented the wound confirmed that the family was not notified and acknowledged that both the physician and family should have been informed and that such notifications should be documented. Review of the facility's policy confirmed the requirement for immediate notification of significant changes in a resident's condition to the family or representative, but no such documentation or notification was found in this case.
Failure to Use Gait Belt and Provide Safe Transfer During Van Transport
Penalty
Summary
A deficiency occurred when a resident with a history of myopathy, leg pain, anxiety, atherosclerotic heart disease, and a history of falls was not properly assisted during a transfer to a transport van for a medical appointment. The resident, who was identified as a fall risk and required one-person assist with transfers, expressed to the CNA that she could not walk to the van and needed a wheelchair. After retrieving a wheelchair, the CNA was unable to place the resident in the designated wheelchair area of the van due to equipment blocking the space and instead attempted to assist her into the front seat without the use of a gait belt. Despite the resident's repeated statements that she lacked the strength to ascend the van stairs, the CNA encouraged her to try and attempted to assist her manually. During the transfer, the resident's legs gave out, resulting in her legs flopping and hitting objects, and the CNA pushed her from behind into the seat. The same process was repeated on the return trip, during which the resident again experienced her legs giving out and was physically lifted and pushed into the seat, resulting in bruising to her knees, legs, and chest. The resident reported pain and bruising, and subsequent imaging showed no fractures. Physical therapy documentation indicated that the resident was a fall risk, experienced dizziness during ambulation, and required contact guard assistance with a gait belt for stair training. Therapy staff confirmed that a gait belt was always used for her safety during such activities. The facility's safe handling program also required the use of gait and transfer belts when manual assistance was needed for ambulation and transfers. The CNA involved admitted to not using a gait belt during the transfer, contrary to facility policy and the resident's care needs.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards in the kitchen, affecting all residents who receive oral nutrition from the facility. During a kitchen tour, it was observed that staff members, including the Culinary Director and a cook, were not wearing hair coverings while preparing food, which is against the facility's Personal Hygiene & Uniform Appearance Policy. Additionally, several food items in the dry storage room, freezer, and chiller were found opened and undated, including bags of gravy mixes, panko, tater tots, potato wedges, and jars of peanut butter, as well as cans of corn and mandarin oranges that were dented. This lack of proper labeling and dating of food items violates the facility's Food and Supply Storage Policy, which requires all foods to be covered, labeled, and dated. Furthermore, the facility failed to maintain proper sanitation levels in the kitchen. During the inspection, the sanitation bucket was tested twice and found to have no sanitation chemical present, as indicated by the test strip's color. The manufacturer's guidelines require a specific ppm level for effective sanitation, which was not met. The Culinary Director was unable to explain the deficiency in the sanitation bucket, which is a violation of the facility's Sanitizing and Disinfectant Solutions Policy. This policy mandates that employees prepare sanitizer solutions according to manufacturer guidelines to prevent contamination in food preparation areas.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain and update its Infection Control Policy, which was last revised in August 2018, and did not conduct infection surveillance since October 2024. This lack of surveillance meant the facility was unable to track infections and implement necessary prevention measures. The Director of Nursing (DON) and the newly appointed Infection Preventionist (IP) acknowledged these deficiencies, highlighting a significant gap in infection control practices. The facility also demonstrated improper handling and storage of linens, with dirty linens left on the floor and clean linens stored in soiled utility rooms, increasing the risk of cross-contamination. Staff members were observed not wearing appropriate Personal Protective Equipment (PPE) when required, such as during contact precautions, and failed to perform proper hand hygiene between resident interactions. These actions were contrary to the facility's policies and contributed to the potential spread of infections among residents. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds, as required by their policy. There was a lack of signage and PPE bins outside residents' rooms, and staff did not wear the necessary PPE during high-contact care activities. This oversight in following EBP protocols further compromised infection control efforts, putting both residents and staff at risk of infection transmission.
