Kensington Place Nrsg & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 3405 South Michigan Avenue, Chicago, Illinois 60616
- CMS Provider Number
- 145829
- Inspections on file
- 50
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Kensington Place Nrsg & Rehab during CMS and state inspections, most recent first.
The facility failed to maintain indoor temperatures within its policy range of 71–81°F, resulting in multiple areas of the building, including resident rooms and hallways, being recorded in the 50s and 60s. Several residents reported feeling cold for days despite having multiple blankets, and staff were observed wearing winter coats and hats indoors. The Maintenance Supervisor acknowledged that temperatures should be at least 71°F and that it was not acceptable for residents to be cold, and a refrigeration technician indicated that an additional heat source would be required to reach the desired temperature. The DON and Assistant Administrator became aware of the cold conditions and instructed staff to close windows and provide extra blankets, while the Administrator reported being notified later and directing maintenance to contact a service company. Facility policies state that residents have the right to a safe, comfortable environment and that indoor temperatures must be maintained between 71°F and 81°F, with prompt interventions when temperatures fall outside this range.
Two cognitively intact residents with multiple chronic conditions, including DM, COPD, hypertensive heart disease, and bilateral BKA, were served lunch meals with pork shoulder meat at 96.6°F, well below the Dietary Manager’s stated standard of at least 145°F and the facility policy requiring potentially hazardous foods to be held above 135°F. The Dietary Manager acknowledged that residents had complained of cold food and confirmed the trays were cold, and a CNA reported routinely reheating residents’ meals in a microwave after complaints, noting residents were still upset because they expected their food to be hot when served.
A resident was physically struck in the face by another resident during an altercation in the dining area, resulting in superficial facial scratches. Both individuals were in wheelchairs and the incident occurred when one became frustrated at being unable to pass. The event was witnessed by staff and other residents, and the facility failed to prevent this instance of resident-to-resident physical abuse.
Two residents, one with schizoaffective disorder and another with dementia, were involved in a physical altercation in a common area. The aggressor struck the other in the face, reportedly after a verbal exchange, resulting in a minor injury. Staff were not immediately present and were alerted by a housekeeper, after which they intervened and separated the residents. The incident was witnessed by multiple staff and residents, and the aggressor was later hospitalized for psychiatric evaluation.
The facility did not conduct annual performance evaluations for CNAs and failed to document or ensure the required 12 hours of in-service training per year. Documentation for in-service hours and evaluations was not available, and staff were unclear about the requirements. This deficiency impacted all 127 residents.
The facility did not post daily nurse staffing information in a highly visible area as required, instead keeping the staffing schedule on a nurse's station ledge where it was not visible to residents. The posted document was also missing key required details, including the facility name, staffing hours by RNs, LPNs, and CNAs, and the resident census.
Several kitchen staff, including cooks and dietary aides, were found to be working without current food handler certifications, as required by facility policy and job descriptions. The facility lacked a system to track or post certifications, resulting in staff with expired or missing credentials preparing food for all residents receiving oral diets. This deficiency was confirmed through interviews, record reviews, and direct observation.
Surveyors observed that kitchen staff failed to label and date opened refrigerated food items, stored personal food and belongings in areas designated for resident food preparation, and did not consistently follow hand hygiene or equipment sanitization protocols. Staff were seen handling food after touching their face or garbage can lids without washing hands, and failed to sanitize thermometer probes between checking different hot foods, resulting in cross-contamination. These failures affected all residents receiving oral diets.
A facility-wide assessment contained numerous inaccuracies, including incorrect resident condition counts, references to another facility, and missing required documentation such as participant names and staffing plans. Leadership could not explain the errors or provide a correct assessment, and the assessment lacked details on recruitment, retention, contingency staffing, and QAPI training, potentially impacting all residents.
A nurse failed to wear a gown while performing G-tube care for a resident on Enhanced Barrier Precautions, despite facility policy and posted instructions requiring both gown and gloves for such care. Additionally, a housekeeping supervisor handled soiled linen and then clean laundry items without performing hand hygiene, and soiled linen was found unbagged in the laundry chute. These actions did not comply with the facility's infection prevention and control policies.
A large amount of lint was observed in and around all three dryers in the laundry area, with lint covering the lint traps, dryer bases, and surrounding floor. The Housekeeping Supervisor reported cleaning lint traps every three days and noted a loose wire in one dryer, which prevented moving the machines for thorough cleaning. It was also confirmed that there was no policy for cleaning lint traps or the laundry area.
The facility did not ensure that all staff received training on Quality Assurance and Performance Improvement (QAPI). Interviews with a housekeeper and an RN revealed a lack of knowledge and training on QAPI, and leadership was uncertain about training requirements. Documentation showed that QAPI training for staff only began after the survey was initiated, and the facility assessment did not identify a need for such training.
The facility did not complete required Level I PASARR screenings for several residents with documented mental health diagnoses, such as schizophrenia and major depressive disorder, despite clear facility policy and staff awareness of the need for these assessments. Staff interviews revealed confusion over responsibility for the PASARR process, leading to missed screenings for affected residents.
The facility did not ensure that two licensed staff conducted and documented shift-to-shift controlled substance counts as required, with multiple instances of missing initials on the narcotic count form. This failure affected four residents prescribed controlled substances from a medication cart, as the required reconciliation was not completed on several occasions.
The facility did not follow its policies for pneumococcal vaccination, failing to vaccinate eligible residents, document vaccine offerings, or record refusals and related education in the medical records. The Infection Preventionist confirmed incomplete and undated consent forms and a lack of proper documentation for multiple residents.
Two residents were found wearing hospital wristbands displaying personal and medical information, such as names, dates of birth, and admission details, after being admitted to the facility. Nursing staff confirmed that removal of these bands is their responsibility, but there was no set timeframe for removal, and it was only done upon resident request. This practice resulted in the exposure of confidential information, contrary to facility policy and privacy requirements.
A resident with cognitive impairment and multiple medical diagnoses was found confined to bed with all four side rails up, despite only having a physician order for half side rails for mobility. Staff interviews confirmed the improper use of side rails, and facility policy requires specific orders for restraints. The care plan did not initially address the restraint issue, leading to a deficiency in ensuring the resident was free from physical restraints.
Two residents with newly diagnosed schizophrenia were not referred for required PASRR Level II screening after their initial Level I screenings indicated no serious mental illness. Staff interviews revealed confusion about the PASRR process and responsibilities, resulting in the facility not following its policy to refer residents for further assessment upon significant change in mental health status.
A resident with multiple chronic conditions was observed receiving oxygen therapy without the required 'Oxygen in Use' sign posted on their room door. Staff confirmed the absence of the sign, which is mandated by facility policy for safety reasons. The resident's care plan and physician orders documented the need for oxygen and related precautions, but the necessary signage was not in place.
