Landmark Of Oak Lawn Rehabilitation And Nursing Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Lawn, Illinois.
- Location
- 9525 South Mayfield, Oak Lawn, Illinois 60453
- CMS Provider Number
- 145942
- Inspections on file
- 45
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Landmark Of Oak Lawn Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
Surveyors found that staff did not provide timely incontinence care to three dependent residents, despite care plans and facility guidelines requiring at least every two-hour checks and peri-care after incontinent episodes. One resident with mild cognitive impairment was repeatedly left in a soiled brief until late morning on consecutive days, with CNAs citing tray service duties and being pulled from other floors as reasons for delay. Another resident with severe cognitive impairment was reportedly not checked for several hours, during which time her brief became heavily soiled with bowel movement before being changed. A cognitively intact resident dependent on toileting hygiene waited in a moderately wet, brownish brief until she used the call light, after which a CNA, newly reassigned to that floor and unaware of her assignment, responded and provided care.
A resident with paraplegia, diabetes, pancreatic cancer, and multiple stage 3–4 pressure ulcers was found with sacral and left ischial dressings that were soiled, dirty, peeling, and dated two days earlier, indicating that daily wound care had not been provided as ordered. When an LPN performed wound care, the wounds were cleansed with saline and treated with medi honey and calcium alginate instead of the physician-ordered debriding product and silicone super absorbent dressing, with the LPN stating the ordered product could not be found. The wound care physician later confirmed that the specific product had been ordered to debride dead tissue and was to be used for the resident’s chronic wounds.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
Several dependent residents with significant self-care deficits did not receive proper assistance with ADLs, including bathing, grooming, and nail care. Observations included uncombed hair, soiled feet, full beards, and long fingernails, with staff either unaware of care schedules or assuming tasks were completed by others. Care plans documented the need for extensive support, but required hygiene and grooming were not consistently provided.
A resident who is totally dependent on staff for all ADLs was unable to access their bedroom shower for over a month due to a broken door, and staff did not provide showering assistance in the resident's preferred location. The DON was unaware of the maintenance issue, and the resident was not assisted with bathing unless they agreed to use a shower on another floor, which they refused.
A resident with multiple chronic conditions was found with an unlabeled inhaler at bedside without timely completion of the required self-administration assessment. Staff interviews revealed inconsistent adherence to policy regarding medication storage and assessment, and the inhaler was not kept in pharmacy-provided packaging as required. The necessary interdisciplinary assessment and documentation were not completed as scheduled.
Two residents with dementia and self-care deficits were observed in the dining area and hallway without proper footwear, despite care plans requiring staff assistance to ensure appropriate shoes and socks. Staff acknowledged the oversight, and in one case, a resident's shoes were found stored in a closet bag, possibly by a family member. The DON confirmed the expectation for all residents to have proper footwear in accordance with facility policy.
A resident with multiple chronic conditions was permitted to self-administer an inhaler per physician order, but the facility did not initiate or update the care plan to reflect this change as required by policy. The necessary assessment and care plan for self-medication were not completed until months after the order was given, as confirmed by the Regional Nurse Consultant.
A resident dependent on enteral tube feeding was observed lying with the head of the bed elevated only to 20 degrees during feeding, contrary to physician orders and facility policy requiring a 30-45 degree elevation to prevent aspiration. The DON and a CNA confirmed the correct procedure was not followed, and the resident's medical record indicated multiple diagnoses necessitating strict adherence to feeding protocols.
A resident with COPD and other medical conditions was found with oxygen tubing left uncovered and unlabeled on a bedside drawer when not in use. The DON confirmed the tubing was not stored in a plastic bag or labeled as required by facility policy, which specifies weekly changes and proper documentation.
The facility did not consistently document shift change counts for controlled substances, as required by policy. On review, a medication cart's controlled substance sign-in sheet was found to have missing nurse initials on several dates, and LPNs confirmed that while counts are supposed to be done and signed each shift, this was not always documented. The DON and Administrator were unaware of the missing signatures and provided copies of the sheets with all dates filled in, despite earlier findings of incomplete records.
A resident with multiple chronic conditions was found with an unlabeled inhaler on the bedside table, contrary to facility policy requiring medications to be stored in pharmacy-provided packaging with proper labeling. Although there was a physician order for bedside self-administration, the required assessment was not completed, and the medication was not stored according to infection control and labeling standards, as confirmed by both an LPN and the DON.
The facility did not follow its activity calendar, failing to engage residents in scheduled tabletop games. During a survey, it was observed that no activities were taking place, and four residents were not engaged by staff. The Activity Director confirmed the absence of activities, and two CNAs present were not facilitating any engagement. This indicates a failure to meet the facility's policy of providing therapeutic recreation opportunities.