Deficiencies in Hygiene and Grooming Care for Residents
Penalty
Summary
The facility failed to provide adequate hygiene and grooming care to residents who were dependent on staff for assistance with activities of daily living (ADL). This deficiency was observed in four residents, including one resident who was found with saturated undergarments and bed linens due to a lack of timely incontinence care. The Certified Nursing Assistant (CNA) responsible for the resident admitted to not providing care since early morning, despite the facility's policy requiring checks every two hours. The Director of Nursing (DON) confirmed that staff should perform hourly rounds and provide necessary care, even if the resident is asleep. Another resident expressed dissatisfaction with her personal grooming, specifically her long, jagged nails and facial hair, which she stated had not been attended to by the staff. The resident's Minimum Data Set (MDS) indicated that she was cognitively intact but dependent on staff for personal hygiene. The DON acknowledged that staff should provide daily personal hygiene, including shaving and nail care, as needed. The facility's policies emphasized the importance of accommodating residents' needs to maintain their dignity and well-being. Additional deficiencies were noted in the care of two other residents who did not receive their scheduled showers. One resident reported not having received a bath or shower since admission, despite having a portable oxygen tank that could be used during showers. The resident's MDS indicated a need for substantial assistance with bathing. Another resident's fiancé reported missed showers on scheduled days, and the resident confirmed this account. The DON stated that residents should receive showers twice a week, and the facility's failure to provide this care was evident in the lack of documentation and adherence to the care plan.
Failure to Document Pacemaker and Defibrillator Information
Penalty
Summary
The facility failed to obtain and document vital information regarding residents' pacemakers and implanted defibrillators, affecting three residents. For Resident 3, the medical record lacked a physician order for the defibrillator, including details on how often it should be checked. There was no documentation of the manufacturer, model, or serial number of the defibrillator, nor was there any record of when it was last assessed. The Director of Nursing confirmed the absence of a policy on pacemakers and defibrillators. Similarly, for Residents 27 and 30, there were no physician orders documenting the pacemakers or their monitoring frequency. The medical records did not include the manufacturer, model, or serial number of the pacemakers, and it was unknown when they were last assessed. The facility's policy on cardiac pacemaker monitoring did not require obtaining this information. The Director of Nursing acknowledged the lack of necessary details in the care plans, emphasizing the importance of having this information available for troubleshooting in case of an emergency.
Failure to Apply Restorative Devices for Resident with Contractures
Penalty
Summary
The facility failed to follow physician orders and apply restorative devices to prevent further worsening of contractures for a resident identified as R23. During observations, it was noted that R23, who is nonverbal and in a comatose state, had severely contracted hands without any assistive restorative devices. The resident's care plan and physician orders specified the use of splints or carrots in the hands to prevent contracture worsening, but these were not in place during the surveyor's visits. The RN, V8, was unaware of the location of these devices and found a soiled carrot under the bed, which was not being used. The facility lacked a restorative nurse and aides, relying on CNAs to perform restorative therapy, which was not being adequately executed. The Director of Nursing (DON) confirmed that R23 was supposed to have rolled towels in both hands, but these were not consistently applied. The facility's policy on restorative nursing indicated that such services should be provided by trained staff under nursing supervision, which was not happening effectively. Additionally, there was no documentation to support the claim that R23's husband was removing the restorative devices, and this behavior was not included in the care plan. R23's medical history includes severe cognitive impairment and dependence on staff for all functional abilities, highlighting the critical need for adherence to restorative care protocols.
Improper Catheter Positioning for Resident
Penalty
Summary
The facility failed to ensure proper positioning of indwelling catheters for a resident, identified as R33, who was observed with a leg bag attached while in bed. This practice was contrary to the facility's policy, which mandates that the urinary drainage bag must be positioned lower than the bladder to prevent backflow and potential urinary tract infections (UTIs). The Director of Nursing (DON) confirmed that the leg bag should not be used when the resident is in bed, as it can lead to improper drainage and increase the risk of UTIs. R33 has a history of UTIs and benign prostatic hyperplasia with lower urinary tract symptoms, making him particularly vulnerable to complications from improper catheter care. His care plan highlighted the risk of UTIs due to catheterization and included approaches such as monitoring for signs of infection and providing good perineal and catheter care. Despite these measures, the improper use of the leg bag while in bed was observed, which could contribute to the resident's risk of developing UTIs and other complications.
