Irving Park Living & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4340 North Keystone, Chicago, Illinois 60641
- CMS Provider Number
- 145415
- Inspections on file
- 32
- Latest survey
- July 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Irving Park Living & Rehab Ctr during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with severe cognitive and physical impairments was injured during a mechanical lift transfer when two CNAs failed to adequately monitor and respond to the resident's agitation, resulting in the resident's foot striking the bed and sustaining a laceration that required sutures. Staff interviews and documentation confirmed that proper supervision and intervention were not provided during the transfer.
The facility failed to follow proper food safety and sanitation practices, affecting all 75 residents receiving food from the kitchen. Cooking equipment was not sanitized for the required 60 seconds, and several food items lacked proper labeling and were past their use-by dates, including deli meats, cheese, and cucumbers. Mold was found on Parmesan cheese, and incorrect labeling was noted on pudding and lemon-flavored water nectar. These deficiencies could lead to foodborne illnesses.
The facility failed to maintain proper sanitation by not keeping dumpster lids closed, potentially attracting pests. A smaller dumpster was overfilled, leaving its lid open, while a larger dumpster's lid was propped open due to improper arrangement of contents. The Cook and Maintenance Director acknowledged the issue, noting the importance of closed lids to prevent rodent attraction. Facility policy mandates timely garbage pick-up and proper containment to prevent pests.
A facility was found deficient in infection control practices, including inadequate hand hygiene by an RN during medication administration and improper PPE use during a gastric tube flush. Additionally, clean linens were left uncovered, and soiled linens were not properly bagged, violating the facility's infection prevention policies.
The facility failed to provide a $60 monthly allowance to eligible residents receiving SSA benefits, despite an increase from $30 to $60 effective January 2024. This affected 16 residents, including one who confirmed receiving only $30. The BOM was aware of the increase but it was not implemented due to staffing issues, violating residents' rights to the correct allowance.
The facility failed to maintain adequate hot water temperatures in several residents' rooms and a third-floor shower room, with temperatures significantly below the required 110 degrees Fahrenheit. Residents resorted to using microwaved water for bed baths. Additionally, the facility did not ensure a safe smoking patio environment, as snow and ice were not removed, posing a fall risk. The Maintenance Director was preoccupied with the annual survey and failed to clear the area.
The facility failed to securely store and properly label medications. A nurse left Aspirin pills unattended on a medication cart, and expired medications were found in storage areas. Additionally, a Breztri aerosphere lacked an open date label. The DON confirmed the need for proper medication disposal and secure storage.
The facility failed to follow standardized pureed recipes, affecting residents on pureed diets. Observations revealed that pureed bread and noodles were not served, and oatmeal was not pureed, contrary to dietary guidelines. The cook cited time constraints, while the Dietary Manager believed oatmeal was soft enough. The Speech Language Pathologist and Consultant Dietitian stressed the importance of adhering to recipes to ensure safety and nutritional adequacy.
The facility failed to provide fortified supplements as prescribed for six residents. The cook prepared oatmeal instead of the prescribed super cereal, mistakenly believing it was equivalent. The dietary manager and consultant dietitian confirmed that super cereal is a fortified food ordered by the physician for residents needing to gain weight. Documentation showed that super cereal was listed on meal tickets and physician orders, but it was not prepared according to the specified recipe.
The facility failed to provide education and assess eligibility for pneumococcal vaccinations for several residents, as required by their policy and CDC guidelines. Despite having chronic conditions and cognitive impairments, these residents did not receive the necessary information or documentation in their medical records, leading to a deficiency in care.
The facility failed to include and update advance directives in the care plans of three residents, leading to discrepancies between care plans and physician orders. One resident's care plan incorrectly indicated a full code status despite having a DNR order, while two others lacked any care plan for advance directives despite having full code orders. This oversight contravenes the facility's policy requiring advance directives to be part of the care plan and reviewed quarterly.
A resident with a PICC line for IV antibiotic therapy did not have their dressing changed as per facility policy, which requires changes every 5-7 days. Observations showed the dressing was overdue for a change, confirmed by both the resident and nursing staff. This failure to adhere to professional standards could lead to infection risks.
