Kenwood Vlge Nrsg And Rhb Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 4505 South Drexel, Chicago, Illinois 60653
- CMS Provider Number
- 145828
- Inspections on file
- 49
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Kenwood Vlge Nrsg And Rhb Ctr during CMS and state inspections, most recent first.
The facility failed to consistently offer COVID-19 vaccination and accurately document vaccination status for multiple residents. An Infection Preventionist/LPN reported that some residents had received prior COVID-19 vaccines and verbally declined further doses, but these refusals were not recorded in the immunization records. Cognitively intact residents stated that staff had not offered them the COVID-19 vaccine for an extended period and that they would have accepted it if offered. On the day of survey, the LPN produced COVID-19 vaccine consent forms dated the prior year, but residents reported signing them only that day and denied any earlier consents. The LPN admitted to completing the consents on the survey date, falsifying dates, and failing to document prior verbal refusals, contrary to the facility’s written policies on maintaining an updated COVID-19 vaccination program.
Two alert male residents with complex medical and psychiatric conditions became involved in a physical altercation after one resident reportedly made repeated threatening and derogatory comments toward the other and approached him as if to fight. The second resident stated he struck the first with a coffee mug in self-defense, causing a head laceration that required stitches and left a visible mark. Nursing staff did not witness the incident and only responded after being alerted by a CNA, finding one resident bleeding from the head and learning from others that the fight began at a resident room doorway and continued into the hallway. The administrator later stated that the injured resident had initiated the confrontation by being aggressive and getting in the other resident’s face, and facility policy defined such willful infliction of injury, including hitting, as physical abuse.
The facility did not maintain current PASARR evaluations for three residents with serious mental illness or related conditions. The Social Service Director acknowledged that PASARRs for these residents were outstanding or expired and that new Level I screenings were required when approvals ended. Record review showed that one resident with dementia and a delusional disorder had an expired Exempted Hospital Discharge 30-day Level I PASARR, while two other residents with schizophrenia, bipolar disorder, and schizoaffective disorder had short-term PASARR approvals without specialized services that had expired without new Level I screenings being completed, contrary to the facility’s PASARR policy.
Multiple residents with dementia, psychiatric conditions, and other complex medical diagnoses were involved in several resident‑to‑resident physical altercations. In separate incidents, a resident reported being pushed by another resident, another resident stated he was hit before a fight began, and a therapist witnessed a roommate enter a room, greet another resident, and then immediately punch him. In another case, a resident became agitated and hit a cognitively impaired resident who was already medically fragile. An LPN confirmed that one aggressor was sent to the hospital after hitting another resident, and the administrator acknowledged that there had been recent physical altercations, despite a written policy guaranteeing residents freedom from all forms of abuse.
A resident with dementia, hemiplegia, a history of falls, and requiring moderate assistance with transfers was found on a bathroom floor by a CNA, who reported the event to a nurse manager and an agency LPN. The agency LPN concluded the resident had not fallen, did not complete an incident report, and the event was not treated or documented as a fall, nor were post-fall or neuro checks initiated. Subsequent nursing staff were not informed of any fall and only later assessed the resident after complaints of pain and a report from the roommate about the prior floor incident, at which point the resident was sent to the hospital. Hospital records documented admission for a fall with a comminuted, displaced clavicle fracture, while facility policies required prompt incident investigation, assessment, and medical intervention for falls.
A resident with multiple chronic conditions was subjected to physical and emotional abuse by an LPN, who was observed on video forcibly restraining, pushing, and threatening the resident. Witnesses, including other residents and staff, confirmed the LPN's aggressive behavior and the resident's distress. Medical evaluation revealed soft tissue swelling and pain in the resident's arms following the incident.
A resident with multiple chronic conditions was not provided with necessary ADL care, including bathing, dressing, and grooming, and was observed in stained clothing with a foul odor and inadequate attire. Staff reported the resident often refused care but did not document these behaviors or attempt to provide clean donated clothing. The resident was sent to a medical appointment unbathed and inappropriately dressed, without proper communication or intervention from nursing staff.
A resident experienced ongoing verbal and mental abuse from another resident, including derogatory name-calling and threats of physical harm, which were reported to multiple staff members. Despite these reports and the facility's policy requiring immediate separation and investigation, the alleged perpetrator was not removed from the area, and the victim continued to feel unsafe. Staff responses were inconsistent, and documentation did not show a thorough investigation or timely intervention.
Two residents experienced ongoing verbal harassment and threats, with one resident repeatedly reporting feeling unsafe due to another's behavior. Despite multiple reports to staff, including LPNs, social services, and the DON, the alleged perpetrator was not promptly separated from the complainant, and a thorough investigation was not conducted according to facility policy. The complainant continued to encounter the aggressor daily, resulting in emotional distress and fear for personal safety.
Two residents reported ongoing verbal harassment and threats, including discriminatory language and threats of violence. Despite multiple staff being informed and documentation in clinical records, the facility did not send required initial and final abuse reports to IDPH, nor did it provide evidence of a thorough investigation or timely action to ensure resident safety.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A resident with multiple complex diagnoses and total dependence on staff did not have a baseline care plan completed within 48 hours of admission, as required by facility policy. The care plan also failed to address the resident's risk for skin breakdown, despite assessment findings. The DON confirmed the omission during record review and interview.
The facility failed to maintain an effective pest control program, resulting in frequent sightings of mice and mouse droppings in resident rooms and common areas. Despite efforts to increase pest control measures, the issue persisted, with residents and staff reporting ongoing problems. Documentation and interviews confirmed the widespread nature of the infestation, highlighting a failure to provide a safe and comfortable environment.
A resident in a wheelchair was physically assaulted by two other residents in separate incidents within the facility. The first incident involved an ambulatory resident with a history of aggression who punched the wheelchair-bound resident in the face, causing significant injuries. The second incident occurred when another ambulatory resident struck the same wheelchair-bound resident in the hallway. Both incidents occurred without adequate staff supervision, despite the facility's policies on abuse prevention and resident rights.
A resident in a wheelchair was assaulted by another resident with known aggressive behaviors in an unsupervised basement dining room, resulting in facial injuries. The aggressive resident, with a history of schizophrenia and conduct disorder, was able to leave their floor without staff supervision. Witnesses confirmed the absence of staff during the incident, highlighting a failure to implement the facility's safety and supervision policies.
A resident with a history of aggressive behavior struck another resident, causing injury, due to the facility's failure to update the behavioral health care plan with effective interventions. Despite known issues, the resident was unsupervised in a communal area, leading to the incident. Staff interviews revealed awareness of the resident's tendencies, but care plans were not revised to address these behaviors adequately.
The facility failed to maintain proper food safety and sanitation standards, affecting all residents receiving oral diets. A freezer lacked a thermometer, and another had improper freezing conditions. Expired food items were found, and the walk-in refrigerator's gauge was non-functional. The dishwasher was not sanitizing effectively, and there were missing entries in the temperature log. The dietary manager and aide failed to adhere to facility policies, impacting dietary services.