A resident was physically struck in the face by another resident during an unprovoked altercation in a hallway, as confirmed by a peer witness. Both residents were cognitively intact, and no staff were present to intervene or witness the incident, resulting in a failure to protect residents from abuse as required by facility policy.
The facility did not post the required [NAME] Program information in accessible areas for residents, affecting all 125 residents. The Social Service Director was unaware of the requirement, and no postings were found on any floor. The Administrator acknowledged the oversight but could not provide a policy on the postings.
The facility failed to maintain required temperatures in residents' rooms and common areas, with temperatures dropping as low as 57.2°F. Residents complained about the cold, and the Maintenance Director admitted to infrequent temperature checks. Additionally, two residents had nonfunctional sinks, forcing them to use alternative methods for water and handwashing. The Assistant Administrator was unaware of these issues, and facility policies on maintenance were not followed.
Two incidents of resident-on-resident physical abuse occurred in the facility. In one case, a cognitively intact resident with schizophrenia assaulted another resident with moderate cognitive impairment. In the second case, a resident with a history of violent behavior struck another resident with a magazine during an activity. Both incidents were witnessed by staff, who intervened immediately.
A resident sustained a laceration on the right leg and was sent to the ER for stitches. The facility failed to follow its incident reporting policy, as the nurse supervisor submitted incomplete initial and final reports together without conducting a thorough investigation or including necessary details such as how the injury occurred, interviews with staff or the resident's roommate, or the intervention of replacing the resident's wheelchair.
A facility failed to thoroughly investigate an incident involving a resident with a leg laceration. The investigation lacked witness statements from staff present during the incident, despite facility policies requiring comprehensive documentation. The resident, with a history of chronic conditions and intact cognitive status, was found bleeding and sent to the hospital, but the investigation was incomplete.
A resident with a history of aggressive behavior slapped another resident in the face, despite staff presence and previous care plan interventions. The incident, which was witnessed by a CNA and an LPN, highlights the facility's failure to protect residents from abuse, as outlined in their abuse policy.
A resident with multiple medical conditions was transported to a medical appointment without footrests on his wheelchair, leading to safety concerns. The CNA escorting the resident did not address the absence of footrests, resulting in the resident's feet dragging and being bumped by doors. The incident led to a confrontation with the resident's family member and an investigation by the facility's administration.
A resident with a history of aggression due to mental illness physically abused another resident, resulting in a head laceration requiring sutures. The incident occurred while the assigned nurse was on a break, and another LPN was occupied with other duties. The facility's abuse prevention policy was not effectively implemented, leading to this deficiency.
The facility failed to secure medication carts on the 1st and 2nd floors, leaving them unlocked and unattended, contrary to policy. RNs admitted the carts should have been locked when not in use, as confirmed by the DON. This oversight posed a potential hazard to residents.
A resident with cognitive deficits perceived a nurse's stern behavior as harsh, leading to a complaint of verbal abuse. Another nurse, aware of the complaint, failed to report it to the facility's administration, violating the facility's abuse policy.
A resident's medication was prepared by one nurse but administered by another, leading to a breach in the facility's medication administration protocol. The nurse who administered the medication did not sign the MAR, contrary to the facility's policy, which requires the same nurse to prepare, administer, and document the medication.
A facility failed to provide adequate staffing, resulting in a resident hitting another with a coffee cup, causing a laceration. Only one CNA and one LPN were present on the floor, contrary to the usual staffing guideline of two nurses and two CNAs. The incident was not witnessed by staff, and the facility's policy for addressing staffing shortages was not followed.
A resident was physically attacked by another new resident shortly after admission, resulting in a superficial laceration. The attack was unprovoked and related to the aggressor's psychiatric condition. Staff intervened promptly, but the facility failed to protect the resident from abuse as per its policy.
The facility failed to provide privacy curtains for several residents, compromising their privacy. Despite being informed, the curtains remained absent, with staff indicating that housekeeping might have removed them for washing. The Housekeeping Supervisor confirmed the lack of curtains and the need for new orders, while the Maintenance Supervisor was ready to install them once available.
The facility failed to maintain functional call lights in the community shower rooms on the second and third floors, affecting 86 residents. Observations confirmed the malfunction, and the maintenance supervisor was unaware due to a lack of reporting. The LPN acknowledged the importance of operational call lights for resident safety, highlighting a lapse in communication and adherence to the facility's policy.
A facility failed to maintain an effective pest control program, leading to a fruit fly infestation in a resident's room. A hole at the floor-wall junction, caused by water damage from the resident's behavior of clogging the toilet and sink, was the source of the infestation. The resident confirmed the issue, which had persisted for weeks, and the facility's pest control policy was not effectively implemented.
A resident with cognitive impairments was verbally abused by a housekeeper, who admitted to using profanity, while two other residents were involved in a physical altercation after one threw water at the other. Staff failed to intervene appropriately and did not follow proper procedures for preventing and addressing abuse.
The facility failed to report a physical altercation between two residents in a timely manner. The incident, involving a resident with schizophrenia and another with COPD, occurred when one resident threw water at the other, leading to a physical confrontation. Despite multiple staff members being aware of the incident, it was not reported immediately as required by the facility's policies.
A resident with multiple medical conditions did not receive timely incontinence care or scheduled showers. The resident reported being left in soiled briefs for extended periods and not receiving a shower for weeks. Observations confirmed the lack of timely care, and documentation was missing to verify that scheduled showers were provided.
The facility failed to protect a resident from physical abuse by another resident. An unprovoked incident occurred where a resident hit another in the face with a chair, causing injury. The aggressor had a history of aggressive behavior and previous convictions. Staff intervened immediately, and the injured resident was sent to the hospital for treatment.
Failure to Maintain Required Indoor Temperatures for Resident Comfort and Safety
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe and comfortable indoor temperatures in accordance with its policy requiring temperatures between 71 and 81 degrees Fahrenheit. Multiple residents reported feeling cold for several days, with one resident stating he had four blankets and was still cold, which the surveyor confirmed by observation. Another resident reported being cold for two days and uncomfortable, and a third resident stated the facility had been cold for a few days and that nothing was being done about it. Staff were also observed wearing winter coats and hats indoors and reported feeling cold. On multiple dates, the Maintenance Supervisor used a handheld infrared thermometer to check temperatures in various rooms and hallways on all three floors. Recorded temperatures were consistently below the facility’s policy threshold, with readings as low as 55.4°F, 58.8°F, 59.7°F, and several readings in the low to mid-60s across different resident rooms and hallways. Even the highest observed readings in resident areas were in the upper 60s, still below the required minimum of 71°F. Plastic coverings were observed on windows and air conditioning units, and residents were observed with multiple blankets, indicating attempts to cope with the cold environment. The Maintenance Supervisor stated he was first informed that the building was cold on a Sunday and that he initially responded by placing plastic on some resident windows but did not check temperatures at that time. He later reported that the building temperature should be at least 71°F and acknowledged it was not acceptable for residents to be cold. The DON reported first learning of the cold conditions from an LPN on a Sunday and stated she informed the Administrator and instructed staff to ensure windows were closed and to provide extra blankets, but she did not know what the building temperature should be. The Assistant Administrator reported becoming aware of the cold the following day and noted that she did not have a temperature gun initially and relied on feeling the cold in the air. The Administrator stated she was first notified of the cold conditions later and acknowledged directing maintenance to contact the service company and the DON to ensure windows were closed. A refrigeration technician stated that an additional heat source would be needed for the facility to achieve the desired 71°F temperature. The facility’s own policies state that residents have the right to a safe, clean, comfortable, and homelike environment and that indoor temperatures are to be maintained between 71°F and 81°F, with prompt interventions when temperatures fall outside this range.