Improper G-Tube Placement Check for Medication Administration
Penalty
Summary
The facility failed to adhere to current standards for checking the proper placement of a gastrostomy tube (g-tube) when administering medications to a resident. During an observation, a registered nurse (RN) was seen checking the g-tube placement by instilling air and auscultating with a stethoscope, rather than aspirating stomach contents as per the facility's policy and physician orders. The Director of Nursing acknowledged that the proper method should involve checking for residual stomach contents, not by auscultating air passage. The resident involved, identified as R23, has a medical history that includes dysphagia, gastro-esophageal reflux disease, and other complications. The resident's care plan and physician orders specifically required checking tube placement by aspirating stomach contents before meals and by auscultating air passage every shift. However, the RN's method of checking placement did not align with these orders or the facility's policy, leading to a deficiency in the care provided to the resident.
Failure to Secure and Contain Respiratory Equipment
Penalty
Summary
The facility failed to properly contain and secure respiratory equipment for four residents, leading to a deficiency in infection control practices. Observations revealed that nebulizer masks for residents were left uncovered on dressers, and in one case, nebulizer tubing was found touching the floor. These residents, who have various respiratory and other health conditions, were not provided with bags to store their nebulizer equipment, as confirmed by their statements. The facility's policy requires that respiratory equipment be bagged and dated when not in use to prevent infection. The residents involved have significant medical histories, including chronic obstructive pulmonary disease, Parkinson's disease, and acute respiratory conditions, which necessitate the use of nebulizers. Despite these needs, the facility did not adhere to its own policy of bagging and dating respiratory equipment, as confirmed by the Director of Nursing. This oversight was observed during a survey, highlighting a lapse in maintaining proper infection control measures for residents requiring respiratory care.
Medication Security Deficiency in LTC Facility
Penalty
Summary
The facility failed to properly secure medications for three residents, leading to a deficiency in medication management. For one resident, several medications, including Preservision AREDS 2, Nasal Mist, ABC Plus Senior Multivitamin, and Magnesium with Zinc, were found on the bedside table and nightstand without any orders for self-medication or bedside storage. The resident expressed distrust in staff administering her medication, which led to her keeping them at her bedside. The facility's policy clearly states that medications should be stored securely and only accessed by authorized personnel, which was not adhered to in this case. Another resident was found with a bottle of prescription Nystatin powder on her overbed table, which she used without recalling the proper application frequency. The resident did not remember which nurse left the medication with her, and there were no assessments allowing her to self-administer medications. Additionally, a third resident had two bottles of fluticasone nasal spray in a bag attached to his wheelchair, which he stated were given to him by a nurse. The facility's Director of Nursing confirmed that no residents were assessed to keep medications at the bedside, and staff were expected to secure medications in a locked place.
Failure to Hold Blood Thinner Leads to Procedure Rescheduling
Penalty
Summary
The facility failed to follow physician orders to hold a blood thinner medication for a resident prior to a scheduled surgical procedure, resulting in the procedure being rescheduled. The resident, who has a complex medical history including chronic congestive heart failure, morbid obesity, and type 2 diabetes, was aware that her blood thinner needed to be held for 72 hours before the procedure. However, the facility did not document or implement the necessary order to hold the medication, leading to the cancellation of the procedure. The resident expressed frustration and emotional distress over the repeated rescheduling of her procedure, which she feared could delay critical findings related to a potential cancer diagnosis. Despite the resident's attempts to provide information from her electronic hospital chart to the facility, the order to hold the blood thinner was not entered. The facility's records showed that the blood thinner was administered within the 72-hour preoperative timeframe, contrary to the physician's instructions. The breakdown in communication and documentation within the facility contributed to the oversight. The MDS Coordinator admitted to not documenting or communicating the verbal preoperative orders received from the physician's office. Additionally, the Administrator and Director of Nursing acknowledged that the fax containing the physician's orders was not reviewed or acted upon in a timely manner, leading to the failure to hold the blood thinner as required.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that the quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for five residents. Specifically, the assessments for residents R14, R20, R21, R34, and R39 were all transmitted significantly late, ranging from 123 to 140 days past the required date. The MDS Coordinator, identified as V3, acknowledged the delays and attributed them to assisting the acting Director of Nursing (DON) with her responsibilities, which caused her to fall behind on her own duties. The facility's policy, titled 'Resident Assessment Schedule' dated May 2022, mandates that assessments be completed on admission and every 90 days thereafter. Despite this policy, the quarterly MDS assessments for the five residents were not completed in a timely manner. V3 confirmed the transmission dates and acknowledged that the assessments were late, indicating a failure to adhere to the facility's established assessment schedule.