Medication carts on the 2nd and 3rd floors were left unlocked and unattended, potentially affecting 99 residents. An LPN on the 2nd floor forgot to lock the cart due to nervousness, while an RN on the 3rd floor left a cart unlocked and a drawer open, making medications accessible to unauthorized individuals. The ADON confirmed that facility policy requires carts to be locked when not in direct visual access.
The facility failed to properly label, date, and contain oxygen equipment for several residents, leading to deficiencies in respiratory care. Observations showed that nasal cannula tubing was not changed or dated as required, and equipment was not stored in plastic bags when not in use, contrary to facility policy. Staff confirmed these lapses, indicating a systemic issue with adherence to respiratory care protocols.
The facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances on the 3rd floor at each shift change, affecting 48 residents. Multiple instances were noted where only one nurse's initials were present on the accountability record, contrary to facility policy. An RN and the ADON confirmed the expectation for two nurses to sign off on narcotic counts at shift changes.
The facility failed to discard an expired multi-dose vial of Tuberculin PPD, which was found in the medication refrigerator on the third floor. The vial was more than 30 days past its open date, contrary to labeling instructions. A RN confirmed the vial should have been discarded. The ADON acknowledged the need to review policies on multi-dose medications, which require dating upon opening and discarding after expiration. This oversight potentially affects all 48 residents on the third floor.
The facility failed to label multi blood glucose test strips with the open date, as observed on the third floor. An RN, new to the facility, could not find documentation of the open date, and the ADON confirmed the need for such labeling to ensure strips are used within their effective period. This oversight potentially affected four residents relying on accurate blood glucose monitoring.
A long-term care facility failed to maintain proper infection control practices, including hand hygiene and PPE use, affecting several residents. An agency CNA did not perform hand hygiene between resident care and failed to use PPE for residents on contact precautions. Additionally, PPE supplies were inadequate, and a resident's urinary catheter drainage bag was improperly handled, dragging on the floor, contrary to facility policy.
A surveyor observed that a handrail on the second floor was cracked and not securely fixed to the wall, potentially affecting all 51 residents on that floor. A LPN acknowledged the crack, and the Maintenance Director confirmed the issue when a corner of the handrail cracked off upon inspection. The Assistant Director of Nursing noted that handrails are essential for resident safety, as they are used for support while walking.
A resident with cognitive and mobility impairments was found with their call light on the floor, out of reach, contrary to their care plan and facility policy. Staff confirmed the call light should be accessible, and the facility's policy and job descriptions emphasize the importance of call light accessibility.
The facility failed to obtain a doctor's order for an advance directive for a resident with significant medical conditions, despite the resident being cognitively intact. The Assistant Director of Nursing acknowledged the requirement for such an order upon admission, but no advance directive was found in the designated book. Facility policy mandates a written physician's order for advance directives and proper labeling of medical records.
The facility failed to maintain the confidentiality of electronic health records, as observed when a nurse and an LPN left residents' medication administration records open and unattended on laptops attached to nursing carts. Both staff members acknowledged the oversight, citing HIPAA as the reason for ensuring records are not left exposed. The Assistant Director of Nursing confirmed the facility's expectation to keep records closed and attended.
The facility failed to maintain a homelike environment by not addressing missing closet drawers in several residents' rooms, leading to clothing being stored in bins on the floor. The Maintenance Director was unaware of the issue, and no maintenance requests were made to address it, despite the facility's policies emphasizing the right to a homelike environment.
A facility failed to conduct a new PASRR for a resident diagnosed with Schizophrenia, as required when a new mental health diagnosis is identified. The resident's initial screen did not suspect mental illness, and no new PASRR was conducted after the diagnosis. Interviews revealed confusion among staff about the process for requesting a new PASRR, and the facility's policy was not adhered to, resulting in the deficiency.
A resident with multiple medical conditions had a wound on the left thigh, but the physician's order incorrectly documented care for the right thigh. The wound was found without a dressing, and the Wound Care Nurse confirmed the error and corrected the order. The facility failed to follow protocol, as no notification was made to reapply the dressing, leading to inadequate wound care.
A resident at high risk for pressure ulcers was found lying on multiple layers of linens on a low air loss mattress, contrary to care plan instructions. Staff confirmed that only one layer should be used to allow the mattress to function properly, but the resident was observed with a flat sheet and a folded sheet, compromising the mattress's effectiveness.
A facility failed to apply a splint or palm grip for a resident with a contracted hand, as observed during a survey. The resident, who is cognitively intact and has a history of hemiplegia and muscle contracture, was seen with clenched fists without the assistive device. Despite a physician's order and a care plan requiring the device's use, documentation of its application was not provided, and the facility's policies on adaptive devices were not followed.
The facility failed to consistently log refrigerator temperatures for two residents, potentially affecting all 58 residents. Observations showed missing temperature documentation for several days in January 2025. The ADON stated that daily checks are necessary to prevent food spoilage. One resident's refrigerator was within the acceptable temperature range, while another resident reported infrequent checks. The facility's policy mandates daily temperature checks, which were not consistently documented.
The facility failed to educate and document the decision of three residents regarding Influenza and Pneumonia vaccines. One resident was not offered the Pneumococcal vaccine or informed about its benefits and risks, with no informed consent in their records. Another resident's records lacked informed consent for the Influenza vaccine, and a third resident was not offered either vaccine despite expressing a desire to receive them. The facility's policy requires education and documentation, which was not followed.
A resident with a history of aggression used another resident's backpack to physically abuse her, despite the facility's policy to prevent abuse. The incident was witnessed by staff, and the residents were separated. Both residents have moderately impaired cognition, and the victim expressed feeling unsafe.
The facility failed to post daily nurse staffing information, affecting all 109 residents. The staffing sheet was not visible in the lobby, and the provided sheet lacked the resident census and nursing staff hours. The Administrator and Receptionist were unaware of the requirement, violating federal regulations.
A facility failed to secure a treatment cart and medications, leaving a treatment cart unlocked and unattended in a hallway and a resident's inhaler visible on a bedside table without proper authorization. Additionally, an oxygen tank was improperly stored on the floor, posing a fire hazard. Staff acknowledged these lapses, which violated facility policies on medication and oxygen storage.
A facility failed to protect two residents from theft, with one resident's money and debit card stolen and used for unauthorized withdrawals. Despite reimbursement and police involvement, the perpetrator was not identified. Another resident reported theft during agency staff shifts. The facility's abuse prevention policy was not effectively implemented, as these incidents were not reported to the IDPH.