The facility failed to investigate and identify the origins of injuries for two residents, leading to deficiencies in their abuse prevention policy. One resident with moderate cognitive impairment sustained a wrist fracture and a large bruise, while another with severe cognitive impairment reported a hip fracture after a fall. Despite medical assessments suggesting falls, the facility classified these injuries as of unknown origin, failing to meet investigation requirements.
A resident with hemiplegia and cognitive impairment was left in a soiled and saturated state for over five hours, contrary to the facility's policy of checking and changing every two hours. The resident was found with a strong smell of urine and expressed feeling cold, highlighting a failure in providing timely incontinence care.
A resident with severe cognitive impairment was physically abused by her roommate, resulting in facial injuries. Despite the resident's vulnerability, the facility did not have an abuse care plan in place. The roommate, known for verbal aggression, admitted to hitting the resident. The facility's policies on abuse prevention and care planning were not adequately followed, contributing to the incident.
The facility failed to follow food safety and sanitation policies, including hand hygiene, thermometer cleaning, and use of standardized recipes. Staff did not wash hands when changing gloves, used thermometers without proper cleaning, and did not maintain sanitizing solution concentration. Meals were prepared without recipes, leading to unmeasured seasoning, potentially affecting residents with dietary restrictions.
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate. Two residents did not receive their medications as prescribed: one due to missing medications and the other due to late administration. Additionally, a nurse left medication unattended, violating facility policy. The DON confirmed that medications should be administered within a specific time frame and under supervision.
A resident with a history of fractures and other medical conditions fell during incontinence care when only one CNA assisted her, despite needing two-person assistance. This resulted in injuries requiring hospital evaluation. The facility's policy mandates two caregivers for such residents, which was not followed.
A resident accessed a medication cart in an LTC facility due to a failure in securing the cart keys. The incident involved a resident with a history of substance abuse and mental health issues. The keys were left unattended by an LPN, contrary to facility policy, allowing the resident to access the cart. The DON was informed, and the incident was investigated, revealing a breach in medication storage protocols.
The facility failed to maintain safe and comfortable room temperatures, with temperatures exceeding 80°F and humidity above 60%. Residents expressed discomfort, and maintenance issues with air conditioning units were unresolved. The facility did not follow its extreme weather policy, affecting all 47 residents.
A resident with a history of psychosis and anxiety reported being physically abused by a nurse during a forced shower, resulting in bruising and scratches. Despite an investigation involving video review and interviews, the facility could not substantiate the claims or determine the cause of the injuries, highlighting a gap in resident protection and investigation processes.
A resident in a LTC facility reported not receiving a shower since admission and was unaware of her shower schedule. Despite being cognitively intact, she only received bed baths, contrary to her preference for showers using a shower bed. The facility lacked documentation on her bathing care, and the administrator admitted they could not provide shower sheets. This failure violated the resident's rights to dignity and self-determination.
A resident was physically abused by an RN after an altercation over heating food. The RN intervened by moving the resident's hands, leading to a physical fight where both parties hit each other. The resident sustained multiple injuries, including a fractured finger. The incident was not promptly reported, delaying the abuse investigation. The DON believed the injuries occurred outside the facility. The facility's abuse prevention policy was not followed, and there were gaps in staff training and documentation, including missing abuse screens and care plans for the resident.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care in accordance with its Guidelines for Incontinence Care and residents’ care plans for three dependent residents. One resident with mild cognitive impairment and documented dependence on toileting hygiene reported in the morning that she thought she was wet; later that morning she was observed wearing a dark, blackish incontinent brief with a strong odor of urine and feces. The CNA assigned stated she had been on duty since 7:00 AM, had been passing meal trays, and had not yet changed the resident. The following day, the same resident reported she had not yet been changed by mid-morning; a CNA then stated she had just been pulled from another floor and had not yet changed the resident. When incontinence care was finally provided, the resident’s brief was moderately wet with urine. The resident’s restorative care plan required checks every two hours and as needed, with perineal cleansing and clothing changes after incontinence episodes. Another resident with severe cognitive impairment and dependence on toileting hygiene was reported by her fiancé to have received no checks between his arrival in the morning and early afternoon. He stated that by early afternoon the resident’s incontinent brief was heavily soaked with bowel movement and was smelly, and that staff changed her at that time. A third resident, cognitively intact but dependent on toileting hygiene, reported waiting to be changed and stated she had last been changed in the early morning by night staff. After the resident activated her call light, a CNA responded and found the resident with a moderately wet, brownish-colored incontinent brief; the CNA stated she had just been moved from another floor, had not received report, and that no nursing assistant had been assigned to that resident. The DON stated that staff are supposed to change incontinent residents every two hours and as needed, and the facility’s undated Guidelines for Incontinence Care require at least every two-hour checks and assistance with cleansing after incontinence episodes, which was not followed in these cases.