Failure to Serve Hot Foods at Safe Temperatures
Penalty
Summary
The facility failed to distribute and serve food in accordance with professional standards by providing lunch meals at unsafe and unsatisfactory temperatures to two cognitively intact residents. One resident had medical diagnoses including type 2 diabetes mellitus, lymphedema, and bilateral below-knee amputations, and another resident had chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, and mild cognitive impairment. On 01/20/26 at 12:29 p.m., both residents’ lunch trays were observed delivered to their bedside. At 12:30 p.m., the Dietary Manager measured the temperature of the pork shoulder meat on both trays and found it to be 96.6°F. The Dietary Manager stated that the food temperature should be at least 145°F and confirmed that the trays were cold. The Dietary Manager reported that residents had informed her they were receiving cold food and that she had needed to come to the nursing units to ensure trays were passed out in a timely manner. A CNA stated that residents had complained about receiving cold food and that when residents complained, she reheated their food in a microwave and informed dietary staff, but residents remained upset because they wanted their food served hot initially. One resident stated that the food he receives is served cold and that staff tell him to have the CNA warm it up, but he feels the food should already be hot. The facility’s “Food Preparation and Service” policy, reviewed 07/2025, specifies that potentially hazardous foods must be maintained below 41°F or above 135°F, and that previously cooked food must be reheated to an internal temperature of 165°F for at least 15 seconds, indicating that the observed food temperatures were within the documented danger zone.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place in the dining area, where two residents, both using wheelchairs, were involved in an altercation. One resident attempted to pass by another but was unable to due to limited space. This led to the resident becoming frustrated, standing up from the wheelchair, and striking the other resident in the face. The assaulted resident sustained two superficial scratches to the face as a result of the incident. Both residents involved had intact cognition as indicated by their BIMS scores, and neither had a prior history of altercations with each other. The resident who was struck reported feeling upset by the event but did not require hospitalization and denied any pain. The incident was witnessed by staff and other residents, who confirmed that the aggressor became frustrated when unable to pass and initiated the physical contact. The facility's abuse prevention and resident rights policies prohibit any form of abuse, including physical injury inflicted by anyone. The deficiency was identified through observation, interviews, and record review, which documented that the facility did not prevent the occurrence of resident-to-resident physical abuse. The event resulted in minor physical injury to one resident and was corroborated by multiple sources, including staff, residents, and medical records. The facility's failure to ensure a safe environment free from abuse for all residents led to this deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents, one of whom was cognitively intact with a history of schizoaffective disorder and cerebral palsy, and the other moderately cognitively impaired with dementia and multiple comorbidities. The incident occurred in the basement dining room, where one resident approached the other and struck him in the face, reportedly in response to being called an inappropriate name. Multiple staff and resident witness statements confirmed that the aggressor hit the other resident, at times using a can of soda, and that the altercation escalated to physical violence before staff intervened and separated the individuals. The injured resident was observed with a superficial scratch under his eye, which was treated with basic first aid and healed without complications. Witness accounts varied regarding the precipitating factors, with some indicating verbal provocation and others stating the attack was unprovoked. The aggressor was subsequently sent to a hospital for psychiatric evaluation due to increased agitation and aggressive behavior, and a petition for involuntary admission was completed, citing the individual's risk of harm to self or others if not treated on an inpatient basis. Documentation and interviews revealed that staff were not present in the immediate area at the time of the incident and were alerted by a housekeeper who witnessed the altercation. The facility's abuse policy prohibits all forms of abuse and affirms residents' rights to be free from such mistreatment. Despite this policy, the facility did not prevent the physical abuse that occurred between the two residents.
Failure to Complete CNA Performance Evaluations and Required In-Service Training
Penalty
Summary
The facility failed to complete annual performance evaluations for certified nursing assistants (CNAs) and did not ensure that CNAs received the required 12 hours of in-service training annually. During the survey, documentation for annual performance evaluations and in-service hours for two CNAs was requested but not provided. The only documents available were competency checklists, which did not indicate the duration or content of training. The staff responsible for education and in-servicing was unsure of the required number of in-service hours and confirmed that there was no documentation of the hours completed. The assistant administrator stated that performance evaluations were not conducted due to union contract stipulations and that there was no facility policy for annual performance reviews for CNAs. The facility's own assessment referenced the requirement for at least 12 hours of in-service training per year for nurse aides, including addressing areas of weakness identified in performance reviews. However, the facility did not have records to show that this requirement was met for the CNAs reviewed, nor did it have a process in place to track or document the hours of in-service training provided. This deficiency affected all 127 residents residing in the facility.
Failure to Properly Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a location that was highly visible to residents, as mandated by regulations. On the day of the survey, the Assistant Administrator provided a document titled 'Nursing Schedule' that was found on top of the ledge of the first floor nurse's station, facing the ceiling and not visible to residents. Both the Assistant Administrator and the Director of Nursing confirmed that this was the document used for posting staffing information and that it was kept at the nurse's station. Additionally, the provided document did not include all required information, such as the facility name, the total number and actual hours worked by RNs, LPNs, and CNAs per shift, or the resident census. The facility's own policy states that nurse staffing data should be posted daily for each shift in accordance with state and federal regulations.
Failure to Ensure Kitchen Staff Maintain Active Food Handler Certifications
Penalty
Summary
The facility failed to ensure that all kitchen staff maintained active food handler certifications, as required for safe and competent food and sanitation service to residents. During the survey, it was found that several kitchen employees, including cooks and dietary aides, either did not have current food handler certificates or had expired certifications. Specifically, four staff members were identified as lacking current certification at the time of the survey, with some only beginning the process of renewal during the survey period. The dietary manager confirmed that it is a requirement for all kitchen staff to have active food handler certification, and that this is also stipulated in the union handbook. Interviews and record reviews revealed that the facility did not have a system in place to track or post the food handler certifications of kitchen staff. The dietary manager stated that, unlike other facilities, certificates were not posted in the kitchen, and there was no clear process for cataloging or maintaining these records. The responsibility for maintaining current certification was placed on the individual employees, and there was uncertainty about who in the facility was responsible for keeping copies of the certificates. This lack of oversight led to a situation where staff were working without the required certification. The deficiency was observed to have the potential to affect all 127 residents receiving oral diets, as the kitchen staff are responsible for preparing and serving food to the entire resident population. The facility's job descriptions for kitchen staff explicitly require sanitation certification, and both the dietary manager and registered dietitian emphasized the importance of current food handler certification for ensuring resident safety and preventing cross-contamination in the kitchen. Despite these requirements, the facility did not ensure compliance among all kitchen staff at the time of the survey.