Failure to Offer and Accurately Document COVID-19 Vaccination and Falsification of Consent Records
Penalty
Summary
The deficiency involves the facility’s failure to offer COVID-19 vaccinations and to accurately document COVID-19 vaccination status for four of five residents reviewed for immunizations. During an interview, the Infection Preventionist/LPN (V25) stated that infection control policies are reviewed annually and that the first positive COVID-19 case in the facility’s current outbreak occurred on February 26, 2026. While reviewing immunization records, V25 reported that certain residents had previously received COVID-19 vaccines in 2024 and that some had refused subsequent doses, but acknowledged that these refusals were not documented in the residents’ immunization records as required. Resident interviews conflicted with the documentation and staff statements. One cognitively intact resident (R25), with diagnoses including hypertensive heart disease without heart failure, lymphedema, multiple sclerosis, and reduced mobility, stated that staff had not offered a COVID-19 vaccine since 2024 and that the resident would have accepted it if offered, including an upcoming dose that had just been mentioned. Another cognitively intact resident (R103), with diagnoses including idiopathic gout, type 2 diabetes mellitus, hypertension, heart failure, osteoarthritis, and stage 3 chronic kidney disease, stated that the vaccine was only offered on the day of the survey and denied that staff had offered the COVID-19 vaccine during the previous year or during the recent outbreak. Further review revealed issues with documentation and consent forms. Shortly after the resident interviews, V25 provided four COVID-19 vaccine consent forms for residents reviewed for immunizations, all bearing dates in 2025. When questioned, V25 admitted not having spoken with these residents that day about vaccines and that only hallway rounds had been done. The residents reported signing the consent forms that day, not in 2025, and denied signing any prior COVID-19 vaccine consents. V25 then admitted to completing the consent documents on the day of the survey, falsifying and tampering with them by adding 2025 dates, and acknowledged that refusals had been verbal only and not documented in the charts. These actions were inconsistent with the facility’s written policies requiring an updated vaccination program for COVID-19 and encouraging staff and residents to remain up to date with recommended COVID-19 vaccine doses.
Failure to Prevent Resident-on-Resident Physical Abuse Resulting in Head Injury
Penalty
Summary
The facility failed to protect residents from physical abuse when two alert male residents were involved in a physical altercation that resulted in injury. One resident with diagnoses including seizures, schizoaffective disorder, alcohol abuse, obesity, hypertension, major depressive disorder, and reflux reported going to another floor, speaking to another resident, and then being struck on the head with a cup, resulting in a head laceration that required stitches and left a visible healed mark on his forehead. Progress notes documented that this resident was observed with head lacerations and minimal bleeding and was transferred to the hospital, in part due to his known primary epileptic seizure disorder. The other resident, with diagnoses including lung disorders, end stage renal disease, heart failure, dependence on renal dialysis, HIV, anemia, and hyperkalemia, reported that the first resident repeatedly directed threatening and derogatory comments toward him when he went to get coffee and that, when the first resident approached and wanted to fight, he struck him with a coffee mug in what he described as self-defense. An LPN stated that this resident told her he could not get the other resident off him and that he hit him with a cup or something, while the injured resident reported that the other resident had been saying things that were triggering him. Another LPN on duty did not witness the incident and only became aware of it when a CNA reported that the residents were fighting; she then found the injured resident bleeding from the top of his head and learned from a roommate that the altercation started at the doorway and continued into the hallway. The administrator stated that the injured resident initiated the incident by being aggressive and getting in the other resident’s face before being struck, and facility policy defined physical abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish, including hitting and similar acts.
Failure to Maintain Current PASARR Evaluations for Residents With Serious Mental Illness
Penalty
Summary
The facility failed to obtain required Pre-admission Screening and Resident Review (PASARR) evaluations for three residents with serious mental illness or related conditions, resulting in outstanding or expired PASARR determinations. During an interview, the Social Service Director stated that outstanding reports meant the PASARRs had expired and that new Level I screenings were required when PASARRs expire or when there is a new onset mental illness diagnosis. The Social Service Director also stated that submitting requested reports is important to complete PASARRs because, for residents with mental health illness, the facility needs to ensure it is following their plan of care, determining the need for psychosocial therapy groups, addressing billing, and confirming that residents are in the appropriate setting. Record review showed that one resident with dementia and a delusional disorder had an initial Level I PASARR marked as an Exempted Hospital Discharge with a 30-day approval, requiring re-screening by or before the 30th day if the stay extended beyond that timeframe; this Level I PASARR had expired and was not updated. A second resident with schizophrenia had an initial Level I PASARR with a short-term approval without specialized services that had an end date, and this Level II PASARR had expired without a new Level I being completed. A third resident with bipolar disorder and schizoaffective disorder also had an initial Level I PASARR with a short-term approval without specialized services and an end date, and this Level II PASARR had expired without a new Level I being done. These actions and inactions were inconsistent with the facility’s PASARR policy, which requires completion of Level I screens for all potential admissions and review of Level II recommendations to determine the facility’s ability to provide specialized services.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from abuse, resulting in several resident‑to‑resident physical altercations. One incident report dated 11/05/25 documents that a resident (R4), who has major depressive disorder, bipolar disorder, essential hypertension, and hyperlipidemia and is care planned as being at risk for abuse due to psychiatric diagnosis and verbal aggression, reported that another resident (R3) pushed him. Another incident report dated 11/20/25 documents an alleged altercation between R6 and R5 after R5 allegedly invaded R6’s personal space, which allegedly escalated into a physical altercation. R6’s care plan identifies him as at risk for health, safety, and behavioral concerns, and during an interview in his bedroom he stated that he was hit by another resident before they began to fight. Additional incident reports show further failures to prevent abuse. A report dated 1/12/26 documents that R7 showed aggression toward R8, who has a cognitive communication deficit, unspecified dementia, essential hypertension, and muscle wasting and atrophy; a therapist’s written witness statement from the same date states that R7 entered the room, greeted R8, and then instantly punched him. Another incident report dated 1/12/26 documents that R9 allegedly became agitated with R10 and allegedly hit R10; R10’s care plan notes that he is at risk for abuse due to poor cognition related to severe dementia with mood disturbance, and he also has diagnoses including an unspecified fracture of the right ilium, adult failure to thrive, unspecified atrial fibrillation, and hypertensive heart disease with heart failure. An LPN stated that R9 was sent to the hospital for hitting R10. The administrator acknowledged that no resident deserves to be hit and that there have been some recent physical altercations between residents, despite a facility policy stating that residents have the right to be free from verbal, sexual, physical, and mental abuse, involuntary seclusion, exploitation, and misappropriation of property by anyone.
Failure to Evaluate and Send Resident to Hospital After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a non-ambulatory resident with dementia was properly evaluated and sent to the hospital after being found on the floor. The resident had diagnoses including unspecified dementia, history of falling, essential hypertension, and hemiplegia/hemiparesis affecting the right dominant side, and required moderate assistance with transfers and used a wheelchair. The resident’s care plan identified a risk for falling related to a history of falls. During a night shift, a CNA found the resident on the bathroom floor around 1:15 a.m. and reported this to the nurse manager and an agency LPN. The CNA stated the resident was a new admission and she was not familiar with the resident’s abilities, and that she did not feel comfortable putting the resident back in bed due to fall risk. According to staff interviews, the nurse manager informed the agency LPN of the fall and instructed her to evaluate the resident. The nurse manager recalled asking the agency LPN if an ambulance should be called, but the agency LPN stated the resident was okay and had not fallen, asserting that the resident had walked to the restroom. The CNA reported that after cleaning the resident, she placed the resident in a geriatric chair in the hallway on 1:1 observation, and that the agency LPN took the resident’s blood pressure. No incident report was completed at that time, and the event was not treated or documented as a fall. The agency RN who worked the following day reported not being informed of any fall, special monitoring, or neurological checks for the resident, and only being called later to medicate the resident for leg pain. Subsequently, another LPN coming on duty was informed by the resident’s roommate that the resident had been found on the bathroom floor during the prior night. This LPN assessed the resident, observed a bruise on the leg, and contacted the physician, receiving orders to send the resident to the hospital for further evaluation. A late entry nursing progress note by the agency LPN later documented that she had been called to the room and observed the resident sitting on the bathroom floor, with the resident denying a fall and stating she was trying to clean herself. The facility’s incident report and hospital documentation show that the resident was ultimately admitted to the hospital with complaints of right leg pain, sepsis, and a comminuted, displaced fracture of the distal third of the clavicle, with the hospital record indicating admission for a fall with clavicle fracture. Facility policies required prompt investigation of incidents, assessment for injury, and seeking medical intervention when necessary, as well as clinical protocols for falls that included physician identification of conditions affecting fall risk and complications.