Failure to Provide Ordered Wound Care for Chronic Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own wound care policy for a resident with multiple chronic pressure ulcers. The resident, an older female with mild cognitive impairment, paraplegia, pancreatic cancer, diabetes, and multiple stage 4 pressure ulcers (left hip, sacral, left ischium, right buttocks) and a stage 3 right heel ulcer, had wound care orders from a wound care physician. The physician ordered a specific product to be applied after cleansing the sacral and left ischium wounds, followed by a silicone super absorbent dressing, to be done daily and as needed. The facility’s policy stated that wound dressing changes are to be performed as ordered by the physician using clean technique on all chronic or contaminated wounds. On observation, CNAs providing incontinence care found the resident’s stage 4 sacral and stage 4 left ischium wounds with soiled, dirty dressings that were peeling off and dated two days prior, indicating that wound care had not been provided the previous day. Later that morning, an LPN performing wound care confirmed that the old dressings were soiled, dirty, peeling, and dated two days earlier, and stated that this indicated no wound care had been done the day before. During the dressing change, the LPN cleansed the wounds with saline, patted them dry, and applied medi honey and calcium alginate instead of the ordered product and silicone super absorbent dressing, explaining that the ordered product could not be found in the treatment cart. The wound care physician later stated that the ordered product was intended to debride dead tissue from the wound bed and that the facility should have used it as ordered.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Adequate ADL Assistance and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for four dependent residents, specifically in the areas of bathing, grooming, and nail care. Observations revealed that one resident was seen with uncombed hair and heavily soiled feet, and staff were unsure when the last shower was provided. Another resident was observed with a full beard, and staff assumed that a family member had performed shaving, while the DON stated that all residents should be groomed daily. A third resident was found in bed with a full beard and long, soiled fingernails; staff believed a hospice aide was responsible for grooming, but the DON clarified that daily assigned CNAs should ensure completion of any unmet care needs. The fourth resident was observed with long, curved fingernails and reported not having received a shower, expressing a preference for nail trimming rather than cutting off nails. All four residents had documented diagnoses such as dementia, Alzheimer’s disease, quadriplegia, and other conditions requiring assistance with personal care. Their care plans indicated a need for extensive support with ADLs, including bathing, dressing, grooming, and personal hygiene. Facility policy requires routine daily care and coordination between residents and caregivers, emphasizing resident preferences. Despite these requirements, the observed lack of grooming and hygiene care demonstrated a failure to meet the established standards for ADL support for these dependent residents.
Failure to Provide Access to Resident's Shower Room Resulting in Lack of Bathing Assistance
Penalty
Summary
A resident with quadriplegia, paraplegia, obesity, and muscle weakness, who is totally dependent on staff for all activities of daily living, was not provided access to a functioning shower in their bedroom for over a month. The resident reported that the shower room door in their bedroom was broken and had not been opened for an extended period, resulting in the resident not receiving a shower during that time. The resident also stated that nursing staff would not assist with showering unless the resident agreed to use a shower room on another floor, which the resident refused. The Director of Nursing confirmed that the resident refused to use the upstairs shower and was unaware of how long the bedroom shower door had been broken or if maintenance had been notified. There was no evidence that the issue had been addressed or that the resident's preference for using their own shower was accommodated. The care plan indicated the resident required total assistance for bathing, but there were no recent shower records, suggesting a lack of bathing assistance during the period the shower was inaccessible.
Failure to Assess and Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for safe self-administration of medication, specifically regarding the use of an inhaler at bedside. During observation, the resident was found with an inhaler on the bedside table that lacked a name or open date, and the resident stated she was allowed to keep it at bedside. Staff interviews revealed inconsistency in the application of facility policy, with a LPN stating that residents are generally not supposed to have medications at bedside unless there is an order, and confirming that she would need to check for such an order. Further review showed that the required self-administration assessment for the resident was not completed on the date it was due, but was instead finalized several months later. The care plan for the resident, who has multiple chronic conditions including multiple sclerosis, COPD, epilepsy, muscle weakness, diabetes, and asthma, was only initiated after the assessment was completed late. Facility policy requires that residents who self-administer medications must be assessed for their ability to do so safely, and that medications kept at bedside must be stored in pharmacy-provided packaging with proper labeling. Staff interviews confirmed that the inhaler was not stored according to these requirements, lacking both the original packaging and necessary labeling. The physician order for the resident did allow for the inhaler to be kept at bedside, but the interdisciplinary team assessment and proper documentation were not completed in a timely manner, resulting in a failure to ensure safe medication self-administration and storage.