A facility failed to ensure a resident with a tracheostomy had the required emergency equipment at the bedside. The resident, with chronic respiratory failure, was observed without an emergency step-down tracheostomy tube readily available. A nurse had to retrieve the tube from the supply room, indicating it was not immediately accessible. The facility's policy requires such equipment to be at the bedside to prevent airway closure if the tracheostomy becomes dislodged.
The facility failed to ensure accurate accountability for controlled substances, leading to discrepancies in medication counts for Clonazepam and Tramadol. Missing nurse initials on the Shift Change Accountability Record indicated incomplete narcotic counts. An LPN confirmed the procedure for counting and signing off on narcotics, while the DON emphasized the importance of accurate records. The facility's policy requires two licensed nurses to verify narcotic log sheets, but failure to follow procedures resulted in unaccounted controlled substances.
A resident with Type 2 Diabetes Mellitus did not receive the prescribed insulin dose due to a nurse's failure to perform a blood glucose check and prime the insulin pen. The nurse administered 15 units of Basaglar insulin without priming the needle, potentially resulting in an incorrect dose. The facility's policies require priming to ensure accurate dosing and prevent air injection.
A resident's personal refrigerator was found to be improperly managed, with a temperature of 58°F and containing expired and undated food items. The facility's policies for maintaining refrigerator temperatures and discarding expired food were not followed, posing a potential health risk to the resident.
A resident with mild dementia and anxiety was verbally and physically abused by her roommate, who also has dementia and a major depressive disorder. The incident involved verbal aggression and physical actions, resulting in a skin tear. Facility staff were aware but failed to immediately report the incident to the administrator, violating the facility's abuse prevention policy.
A facility failed to notify a resident's family about a hospitalization due to suicidal ideation, as required by their policy. The resident's POA requested a report but did not receive an update. The Director of Nursing claimed to have contacted the POA, but there was no documentation in the electronic health record to confirm this communication.
A facility failed to protect residents from sexual abuse, as a male resident with cognitive impairments allegedly assaulted another male resident. Despite a history of inappropriate behavior, the facility did not update interventions in the resident's care plan, leading to repeated incidents. The facility's abuse prevention policy was not effectively implemented, and the investigation into the incident remained inconclusive.
A facility failed to promptly investigate an alleged incident of staff-to-resident abuse when a resident reported being struck in the groin by a CNA during care. The incident was reported by the resident's family, but the facility delayed initiating a formal investigation, contrary to its abuse prevention policy. The resident, who had a urinary catheter, experienced pain and reported the CNA's rough handling, but the facility initially treated the report as a concern rather than potential abuse.
A resident in a LTC facility experienced repeated unwanted touching by another resident, leading to psychosocial harm. Despite the resident's complaints and evidence provided to staff, the behavior persisted, indicating a failure in the facility's abuse prevention measures.
A resident with chronic pain did not receive PRN Oxycodone for breakthrough pain as ordered by their physician. Despite the resident's request and the physician's instructions, the nursing staff failed to administer the medication, citing a misunderstanding of the timing between scheduled and PRN doses. The facility's documentation confirmed the resident's claim, highlighting a deficiency in pain management practices.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Injury During Mechanical Lift Transfer Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, neuroleptic-induced parkinsonism, and significant functional limitations was being transferred using a mechanical lift by two CNAs. During the transfer from a specialized chair to the bed, the resident became agitated and moved around, resulting in his right foot striking the footboard of the bed. This incident caused a laceration to the resident's right fifth toe, which required hospital treatment and sutures. Staff interviews revealed that two CNAs were present during the transfer, with one operating the mechanical lift and the other guiding the resident. Both staff members acknowledged the need for careful monitoring during mechanical lift transfers, especially for residents who are dependent and may become anxious or impulsive. The DON stated that the staff should have stopped the transfer and notified the nurse when the resident became agitated, but this did not occur, leading to the injury. Documentation confirmed that the resident was dependent for all ADLs and required substantial/maximal assistance, with a care plan specifying the use of a mechanical lift and two-person assist for transfers. The facility's policy also required two staff for safe mechanical lift operation. Despite these protocols, the resident sustained an injury during the transfer due to inadequate supervision and failure to appropriately respond to the resident's agitation.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in its kitchen, which could potentially affect all 75 residents receiving food prepared there. During a kitchen tour, it was observed that cooking equipment was not being sanitized according to the manufacturer's directions. Specifically, the equipment was dipped in the sanitizing solution for less than 10 seconds, whereas it should have been submerged for at least 60 seconds to ensure proper sanitation. This improper sanitization process was acknowledged by the Dietary Manager, who confirmed that inadequate sanitization could lead to foodborne illnesses. Additionally, the facility did not adhere to proper food labeling and storage practices. Several food items in the reach-in coolers were found without proper labeling, including opened packages of deli ham, turkey, and Swiss cheese, which lacked open or use-by dates. An unopened bag of grated Parmesan cheese was found with visible mold, and cucumbers showed signs of spoilage. Furthermore, a container of butterscotch pudding and a container of lemon-flavored water nectar were labeled with incorrect use-by dates, indicating they were past their safe consumption period. The facility's policies require all food items to be labeled with a prepared or opened date and a use-by date to prevent serving expired items, but these practices were not followed, posing a risk of foodborne illness to residents.
