Hitz Memorial Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Alhambra, Illinois.
- Location
- 201 Belle Street, Alhambra, Illinois 62001
- CMS Provider Number
- 145921
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Hitz Memorial Home during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and multiple comorbidities was the subject of repeated sexual abuse allegations involving a family member. Over several episodes, CNAs and a dietary aide reported seeing the family member very close to the resident, quickly moving his hands from the resident’s lap or from under a blanket, the resident’s shirt lifted exposing her breasts, and the family member jumping back or appearing anxious when staff entered. Staff also reported the resident appearing shocked, jumpy, and crying after visits, and law enforcement later received a report that the family member had exposed himself near the resident’s face. Facility leadership conducted limited investigations that omitted key staff observations, relied on the family member’s explanations and unverified personal video footage, did not consistently collect or reconcile written statements, did not verify or preserve objective evidence, and did not implement care plan interventions or protective measures to safeguard the resident from further potential abuse, despite an abuse policy requiring immediate reporting and action.
A resident with dementia and severe cognitive impairment had multiple staff-reported incidents of possible sexual abuse involving a family member, including observations of the family member quickly moving hands from the resident’s lap area, standing over the resident and jumping when staff entered, and being in close physical positions with the resident’s clothing reportedly pushed up. While some earlier incidents were reported to external agencies and deemed unfounded, later December reports were not fully investigated or reported as required. The administrator and BOM relied on unverified video footage from the family member’s personal device, did not confirm the recording’s date or time, did not preserve or obtain the video, and did not initiate a formal abuse investigation or state reporting, despite facility policy and state rules requiring immediate reporting and thorough investigation of suspected abuse or reasonable suspicion of a crime.
A facility failed to verify the active license of an RN, allowing her to work 35 shifts unlicensed. The RN administered medications to several residents, despite her license being expired at the time of hire. The oversight occurred during the background check process, where the Administrator missed the expiration date. The RN believed she had renewed her license but lacked proof, and it was later confirmed that the renewal was not processed.
A resident with multiple diagnoses, including osteoporosis and PTSD, fell while attempting to self-transfer. The attending LPN failed to assess the resident's condition and used inappropriate language and rough handling, causing distress. Witnesses reported the incident, but the facility did not immediately call the police or provide a timely medical evaluation, leading to a deficiency in care.
The facility failed to employ a full-time DON, potentially affecting all 43 residents. Since February 2024, the administrator has been performing DON duties due to hiring challenges, including salary demands. The administrator reported working 65-70 hours weekly on care plans and other responsibilities. No DON was observed during the investigation, and the Quality Assurance Members list lacked a designated DON.
A facility failed to adhere to a physician's wound care orders for a resident with severe cognitive decline and a history of skin picking. The resident's umbilicus wound was found open to air with drainage, despite orders to cleanse and dress it. Staff acknowledged the resident's behavior of removing dressings, but the prescribed care was not consistently applied, leading to a deficiency.
A resident with cognitive impairment fell while attempting to self-transfer and was verbally abused and mishandled by an LPN, who failed to assess her condition. Despite the resident's requests for police and ambulance assistance, the facility did not notify authorities, breaching their policy. Conflicting accounts from staff and witnesses complicated the situation, but the facility recognized the inappropriate behavior and terminated the LPN.