Failure to Ensure Residents Wore Proper Footwear in Common Areas
Penalty
Summary
Two residents were observed in common areas of the facility without proper footwear, which is inconsistent with their care plans and facility policy regarding dignity and personal possessions. One resident, diagnosed with dementia and requiring assistance with personal care, was seen exiting the dining area without socks or shoes after having spent the entire morning in the dining room. A CNA acknowledged the resident's lack of footwear and stated she was just beginning to assist the resident with socks and shoes. The Director of Nursing confirmed the expectation that this resident should have shoes and socks on daily, especially since the resident walks the hallway. The resident's care plan specifically included interventions to ensure proper footwear and nonskid socks prior to activities of daily living. Another resident, with diagnoses of Alzheimer’s disease and dementia and also requiring assistance with personal care, was observed sitting in the dining room without shoes. A CNA reported being unable to find the resident's shoes at the start of the shift. Upon searching the resident's room, the shoes were found in a plastic bag on a closet shelf, possibly placed there by the resident's daughter. The Director of Nursing reiterated the expectation that all residents should have socks and shoes on. The care plan for this resident also included interventions to ensure the resident wore appropriate footwear to promote safety and mobility during ambulation, wheelchair use, and transfers.
Failure to Timely Update Care Plan for Self-Medication Administration
Penalty
Summary
The facility failed to update the care plan for a resident who was authorized to self-administer medication. Despite having an active physician order allowing the resident to keep an inhaler at bedside and self-administer Albuterol as needed, no care plan was initiated at the time the order was received. The care plan was only created several months later, after the deficiency was identified. The facility's own policy requires that a care plan be developed and updated when there is a change in medication scheduling, dose, or the resident's condition, and that the interdisciplinary team must approve and document the resident's ability to self-administer medications. The resident involved had multiple complex diagnoses, including multiple sclerosis, COPD, epilepsy, muscle weakness, diabetes, and asthma. The assessment for self-administration of medications was not completed as required, and the care plan addressing the resident's desire and ability to self-administer medication was not initiated until after the deficiency was noted. This lapse was confirmed by the Regional Nurse Consultant, who acknowledged that the care plan should have been started when the self-administration order was received.
Failure to Maintain Proper Bed Elevation During Enteral Feeding
Penalty
Summary
A dependent resident receiving enteral tube feeding was found lying in bed with the head of the bed elevated only to a 20-degree angle while the feeding was infusing. Observation confirmed that the resident was positioned low in the bed, with feet touching the footboard, and the head of the bed was not elevated to the required angle. A CNA acknowledged that the resident should have been positioned with the head of the bed at a 40-degree angle to prevent choking and that it was her responsibility to monitor the resident when the hospice CNA was not present. The CNA then repositioned the resident and adjusted the bed elevation accordingly. The Director of Nursing confirmed that all residents with feeding tubes should have the head of the bed elevated at a 30-40-degree angle and be properly positioned in bed to prevent aspiration. The resident's medical record indicated diagnoses of unspecified protein calorie malnutrition, gastrostomy status, chronic kidney disease, and muscle wasting, with a physician order specifying that the head of the bed should always be elevated at a 45-degree angle during tube feeding, except during activities of daily living. Facility policy also required nurses to maintain the head of the bed at 30-45 degrees during and after tube feeding. These requirements were not followed at the time of observation.
Failure to Properly Store and Label Oxygen Tubing
Penalty
Summary
The facility failed to ensure proper storage, labeling, and timely changing of oxygen tubing for a resident requiring respiratory care. During observation, a resident with diagnoses including COPD, hypertension, tobacco use, and other conditions was found with oxygen tubing left uncovered on top of a bedside drawer when not in use. The resident stated that staff placed the tubing there when it was not needed. The DON confirmed the tubing was uncovered, unlabeled, and not stored in a plastic bag as required by facility policy, which mandates that oxygen tubing be changed at least weekly or as needed, and labeled with the date, time, and staff initials. The resident had an active physician order for oxygen administration due to COPD/asthma exacerbation.
Failure to Document Controlled Substance Shift Change Counts
Penalty
Summary
The facility failed to properly account for controlled substances by not ensuring that the Shift change accountability record was consistently completed. During observations and interviews, it was found that the controlled substance sign-in sheet for one medication cart had missing initials on several dates, indicating that the required signatures from both the incoming and outgoing nurses were not always documented. Licensed Practical Nurses confirmed that while the narcotic count is supposed to be performed and documented at every shift change, there were instances where initials were missing, and it was unclear whether the count had actually been performed on those dates. Further review with the Director of Nursing and the Administrator revealed that they were unaware of the missing initials and expected the narcotic count and sign-in process to be completed every shift. When asked to provide documentation, copies of the sign-in sheets were produced with all dates filled in, despite earlier observations of missing initials. The facility's policy requires that both nurses count and sign for controlled substances at each shift change, but this procedure was not consistently followed as evidenced by the incomplete records.