Improper Dumpster Management Leads to Sanitation Deficiency
Penalty
Summary
The facility failed to ensure proper sanitation practices by not keeping the dumpster lids closed, which could lead to the harborage and feeding of pests, insects, and rodents. During an observation, a smaller dumpster near the back door was found overfilled with garbage bags, leaving the lid open. A larger dumpster in the parking lot was also observed with its lid propped open due to an old refrigerator and empty cardboard boxes inside, preventing the lid from closing. The Cook (V12) acknowledged the issue, stating that the smaller dumpster was too full to close the lid and that the larger dumpster had room for more garbage but was not properly arranged to allow the lid to close. The Maintenance Director (V6) confirmed that the lids should be closed to prevent rodent attraction, noting that the facility uses a pest control company with rat houses set up around the building. The facility's policy requires timely garbage pick-up and proper containment to prevent pests, with the maintenance director or designee responsible for ensuring dumpsters are covered at all times.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as observed during a survey. A Registered Nurse (RN) was seen administering medications to residents without performing hand hygiene between resident contacts. Specifically, the RN did not wash hands after handling medication cups and before preparing medications for another resident. This lapse in hand hygiene occurred despite the presence of Enhanced Barrier Precautions for residents with specific medical conditions, such as a PICC line, Foley catheter, and Klebsiella Pneumoniae, which require strict infection control measures. Additionally, the RN failed to wear appropriate Personal Protective Equipment (PPE) during a high-contact resident care activity. While flushing a gastric tube for a resident, the RN did not don a gown, which is required under Enhanced Barrier Precautions. This oversight was acknowledged by the RN, who admitted the potential for infection spread due to not wearing a gown during the procedure. The facility also demonstrated deficiencies in the handling and storage of linens. Clean linens were observed uncovered and exposed to potential contaminants in the basement hallway, contrary to the facility's policy requiring linens to be covered when not in use. Soiled linens were not properly bagged before being placed in the laundry chute, increasing the risk of contamination. These practices were inconsistent with the facility's infection prevention and control program, which mandates annual review and adherence to established guidelines.
Failure to Implement Increased Monthly Allowance for SSA Residents
Penalty
Summary
The facility failed to provide a $60 monthly allowance to eligible residents receiving Social Security Administration (SSA) benefits, despite an increase from $30 to $60 that took effect in January 2024. This deficiency affected 16 eligible residents, including one resident who was alert and oriented, and who confirmed during a resident council meeting that he had been receiving only $30 per month. The Business Office Manager (BOM) acknowledged awareness of the increase but stated that the facility had not yet implemented it. The Administrator confirmed that the resident should have been receiving the increased allowance and verified the oversight with corporate staff. The facility's Trust Fund Policy, effective January 2024, stipulated that residents receiving SSA benefits should receive a $60 monthly allowance. However, due to staffing issues, the increase was not implemented, and residents continued to receive the outdated amount. The facility's failure to adjust the allowance in accordance with the updated policy resulted in a violation of residents' rights to receive the correct personal needs allowance.