Multiple Food Safety and Sanitation Failures in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and sanitation practices in the kitchen, as evidenced by multiple observations of staff not following established protocols. Surveyors observed that opened refrigerated food items, such as a package of bologna slices, were not labeled or dated, and staff were unable to confirm when the items were opened. Additionally, staff personal food and drink items, including water bottles, soda bottles, and a grocery sack containing polish beef sausages, were stored in the kitchen refrigerator and freezer designated for resident food, contrary to facility policy. Personal belongings such as cellular phones, keys, and a music speaker were also found on food preparation surfaces and equipment, including the main prep table and meat slicer ledge, where resident food was being prepared. Hand hygiene and cross-contamination prevention measures were not consistently followed by kitchen staff. One cook was observed wiping perspiration from their forehead with a gloved hand and then continuing to plate resident meals without changing gloves or performing hand hygiene. Staff were also seen touching garbage can lids and then handling food or equipment without washing hands. During food preparation, equipment such as a food processor was not properly cleaned, as visible food residue remained after washing, rinsing, and sanitizing. The equipment was not allowed to fully air dry before being used again, and visible moisture droplets were present on the equipment when it was used to prepare additional food items. Temperature monitoring procedures for hot foods were not followed according to policy. A cook was observed using an electric thermometer to check the temperature of multiple food items without sanitizing the probe between uses, resulting in visible food residue being transferred from one item to another. Both the Dietary Manager and Registered Dietitian confirmed that staff are required to sanitize the thermometer probe with alcohol wipes between each food item to prevent cross-contamination. The facility's own policies and job descriptions require strict adherence to food safety, hand hygiene, and equipment sanitization protocols, which were not followed during the survey period. All 127 residents receiving oral diets were affected by these failures.
Inaccurate Facility Assessment and Documentation Failures
Penalty
Summary
The facility failed to complete an accurate and comprehensive facility-wide assessment, which is required to determine the necessary resources to care for residents competently during both routine operations and emergencies. The assessment contained multiple inaccuracies, such as listing incorrect numbers of residents with specific conditions, referencing another facility's name and data, and including staffing and population details that did not match the actual facility. Additionally, the assessment did not document the names of staff, residents, or family members who participated in its development, and omitted required information about recruitment, retention, contingency staffing plans, and QAPI training. During interviews, facility leadership acknowledged the involvement of the interdisciplinary team in developing the assessment but could not explain the presence of erroneous data or references to another facility. The Assistant Administrator and Nurse Consultant confirmed there was no other facility assessment available and could not account for the discrepancies. The facility's policy requires an annual review and documentation of a facility-wide assessment, but the provided assessment did not meet these requirements, potentially affecting all 127 residents residing in the facility.
Failure to Follow PPE and Hand Hygiene Protocols During Resident Care and Laundry Handling
Penalty
Summary
A deficiency occurred when a registered nurse failed to wear the required personal protective equipment (PPE), specifically a gown, while performing gastrostomy (G-tube) care for a resident on Enhanced Barrier Precautions (EBP). The nurse entered the resident's room, which had a visible EBP sign, and conducted a G-tube placement check using gloves but did not don a gown. The nurse handled the resident's G-tube and associated equipment, including removing and connecting a piston syringe, without the additional barrier protection mandated by facility policy and the posted EBP instructions. Both the infection preventionist and the nurse acknowledged that EBP requires the use of gown and gloves for device care, such as G-tube management, to prevent the transfer of microbes to residents with medical devices or open wounds. Another deficiency was observed in the facility's laundry operations. The housekeeping supervisor was seen pushing a soiled linen cart with bare hands into the laundry area and then handling clean laundry items without performing hand hygiene. The supervisor also touched multiple surfaces after handling soiled items and noted that soiled linen was present in the laundry chute without being contained in a bag, contrary to facility policy. The supervisor admitted that hand hygiene should have been performed after handling the soiled cart and before touching clean items, and that soiled linen should always be bagged to prevent contamination. Facility policies require the use of PPE during high-contact resident care activities, such as feeding tube care, and mandate hand hygiene when moving from dirty to clean tasks. The policies also specify that contaminated linen must be placed in biohazard bags and that staff must follow recognized hand hygiene procedures to prevent the spread of infection. These requirements were not followed during the observed incidents, resulting in deficiencies in the facility's infection prevention and control program.
Failure to Maintain Clean and Safe Laundry Area Due to Inadequate Lint Trap Cleaning
Penalty
Summary
The facility failed to maintain a clean and safe environment in the laundry area by not thoroughly cleaning the lint screens and surrounding areas of all three dryers. On observation, a large amount of lint was found covering the lint trap catchers, the base of the dryers, and the floor around the dryers. The Housekeeping Supervisor stated that lint traps are cleaned every three days and acknowledged the presence of a loose wire in one of the dryers, which was awaiting repair. The supervisor also indicated an inability to move the dryers for cleaning until the repair was completed. Additionally, it was confirmed by the Assistant Administrator that there was no policy in place for cleaning lint traps or for the laundry area in general.
Failure to Train All Staff on QAPI Program
Penalty
Summary
The facility failed to ensure that all staff were trained on Quality Assurance (QA) and Performance Improvement (QAPI), affecting all 127 residents. Interviews revealed that a housekeeper and a registered nurse were unaware of what QAPI was and had not received training on it. The assistant administrator stated that while staff receive training on hire and participate in other trainings such as handwashing, floor staff do not participate in QAPI meetings and it was unclear if QAPI training for all staff was required. The nurse consultant and administrator were also unsure about the requirement for all staff to receive QAPI training. The infection preventionist/QA nurse confirmed responsibility for QAPI programming and acknowledged that not all staff had been trained, with QAPI training only beginning after the survey started. Additionally, the facility assessment did not identify a need for staff training on QAPI.