Inadequate Peri-Care and Catheter Care Leading to Potential UTIs
Penalty
Summary
The facility failed to provide proper peri-care and catheter care, leading to potential risks of urinary tract infections (UTIs) for several residents. For instance, a CNA did not adequately clean the inner labia and urethra of a resident during incontinence care, and another resident's catheter was not secured, causing it to pull during transfers. These actions were observed during specific instances where residents required extensive assistance or were totally dependent on staff for toileting hygiene. In one case, a resident with multiple medical diagnoses, including end-stage renal disease and a history of UTIs, was not properly cleaned by a CNA who failed to separate the labia and clean the inner corners and urethra. Another resident with an indwelling urinary catheter had the catheter tubing unsecured, which was observed to pull during transfers, and the resident's husband confirmed that the facility had lost the leg strap used to secure the catheter. Additionally, other residents were observed receiving inadequate peri-care. For example, a resident with severe cognitive impairment and a history of UTIs was not properly cleaned by a CNA who used the same gloves throughout the process and did not clean the inner labia. Another resident with multiple wounds did not receive proper incontinence care after wound care was completed, and protective ointment was applied in a manner that did not follow proper hygiene protocols. The facility's policy on perineal care was not adhered to in these instances, leading to potential risks of infection and skin irritation.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to follow standard infection control practices regarding hand hygiene and gloving during the provision of perineum and catheter care. On multiple occasions, staff members were observed changing gloves without performing hand hygiene and handling soiled items without proper sanitization. For instance, a CNA provided incontinence care to a resident without sanitizing hands between glove changes and did not disinfect the peri-care cleansing spray after use. Additionally, the same CNA and another staff member transferred a resident without wearing gloves and handled soiled linens without hand hygiene or proper containment, further compromising infection control protocols. Another incident involved a CNA emptying a urinary catheter bag and changing gloves without performing hand hygiene before repositioning the resident. Similarly, during incontinence care for another resident, the CNA changed gloves between dirty and clean tasks without sanitizing hands, thereby increasing the risk of infection. The facility's Regional Director confirmed that staff must wash or sanitize hands between glove changes and disinfect any items touched with soiled gloves to prevent the spread of infection. Further observations revealed that staff members continued to neglect hand hygiene protocols during resident care. For example, a CNA and another staff member used the same gloves for multiple tasks, including perineal care and repositioning a resident, without sanitizing hands. Additionally, during wound care rounds, the Director of Nursing failed to perform hand hygiene between glove changes and touched various items with soiled gloves. These actions were contrary to the facility's infection control policies, which mandate hand hygiene before and after each care contact and the disinfection of items used during care to prevent infection spread.
Failure to Notify Physician and Update Care Plan for New Skin Wound
Penalty
Summary
The facility failed to notify the physician of a new skin wound, obtain orders for treatment, and update the care plan for a resident. The resident, a male with severe cognitive impairment and multiple diagnoses including cerebrovascular disease and vascular dementia, was observed with a bruise and a deep, open wound on his left upper arm. Despite the wound being noticed by a hospice CNA, it was not properly documented or communicated to the facility nurse or physician. The wound was first observed on a Friday, but no action was taken until the following Tuesday when it was noted to have worsened. The facility's wound care policy requires immediate assessment, documentation, and physician notification for new skin conditions, which was not followed in this case. Interviews with various staff members, including the hospice CNA, facility RN, and hospice nurse, revealed a lack of communication and documentation regarding the resident's wound. The hospice CNA claimed to have notified the facility nurse, but the nurse denied receiving any such information. The primary physician and the Director of Nursing were also unaware of the wound until it was brought to their attention days later. The facility's wound care policy mandates weekly skin assessments and immediate action for new wounds, but these protocols were not adhered to, resulting in a lack of timely treatment and care for the resident.