Failure to Protect Resident from Physical and Emotional Abuse by LPN
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) physically and emotionally abused a resident with multiple medical conditions, including epilepsy, vascular dementia, and diabetes. The resident, who was alert and oriented, reported being hurt in the arms and neck by the LPN. Video footage confirmed that the LPN pushed the resident's hand away, used her foot to move the resident's legs, forcibly held the resident's hands down, pointed a finger in the resident's face, pushed the resident back into a Geri chair, squeezed the resident's hand, and yanked the resident back by grabbing the shirt collar. Witnesses, including other residents and staff, corroborated hearing the resident express pain and distress, and observed the LPN yelling, cursing, and making threatening statements toward the resident. Medical records documented that the resident had redness and discoloration on both arms, mild pain, and x-ray results showed mild soft tissue swelling in both arms. The incident was reported to the facility's administration and the police, and the LPN was immediately removed from duty. Multiple staff and residents provided statements describing the LPN's aggressive and inappropriate physical contact, as well as the resident's visible fear and distress during and after the incident. The facility's abuse policy affirms residents' rights to be free from abuse and mistreatment by staff. Despite the LPN having completed abuse and neglect training, the actions observed and reported constituted physical and emotional abuse, as confirmed by facility leadership and video evidence. The deficiency was identified through direct observation, interviews, record review, and corroborating witness statements.
Failure to Provide ADL Care and Appropriate Attire for Resident
Penalty
Summary
The facility failed to follow its Activities of Daily Living (ADL) policy by not providing necessary care such as bathing, dressing, and grooming for a resident with multiple medical diagnoses, including cerebral ischemia, hypertension, type II diabetes, arthritis, constipation, and unspecified psychosis. The resident was observed sitting on the bed with an open hoodie, no shirt, stained pants, one sock, untied shoes, and a strong foul odor. The resident reported only having one sock and no other clothes, and stated that showers had not been offered for a long time. Staff interviews confirmed the resident had limited clothing and often refused showers and changes of clothes, but also revealed that no attempts were made to provide clean donated clothing that morning due to the expectation of refusal. The resident's care plan did not document any non-compliance with care or adverse behaviors, despite staff stating a history of refusals. On the day of a medical appointment, the resident was sent out inappropriately dressed, without a coat, and unbathed, which was noted by the physician's office. The nurse was not informed that the resident had refused to shower or change clothes before the appointment, and the director of nursing was notified only after the hospital called about the resident's attire. The facility's ADL policy requires recognition and evaluation of inability or risk for decline in ADL performance, and the resident rights policy emphasizes respect and dignity, both of which were not upheld in this instance.
Failure to Protect Resident from Ongoing Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by another resident and did not take adequate steps to prevent further abuse, including failing to remove the alleged perpetrator from contact with the victim. The affected resident reported ongoing harassment, including being called derogatory names related to race, gender, and sexual orientation, as well as threats of physical harm and death. These incidents were reported to multiple staff members, including the receptionist, social worker, and nursing staff, but the alleged perpetrator remained on the same floor and continued to have access to the victim. The victim expressed feeling unsafe, scared, and unable to sleep due to the ongoing threats and lack of intervention. Interviews and record reviews revealed that the facility staff were aware of the allegations and the ongoing nature of the abuse. Documentation showed that the victim repeatedly reported feeling unsafe and requested that the perpetrator be moved to another floor, but this was not done in a timely manner. Staff interviews indicated inconsistent responses to the allegations, with some staff reporting the incidents to supervisors and others stating that the situation was not considered abuse because both parties were verbally aggressive. Despite the facility's policy requiring immediate separation of residents in abuse allegations and prompt reporting to the state agency, the alleged perpetrator was not removed from the area, and the incident was not reported as required. Both residents involved were cognitively intact and able to move independently in their wheelchairs. The perpetrator had a documented history of verbal aggression toward staff and other residents. Progress notes and staff interviews confirmed that the victim's complaints were documented, but the facility did not provide evidence of a thorough investigation or timely intervention to ensure the victim's safety. The facility's own policies required removal of the alleged abuser and immediate evaluation, but these steps were not followed, resulting in the victim continuing to feel threatened and unsafe.
Failure to Investigate and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and did not take adequate steps to prevent potential further abuse between two residents. One resident reported ongoing verbal harassment, including racial and sexual slurs, as well as threats of physical harm and death from another resident. Despite multiple reports to various staff members, including the receptionist, social worker, and nursing staff, the alleged perpetrator was not removed from the area or separated from the complainant for an extended period. The complainant continued to encounter the alleged perpetrator daily, which resulted in feelings of fear, emotional distress, and inability to sleep. Interviews and record reviews revealed that staff were aware of the ongoing issues but did not consistently follow the facility's abuse prevention policy. Documentation showed that the complainant repeatedly expressed feeling unsafe and requested that the alleged perpetrator be moved to another floor, but this was not done in a timely manner. Staff interviews indicated confusion about who was responsible for the investigation and reporting during the administrator's medical leave, and there was a lack of clear documentation of a thorough investigation or timely reporting to the state agency. Some staff minimized the severity of the incidents, attributing the interactions to mutual verbal aggression, while others acknowledged the threatening behavior as verbal abuse. Both residents involved were cognitively intact and able to move independently in their wheelchairs. The alleged perpetrator had a documented history of verbal aggression toward staff and other residents. Progress notes and interviews confirmed that threats and derogatory language were used, and that the complainant's concerns were not promptly or adequately addressed. The facility's failure to separate the residents and conduct a thorough investigation resulted in the complainant continuing to feel unsafe and unprotected.