Failure to Complete Required PASARR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that required preadmission screening assessments (PASARR) were completed for residents identified with mental illness or intellectual disabilities. Specifically, four residents with diagnoses such as schizophrenia, schizoaffective disorder, and major depressive disorder did not have documentation of a completed Level I PASARR screening in their health records. These residents were admitted or readmitted to the facility over a range of years, and their diagnoses and medication orders, including antipsychotic prescriptions, were clearly documented in their records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for completing PASARR screenings. The Business Office Manager/Admissions Director and the Social Services Director each described different understandings of their roles in the PASARR process, with both indicating that collaboration was supposed to occur, but in practice, there was a lack of coordination. Staff acknowledged that initial PASARR screenings had not been completed for the affected residents and were unsure why this had not occurred. In some cases, staff only became aware of the missing screenings after being prompted by surveyors or after contacting the state agency responsible for PASARR oversight. Facility policy requires that a Level I PASARR screen be completed for all potential admissions, regardless of payer source, to determine if the individual meets criteria for serious mental illness or intellectual disability. The policy also outlines procedures for referral to the state PASARR representative for Level II screening when indicated. Despite these policies, the required screenings were not completed for the identified residents, resulting in a failure to ensure that individuals with mental illness or intellectual disabilities received appropriate preadmission assessment.
Failure to Complete Shift-to-Shift Controlled Substance Counts
Penalty
Summary
The facility failed to ensure that two licensed personnel conducted a physical inventory of controlled substances at each change of shift, as required by facility policy. During a review of the medication cart and Controlled Substances Check Form for April 2025, multiple instances were identified where the required initials of the nurses coming on and going off shift were missing. Specifically, there were several dates where either the 'Nurse's Initials On' or 'Nurse's Initials Off' boxes were left blank, indicating that the controlled substances were not reconciled at the end and beginning of those shifts. Interviews with nursing staff and the Director of Nursing confirmed that the expectation is for both the incoming and outgoing nurses to count the narcotics together and document their initials on the form if the count is correct. The facility's policy and job descriptions for both Registered Nurses and Licensed Practical Nurses require accurate documentation and reconciliation of narcotic records for each shift. The failure to complete these checks and documentation affected four out of eighteen residents who were prescribed controlled substances from the second-floor long hall medication cart.
Failure to Document and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to follow its own policies and procedures for immunizing residents against pneumococcal disease in accordance with national standards of practice. Specifically, nine residents were not vaccinated with the pneumococcal vaccine, and there was no documentation in their electronic medical records regarding the offering of the vaccine, education about its benefits and side effects, or any record of refusal. Review of physician orders and immunization records for these residents showed no evidence of pneumococcal vaccination or related documentation from admission through the review period. During interviews, the Infection Preventionist (IP) acknowledged that while pneumococcal vaccines are supposed to be offered upon admission and during influenza season, there was no proof of offering the vaccine to the affected residents except for undated and incomplete consent forms. The IP also stated that refusals were not routinely documented in the residents' charts and that vaccination forms were not properly completed. Facility policies require assessment for vaccine eligibility, offering the vaccine within thirty days of admission, and documentation of refusals, but these procedures were not followed for the residents in question.
Failure to Remove Hospital Wristbands Compromises Resident Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical information for two residents. Both residents were observed wearing hospital-issued wristbands after being admitted to the facility. The wristbands displayed sensitive information, including medical record numbers, admission dates, dates of birth, names, and the name of a medical doctor. Staff interviews confirmed that the responsibility for removing these bands lies with the nursing staff upon admission, but there was no established timeframe for removal, and removal was only performed upon resident request. The Director of Nursing acknowledged that the hospital bands typically contain personal and clinical information and that their continued use after admission could result in the disclosure of confidential information. The facility's own policy, as presented, affirms residents' rights to privacy and confidentiality of personal and medical records. Despite this, the observed practice allowed for the ongoing public display of protected health information, in violation of privacy standards.
Failure to Ensure Resident Free from Physical Restraints
Penalty
Summary
A resident with diagnoses including hypertension, psychotic disturbance, schizophrenia, and gastro-esophageal reflux disease was found lying in bed with all four side rails up. The physician order sheet did not document an active order for a restraint, but did include an order for half side rails to be used for mobility and repositioning. The resident's Minimum Data Set indicated cognitive impairment with a BIMS score of 6 out of 15, and documented daily use of side rails as physical restraints. The care plan did not initially address a restraint problem, and was only updated to include half side rails after the incident. Staff interviews revealed that all four side rails were up, contrary to the physician's order for only half side rails. Nursing staff were either unaware of the reason for all four side rails being up or acknowledged that only half side rails should have been used. Facility policy defines physical restraints as any device that restricts freedom of movement and requires specific physician orders detailing type, reason, duration, and justification. The use of all four side rails without proper order or documentation resulted in the resident being confined to bed, constituting a failure to ensure the resident was free from physical restraints.
Failure to Refer Residents with New Serious Mental Illness Diagnoses for Required PASRR Level II Screening
Penalty
Summary
The facility failed to refer residents with newly diagnosed serious mental illnesses for required Pre-Admission Screening and Resident Review (PASRR) Level II assessments. Specifically, two residents were identified as having been diagnosed with schizophrenia after their initial PASRR Level I screenings, which had determined that no Level II review was necessary at the time. Despite these new diagnoses, the facility did not submit updated PASRR screenings as required by regulation and facility policy. For one resident, the face sheet documented a diagnosis of schizophrenia after the initial PASRR Level I screening, which had not identified a serious mental illness. The resident's care plan noted behaviors potentially related to mental health issues, including aggression and verbally inappropriate behaviors. Similarly, another resident was diagnosed with schizophrenia after their initial PASRR Level I screening, and was receiving antipsychotic medication. The care plan for this resident also referenced psychological conditions related to the new diagnosis. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for PASRR submissions and the process for handling new diagnoses of serious mental illness. Staff members provided inconsistent accounts of their roles and the requirements for resubmitting PASRR screenings when new mental health diagnoses are identified. Facility policy requires referral for Level II review upon significant change, such as a new diagnosis of serious mental illness, but this procedure was not followed for the two residents in question.
Failure to Post Oxygen in Use Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident receiving oxygen therapy did not have an 'Oxygen in Use' sign posted on the outside of their room door, as required by facility policy. During observation, the resident was seen with a nasal cannula connected to an oxygen concentrator set at two liters per minute. The resident confirmed ongoing oxygen use for three months. Staff interviews revealed that the sign was missing, and both the RN and DON acknowledged that the sign should have been posted for safety reasons, in accordance with facility policy. The facility's policies on oxygen therapy and smoking both require visible signage when oxygen is in use in a resident's room. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, asthma, and chronic kidney disease, and was cognitively intact. The resident's care plan included the administration of oxygen and observation of oxygen precautions. Despite these documented needs and orders, the required safety signage was not present at the time of the surveyor's observation.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when an altercation occurred between two residents in a hallway. According to interviews and record review, one resident approached another, used profanity, and struck the resident across the face with an open hand while the second resident was conversing with a peer. The incident was unprovoked according to a witness, and there were no staff present to observe the event. The resident who was struck reported the incident, and the peer confirmed the account, stating that the aggressor hit the resident in the face hard. The aggressor claimed that the other resident initiated the altercation, but this was not corroborated by the witness or the victim. Both residents involved were documented as cognitively intact based on their most recent BIMS scores. The aggressor had a history of psychotic disorder and other medical conditions, while the victim had chronic obstructive pulmonary disease and other diagnoses. The facility's abuse policy affirms the right of residents to be free from abuse and outlines definitions and prohibitions against such behavior. Despite these policies, the facility did not ensure the prevention of abuse in this instance, as the altercation occurred without staff intervention or supervision.