Deficiencies in Hot Water Supply and Smoking Patio Safety
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment by not ensuring adequate hot water temperatures in several residents' rooms and a third-floor shower room. Residents reported that the water in their rooms was not warm enough for bathing, with some having to resort to using microwaved water for bed baths. The water temperatures in the affected areas were measured significantly below the required 110 degrees Fahrenheit, with readings ranging from 63 to 72 degrees Fahrenheit. The issue arose after one of the facility's hot water tanks rusted and failed, and a replacement was ordered but not yet delivered. Additionally, the facility did not maintain a safe smoking patio environment, as snow and ice were not removed, posing a potential fall risk to residents. On one occasion, six residents were observed smoking on a patio covered with snow and ice. The Maintenance Director was responsible for snow removal but was preoccupied with the annual survey and failed to clear the area. The Social Service Director acknowledged the oversight and intended to address it. The report highlights the residents' dissatisfaction and discomfort due to the lack of hot water, with some residents unable to shower or bathe adequately. The facility's policies on water temperature, smoking safety, and fall prevention were not adhered to, contributing to the deficiencies observed by the surveyors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications, as observed during a survey. A registered nurse left a clear cup containing Aspirin 325 mg pills unattended on top of a medication cart while administering medications to residents. This occurred multiple times, leaving the medication accessible to anyone passing by. The nurse acknowledged the oversight when questioned by the surveyor, admitting that someone could have taken the pills. Additionally, the survey revealed expired medications in the facility's storage areas. In the second-floor medication storage room, a bottle of Liquid Pain Relief Acetaminophen was found with an expiration date of 12/24. Similarly, a medication cart contained expired bottles of B complex and docusate sodium liquid, both with expiration dates of 10/24. Furthermore, a Breztri aerosphere was found without an open date label, contrary to the facility's policy requiring opened medications to be dated. The Director of Nursing confirmed that expired medications should be removed and properly disposed of, and that medications should not be left unattended on medication carts.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to adhere to standardized pureed recipes during food preparation, affecting seven residents on pureed diets. During a dining tour, it was observed that residents on regular diets received roast turkey, egg noodles, mixed vegetables, fruit cup, and bread with margarine, while those on pureed diets received pureed turkey, mashed potatoes, pureed vegetables, and pureed dessert. Notably, pureed bread and pureed buttered noodles were not served to residents on pureed diets. The cook, V12, admitted to substituting mashed potatoes for pureed egg noodles and not preparing pureed bread due to time constraints. Additionally, during breakfast, oatmeal was served to both regular and pureed diet residents without being pureed, as V12 and the Dietary Manager, V11, believed it was soft enough. The Speech Language Pathologist, V21, emphasized the importance of pureeing foods like oatmeal to prevent choking and aspiration risks for residents with mastication difficulties. The Consultant Registered Dietitian, V19, highlighted the necessity of following diet spreadsheets and recipes to ensure meals meet dietary requirements and maintain the correct texture and consistency. The facility's documentation, including physician order sheets, meal tickets, diet spreadsheets, and recipes, indicated that pureed buttered noodles and bread should have been served, and oatmeal should have been pureed. The failure to follow these guidelines could potentially lead to nutritional deficiencies and compromised safety for residents on pureed diets.
Failure to Provide Prescribed Fortified Supplements
Penalty
Summary
The facility failed to provide fortified supplements as prescribed by the physician for six residents. During an observation of the breakfast tray line, it was noted that the cook prepared only one type of hot cereal, oatmeal, instead of the prescribed super cereal. The cook mistakenly believed that adding brown sugar and cinnamon to oatmeal made it equivalent to super cereal, which is incorrect. The dietary manager confirmed that super cereal is a fortified food specifically recommended by the registered dietitian and ordered by the physician for residents needing to gain weight. The super cereal is listed on the residents' meal tickets to be served at breakfast daily, and there is a specific recipe that should be followed. The consultant registered dietitian explained that fortified foods like super cereal are used to add extra calories and protein to a resident's diet, particularly for those losing weight. If super cereal is ordered by the physician, it should be provided to the resident to ensure the planned or desired weight gain occurs. The facility provided documentation showing that the residents' breakfast meal tickets and physician orders included super cereal. However, the cook did not prepare it according to the specified recipe, which includes ingredients such as non-fat dried milk, evaporated milk, margarine, brown sugar, and granulated sugar. This failure to provide the prescribed fortified supplement could potentially impact the residents' nutritional status and weight gain goals.