Failure to Timely Report and Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to timely report and investigate allegations of abuse between two residents, as required by state regulations and facility policy. Multiple staff interviews and record reviews revealed that one resident repeatedly reported being verbally harassed, threatened with violence, and subjected to derogatory and discriminatory language by another resident. The affected resident expressed feeling unsafe, emotionally distressed, and unable to sleep due to ongoing threats and harassment. Despite these reports, there was no evidence that the initial and final reports of the abuse allegations were sent to the Illinois Department of Public Health (IDPH) as required. Staff interviews indicated that the abuse allegations were communicated to various facility personnel, including the receptionist, social services, nursing staff, and management. Documentation in the resident's clinical records confirmed that the resident reported threats of violence and derogatory language, and that staff were aware of the situation. However, staff responses varied, with some staff stating that the incident was not considered abuse and therefore not reportable, while others acknowledged the seriousness of the threats and the need for investigation. There was a lack of consensus and clear documentation regarding the investigation process, and the facility was unable to provide evidence of a thorough investigation or timely reporting to IDPH. Both residents involved were cognitively intact and able to communicate their experiences. The resident accused of making threats had a documented history of verbal aggression toward staff and other residents. Despite ongoing complaints and documentation of threatening behavior, the facility did not separate the residents or take sufficient action to ensure safety, nor did it fulfill its obligation to report the allegations and investigation results to the appropriate authorities within the required timeframes.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Develop Baseline Care Plan for Immediate Needs
Penalty
Summary
The facility failed to follow its policy and procedure for developing a baseline care plan to address a resident's immediate needs within 48 hours of admission. Specifically, for one resident with multiple complex diagnoses—including cerebral infarction, COPD, chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, dysphagia, and major depressive disorder—no baseline care plan was completed in the electronic chart. The resident was cognitively intact but totally dependent on staff for activities of daily living. The care plan also did not address the resident's risk for skin breakdown, despite the assessment indicating a mild risk due to immobility. During interviews, the DON confirmed that the baseline care plan should have been completed within 48 hours of admission and should have included individualized interventions for skin breakdown prevention. The facility's own policy requires a preliminary plan of care to be developed within 24 hours of admission to meet immediate needs. Review of the electronic chart with the DON confirmed the absence of the required baseline care plan for this resident.
Facility Fails to Control Mice Infestation
Penalty
Summary
The facility failed to provide an effective pest control program, as evidenced by multiple reports and observations of mice within the premises. Residents and staff reported frequent sightings of mice in various areas, including resident rooms, the dining room, and the nurse station. Mouse droppings were observed on bed frames, radiators, and floors, indicating a widespread issue. The presence of mice was confirmed by both residents and staff, with some residents expressing concern over the aggressive nature of the mice. Interviews with staff and residents revealed that the issue had been ongoing, with complaints dating back several months. The facility's pest control measures, which included weekly visits from a pest control company and the use of traps and peppermint deterrents, were insufficient to address the problem. The administrator acknowledged the presence of mice and stated efforts were being made to seal the building and increase pest control visits, but these measures had not yet resolved the issue. Documentation from pest control service reports and resident grievance forms further corroborated the extent of the problem. Reports indicated multiple instances of mice and other pests being found within the facility, and residents had formally complained about mouse droppings in their rooms. Despite the facility's policy to maintain a pest-free environment, the ongoing presence of mice demonstrated a failure to uphold this standard, impacting the residents' right to a safe and comfortable living environment.
Failure to Protect Resident from Abuse by Other Residents
Penalty
Summary
The facility failed to protect a resident, identified as R2, from abuse by two other residents, R1 and R8. On one occasion, R1, an ambulatory resident with a history of aggressive behavior, physically assaulted R2, who is wheelchair-bound, in the basement dining room. R1 punched R2 in the face, resulting in a nasal fracture and other injuries. The incident occurred without staff supervision in the dining room, and R2 was left vulnerable to the attack. R1's care plan indicated a history of physical aggression, yet there were no measures in place to prevent R1 from accessing unsupervised areas where R2 was present. In a separate incident, R8, another ambulatory resident, struck R2 in the back of the head while R2 was in the hallway. This incident was witnessed by a CNA, who reported that R8 claimed it was an accident. However, video footage confirmed that R8 intentionally hit R2. R8's medical records indicated cognitive intactness, suggesting that the action was deliberate. Despite R2's history of being a victim of abuse, the facility failed to provide adequate supervision and protection. The facility's policies on abuse prevention and resident rights emphasize the importance of protecting residents from abuse and ensuring their safety. However, the lack of staff presence in communal areas and failure to monitor residents with known aggressive behaviors contributed to the incidents of abuse against R2. The facility's inaction in providing a secure environment for R2, despite previous incidents of abuse, highlights a significant deficiency in their duty to protect residents from harm.
Lack of Supervision Leads to Resident Assault in Dining Room
Penalty
Summary
The facility failed to provide adequate supervision in the basement dining room, resulting in a resident being assaulted by another resident. The incident involved a resident in a wheelchair, who was punched twice in the face by an ambulatory resident known for aggressive behaviors. This attack led to the victim sustaining a facial skin tear, periorbital contusion, and a nasal fracture. The victim, who has a history of Parkinson's disease, schizophrenia, and moderate cognitive impairment, was left unsupervised in the dining room at the time of the incident. The aggressive resident has a documented history of paranoid schizophrenia, conduct disorder, and aggressive behavior, requiring supervision due to poor decision-making skills. Despite this, the resident was able to leave their floor and enter the basement dining room without staff supervision. Witnesses, including another resident and a vending machine vendor, confirmed that no staff were present during the altercation. The aggressive resident's care plan included interventions for managing aggressive behavior, but these were not effectively implemented. Interviews with facility staff revealed a lack of awareness and monitoring of the aggressive resident's movements and behaviors. Staff members acknowledged the resident's history of aggression and the need for supervision, particularly in communal areas. However, on the day of the incident, the basement dining room was left unsupervised, allowing the aggressive resident to attack the victim. The facility's policies on safety and supervision were not adequately followed, contributing to the incident.