Failure to Post Required Program Information
Penalty
Summary
The facility failed to post the required [NAME] Program information in areas easily accessible to residents, affecting all 125 residents. On February 18, 2025, a surveyor observed that the 3rd floor lacked the necessary postings. The Social Service Director (V7) admitted to never having posted the information and was unaware of its required presence on the floors. During further rounds, no postings were found on the 1st and 2nd floors either. When informed, the Administrator (V1) acknowledged the oversight and stated that the information should be posted on each floor. As of February 19, 2025, neither V1 nor V7 could provide a facility policy regarding the [NAME] Program posting.
Temperature and Sink Deficiencies in Facility
Penalty
Summary
The facility failed to maintain the required temperature range of 71 to 80 degrees Fahrenheit in residents' rooms, common area hallways, and dining areas across all three floors. Observations revealed temperatures as low as 57.2 degrees Fahrenheit, with residents wearing winter coats indoors. Complaints from residents about the cold were noted, and the Maintenance Director admitted to only checking temperatures during severe weather. The Assistant Administrator was unaware of the temperature issues, and no temperature logs were available for several months. Additionally, the facility failed to ensure that sinks in the rooms of two residents were functioning properly. One resident reported that their bathroom sink had been nonfunctional since early January, forcing them to use a community bathroom sink for water. Another resident's sink was also broken, and they were unable to wash their hands properly after using the toilet. The Maintenance Director was informed of the issue but was unsuccessful in repairing the sinks and had difficulty securing a plumber. The facility's policies on maintaining a safe environment and preventive maintenance were not followed. The Maintenance Director did not report the issues to the Assistant Administrator, and there was a lack of communication and documentation regarding the temperature and sink problems. The facility's failure to address these issues in a timely manner resulted in discomfort and inconvenience for the residents.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by fellow residents, affecting two specific cases. In the first case, a resident with schizophrenia and delusional disorders, who was cognitively intact, physically assaulted another resident with moderate cognitive impairment by hitting them on the head. This incident was witnessed by staff, who intervened immediately, and the aggressor was subsequently sent to the hospital. The facility's report indicated that the aggressor had been exhibiting paranoid and sexual statements during the incident. In the second case, a resident with a history of bipolar disorder and violent behavior, who was also cognitively intact, struck another resident on the head with a magazine during an activity session. This altercation was triggered by a verbal exchange and was observed by staff, who promptly separated the individuals involved. The aggressor was sent for a psychiatric evaluation following the incident. The facility's policy affirms the residents' right to be free from abuse, yet these incidents demonstrate a failure to uphold this standard.
Incomplete Incident Reporting for Resident Injury
Penalty
Summary
The facility failed to adhere to its policy for reporting incidents and accidents, specifically in the case of a resident who sustained a 3-4 inch laceration on the inner right leg. The incident was initially reported by the resident, who was sent to the hospital emergency room and received 10 stitches. However, the initial and final reports were completed together by a nurse supervisor, V8, without conducting a thorough investigation or including necessary details such as how the injury occurred, interviews with staff or the resident's roommate, or the intervention of replacing the resident's wheelchair. The Director of Nursing (DON), V2, and the Assistant Administrator, V3, acknowledged that the reports were incomplete and did not follow the facility's policy. V2 mentioned that the resident claimed to have cut his leg on the wheelchair while attempting to prop his leg on it, but this information was not included in the final report. Additionally, the maintenance team found no sharp parts on the wheelchair, and a new wheelchair was provided to the resident, yet this intervention was also omitted from the report. The facility's policy requires that each incident involving a resident be documented thoroughly, including the incident's date, time, location, description, witnesses, and any treatment provided. The nurse supervisor, V8, did not follow this protocol, as the initial and final reports were submitted together without the necessary details and investigation. The Assistant Administrator, V3, confirmed that the reports should have been separate and should have included interviews with staff and the resident's roommate, as well as the plan to replace the wheelchair.
Failure to Conduct Thorough Incident Investigation
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident, identified as R1, who was found with a laceration on his leg. The incident occurred during the night shift, and the investigation packet for the incident only included a witness statement from R1, taken by the Wound Care Nurse. However, the investigation did not include statements from other staff members who were present during the incident, such as the Certified Nursing Assistants (CNAs) and the Licensed Practical Nurse (LPN) who were assigned to R1 during the relevant shifts. Interviews with the staff revealed that the CNAs and the LPN were not asked to provide witness statements, despite being involved in the incident. The CNAs recalled the events of the night, noting that R1's roommate alerted them to R1's condition, and they found R1 bleeding from a laceration on his leg. The LPN and the Nurse Supervisor assessed the situation and determined that R1 needed to be sent to the hospital for further treatment. Despite these interactions, no formal witness statements were collected from the staff involved. The facility's policies and procedures require that all incidents be documented and investigated thoroughly, including obtaining witness statements from all involved parties. The failure to collect comprehensive witness statements and conduct a thorough investigation represents a deficiency in the facility's adherence to its own policies and regulatory requirements. R1's medical history includes conditions such as chronic obstructive pulmonary disease, schizophrenia, and diabetes, and his cognitive status was noted as intact, which should have facilitated a more complete investigation process.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident R2, who has a history of aggressive behavior and a diagnosis of schizoaffective disorder, approached Resident R1 and slapped her on the face without provocation. This incident was witnessed by staff members, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), who confirmed that R2 slapped R1 and then walked away laughing. Despite the lack of physical injury to R1, the incident was reported as it constituted physical abuse. R1, who has a diagnosis of dementia and other health conditions, was moderately impaired cognitively, as indicated by her Brief Interview for Mental Status (BIMS) score. The facility's records show that R1 was at risk for abuse, and her care plan included a goal to prevent instances of abuse. R2's care plan also acknowledged her history of aggressive behavior and included strategies to anticipate and reduce such behaviors. However, these measures were not effective in preventing the incident. The facility's abuse policy emphasizes the right of residents to be free from abuse and outlines the need for a secure environment to prevent mistreatment. Despite this policy, the staff's efforts to redirect R2 and manage her behavior were insufficient, leading to the failure to protect R1 from abuse. The incident highlights the challenges in managing residents with unpredictable and impulsive behaviors, as well as the need for effective interventions to prevent abuse in the facility.