Failure to Thoroughly Investigate and Protect Cognitively Impaired Resident From Repeated Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple allegations of sexual abuse and to protect a cognitively impaired resident from potential further abuse during and after those investigations. The resident, admitted with diagnoses including hypertension with heart failure, dementia, narcolepsy, chronic respiratory failure, and osteoarthritis, was documented as severely cognitively impaired and unable to consent to sexual advances. Hospital records and family statements indicated the resident had always been mentally slow and did not like to be touched. Despite this vulnerability, the facility did not implement protective measures after repeated staff reports of concerning interactions between the resident and a family member. The first allegation occurred when a CNA reported feeling uncomfortable after entering the resident’s room and observing the family member quickly moving his hands away from the resident’s lap/stomach area on two occasions. The written investigation from the Administrator and Social Services Director concluded no abuse occurred, relying largely on the family member’s explanation that he was startled and holding a computer, and did not document any protective interventions or assessment of the resident’s vulnerability. Later interview with the CNA revealed additional details not included in the investigation, including that the resident’s shirt was lifted exposing her breast, that the resident would not have been able to expose herself, and that the family member intervened quickly when staff attempted to adjust the resident’s clothing. No additional staff statements or corroborating documentation were included in the investigation. A second documented allegation involved staff observations of the same family member positioned very close over the resident, with the resident’s wheelchair reclined and the family member reacting abruptly when staff entered, including jumping up and requesting privacy. A dietary aide’s written statement indicated she saw the family member’s hands under the resident’s blanket and that he jumped up quickly when she entered, causing a pillow to fall. In interviews, staff described not being able to see the family member’s hands, the resident appearing shocked and jumpy, and reports that the resident cried after the family member’s visits and seemed not to want to be touched. These details, including the aide’s observation of the arm under the blanket, were not reflected in the facility’s written investigation, which the Administrator and Business Office Manager confirmed as complete. Additional allegations arose in December when a CNA reported entering the room and seeing the family member with one leg on a chair and the resident’s shirt pushed up below her breasts, with the family member stating they were playing cards and telling the CNA to leave. The CNA stated he wrote a report and left it at the nurse’s desk, and another CNA confirmed being told of this incident but did not report it herself. The Administrator and Business Office Manager acknowledged being told about the leg-on-chair incident and viewing video footage from the family’s personal camera on the family member’s cell phone, but they did not initiate a formal investigation, did not verify the date or time of the footage, and relied on the video and the family member’s denial to decide not to investigate further. Another CNA later reported seeing the family member with his leg up on the resident’s wheelchair, wearing nylon shorts, jumping back and pulling his pant leg down when she entered, and appearing very anxious; she reported this to the Business Office Manager. Throughout these events, the facility did not initiate thorough investigations, did not consistently collect and reconcile staff statements, did not verify or preserve objective evidence, and did not implement care plan interventions or protective measures to keep the resident safe from further potential abuse. The facility’s abuse policy required immediate reporting of suspected abuse to the Administrator and mandated that the Administrator or designee report abuse to the state agency per state and federal requirements, and that employees report reasonable suspicion of a crime against a resident to law enforcement. Despite this, the Administrator stated she did not begin a sexual abuse investigation when informed by the surveyor because she did not know who it involved, and acknowledged that the investigations from the earlier dates were the complete investigations. The resident’s care plan, updated shortly before the survey, addressed self-care deficits but did not include any potential for abuse or interventions to keep the resident safe. Law enforcement later indicated that a staff member reported seeing the family member drop his pants and have his penis in the resident’s face and stated that the facility needed to take action and remove the family member and find a new POA. The surveyors determined that Immediate Jeopardy began with the first allegation and that the facility failed to protect the resident from further allegations of abuse and failed to conduct thorough investigations into four separate sexual abuse allegations involving the same family member.
Removal Plan
- Issued a visitor restriction notice to V17 by the Social Services Director to ensure R42’s safety.
- Abuse Coordinating Team called V39 to inform her the visitor restriction was moved to indefinite and explained the reasons.
- Mailed the visitor restriction letter and emailed it to V17 and V39.
- Obtained email acknowledgement of receipt of the restriction.
- Informed V17 the restriction is indefinite and related to safety concerns regarding incidents.
- Administrator ordered a camera system for public areas (hallways) to aid staff/resident safety and monitor visitors.
- Implemented nursing rounds at the end of every shift to verify the resident has remained free of abuse.
- Social Services Director initiated visits with the resident twice weekly to monitor for psychosocial changes.
- Interviewed all residents and documented they reported feeling safe and free of abuse/neglect.
- Administration to round on every shift to monitor activities.
- Initiated a sexual abuse care plan for R42.
- Updated the physician (Dr. [NAME]).
- Initiated an Abuse Checklist to ensure compliance and document all required steps with abuse reporting.
- Completed all-staff in-services on the Abuse Checklist.
- Implemented a team-based approach for all investigations to ensure accuracy and completeness for each allegation received.
- Implemented the Abuse Checklist for Abuse Coordinators to use with all received documentation (including statements) to conduct thorough investigations including resident assessments and interviews.
- Re-inserviced all staff on the facility Abuse and Neglect Policy.
- Abuse Coordinators conducted random competency checks.
- Added the new Abuse Checklist to new staff onboarding.