Failure to Provide Pneumococcal Vaccination Education and Assessment
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of pneumococcal vaccinations to eligible residents or their representatives. This deficiency was identified through interviews and record reviews, which revealed that several residents, including those with severe cognitive impairments and chronic conditions, did not receive the necessary education or assessment for pneumococcal vaccination eligibility. The facility's policy mandates that residents or their representatives be informed about the significant risks and benefits of vaccines, but this was not documented in the residents' medical records. The surveyor's findings highlighted that five residents, among a sample of 48, were not assessed for pneumococcal vaccination eligibility, nor were they offered the vaccine. These residents had various medical conditions, such as Alzheimer's disease, dementia, hypertension, diabetes, and chronic kidney disease, which could increase their risk of complications from pneumococcal infections. Despite the facility's policy and CDC guidelines, there was no documentation of education or assessment in the records of these residents, indicating a lapse in following the established procedures. Interviews with the facility's Infection Preventionist and Director of Nursing confirmed that the facility was supposed to follow CDC guidelines for pneumococcal immunization, which includes providing education and documenting it in the residents' health records. However, the records reviewed showed a lack of documentation for education and assessment, and some residents had outdated or missing immunization records. This failure to adhere to the facility's policy and CDC guidelines resulted in a deficiency in the care provided to the residents.
Failure to Update and Include Advance Directives in Care Plans
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the inclusion and updating of advance directives in residents' comprehensive care plans. This deficiency was identified for three residents out of a sample of 48. For one resident, there was a discrepancy between the care plan, which indicated a full code status, and the physician's orders and POLST form, which both indicated a Do Not Resuscitate (DNR) status. The Social Service Director acknowledged this inconsistency and emphasized the importance of having the care plan reflect the resident's wishes to ensure appropriate action during emergencies. Another resident had a physician's order for full code status but lacked a corresponding care plan for advance directives. Similarly, a third resident, who had intact cognition and a physician's order for full code status, also did not have a care plan for advance directives. The facility's policy mandates that advance directives be included in the care plan and reviewed quarterly, but this was not followed, leading to a lack of clear guidance for staff on how to proceed in emergency situations.
Failure to Timely Change PICC Line Dressing
Penalty
Summary
The facility failed to adhere to professional standards for the maintenance of a PICC line for a resident, identified as R130, who required intravenous antibiotic therapy due to osteomyelitis. The resident's care plan specified the need for IV antibiotic therapy with ceftriaxone and indicated that the IV site should remain free of infection signs. However, observations revealed that the PICC line dressing, dated 01/07/25, was not changed by the required date of 01/14/25, as per the facility's policy. This oversight was confirmed by the resident, who mentioned that the dressing change was pending, and by the Registered Nurse, who acknowledged the dressing should be changed every seven days. The Director of Nursing further confirmed that the PICC line dressings are to be changed weekly or as needed, and failure to do so could lead to infection control issues and hinder the assessment of the site. The facility's policy mandates that PICC line dressings be changed every 5-7 days or sooner if compromised. The lack of timely dressing change for R130's PICC line, as documented in the Medication Administration Record, highlights a deficiency in maintaining the standard of care required for intravenous access devices, potentially exposing the resident to infection risks.
Failure to Provide Emergency Tracheostomy Equipment at Bedside
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy had the required emergency equipment at the bedside. The resident, who has multiple diagnoses including chronic respiratory failure and a tracheostomy, was observed without the necessary emergency step-down tracheostomy tube readily available. During an observation, a registered nurse was unable to locate the emergency step-down tracheostomy tube at the resident's bedside and had to retrieve it from the supply room. This indicates that the emergency equipment was not immediately accessible in the event of a tracheostomy dislodgement. The Director of Nursing confirmed that the emergency tracheostomy supplies should be easily accessible at the head of the bed to prevent potential airway closure if the tracheostomy becomes dislodged. The facility's policy on tracheostomy care requires that an emergency tracheostomy tube replacement, either the same size or one size smaller, should be kept at the bedside. The failure to adhere to this policy and ensure the availability of emergency equipment at the bedside represents a deficiency in the facility's respiratory care for the resident.
Controlled Substance Accountability Deficiency
Penalty
Summary
The facility failed to ensure accurate shift change reconciliation and accountability for controlled substances, specifically Clonazepam and Tramadol, leading to discrepancies in medication counts. This issue was identified in one of the three medication carts used for storing controlled narcotics. The Shift Change Accountability Record for Controlled Substances was found to have missing nurse initials for specific shifts, indicating that the narcotic count was not completed as required. Additionally, discrepancies were noted in the medication counts for two residents: one Tramadol tablet was missing from a resident's medication card, and two Clonazepam tablets were missing from another resident's medication card. During the review, a Licensed Practical Nurse (LPN) confirmed the procedure for counting and signing off on narcotics at the beginning and end of each shift, and the Director of Nursing (DON) explained the importance of the Shift Change Accountability Record in ensuring accurate narcotic counts. The facility's policy requires two licensed nurses to verify the narcotic log sheets, and any discrepancies should be reported to the DON or administrative nursing staff for investigation. However, the failure to adhere to these procedures resulted in unaccounted controlled substances, raising concerns about potential medication mismanagement.
