Lee Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Plaines, Illinois.
- Location
- 1301 Lee Street, Des Plaines, Illinois 60018
- CMS Provider Number
- 145382
- Inspections on file
- 33
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Lee Manor during CMS and state inspections, most recent first.
Surveyors found that staff failed to provide timely incontinence care to four cognitively impaired, toileting-dependent residents. Multiple residents were observed late in the morning with urine-soaked briefs, brownish discoloration, and wet linens, despite care plans requiring frequent toileting assistance and peri-care with each incontinent episode. CNAs reported not having changed some residents since early morning, using double briefs on a resident who voided frequently, and planning to change residents only when they were next seen, while the DON later acknowledged that leaving residents in urine-soaked briefs and using two diapers was not acceptable.
A resident with significant cognitive and physical impairments developed a pressure ulcer that was not properly assessed or documented after initial signs of skin breakdown were observed. Despite verbal reporting by a CNA, no formal wound assessment or documentation occurred, and treatment orders were inconsistently recorded in the TAR. The wound progressed and required debridement, with facility policies for wound care assessment and documentation not followed.
A dependent, nonverbal resident with multiple diagnoses, including Alzheimer's and Parkinson's, was injured after falling from bed when a CNA attempted to reposition her alone, contrary to facility practice requiring two-person assist for such residents. The resident sustained a head laceration that required a staple, and the care plan did not specify the required level of assistance.
Three residents experienced significant unplanned weight loss due to the facility's failure to identify, assess, and implement effective interventions. In each case, there were missed notifications to physicians and dietitians, lack of timely dietary follow-up, missing or incomplete documentation of calorie counts, and care plans that were not updated in response to ongoing poor intake and weight loss.
A nurse administered medications, including an antibiotic, to a resident nearly two hours late without notifying the MD or documenting the reason for the delay, as required by facility policy. Staff interviews confirmed that neither physician notification nor proper documentation occurred for the late administration.
A resident with severe cognitive and physical impairments experienced worsening hearing loss due to hardened ear wax that was not fully removed as recommended by an audiologist. Facility staff did not coordinate a timely follow-up appointment for further wax removal after a COVID-19 outbreak, and the resident remained unable to hear or communicate effectively despite the use of hearing aids and alternative communication methods.
A resident with significant mobility and cognitive impairments was found with both upper and lower quarter side rails and bolsters in use, but staff were inconsistent in their knowledge of the intended number of rails and lacked assessments for the bolsters. The care plan did not specify the number of rails or mention bolsters, and documentation failed to clearly address the devices in use, resulting in a deficiency related to inadequate assessment and documentation of side rail use.
Surveyors determined that required daily Nurse Staffing Data was not posted in a prominent area for residents and visitors. The DON and Administrator confirmed the absence, attributing it to the scheduler being on leave, and the Receptionist had not seen the data that morning.
A resident with multiple health issues was found unresponsive after a shower, leading to a delayed 911 call. The resident suffered a blunt force head injury, likely from a fall, resulting in extensive intracranial hemorrhage and death. The facility failed to determine the cause of the injury, contributing to the resident's deteriorating condition.
A resident with dementia was allowed to leave the facility without a doctor's order or consent from their POA. The resident, who had significant cognitive impairments, was taken out by a surrogate decision maker without proper authorization. The facility failed to notify the POA, who was unaware and concerned for the resident's safety, leading to police involvement. Documentation confirmed the lack of required authorization.
The facility failed to implement appropriate infection prevention and control practices during medication administration by not disinfecting medical equipment such as blood pressure apparatus and oximeter after each resident use. The RN used the same equipment on multiple residents without disinfecting it between uses, despite the facility's policy requiring disinfection to prevent the spread of infection.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and toileting hygiene to dependent residents, as identified through observation, interview, and record review. Four residents with documented severe or moderate cognitive impairment and dependence on toileting hygiene were found with urine-soaked briefs and wet linens late in the morning. One male resident was observed in bed pointing to his soaked incontinent brief at 9:40 AM; a CNA who had started work at 7:00 AM acknowledged she had not yet changed him. His care plan included cleaning the peri-area with each incontinent episode. Another male resident was observed at 10:10 AM lying on a low bed wearing two incontinent briefs with wet mattress linens; the inner brief was urine-soaked with brownish discoloration. The CNA caring for him stated that she put two diapers on him because he urinated a lot and planned to change him to one diaper, despite his care plan directing staff to assist him by toileting frequently. A female resident with moderate cognitive impairment and dependence on toileting hygiene was observed at 10:15 AM in bed with a brownish discolored, urine-soaked incontinent brief. The CNA reported that this resident had last been changed around 7:00 AM by the night CNA and that she was going to change her at that time, although the care plan called for frequent toileting assistance. Another female resident with severely impaired cognition and dependent on toileting hygiene was observed at 10:20 AM with a urine-soaked brief showing brownish discoloration through to the outside of the brief and mild wet padding. A hospice CNA stated she visits this resident twice per week and was going to change her then. This resident’s care plan required incontinence care after every diaper change. The DON stated that it was not acceptable to leave residents in urine-soaked, brownish-colored briefs and referenced the issue of staff putting two diapers on residents and the need to check residents frequently.