Improper Storage and Labeling of Bedside Medication
Penalty
Summary
A deficiency was identified when a resident's medication, specifically an inhaler, was found on top of the bedside table without a name or open date visible. The resident stated she was permitted to keep the inhaler at her bedside. Upon inquiry, an LPN confirmed that while some residents are allowed to have medications at bedside, she would need to verify if there was an order for this. Further interviews revealed that all medications should be kept in their original packaging, which includes the resident's name, medication name, instructions, and the date opened, and should be stored in the package for infection control purposes. The DON also stated that medications kept at bedside should remain in pharmacy-provided packaging with proper labeling. The resident involved had multiple diagnoses, including multiple sclerosis, COPD, epilepsy, muscle weakness, diabetes, and asthma, and had an active physician order for an albuterol inhaler to be kept at bedside. However, the self-administration of medications assessment had not been completed at the time of the observation, and the inhaler was not stored according to facility policy or manufacturer/supplier recommendations. Facility policy requires that medications for bedside storage be kept in containers dispensed by the pharmacy, with appropriate labeling and documentation, which was not followed in this instance.
Failure to Engage Residents in Scheduled Activities
Penalty
Summary
The facility failed to adhere to its activity calendar and engage residents in scheduled social activities, specifically tabletop games, on February 25, 2025. During a surveyor's visit to the dining room on the second floor at 11:25 am, it was observed that no activities were taking place, despite the activity calendar indicating that tabletop games were scheduled for 11:00 am. The Activity Director, identified as V6, confirmed the absence of activities and stated that she was responsible for conducting them. Two CNAs, V7 and V8, were present in the dining room but were not engaging residents in any activities. Instead, they were involved in other tasks such as talking to a resident and performing one-to-one monitoring. Four residents, identified as R6, R7, R8, and R9, were observed in the dining room, none of whom were engaged in social activities. R6 and R7 were seen with their heads down on the table, while R8 and R9 were sitting without engagement. The facility's policy emphasizes the importance of providing a variety of therapeutic recreation opportunities to meet the physical, mental, and psycho-social well-being needs of each resident. However, the lack of adherence to the activity schedule and the absence of staff engagement with residents indicate a failure to meet these policy standards.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not adequately investigating and identifying the origins of injuries sustained by two residents, R1 and R2. R1, who had moderate cognitive impairment and muscle weakness, was found with a discoloration on her left arm, which was later diagnosed as an acute wrist fracture. Additionally, R1 had a large bruise on her right flank. Despite R1's inability to explain the injuries, the facility did not determine the cause of these injuries, and staff were unaware of the right flank bruise. Medical professionals suggested that R1's fracture could be associated with a fall, yet the facility classified the injury as of unknown origin. R2, diagnosed with cerebral palsy and severe cognitive impairment, reported pain in her right hip, which was later identified as a fracture. R2 claimed to have fallen while attempting to transfer herself to a wheelchair, but the facility's investigation concluded that there was no recent fall. Despite R2's report and the orthopedic surgeon's assessment that the fracture was consistent with a fall, the facility classified the injury as of unknown origin. The facility's failure to properly investigate and document these incidents resulted in a lack of clarity regarding the cause of R2's injury. The facility's policy on injuries of unknown origin requires a thorough investigation, including reviewing medical records and interviewing witnesses, to determine the cause of such injuries. However, in both cases, the facility did not meet these requirements, leading to a deficiency in protecting residents from potential abuse or neglect. The lack of proper documentation and investigation into the residents' injuries highlights a significant oversight in the facility's adherence to its abuse prevention program.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident diagnosed with hemiplegia, hemiparesis, functional quadriplegia, and reduced mobility, who requires assistance with personal care. The resident, who has moderate cognitive impairment and is always incontinent of urine, was left soiled and saturated in urine for over five hours. The care plan for the resident indicated the need for appropriate cleansing and peri-care after each incontinent episode, but this was not adhered to. On the day of observation, the resident was found in bed with a strong smell of urine, lying on a wet pad with a large dark brown ring, indicating prolonged exposure to urine. The resident's adult brief was saturated with dark yellow urine, and the resident expressed feeling cold. The CNA responsible for the resident admitted that the last change occurred at 7:30 am, despite the policy requiring checks and changes every two hours. This neglect in care was confirmed by a nurse who observed the same conditions.