Failure to Provide Proper Adaptive Devices for ROM
Penalty
Summary
The facility failed to assess and provide proper adaptive devices to a resident (R30) to prevent further reduction in range of motion (ROM). R30, who has multiple medical diagnoses including non-traumatic intracerebral hemorrhage, altered mental status, and aphasia, was observed multiple times with tightly clenched hands and hand rolls that were too large and not placed correctly. Despite the presence of hand rolls, they were ineffective due to their size, and there was no documented rehabilitation evaluation for R30. The Rehab Director acknowledged the issue and provided a smaller hand roll but confirmed the lack of a documented evaluation by an occupational therapist. R30's husband expressed concern about the potential development of hand contractures and was observed giving passive range of motion (PROM) exercises to R30. He mentioned that a friend, who is a therapist, recommended the use of hand roll splints to prevent contractures. The facility's Regional Director/RN stated that it is routine for residents requiring extensive assistance to be evaluated by a therapist upon admission to determine the need for physical or occupational therapy. However, this evaluation was not conducted for R30, leading to the deficiency in care.
Failure to Document Antipsychotic Medication Use and Develop Dose Reduction Interventions
Penalty
Summary
The facility failed to document the reason for the use of an antipsychotic medication and develop interventions for dose reduction for a resident. The resident, who is [AGE] years old, was admitted with multiple medical diagnoses including unspecified psychosis and depression. Despite being on Risperidone since April 5, 2023, there was no documentation in the physician notes from February 2024 to the present addressing the use of this medication. Additionally, the psychotropic care plan dated April 6, 2023, did not include any targeted behavior to justify the use of Risperidone. Interviews with staff revealed that the resident experiences periods of forgetfulness but does not exhibit aggressive or unusual behaviors such as hallucinations or paranoia. The resident is also at high risk for falls due to occasional loss of balance. The Regional Director acknowledged that the resident should have been seen by a psychiatrist to evaluate the appropriateness of the medication and that the care plan should have been reviewed and adjusted within 21 days.
Failure to Follow Standardized Recipe for Pureed Diets
Penalty
Summary
The facility failed to follow the standardized recipe for pureed butternut squash during meal preparation for two residents on pureed diets. On April 15, 2024, the Dietary Manager confirmed that only two residents were on pureed diets. During the preparation of the pureed lunch meal, the cook used two #8 scoops of cooked butternut squash and added three ladles of broth, resulting in a total of 6 ounces of broth. This mixture appeared watery, prompting the cook to add a tablespoon of thickener to achieve a more cohesive consistency. The standardized recipe, however, required specific amounts of low sodium chicken base, hot water, and food thickener, which were not followed. The facility's diet manual emphasized the importance of using a standardized recipe when adding liquids and other items during pureeing to ensure nutritional values are maintained. The dietitian confirmed that following the recipe is crucial to prevent compromising nutrient values. The facility's scoop size equivalent chart indicated that a #8 scoop equals 4 ounces. The meal tickets for the two residents confirmed they were on pureed diets. The failure to adhere to the standardized recipe for pureed butternut squash was observed, documented, and confirmed by the dietitian, highlighting a deficiency in the facility's meal preparation process for residents on pureed diets.
Failure to Serve Pureed Beef in Desired Consistency
Penalty
Summary
The facility failed to serve pureed braised beef in the desired consistency for two residents on pureed diets. During an observation of the pureed lunch meal preparation, the cook placed cooked braised beef and beef broth into a blender and pureed the mixture. However, the resulting product had shreds of beef and appeared granular, which required chewing. The Dietary Manager, who was present, acknowledged the inconsistency and mentioned that another blender pureed food better. The facility's recipe for pureed beef tips and directives for pureed diets indicated that the food should be smooth and pudding-like in consistency to be easily swallowed without chewing. The deficiency was identified during an interview with the Dietitian, who confirmed that pureed products should be smooth and close to pudding consistency. The meal tickets for the two residents indicated that they were on pureed diets, which are intended for individuals with chewing or swallowing difficulties or dysphagia. The facility's failure to provide pureed beef in the correct consistency posed a risk to these residents, as the food was not safe to be served in its irregular form.
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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