Failure to Update Behavioral Health Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to adequately revise and review a resident's behavioral health care plan, which was ineffective in preventing an incident of physical aggression. A resident with a history of paranoid schizophrenia and aggressive behavior struck another resident in the face, causing a nasal bone fracture and other injuries. The incident occurred in the basement dining room, where the aggressive resident was unsupervised, despite known behavioral issues that required monitoring. Interviews with staff revealed that the aggressive resident had a history of verbal and physical aggression, including threats and altercations with staff and other residents. The care plan for this resident, which was supposed to address these behaviors, was not updated with effective interventions. Staff members, including the LPN and the Psychiatric Rehabilitation Services Assistant, were aware of the resident's aggressive tendencies but did not implement or document new strategies to manage these behaviors effectively. The facility's policies on managing challenging behaviors and ensuring resident safety were not followed. The interdisciplinary team failed to regularly review and update the care plan to include individualized interventions based on the resident's history and triggers. The lack of supervision and inadequate care planning contributed to the incident, highlighting deficiencies in the facility's approach to behavioral health management and resident safety.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, affecting all residents receiving oral diets. During an inspection, it was observed that a stand-up freezer lacked an internal thermometer, and another freezer had a thermometer reading 37 degrees Fahrenheit, indicating improper freezing conditions. Additionally, expired food items, such as cottage cheese, were found in the refrigerator, and the walk-in refrigerator's external gauge was non-functional, with an internal temperature reading of 43 degrees Fahrenheit. These conditions were not in compliance with the facility's policy, which requires refrigeration at 41 degrees Fahrenheit or below and freezing at 0 degrees Fahrenheit or below. The facility also failed to ensure the proper functioning and monitoring of the dishwasher. A dietary aide was observed using the dishwasher, which was not sanitizing effectively, as indicated by test strips showing only 10 ppm of sanitizer concentration. The dietary manager acknowledged the issue and mentioned that the dishwasher had not been working properly, necessitating the use of disposable utensils and plates. Furthermore, there were missing entries in the dishwasher temperature log, indicating a lack of consistent monitoring and documentation. The dietary manager admitted to being unaware of the missing thermometer in the freezer and the expired food items, and stated that the dishwasher had been serviced to address the sanitizing issue. The facility's policies on refrigerator and freezer temperatures, labeling and dating foods, and dishwashing machine operation were not adhered to, leading to these deficiencies. The dietary aide and manager were responsible for ensuring compliance with these standards, but failed to do so, impacting the quality of dietary services provided to the residents.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts on the 2nd and 3rd floors were locked while unattended, potentially affecting 99 residents. On the 2nd floor, a Licensed Practical Nurse (LPN) left the medication cart unlocked and unattended while checking the medication fridge, admitting to forgetting to lock it due to nervousness. The Assistant Director of Nursing (ADON) confirmed that the facility's policy requires medication carts to be locked when not in direct visual access to prevent unauthorized access to medications. On the 3rd floor, a Registered Nurse (RN) left a medication cart unlocked and a drawer open while attending to a resident, leaving the cart out of visual sight. The RN acknowledged that this action made medications accessible to other residents and staff, which could lead to harm if a resident took another's medication. The ADON reiterated that the facility's policy mandates that medication carts be locked when unattended to prevent unauthorized access.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to properly label, date, and contain oxygen equipment for four residents, leading to deficiencies in respiratory care. Observations revealed that nasal cannula tubing for a resident with COPD and other health conditions had not been changed in over a month, despite physician orders and facility policy requiring weekly changes. The tubing was also not dated, and the resident confirmed the lack of timely changes. Additionally, the facility's policy mandates that oxygen equipment be stored in a plastic bag when not in use to prevent infection, which was not adhered to. Further observations showed that other residents' oxygen equipment, including nasal cannulas and CPAP masks, were not properly labeled with dates or contained when not in use. Staff interviews confirmed that the facility's expectations were not met, as oxygen tubing and humidifier bottles should be changed weekly, dated, and stored appropriately. These failures were consistent across multiple residents, indicating a systemic issue with the facility's adherence to its own respiratory care policies.
Failure to Conduct Proper Controlled Substance Inventory
Penalty
Summary
The facility failed to ensure that two licensed personnel conducted a physical inventory of controlled substances on the 3rd floor at each change of shift. This deficiency was observed during a review of the Shift Change Accountability Record for Controlled Substances, where it was noted that on multiple occasions, only one licensed personnel's initials were present instead of the required two. Specific dates where this occurred include the 2nd shift on January 3rd, 17th, 18th, 24th, and 27th of 2025. This failure to adhere to the facility's policy has the potential to affect all 48 residents on the 3rd floor. During the survey, a Registered Nurse (RN) acknowledged the issue, stating it was their first day and confirming that narcotics should be counted every shift by two nurses. The Assistant Director of Nursing (ADON) affirmed the facility's expectation that the narcotic count should be done at the beginning and end of every shift, signed off by two nurses immediately. The facility's policy on Controlled Substance Storage requires a physical inventory of all controlled substances by two licensed nurses at each shift change, which was not consistently followed as documented in the report.
Expired Multi-Dose Vial Not Discarded
Penalty
Summary
The facility failed to discard an expired opened multi-dose vial of Tuberculin PPD, which was observed in the medication refrigerator on the third floor. The vial had an open date and a discard date, indicating it was more than 30 days past the open date, contrary to the tuberculin label instructions that state it should be discarded after 30 days. This oversight was confirmed by a Registered Nurse (RN) who acknowledged that the vial should have been thrown out as it was considered expired. The Assistant Director of Nursing (ADON) was interviewed and acknowledged the need to review the policy regarding multi-dose medications and supplies, which require dating upon opening and discarding after the expiration date. The facility's Medication Administration Policy and Storage of Medications policy both emphasize the importance of labeling multi-dose vials with open and expiration dates and storing medications safely and securely. The failure to adhere to these policies has the potential to affect all 48 residents on the third floor reviewed for labeling and storage of drugs and biologicals.
Failure to Label Blood Glucose Test Strips with Open Date
Penalty
Summary
The facility failed to ensure that the container of multi blood glucose test strips was labeled with the open date, which is necessary to track the expiration of the strips. This oversight was observed during a survey on the third floor, where an opened container of test strips without an open date was found in the medication cart. The Registered Nurse (RN) present, who was new to the facility, was unable to locate any documentation of the open date and was unaware of the specific expiration period for the strips once opened. The Assistant Director of Nursing (ADON) confirmed that multi-dose medications and supplies, such as blood glucose test strips, need to be dated once opened to ensure they are used within their effective period. The facility's policy and the manufacturer's instructions both require that the open date be recorded and that the strips be used within three months of opening to maintain accuracy in blood glucose readings. The failure to label the strips with an open date potentially affected four residents who rely on accurate blood glucose monitoring.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, particularly in hand hygiene and the use of personal protective equipment (PPE). An agency certified nursing assistant (CNA) was observed passing meal trays to residents without performing hand hygiene between resident care. This included entering rooms of residents on contact precautions without donning gowns and gloves, despite clear signage indicating the need for such precautions. Additionally, PPE bins outside certain residents' rooms were found to be lacking necessary supplies, such as gloves and masks, and there were no garbage bins for disposing of used PPE. The report highlights specific residents affected by these deficiencies. Resident R27, with a diagnosis of Clostridium difficile, was on strict contact isolation, yet the CNA failed to adhere to the necessary precautions. Similarly, Resident R58, on contact isolation for MRSA, did not have the required PPE available outside their room. The lack of proper PPE and hand hygiene practices was further compounded by the absence of biohazard bins for disposing of PPE, as noted by the facility's infection preventionist. Another significant issue was the improper handling of urinary catheter drainage bags. Resident R106 was observed with a catheter drainage bag dragging on the floor, which is against the facility's policy. This was confirmed by a CNA and the Assistant Director of Nursing, who acknowledged that the drainage bag should be kept off the floor to prevent infection. The facility's catheter care policy explicitly states that catheter tubing and drainage bags should not touch the floor, yet this protocol was not followed, posing a risk of infection to the resident.