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse, resulting in an incident where one resident hit another in the face. The affected resident, who has a history of dementia and other mental health disorders, was found with discoloration around her left eye and bleeding from her nose and mouth. She was sent to the hospital and diagnosed with a facial hematoma due to physical trauma. Despite the resident's severe cognitive impairment, the facility did not have an abuse care plan in place for her. The incident occurred when the resident was in her room with her roommate, who was identified as the alleged perpetrator. The roommate, who has a history of verbal aggression and had previously requested a room change due to conflicts with peers, was found with blood on her hand and admitted to hitting the resident because she was in her space. Staff members, including a CNA and a restorative aide, witnessed the aftermath of the incident and reported the roommate's aggressive behavior. However, the facility's administrator expressed uncertainty about how the resident sustained her injuries, citing the resident's tendency to wander and her severe cognitive impairment. The facility's policies on abuse prevention and care planning were not adequately followed. The interdisciplinary team did not develop an abuse care plan for the resident, despite her vulnerability and the incident of abuse. The facility's policy requires care plans to be developed for residents with identified problems, but the resident's care plan did not address the risk of abuse. The facility's failure to implement appropriate care planning and monitoring contributed to the resident's exposure to abuse and subsequent injury.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its food safety and sanitation policies, which resulted in multiple deficiencies during food preparation. Staff members, including V13, did not perform hand hygiene when changing gloves, which is a critical step in preventing cross-contamination. V13 was observed repeatedly removing gloves, discarding them, and putting on new gloves without washing hands in the handwashing sink. This practice was consistent throughout the food preparation process, including when V13 interacted with delivery personnel and handled various food items. Additionally, the facility did not maintain proper sanitation practices with the use of thermometers and sanitizing solutions. V13 used a thermometer to check food temperatures without cleaning it with alcohol wipes before and after use, instead rinsing it with water and wiping it with a wet towel that was not stored in a sanitation bucket. The sanitizing solution in the kitchen was also found to be below the required concentration, indicating a failure to maintain proper sanitation levels. The facility's staff did not follow standardized recipes during food preparation, which is essential for ensuring accurate measurements and adherence to dietary restrictions. V13 prepared meals without using recipes, leading to unmeasured seasoning of food items, which could affect residents with dietary restrictions. The Dietary Manager, V12, confirmed that recipes were available but were not utilized by V13 during the preparation of meals. These failures in following established policies and procedures have the potential to impact all residents receiving meals from the facility's kitchen.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during a survey. This deficiency was observed during medication administration for two residents. One resident, with diagnoses including anemia and benign prostatic hyperplasia, did not receive their prescribed medications, Cyanocobalamin and Finasteride, because the medications were missing from the cart. Another resident, with conditions such as anemia and gastric-esophageal reflux disease, received their Pantoprazole Sodium medication late, outside the facility's allowed time frame. Additionally, during the administration of medication to the second resident, the nurse left the medication unattended on a table while retrieving a straw, which is against the facility's policy that requires medications to be under the nurse's supervision at all times. The Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time and that any deviations should be reported to a physician or in-house nurse practitioner. The facility's policy also mandates that nurses ensure residents swallow their medications, which was not adhered to in this instance.
Failure to Provide Adequate Assistance During Incontinence Care
Penalty
Summary
The facility failed to prevent an accident involving a resident who required two staff members for assistance during incontinence care. The resident, a female with a history of multiple medical conditions including a left peri-prosthetic hip fracture and osteoporosis, experienced a fall while being assisted by only one staff member. This incident resulted in the resident sustaining a left forehead hematoma, a skin tear on the right forearm, and a fracture of the left fifth metacarpal, necessitating an emergency hospital transfer. The incident occurred when the resident rolled out of bed during incontinence care provided by a single Certified Nursing Assistant (CNA), despite the resident's care plan indicating the need for two-person assistance. The CNA admitted to providing care alone, which led to the resident rolling out of bed and hitting her face on an oxygen concentrator. The resident was subsequently assessed by an Agency Registered Nurse, who confirmed the need for two-person assistance due to the resident's dependency and size. The Director of Nursing and the facility's Administrator acknowledged that the CNA should have followed the care plan and requested assistance. The facility's policy on incontinence care requires two caregivers to assist residents who are dependent, as outlined in the Minimal Data Set assessment. The failure to adhere to this policy directly contributed to the resident's fall and subsequent injuries.