Failure to Administer Correct Insulin Dose
Penalty
Summary
The facility failed to ensure that a resident received the prescribed amount of insulin, resulting in a significant medication error. The resident, identified as R25, has multiple diagnoses including Type 2 Diabetes Mellitus, which requires careful management of blood glucose levels. The physician's order specified that R25 should receive 15 units of Basaglar insulin twice a day, with blood sugar monitoring before meals and at bedtime. However, on the day of the incident, the registered nurse (V4) did not perform the required blood glucose check before administering the insulin. Additionally, the nurse failed to prime the insulin Kwik pen, which is necessary to ensure the correct dose is delivered and to prevent air from being injected. The Director of Nursing (V18) confirmed that the proper procedure for insulin administration includes priming the needle to avoid air injection and ensure the correct dose is given. The facility's policies on medication and insulin administration emphasize the importance of monitoring and priming to prevent medication errors. The nurse's failure to follow these procedures resulted in the potential for R25 not receiving the full prescribed dose of insulin, constituting a significant medication error as per the facility's standards and policies.
Improper Management of Resident's Personal Refrigerator
Penalty
Summary
The facility failed to properly manage and maintain the personal refrigerator of a resident, identified as R53, which led to potential health risks. Upon inspection, the refrigerator was found to be warm, with a thermometer reading of 58 degrees Fahrenheit, indicating it was not functioning correctly. Several food items inside the refrigerator were either expired or not dated, including smoked ham, a defrosted beef pot pie, strawberry creme parfait, and rice pudding. The Certified Nursing Assistant (CNA) and Maintenance Director confirmed the refrigerator's inadequate temperature and the presence of expired food items, acknowledging the risk of food spoilage and potential illness if consumed by the resident. The facility's policies require maintenance and housekeeping staff to ensure refrigerators are in proper working order and for CNAs to check and discard expired food items. However, these procedures were not followed, as evidenced by the undated and expired food items found in R53's refrigerator. The Maintenance Director and Dietary Manager both emphasized the importance of maintaining refrigerator temperatures at 40 degrees Fahrenheit or below to prevent foodborne illnesses. Despite these guidelines, the facility's failure to adhere to its policies resulted in a deficiency that could affect the health and safety of the resident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. One resident, with a diagnosis of mild dementia and anxiety, reported being verbally and physically abused by her roommate, who also has dementia and a major depressive disorder. The incident involved the roommate throwing tissues and a cup of water on the floor and poking the resident's hand, resulting in a skin tear. The facility's incident report confirmed the abuse, and the social services notes documented the roommate's verbal aggression and physical actions. The facility's staff, including the Assistant Director of Social Services and several Licensed Practical Nurses, were aware of the incident but failed to immediately report it to the administrator as required by the facility's abuse prevention policy. The administrator was only informed the day after the incident occurred. The facility's policy mandates immediate reporting of any abuse allegations to the administrator, which was not adhered to in this case. The failure to promptly report and address the incident contributed to the deficiency in protecting the resident from abuse.