- QAPI members to hold a monthly QAPI meeting to discuss abuse investigations, staff compliance, and staff understanding of facility policy.
Failure to Follow Abuse Policy and Fully Investigate Repeated Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy in preventing, reporting, and investigating multiple allegations of possible sexual abuse involving one resident. The resident was admitted with diagnoses including hypertension with heart failure, dementia, narcolepsy, chronic respiratory failure, primary osteoarthritis, and was documented as severely cognitively impaired with a self-care deficit. Hospital records noted that a family member reported the resident had always been mentally slow and did not like to be touched. Despite this condition and vulnerability, the facility did not consistently treat staff reports of concerning interactions between the resident and a family member as abuse allegations requiring full investigation and reporting. In one prior incident, a CNA reported entering the resident’s room and observing the family member quickly moving his hands away from the resident’s lap/stomach area on two occasions, which made the CNA uncomfortable. This incident was reported to the Social Services Director and Administrator, who notified the Ombudsman, Medical Director, local police, and the resident’s POA. The facility’s investigation concluded that no abuse occurred, based on the CNA’s statement that she did not actually see inappropriate touching. In a separate incident, two CNAs reported that when they entered the resident’s room to obtain vitals, the family member jumped, grabbed an electronic device, told them to come back later because they were busy, and was again observed standing over the resident with his hands down by her wheelchair, jumping when they entered. Police, Adult Protective Services, the Medical Director, POA, and Ombudsman were notified, and both external agencies stated there was no evidence of abuse; the facility deemed the allegation unfounded. Later, additional staff reports in December described further concerning observations that were not handled in accordance with the facility’s abuse policy. One CNA stated she entered the room to get a mechanical lift and saw the family member standing next to the bed with one leg on a chair and the resident’s shirt pushed up below her breasts; the family member was rude, said they were playing cards, and told her she did not need to be there. She reported this to the Administrator and wrote a statement, but the Administrator later stated she never received the written statement. Another CNA reported seeing the family member with his leg up on the resident’s wheelchair, pant leg up to his thigh, wearing nylon shorts, and jumping back anxiously when she entered; she reported this to the Business Office Manager. The Administrator and Business Office Manager acknowledged being told that the family member had his leg on a chair and jumped back when staff entered, but stated they were told no body parts were exposed. They did not initiate a formal investigation, did not verify or preserve the date and time of the video footage shown on the family member’s personal device, and did not report the December concerns as abuse allegations, despite the facility’s policy and state rules requiring immediate reporting of suspected abuse or reasonable suspicion of a crime against a resident. The facility’s abuse policy requires that any employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation, or misappropriation immediately report it to the Administrator, and that the Administrator or designee report abuse to the state agency per state and federal requirements. Nursing Home 1150B Rules and Regulations further require all employees to report any reasonable suspicion of a crime committed against a resident by calling 911 or the county sheriff. In the December incidents, the Administrator and Business Office Manager relied on unverified video footage from the family member’s personal cell phone, did not confirm the recording’s date or time, did not conduct or document a complete investigation, and did not treat the staff reports as reportable abuse allegations. These actions and omissions demonstrate the facility’s failure to implement its abuse prevention, reporting, and investigation policies for this resident.
Unlicensed RN Worked 35 Shifts
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was employed with a current and active license, resulting in the RN working unlicensed upon hire. The RN, identified as V4, was found to have an expired license during a background check review. Despite the facility's policy requiring verification of board registrations and certifications before employment, V4 was hired and worked 35 shifts without a valid license. The Administrator, V1, admitted to conducting the background check but overlooked the expiration date on V4's RN license. V4 believed she had renewed her license but could not provide a receipt, and upon contacting the Illinois Department of Financial and Professional Regulation, it was confirmed that the renewal was not processed due to non-payment. During the period V4 worked unlicensed, she administered medications to residents R2, R3, R4, and R5, as documented in their Medication Administration Records (MARs). The facility's staffing included two nurses and five CNAs for day and evening shifts, with V4 working on Hall-Two. The facility's policy on employee screening and training mandates that licensed staff must not have disciplinary actions against their licenses, and criminal background checks are required. However, the oversight in verifying V4's license status led to her working without a valid license, contrary to the facility's policy and state regulations.