Medication Storage Breach in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were stored safely and securely, as required by their policy. This deficiency was identified when a resident, referred to as R4, accessed the medication cart. On the night shift of 10/20/24, a Registered Nurse (RN), V8, reported receiving information from a Licensed Practical Nurse (LPN), V11, that R4 had gotten into the medication cart. A Certified Nursing Assistant (CNA), V2, witnessed R4 with the nurse's keys in her hands and observed her putting the keys back in the binder on the nurse's cart. V2 reported this to the nurse, who was attending to another resident at the time. The Director of Nursing (DON), V5, was informed of the incident on 10/21/24 by a manager. V5 investigated by speaking with V12, who reported the incident, and attempted to contact V11, who was unavailable. V5 learned that V11 had left the keys in a drawer during wound care for another resident, contrary to the facility's policy that requires nurses to keep the medication cart keys on them at all times. The facility's policy also mandates that medication carts and supplies be locked or attended by authorized personnel. R4 had a history of substance abuse and mental health issues, including a past suicide attempt by taking pain pills. R4's care plan noted socially inappropriate behavior and non-compliance with safe smoking regulations. Despite these concerns, there were no progress notes related to R4 being seen with the medication cart keys from 10/18/24 to 10/22/24. R4 was eventually discharged to another facility on 10/22/24. The facility's failure to secure the medication cart allowed R4 to access it, which was a breach of their medication storage policy.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe and comfortable environment for its residents, as evidenced by room temperatures exceeding 80 degrees Fahrenheit and humidity levels above 60%. This issue was observed in multiple resident rooms, despite the central air conditioning and portable fans being operational. The facility did not identify all residents at high risk for heat stroke or heat exhaustion, nor did it follow its extreme weather conditions policy to monitor ambient temperatures effectively. This failure affected all 47 residents in the facility. Observations and interviews revealed that residents and their family members expressed discomfort due to the high temperatures. Some residents reported that their air conditioning units were not functioning properly, and maintenance logs indicated unresolved issues with these units. Additionally, residents were not consistently provided with cold drinks or ice water, and some were not assisted into cooler areas of the facility. The facility's maintenance staff was not present for a period, and there was a lack of documentation regarding the monitoring of room temperatures and resident conditions. The facility's contracted HVAC service provider identified significant maintenance issues, including nonfunctional compressors and clogged convectors in resident rooms. The facility's maintenance records showed a lack of preventive maintenance, contributing to the inadequate cooling. The facility's policies required monitoring of ambient temperatures and resident conditions during extreme weather, but these were not followed, leading to the deficiency.
Removal Plan
- Facility Administrator initiated additional monitoring of air temperatures, taking and tracking air temperatures every 2 hours. This is still currently in place and will be continued until all room temperatures are consistently at 75 degrees or below; at which time daily monitoring of temperatures will resume in accordance with facility standard procedures.
- Facility Administrator assigned department managers to assist direct care staff with monitoring residents every 2 hours and questioning residents about comfort. Residents in rooms with the highest recorded temperatures were also asked/encouraged to move to another/cooler room.
- Facility Administrator provided residents with fans as available.
- Facility Activity personnel passed out popsicles to residents, in accordance with prescribed diets.
- Facility Administrator instructed licensed nurses and C.N.A.s to increase monitoring of all residents and increase the provision of ice/water. Administrator also encouraged staff to encourage mobile residents' use of hydration stations provided on both floors.
- Facility DON implemented additional temperature (vital) monitoring (2 times/shift) for all residents.
- Facility Nursing Managers identified residents with higher risk for negative effects related to hot temperatures. Residents with mobility, respiratory, g-tube dependent, and other concerns outlined in the facility's Extreme Weather policy were identified and additional interventions were put in place, such as additional g-tube flushes, checking/changing of positioning/clothing/linen for residents in bed, etc.
- Facility Administrator and DON initiated a rounding tool to document the 2-hour rounding being completed by nursing management, and ensure the following: Frequent monitoring of residents with mobility concern (bed-bound), Frequent monitoring of residents with compromised ability to verbalize discomfort, Frequent monitoring of resident body temperature, Presence of ice/water/appropriate hydration in the resident room.
- Facility's nursing management, initiated nurses monitoring for signs/symptoms of heat exhaustion and heat stroke every 4 hours; with documentation in the residents' MARs.
- Facility Administrator conducted education to all staff on facility extreme hot weather policy and checking for signs/symptoms of hyperthermia.
- Facility RDO arranged for the Maintenance Director at an affiliated facility to assess the HVAC function, in observation of the PTAC units in the lobby and conference room not working, and anticipation of continuous high temperatures expected during the week. Temperatures on the care units were not noted as a concern at this time.
- Assisting Maintenance Director contacted the facility's contracted HVAC service provider to provide further assessment of the HVAC system and planned to secure parts for repair of the PTAC units in the facility's lobby and conference rooms.
- Assisting Maintenance Director repaired the PTAC unit in the facility's conference room and verified availability and function of 17 window A/C units. The assisting Maintenance Director developed a plan and secured the additional staff needed to install the units.
- Facility's contracted HVAC service provider assessed the HVAC system and performed service to the facility's chillers and compressors; providing the facility with 50% function of the system that provides A/C to the public areas, (hallways and dining rooms). The facility Administrator and management were told that a repair to the rooftop unit will be needed and could be scheduled when outside temperatures subside, however the current function % would be sufficient to provide the amount of A/C necessary to maintain appropriate temperatures throughout the building in the interim.
- Assisting Maintenance Director returned to the facility to install window units on the second floor, where the rooms with the highest temperatures were located. A/C units were installed in the following rooms: 200 (4 bed-room - 2 units installed), 203, 206, 207, 208, 209, 211, 210, 214, 215, 217, 218, 222, 223, 224, Facility lobby.