Unsecured Handrail Poses Risk to Residents
Penalty
Summary
The facility failed to ensure that the handrail on the second floor was firmly secured to the wall, which has the potential to affect all 51 residents on that floor. During an observation by a surveyor, it was noted that the handrail was cracked and not securely fixed to the wall. When the surveyor inquired about the handrail, a Licensed Practical Nurse acknowledged the crack. Later, the surveyor pointed out the issue to the Maintenance Director, who confirmed the problem by grabbing the handrail, causing a corner to crack off. The Assistant Director of Nursing stated that the handrails are used by residents when they walk and should be secured to prevent falls. The facility's policy on Resident Rights Guidelines emphasizes the right to a safe and comfortable environment, and the job descriptions for the Maintenance Director and Maintenance Assistant include responsibilities for ensuring the facility is maintained in safe operating order. Despite these guidelines, the unsecured handrail posed a risk to resident safety.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call device was within reach, as required by the resident's care plan and facility policy. The resident, who has a diagnosis including a fracture of the left ulna, dementia, and mobility issues, was observed by a surveyor with the call light on the floor behind the bed, out of reach. The resident confirmed the inability to reach the call light. A staff member from Central Supply acknowledged the call light should be attached to the bed and accessible to the resident. A registered nurse and the Assistant Director of Nursing both stated that call lights should be within reach of residents. The facility's call light policy and the job description for Certified Nursing Assistants both emphasize the importance of ensuring residents have access to call lights.
Failure to Obtain Advance Directive Order
Penalty
Summary
The facility failed to obtain a doctor's order for an advance directive for a resident, identified as R58, who was part of a sample of 58 residents reviewed for advance directives. R58's medical history includes atherosclerotic heart disease, chronic kidney disease, end-stage renal disease, and bilateral below-the-knee amputations. Despite being cognitively intact with a BIMS score of 14, there was no physician order for advance directives, such as Full Code or Do Not Resuscitate status, documented in R58's records. Additionally, the Admission Record Form for Advance Directive section indicated that no advance directives were selected for this resident. During an interview, the Assistant Director of Nursing (ADON) acknowledged that a doctor's order for an advance directive should be obtained upon admission and that the nurse is responsible for acquiring this order. The ADON also mentioned that staff could refer to an advance directive book on the crash carts to determine a resident's advance directive status. However, upon inspection, the surveyor found that there was no advance directive for R58 in the book on the first floor where the resident resides. The facility's policy requires a written physician's order in response to a resident's advance directive regarding CPR and mandates that each medical record binder be labeled to quickly identify advance directives.
Failure to Maintain Confidentiality of Electronic Health Records
Penalty
Summary
The facility failed to ensure the confidentiality of electronic health records, which is a requirement under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). During an observation on the 3rd floor, a Registered Nurse (V16) left a nursing cart unattended with a resident's medication administration record open on the attached laptop. This occurred when V16 walked away to the nursing station, leaving the electronic medical record of a resident (R63) exposed and accessible. Upon returning, V16 acknowledged the oversight and attributed it to a failure to close the record, citing HIPAA as the reason for the necessity of maintaining confidentiality. A similar incident was observed on the 2nd floor involving a Licensed Practical Nurse (V7), who left another resident's (R44) medication administration record open and unattended on a laptop attached to a nursing cart. V7 had walked away to retrieve an identification badge, leaving the record exposed. Upon returning, V7 admitted to forgetting to close the record, acknowledging the importance of doing so under HIPAA regulations. The Assistant Director of Nursing (V2) confirmed that the facility's expectation is to keep electronic medical records closed and attended, aligning with HIPAA requirements. The facility's policy on privacy and confidentiality supports this expectation, emphasizing the need to protect residents' personal and medical information.
Failure to Maintain Homelike Environment Due to Missing Closet Drawers
Penalty
Summary
The facility failed to ensure a homelike environment for its residents by not addressing missing closet drawers in several rooms. Observations revealed that four residents' closets were missing bottom drawers, which led to clothing being stored in plastic bins on the floor. This issue was noted during a survey, where residents expressed their dissatisfaction with the current state of their storage. One resident mentioned that the drawers had been missing since their admission to the facility five years ago. The residents involved had varying levels of cognitive impairment, with some having intact cognition and others being moderately to severely impaired. The Maintenance Director was unaware of the missing drawers and stated that no staff had reported the issue. The director mentioned that replacing the drawers would require the owners' approval since they were custom-made. A review of maintenance request forms from the previous months showed no requests for replacing the missing drawers. The facility's policies and job descriptions for maintenance staff include responsibilities for repairing resident property, but these duties were not fulfilled in this instance. The facility's Resident Rights Guidelines emphasize the right to a homelike environment, which was not upheld in this case.
Failure to Conduct New PASRR for Resident with New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASRR) for a resident who was diagnosed with Schizophrenia on 4/18/2022. This oversight was identified during a survey, which revealed that the resident, who had been admitted earlier, had a Brief Interview of Mental Status score of 15 and a Minimum Data Sheet section D (Mood) severity score of 10. Despite these indicators, the resident's Obra-I Initial Screen dated 7/24/2019 did not suspect any developmental disability or mental illness, and no new PASRR was conducted following the new diagnosis. Interviews with facility staff, including the Administrative Assistant/Office Manager and the Administrator, indicated a lack of clarity regarding the process for requesting a new PASRR when there is a change in a resident's condition. The Social Service Director confirmed that a new PASRR should have been requested to ensure the resident's continued appropriateness for the skilled nursing home setting. The facility's policy on PASRR, which involves coordination with the appointed agency Maximus, was not followed, leading to the deficiency noted by the surveyors.
Failure in Wound Care Management Due to Documentation Error
Penalty
Summary
The facility failed to provide necessary treatment to promote healing and accurately assess the site of a skin impairment for a resident with a wound. The resident, who has a medical history including hemiplegia, hemiparesis, congestive heart failure, aphasia, and osteoarthritis, was found to have a wound on the left upper posterior thigh. However, the physician's order incorrectly documented the wound care for the right thigh. This discrepancy was confirmed by both the Registered Nurse and the Wound Care Nurse, who acknowledged the error and corrected the order to reflect the correct location on the left thigh. During an observation, the wound on the resident's left thigh was found without a dressing, appearing red, moist, and non-blanchable. The Wound Care Nurse confirmed that the dressing might have fallen off and stated that the protocol requires staff to notify the nurse or wound care nurse to apply a new dressing. However, no notification was made, resulting in the resident's wound being left without proper dressing and care. The facility's failure to adhere to its own protocol and ensure accurate documentation and communication led to this deficiency in wound care management.
Improper Use of Low Air Loss Mattress for High-Risk Resident
Penalty
Summary
The facility failed to ensure proper use of a low air loss mattress for a resident identified as being at high risk for pressure ulcers. The resident, who is cognitively impaired and dependent on assistance for all self-care and mobility, was observed lying on multiple layers of linens on the mattress. This setup included a flat sheet and a folded sheet, which is contrary to the intended use of the low air loss mattress. The resident's care plan and hospice order specified the use of a low air loss mattress, and the Braden scale assessment indicated a high risk for pressure ulcers, necessitating a pressure-reducing device for the bed. Interviews with facility staff, including a registered nurse and the assistant director of nursing, confirmed that the low air loss mattress should only have one layer of linen to function effectively. The presence of multiple layers of linens interferes with the mattress's ability to distribute air and relieve pressure, which is essential for preventing further skin breakdown. The manufacturer's guide for the mattress did not specify the number of layers to be used, but staff acknowledged the importance of maintaining a single layer to ensure the mattress's effectiveness.