Failure to Prevent Abuse and Neglect in Resident Care
Penalty
Summary
The facility failed to prevent verbal and physical abuse and neglected to accurately assess a resident for injury prior to initiating a transfer. This incident involved a resident, identified as R99, who was admitted with multiple diagnoses including osteoporosis, anxiety, and post-traumatic stress disorder. On the day of the incident, R99 attempted to self-transfer from her recliner and fell, subsequently complaining of right hip pain. Despite these complaints, the attending LPN, identified as V5, did not conduct a proper assessment before transferring the resident back to her chair, which was done in a rough manner, causing further distress to the resident. Witnesses, including a CNA identified as V9, reported that V5 used inappropriate language and displayed aggressive behavior towards R99. V5 reportedly told the resident, "I'm tired of your s**t. If you don't like it, you can go home," and proceeded to lift the resident by her arms without assessing her condition. This action was perceived as abusive by the CNA, who immediately reported the incident to the facility's administration. The resident expressed fear and requested the police and an ambulance, indicating the level of distress caused by the incident. The facility's policy clearly states that residents should be free from abuse and neglect, and any suspicion of abuse should be reported immediately. However, the report indicates that the police were not called, and there was a delay in addressing the resident's request for medical evaluation. The facility's investigation revealed conflicting accounts of the incident, but the decision was made to terminate the LPN involved. The report highlights a failure in adhering to the facility's abuse and neglect policy, resulting in a deficiency in the care provided to the resident.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), which has the potential to affect all 43 residents residing in the facility. On September 9, 2024, the administrator, identified as V1, stated that she had been performing the duties of the DON since February 2024 due to the inability to hire a qualified candidate. The facility had been actively searching for a DON but faced challenges, such as candidates requesting a salary of $70 an hour, which the facility could not accommodate. V1 reported working 65-70 hours a week to manage care plans and other DON responsibilities. During the investigation, no observations of a DON were made, and the facility's Quality Assurance Members list did not include a staff member designated as the DON.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to follow a physician's order for wound dressing for a resident with multiple medical conditions, including severe cognitive decline and dependency on staff for all care. The resident, who has a history of picking at their skin, was observed with an umbilicus wound open to air and creamy white drainage, contrary to the physician's order to cleanse the wound, apply xeroform, and cover it with a dry dressing. Staff members, including a CNA and an RN, acknowledged that the resident often removes the dressing, and the wound care orders were not consistently followed, as evidenced by the missing dressing on the morning of the observation. The resident's progress notes documented ongoing issues with the umbilicus wound, including measurements and descriptions of the wound bed and drainage. Despite the physician being aware of the resident's behavior of removing dressings, the facility did not ensure adherence to the prescribed wound care regimen. The facility's policy for skin issues and pressure ulcers requires documentation of all skin concerns, but the report highlights a lapse in following the treatment orders as written, contributing to the deficiency.
Failure to Prevent and Report Abuse and Neglect
Penalty
Summary
The facility failed to adhere to its Abuse and Neglect Policy, resulting in an incident involving a resident, identified as R99, who experienced both verbal abuse and neglect. R99, who was moderately cognitively impaired and required substantial assistance for chair transfers, fell while attempting to self-transfer from her recliner. A Certified Nursing Assistant (CNA), identified as V9, witnessed the incident and reported that a Licensed Practical Nurse (LPN), identified as V5, responded inappropriately by verbally abusing R99 and physically mishandling her by lifting her roughly by the arms without assessing her condition. The incident was further compounded by the facility's failure to notify the appropriate authorities as required by their policy. Despite R99's requests for police and ambulance assistance, these were not immediately acted upon. The CNA reported the incident to the Assistant Director of Nursing (ADON), but the local police were not informed, which is a breach of the facility's policy that mandates reporting any reasonable suspicion of a crime against a resident to law enforcement. The situation was exacerbated by conflicting accounts from staff and witnesses. While the CNA and a family member reported the LPN's abusive behavior, the resident's roommate and the LPN provided differing accounts, suggesting no abuse occurred. Despite these conflicting reports, the facility's administration recognized the inappropriate nature of the LPN's actions and the failure to follow protocol, leading to the LPN's suspension and eventual termination. However, the lack of immediate action to protect the resident and report the incident to authorities highlights a significant deficiency in the facility's handling of abuse and neglect cases.
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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