- Facility's contracted HVAC service provider returned to the facility to do additional assessment and service to the ground level chiller, central A/C units to maximize A/C performance to facility public areas. The provider also initiated assessment and service to the convectors in the resident rooms. The Administrator will ensure that the HVAC service provider provides routine maintenance annually of the HVAC systems, in accordance with the facility PM program.
- Facility's contracted HVAC service provider completed the assessment and service to all the convectors in the residents' rooms. The Administrator will ensure that the convectors are assessed/cleaned/serviced monthly by the Maintenance Director or designee (HVAC service provider). The company's corporate maintenance director or designee (HVAC service provider) will perform quarterly audit of the primary HVAC system to ensure proper maintenance/function in between annual inspections provided by the HVAC service provider. The corporate maintenance director or designee (HVAC service provider) will also complete random audits of the individual room convectors on a quarterly basis to ensure compliance with monthly maintenance.
Failure to Determine Cause of Resident's Injuries
Penalty
Summary
The facility failed to prevent or determine the cause of an injury of unknown origin for a resident, identified as R1, who sustained bruising to the left hip, left hand, and left shin, as well as superficial scratches to the back. R1, a female resident with a history of psychosis, anxiety disorder, acute stress reaction, and adult physical abuse, reported an incident involving rough treatment by an agency staff nurse. Despite R1's intact cognition, as indicated by a BIMS score of 15, her statements were inconsistent with the evidence gathered during the investigation. The facility's report noted discrepancies in R1's account, such as claims of clothing being ripped and multiple staff being present, which were not supported by video evidence. The facility's progress notes and a police report detailed R1's allegations of being forced to shower and physically abused by a nurse, including being pushed, grabbed, and struck with a shower head. However, the facility's investigation, which included reviewing video footage and interviewing staff and residents, did not substantiate these claims. The administrator, V1, noted that the nurse was the only person observed entering R1's room, contradicting R1's account of multiple individuals being involved. Despite the investigation, the facility was unable to determine how R1 sustained her injuries, as no staff reported any incidents of abuse, and R1 was uncooperative in providing further details. The facility's abuse prevention policy mandates documentation and investigation of all incidents, allegations, or suspicions of abuse, neglect, or injuries of unknown origin. However, the facility's failure to ascertain the cause of R1's injuries highlights a gap in their ability to protect residents from harm. The administrator acknowledged the lack of information regarding the injuries and the inability to obtain further details from the hospital due to the resident's daughter's refusal to share information. This incident underscores the importance of thorough investigations and effective communication to ensure resident safety and compliance with regulatory standards.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's preference for showering, which is a violation of the resident's rights to a dignified existence and self-determination. The resident, identified as R4, reported during an interview that she had never received a shower since her admission to the facility and was unaware of her designated shower days. The surveyor had to inform R4 of her shower schedule, which was set for Monday and Thursday evenings. R4 expressed a preference for using a shower bed, as she had done at home, but was not informed about the availability of a shower chair in the facility. Despite being cognitively intact with a BIMs score of 15, R4 had only received bed baths during her three-week stay at the facility, which did not meet her personal preference for showering. The facility's administrator, identified as V12, acknowledged the lack of specific documentation regarding R4's bathing care and skin assessment. The facility did not have shower sheets for R4, and the administrator stated that they could not provide them. The facility's policy on resident rights emphasizes the importance of providing care that maintains or enhances each resident's dignity and respect, including grooming residents as they wish to be groomed. However, the facility's failure to offer R4 a shower or inform her of the available options did not align with this policy, resulting in a deficiency in honoring the resident's rights.
Failure to Protect Resident from Physical Abuse and Delayed Reporting
Penalty
Summary
The facility failed to protect a resident (R1) from physical abuse by staff and did not promptly report the incident as required by their abuse protocols. The incident occurred on 3/2/24 when R1 was physically abused by a Registered Nurse (V3) after becoming upset when he couldn't heat up food by himself. The nurse, V3, physically intervened by taking R1's hands from the tray cart and placing them on his walker. This intervention escalated into a physical altercation between V3 and R1, with both hitting each other with closed fists. R1 sustained injuries to his head, neck, back, and right finger, resulting in a fracture to his right third digit. Despite the altercation, the facility failed to promptly report the incident, leading to a delay in initiating an abuse investigation. The deficiency was further compounded by the lack of proper documentation and follow-up by facility staff. The Director of Nursing (V2) did not believe the assault occurred at the facility and thought it happened with the EMTs or in the emergency department. Additionally, the facility's abuse prevention program policy, last revised in 01/2019, outlined clear procedures for reporting and preventing abuse, neglect, and mistreatment of residents. However, there were gaps in staff training and awareness, as evidenced by the lack of abuse screens or care plans for R1 in his medical records. The failure to adhere to established protocols and promptly report incidents of abuse highlights a critical lapse in resident safety and protection within the facility.
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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