Failure to Provide Adequate Wheelchair Safety Measures
Penalty
Summary
The facility failed to adhere to its Nursing Service Policy by not adequately identifying and assessing a resident's needs, particularly regarding the use of assistive devices and safety measures. A resident, who is a seventy-eight-year-old with multiple medical conditions including chronic gout, liver cancer, and reduced mobility, was involved in an incident where the lack of footrests on his wheelchair led to potential safety concerns during a medical appointment. The resident, who is cognitively intact and uses a wheelchair due to his medical conditions, expressed discomfort and dissatisfaction with the way he was transported without footrests, which resulted in his feet dragging on the ground and being bumped by doors. During the incident, a Certified Nurse Assistant (CNA) was responsible for escorting the resident to a medical appointment. The CNA noticed the absence of footrests but did not address the issue, assuming the resident could walk. As the resident was transported to the clinic, his feet repeatedly fell to the ground, and the CNA had to stop frequently to allow the resident to rest. The situation escalated when the resident's family member confronted the CNA about the lack of footrests, leading to a verbal altercation. The CNA attempted to maneuver the resident's wheelchair through doors by pulling it backward, which resulted in the resident's legs being bumped by a door. The Director of Nursing (DON) and the Administrator were informed of the incident. The DON acknowledged that all residents being pushed in wheelchairs should have footrests to prevent injury. The Administrator investigated the incident after the resident's family member raised concerns, including a letter from the medical clinic staff who witnessed the incident. The investigation revealed that the CNA was on the phone during the incident, which may have contributed to the lack of attention to the resident's safety needs. Despite the incident, the resident reported feeling safe at the facility and did not sustain any injuries.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident (R2) from physical abuse by another resident (R1), resulting in R2 sustaining a laceration to the head that required four sutures. R1, who has a history of aggressive behavior due to mental illness, was involved in an altercation with R2. R1's medical records indicate cognitive intactness, and the care plan noted a history of aggression. R2, also cognitively intact, was at risk for abuse due to mental health diagnoses. The incident occurred when R1 allegedly hit R2 with a shoe and a cup, causing a head injury. The incident was not witnessed by staff, as the assigned nurse was on a lunch break, and another LPN was busy with other residents. The facility's abuse policy, which affirms residents' rights to be free from abuse, was not effectively implemented to prevent this occurrence. The Assistant Director of Nursing confirmed the incident as abuse, and a physician highlighted the need for monitoring and separation of residents with psychiatric conditions to prevent such incidents.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication was securely locked in the treatment cart when not in use, posing a potential hazard to residents on the 1st and 2nd floors. On two separate occasions, the treatment carts on both floors were observed to be unlocked and unattended. The 2nd floor cart was found in the hallway without supervision, and when questioned, the RN acknowledged that the cart should have been locked according to facility policy. Similarly, the 1st floor cart was also found unlocked, with the RN admitting that it was not typically locked for convenience, despite acknowledging the policy requirement for it to be secured when not in use. The Director of Nursing (DON) confirmed that the facility's policy mandates that medication carts must be locked when not in use and not in the nurse's visible sight. The facility's policy, effective from 10/25/24, clearly states that medications and biologicals should be stored safely and securely, accessible only to authorized personnel. The failure to adhere to this policy was evident in the observations made by the surveyor, highlighting a lapse in ensuring the safety and security of medication storage within the facility.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to immediately report an allegation of verbal abuse involving a resident, identified as R5, who was admitted with multiple medical conditions including meningitis, seizures, and cognitive communication deficit. The incident involved a Licensed Practical Nurse (LPN), V3, who admitted to being stern with R5, which the resident perceived as harsh or rude. This led to R5 refusing medication from V3, prompting another nurse, V4, to take over R5's care. V4 acknowledged that R5 complained about V3's tone of voice and admitted that she should have reported the incident as a potential form of emotional abuse. Despite being aware of the resident's complaints, V4 did not report the incident to the facility's Administrator (V1) or the Director of Nurses (V2), as required by the facility's abuse policy. The policy mandates that any suspicion or allegation of abuse must be reported immediately to a supervisor and then to the administrator. V1 and V2 were unaware of the situation until informed by the surveyor, highlighting a breakdown in the internal reporting process. The facility's policy also requires that any allegation of abuse be investigated and reported to the Department of Public Health, which was not done in this case.
Medication Administration Protocol Breach
Penalty
Summary
The facility failed to adhere to professional standards of medication administration and its own policy, affecting a resident identified as R5. The issue arose when R5's medication was prepared by one nurse, V3, but administered by another nurse, V4. Despite V4 being the one to administer the medication, V3 signed the Medication Administration Record (MAR) as if she had administered it. This discrepancy was confirmed through interviews and record reviews, revealing that V3 had been signing out the administration of R5's medication since the resident's admission, even though V4 was the one administering it. The Director of Nurses (V2) acknowledged the breach in protocol, stating that the nurse who prepares and administers the medication should be the one to sign the MAR. Both V3 and V4 admitted to the error, with V4 confirming that she should have signed the MAR after administering the medication. The facility's policy, updated in March 2022, clearly states that the same licensed nurse who prepares the medications should also administer them and record the administration promptly. This guideline was not followed, leading to a failure in meeting professional standards of quality in medication administration for R5.
Insufficient Staffing Leads to Resident Injury
Penalty
Summary
The facility failed to provide sufficient staffing to meet the behavioral needs of a resident, leading to an incident where one resident hit another with a plastic coffee cup, resulting in a laceration that required hospital treatment. The incident occurred on the 3rd floor, where only one CNA and one LPN were present at the time, despite the facility's usual staffing guideline of two nurses and two CNAs per shift. The LPN on duty was in the nursing station and did not witness the altercation, as the other nurse was on break and the CNA was monitoring residents in the dining area. The facility's investigation revealed that the staffing on the day of the incident was insufficient, as confirmed by the Director of Nurses, who acknowledged that the staffing did not meet the residents' needs. The facility's policy for addressing staffing shortages, which includes calling staff to work overtime or using departmental heads, was not implemented or documented on the day of the incident. The physician expressed concern about the potential severity of such incidents, emphasizing the need for residents to be monitored and separated to prevent serious injuries.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. Resident R1 was sitting in the dining room when R2, a new admission to the facility, approached and physically attacked R1 without provocation. R1 sustained a superficial skin laceration on the forehead as a result of the altercation. Staff intervened promptly to separate the residents, and both were sent to the hospital for evaluation. R1, an elderly resident with a history of psychiatric diagnoses including paranoid schizophrenia and bipolar disorder, was noted to have an intact cognitive status with a BIMS score of 15. Despite her psychiatric conditions, R1 was not the aggressor in this incident. R2, who also has a history of psychiatric issues, including schizophrenia and delusional disorders, was symptomatic and exhibited aggressive behavior shortly after being admitted to the facility. The facility's investigation revealed that R2 had been in the facility for only about 45 minutes before the attack occurred. Staff interviews and progress notes confirmed that R2's behavior was unprovoked and likely related to her psychiatric condition. The facility's abuse policy, which prohibits abuse and mistreatment of residents, was not effectively implemented in this case, resulting in a failure to protect R1 from physical harm.