Failure to Notify Family of Resident's Hospitalization
Penalty
Summary
The facility failed to adhere to its policy of notifying family members about a resident's change in condition. This deficiency was identified for one resident out of a sample of three. The resident, referred to as R1, was sent to the hospital on October 31, 2024, due to suicidal ideation. The resident's Power of Attorney (POA), V3, requested a report on November 5, 2024, regarding the incident, but did not receive an update. The facility's Director of Nursing (V2) acknowledged that although she was informed of the request and claimed to have contacted V3, there was no documentation in the resident's electronic health record to confirm this communication. The facility's policy requires that any notification to the family about a resident's condition be documented in the electronic health record, including details of who was notified, the date, time, and the response. However, the documentation provided by the facility was incomplete and did not include the resident's name or signatures. The lack of proper documentation in the electronic health record indicates that the facility did not fulfill its obligation to notify the family as per its policy.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two male residents. Resident R4, who has a history of dementia with behavioral disturbances and other cognitive impairments, was involved in an incident where he allegedly sexually assaulted resident R3, who is cognitively intact. R3 reported that R4 put his hands down R3's diaper, prompting R3 to push R4's hand away and call for assistance. A CNA responded to the call light and found R4 sitting on his bed. The CNA reported the incident to the nurse, and R4 was moved to a different room. This incident was not isolated, as R4 had a previous report of inappropriate touching on another resident earlier in the year. The facility's failure to implement effective interventions following R4's previous inappropriate behavior contributed to the recurrence of such incidents. Despite R4's documented history of sexually inappropriate behavior, there were no changes in interventions in his care plan after the initial incident. The facility's abuse prevention policy emphasizes the residents' right to be free from abuse, yet the lack of adequate measures to prevent further incidents indicates a failure to adhere to this policy. The final incident investigation report did not conclusively determine the outcome of the abuse allegation, leaving the situation unresolved.
Failure to Timely Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly and timely investigate an alleged incident of potential staff-to-resident abuse involving a resident who reported being struck in the groin area by a CNA during patient care. The incident was initially reported by the resident's family on 8/7/2024, but the facility did not begin a formal investigation until 8/15/2024, after the ombudsman was informed by the family. The resident, who had a urinary catheter, reported that the CNA was rough and caused pain while checking the resident's diaper, leading to the resident's sister contacting the facility to express her concerns. Despite the family reporting the incident to the facility on 8/7/2024, the initial response was to view it as a concern rather than a potential abuse case, and the CNA was not immediately removed from duty. The facility's policy requires immediate reporting of any allegations of abuse to the administrator, but this protocol was not followed. The lack of documentation in the medical record regarding the allegations and the delay in starting the investigation contributed to the deficiency identified by the surveyors.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in psychosocial harm. The incident involved a resident, who had been in the facility for about two years, experiencing unwanted touching by another resident. The affected resident, who was cognitively intact but physically dependent due to medical conditions, reported that the other resident repeatedly attempted to touch them inappropriately. Despite the resident's complaints to staff, the unwanted behavior continued, leading the resident to record a video of the incident as evidence. The report details that the resident showed the video to the facility's Social Services Director and Administrator, as well as to the police and hospital staff. The video depicted the other resident approaching the bed and attempting to touch the resident under the covers. The resident expressed feeling violated and unsafe, and despite informing staff multiple times, the behavior persisted. Another resident corroborated the account, stating they had also experienced similar unwanted advances from the same individual. The facility's staff, including CNAs and nurses, were aware of the situation, with several staff members witnessing or being informed of the inappropriate behavior. However, the facility's response was inadequate, as there was no documented care plan addressing the risk of abuse for the affected resident. The facility's policy on abuse prevention and reporting was not effectively implemented, as the resident continued to experience unwanted contact despite raising concerns with multiple staff members.
Failure to Administer PRN Pain Medication as Ordered
Penalty
Summary
The facility failed to administer a PRN dose of pain medication to a resident, identified as R3, for breakthrough pain, despite the resident's request and the physician's instructions. R3, who has a history of chronic pain syndrome and other medical conditions, reported that the nurses were not administering the PRN medication as needed, particularly when it was requested less than four hours after a scheduled dose of Oxycontin. The physician's order clearly stated that the PRN Oxycodone should be administered based on the last PRN dose, not the scheduled dose, allowing for up to four doses per day. During the survey, it was revealed that the nurse, identified as V5, did not administer the PRN Oxycodone when R3 requested it on a specific date, despite R3's complaint of pain. V5 admitted to asking R3 to wait for the PRN medication, believing that the scheduled Oxycontin had not yet taken full effect. The facility's EMAR and narcotic log showed no documentation of the PRN Oxycodone being administered during the shifts V5 worked, supporting R3's claim of not receiving the medication. The Director of Nursing, V2, acknowledged the issue, stating that agency nurses were not following the physician's orders correctly, leading to R3 not receiving the PRN medication as needed. The facility's pain management policy emphasizes the importance of providing comfort and administering medications as ordered, yet the documentation and actions of the nursing staff did not align with these guidelines, resulting in a deficiency in pain management for R3.
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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