Failure to Apply Adaptive Device for Contracture Management
Penalty
Summary
The facility failed to ensure that an adaptive device, specifically a splint or palm grip, was in place for a resident with a contracted hand. This deficiency was observed during a survey when the resident was seen lying in bed with both hands clenched tightly in a fist shape, without the assistive device on either hand. The resident, who is cognitively intact with a BIMS score of 15, has a medical history that includes hemiplegia, hemiparesis, osteoarthritis, and muscle contracture. Despite a physician's order for the use of a carrot splint to assist with contracture prevention and mobility, the device was not observed on the resident during the survey. The resident's care plan indicated the need for a splint or carrot device to be applied and removed with staff supervision or assistance 6-7 days per week. However, the restorative nurse confirmed that the resident should have the device on when not receiving care and noted that the resident had only refused it twice. Despite this, documentation of the application of the device was not provided upon request. The facility's policies on the application of splints and the use of adaptive devices were not adhered to, as there was no record of the device being applied as ordered by the physician.
Failure to Log Refrigerator Temperatures for Residents
Penalty
Summary
The facility failed to properly log refrigerator temperatures for two residents with personal refrigerators in their rooms, which has the potential to affect all 58 residents in the sample. Observations revealed that the temperature logs for the personal refrigerators of two residents, R7 and R16, were missing documentation for several days in January 2025. Specifically, R7's temperature log was missing entries for multiple consecutive days, and R16's log was missing entries for four days. The Assistant Director of Nursing (ADON) stated that refrigerator temperatures must be checked daily to ensure proper operation and prevent food spoilage, which could lead to residents experiencing upset stomachs. During the survey, it was observed that R7's refrigerator contained food items and had a thermometer reading of 40 degrees Fahrenheit, which is within the acceptable range according to the facility's policy. R16, who has diagnoses including depression, obesity, chronic kidney disease, and atrial fibrillation, reported that staff clean the refrigerator but do not check it daily. R16's Brief Interview for Mental Status (BIMS) score indicated cognitive intactness. The facility's policy requires daily temperature checks by the 11-7 nurse at the start of the shift, but this was not consistently documented, leading to the deficiency.
Failure to Provide Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that residents received education on the benefits and risks of Influenza and Pneumonia vaccines, and did not provide the opportunity for residents to receive these vaccinations. This deficiency affected three residents out of five reviewed for immunizations. One resident stated that the facility did not offer the Pneumococcal vaccine nor provided education on its benefits or risks. The resident's medical records lacked informed consent or documentation of education regarding the vaccine. Another resident's records also did not display any informed consent or education provided for the Influenza vaccine, and the Infection Preventionist could not provide a copy of the informed consent form despite claiming a verbal declination was received. Additionally, a third resident reported that the facility did not offer either the Pneumococcal or Influenza vaccines and did not provide information on the benefits or risks. This resident expressed a desire to receive both vaccines. The facility's policy on immunizations states that residents or their representatives should be educated about the benefits and potential side effects of the vaccines and be given the opportunity to accept or refuse them. However, the facility failed to document the education provided and the residents' decisions in their clinical records, as required by their policy.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident, R2, from physical abuse by another resident, R1. On January 6, 2025, an incident occurred where R1 used R2's backpack to hit R2. This incident was witnessed by a housekeeper who observed R1 taking the backpack from R2's wheelchair and using it to strike R2. R2 attempted to shield herself from the blows by raising her hands. The staff intervened and separated the two residents, but R1 did not provide a reason for the attack. R1 has a history of physical aggression as documented in his care plan, which includes behaviors such as hitting and kicking. R1's cognitive status is moderately impaired, with a BIMS score of 09. R2, who also has a moderately impaired cognitive status with a BIMS score of 08, expressed feeling unsafe following the incident. R2's care plan indicates she is at risk for abuse due to her impaired cognition and communication abilities. The facility's abuse prevention policy emphasizes the right of residents to be free from abuse and outlines the facility's responsibility to prevent such occurrences. Despite this policy, the incident on January 6, 2025, demonstrates a failure to ensure a safe environment for R2, as the facility did not prevent the physical abuse from occurring.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nursing staffing information, which has the potential to affect all 109 residents residing in the facility. Upon entrance to the facility, the daily staff posting was not observed in the lobby, as required. The staffing sheet provided by the Staffing Coordinator was incomplete, lacking the resident census and nursing staff hours. The Administrator acknowledged the absence of the posting and admitted that it had not been correctly displayed. Further interviews revealed that the staffing posting was supposed to be visible in the lobby for residents and visitors to access, but this was not being done. The Receptionist, who had been in the position for three months, was unaware of the requirement to post the staffing sheet daily. The facility's policy and federal regulations mandate that the nurse staffing data, including the facility name, current date, total number, and actual hours worked by nursing staff, as well as the resident census, be posted in a clear and readable format in a prominent place accessible to residents and visitors.
Failure to Secure Treatment Cart and Medications
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by an unlocked treatment cart left unattended in the hallway and a resident's inhaler left on a bedside table visible from the hallway. The treatment cart was observed on the 1st floor, across from the elevator, without being in the visual vicinity of a nurse, contrary to the facility's policy that requires carts to be locked when not in use. Additionally, a resident's inhaler, which was not in its original packaging or labeled by the pharmacy, was found on the bedside table. The resident confirmed using the inhaler for breathing, but there was no physician's order for the inhaler to be kept at the bedside, suggesting it was brought from home without proper authorization. Furthermore, an oxygen tank was improperly stored on the bare floor in the resident's room without a holder, posing a fire hazard. The facility's policy mandates that oxygen tanks not in use should be stored in a designated oxygen room and secured in a holder. The staff, including the Assistant Director of Nursing, Registered Nurses, and the Director of Nursing, acknowledged the lapses in following the facility's protocols regarding medication and oxygen storage. The facility's policies clearly state that medications should be stored safely and only accessible to authorized personnel, and oxygen tanks should never be left free-standing in resident rooms.
Failure to Protect Residents from Theft
Penalty
Summary
The facility failed to protect a resident, identified as R2, from abuse in the form of theft. R2 reported that their money and debit card, which were kept in their pillow, were stolen and subsequently used for unauthorized withdrawals. Despite the facility reimbursing R2 and involving the police, the perpetrator was not identified, leaving R2 feeling sad and leery. R2's medical records indicate they are not cognitively impaired, with a BIMS score of 15, and have been diagnosed with conditions such as Myasthenia gravis, Type 2 diabetes, hypertension, restless leg syndrome, and foot pain. Another resident, R3, also reported a theft incident, stating that their money was stolen approximately three months prior, particularly when agency staff were present during night shifts. R3, who has been a resident for eleven years, expressed dissatisfaction with the situation, despite being reimbursed by the facility. The facility's grievance forms documented these incidents, but the administrator did not report them to the Illinois Department of Public Health, citing that R3's money was misplaced rather than stolen. The facility's abuse prevention policy includes measures to prevent misappropriation of property, but these incidents suggest a failure in its implementation.
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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