Privacy Curtain Deficiency
Penalty
Summary
The facility failed to ensure that privacy curtains were available and properly installed for seven residents, compromising their privacy. During observations on the second and third floors, the surveyor noted that privacy curtains were missing for several residents. Despite being informed of the issue, the curtains remained absent the following day. The Registered Nurse and Certified Nurse Assistant acknowledged the absence of curtains and indicated that housekeeping might have removed them for washing. Further investigation revealed that the Housekeeping Supervisor confirmed the lack of privacy curtains in both the laundry room and housekeeping office, stating that the administration was aware of the need to order new curtains. The Maintenance Supervisor also confirmed readiness to install the curtains once they were available. The facility's policies emphasize the importance of resident privacy and dignity, highlighting a failure to adhere to these standards due to the absence of necessary privacy curtains.
Non-Functional Call Lights in Shower Rooms
Penalty
Summary
The facility failed to maintain a functioning call light system in the community shower rooms on both the second and third floors, potentially affecting all 86 residents residing on these floors. During the survey, it was observed that the call lights by the toilets in these shower rooms were not operational. This issue was confirmed through observations made by the surveyor on two separate occasions, with the assistance of CNAs on each floor who attempted to activate the call lights without success. The maintenance supervisor was unaware of the malfunction as it had not been reported in the maintenance logbook, which is checked daily. The LPN acknowledged the importance of having operational call lights in the shower rooms to ensure resident safety and communication of needs. Despite the facility's policy requiring immediate reporting of defective call lights to maintenance, there was no record of such a report being made, indicating a lapse in communication and adherence to protocol.
Pest Control Deficiency Due to Water Damage
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an active infestation of fruit flies in one resident's room. During an observation, a 5x5 inch hole was found at the floor-wall junction near the toilet room entrance, from which over 100 fruit flies were seen originating. The fruit flies were present on all wall surfaces and the ceiling, and were observed on the resident's face and arms as they sat on their bed. The resident confirmed the presence of fruit flies and mentioned that they had been coming from the hole in the wall, which had been there for a couple of weeks due to a water leak. The Maintenance Supervisor noted that the resident had a behavior of clogging the toilet and hand sink, causing water overflow and flooding, which led to water damage and the fruit fly infestation inside the wall. The facility's policy, titled 'Guideline for Pest Control' with an effective date of 11/1/23, states that the facility should maintain an effective pest control program to remain free of pests and rodents, with strategies focusing on areas prone to infestations. However, the presence of fruit flies in the resident's room indicates a failure to adhere to this policy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member and two residents from physical abuse by another resident. In the first incident, a resident with schizoaffective disorder and cognitive impairments followed a housekeeper into a soiled utility room. The door was closed, and when it was opened, the resident was found on the floor with scratches on her hand, and the housekeeper was using profanity towards her. The housekeeper admitted to being verbally inappropriate, which was confirmed by a Licensed Practical Nurse who witnessed the incident. In the second incident, two residents were involved in a physical altercation. A resident with schizophrenia and other psychiatric disorders approached another resident with chronic obstructive pulmonary disease and anxiety disorder in the dining room. The first resident threw water at the second resident, leading to a physical fight. The altercation was reported by another resident, and a Certified Nursing Assistant witnessed the event. The staff did not immediately assess the situation, and the resident who initiated the altercation was later sent to the hospital due to behavioral issues. The facility's abuse policy affirms the right of residents to be free from abuse, but these incidents indicate a failure to maintain a secure environment. The staff involved did not follow proper procedures for preventing and addressing abuse, as evidenced by the verbal abuse from the housekeeper and the physical altercation between residents. The facility's response to these incidents was inadequate, as staff failed to intervene appropriately and did not follow the reporting and notification process effectively.
Failure to Timely Report Resident Altercation
Penalty
Summary
The facility failed to report an incident of abuse in a timely manner involving two residents, R2 and R3. R3, who has a history of schizophrenia, hallucinations, conduct disorder, bipolar disorder, and depressive disorder, was involved in a physical altercation with R2, who has chronic obstructive pulmonary disease (COPD) and an anxiety disorder. The incident occurred on 6/18/2024, but was not reported until the following day, 6/19/2024. The altercation began when R3 threw water at R2, leading R2 to physically retaliate. Multiple staff members, including a CNA and LPNs, were aware of the incident but failed to report it immediately as required by the facility's internal reporting procedures. The report highlights that the CNA who witnessed the incident informed an LPN, but no immediate assessment was conducted, and the incident was not reported to the administrator or compliance officer as per protocol. The Social Service Director was informed by another resident about the altercation, which led to the eventual reporting of the incident. The facility's policy mandates that any incident or suspicion of abuse must be reported immediately to the administrator or a designated individual in their absence. The delay in reporting this incident constitutes a deficiency in the facility's adherence to its abuse reporting policies.
Failure to Provide Timely Incontinence Care and Scheduled Showers
Penalty
Summary
The facility failed to provide timely incontinence care and scheduled showers for a resident who required assistance with these activities. The resident, who has multiple medical conditions including spinal stenosis, hypertensive heart disease, and overactive bladder, was observed to be lying in bed and reported being incontinent of bowel and bladder. The resident stated that she had informed the staff of her need to be changed, but incontinence care was not provided every two hours as required. During an observation, a CNA confirmed that the resident had not been changed for the morning shift, and the resident experienced another incontinence episode during the care process. Additionally, the resident reported not having received a shower for an extended period, possibly more than a couple of weeks or even a month, since returning from another facility. The facility's shower schedule indicated that the resident was supposed to receive showers twice a week, but there was no documentation to confirm that a shower was provided on the scheduled date. The Director of Nursing confirmed that staff is expected to perform incontinence care every two hours and provide showers as scheduled, with proper documentation. However, the lack of documentation suggested that the care was not provided as required.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. On 4/15/24, a resident (R1) was observed hitting another resident (R2) in the facial area with a chair, causing a laceration with light bleeding. Staff immediately intervened and separated the residents. R2 was assessed by the Nurse on Duty and later sent to an acute hospital for eye trauma. R2 returned to the facility with a small scratch and discoloration on the right side of the right eye. Witness statements and progress notes corroborate the incident, indicating that R1's actions were unprovoked and resulted in physical harm to R2. R1's clinical records reveal a history of aggressive behavior and previous psychiatric hospitalizations. R1's care plan noted that R1 is an Identified Offender with a history of qualifying convictions, including domestic battery, criminal trespass, assault, and attempted murder. Interviews with staff and residents confirmed the sequence of events, with one witness stating that R1 walked into the dining room, pulled a chair, and hit R2 in the face. The facility's Abuse Prevention Program-Policy emphasizes the residents' right to be free from abuse, yet the incident on 4/15/24 demonstrates a failure to uphold this policy, resulting in physical harm to R2.
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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