Failure to Assess, Document, and Treat Pressure Ulcer Leads to Wound Deterioration
Penalty
Summary
A resident with multiple diagnoses, including Alzheimer's Disease, Parkinson's Disease, diabetes, and vascular dementia, was found to have developed a pressure ulcer while under the care of the facility. The resident was completely dependent on staff for mobility and personal care, requiring regular turning and repositioning. Despite a certified nursing assistant (CNA) observing a reddened area on the resident's buttocks and verbally reporting it to a nurse, there was no documentation or formal wound assessment completed at that time. The CNA continued to apply barrier ointment and turn the resident, but the initial signs of skin breakdown were not formally recorded or addressed in the medical record. The wound care nurse later confirmed that the area was red and classified it as a superficial Stage 1 pressure injury but did not document an assessment. The wound care nurse was then absent on vacation, and the wound was not reassessed or documented until a hospice nurse identified a new pressure ulcer on the sacrum several days later. The wound was initially coded incorrectly in the Minimum Data Set (MDS) and was not properly staged or documented as a deep tissue injury. Treatment orders for the wound were not consistently entered into the Treatment Administration Record (TAR), and some prescribed treatments were missing from the record, making it unclear whether they were administered as ordered. The facility's own policies required full assessment and documentation of pressure sores, including location, stage, and measurements, as well as ensuring physician orders for wound care procedures. These protocols were not followed, resulting in a lack of timely and accurate documentation, incomplete treatment records, and a failure to implement effective interventions to prevent further deterioration. As a result, the resident's pressure ulcer progressed to an unstageable wound requiring debridement.
Failure to Provide Required Two-Person Assist During Bed Repositioning Results in Resident Fall and Head Injury
Penalty
Summary
A dependent resident with multiple diagnoses, including Alzheimer's Disease, Parkinson's Disease, vascular dementia, and a cognitive communication deficit, experienced a fall from bed resulting in a head injury that required a staple. The resident was nonverbal and required assistance with activities of daily living. According to the facility's practice, such a resident should have been repositioned in bed with the assistance of two staff members. However, on the date of the incident, a CNA attempted to turn the resident alone, during which the resident slid off the bed and sustained a laceration to the back of the head. Interviews with facility staff confirmed that the resident was dependent and should have received a two-person assist for bed repositioning. The Assistant Director of Nursing and the Restorative Nurse both stated that dependent residents require two staff for repositioning. The resident's care plan and assessment did not specify the number of staff required for assistance, and the CNA involved in the incident was not available for interview. The incident report and progress notes documented the fall and subsequent injury, as well as the resident's return from the hospital with a staple applied to the head wound.
Failure to Prevent and Address Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to identify, assess, and implement effective interventions to prevent unplanned significant weight loss in three residents. For one resident with Alzheimer's disease, vascular dementia, heart failure, and dysphagia, there were repeated nursing notes documenting poor appetite, refusal to eat, and minimal intake over several weeks. Despite these ongoing issues, there was inconsistent notification to the physician, lack of timely dietary follow-up, and no new interventions added for months. The resident experienced a 14% weight loss over six months, with documentation showing variable and often poor intake, and no evidence of completed calorie counts as ordered. The dietitian was not notified of significant weight loss in March, and interventions remained unchanged despite continued decline. Another resident with Alzheimer's disease, vascular dementia, and heart failure experienced an 8% weight loss in one month. There was no documentation that the physician was notified of the weight loss in March, and dietary notes were missing for February and March. Although a calorie count was ordered, there was no evidence it was completed or reviewed. The dietitian confirmed not being notified of the weight loss and did not follow up on the calorie count. Interventions in the care plan were not updated in response to the ongoing weight loss, and the resident's intake remained variable and often poor. A third resident with malignant neuroendocrine tumors, gastrostomy, and dysphagia experienced a 10% weight loss in one month. The resident was hospitalized and returned with a G-tube, but there was no documentation of new interventions to address the weight loss prior to hospitalization. The dietitian was not notified of the weight loss before the resident left for the hospital, and the care plan lacked updated interventions for nutritional risk. Weights were inconsistently documented, and the facility's process for monitoring and responding to significant weight loss was not followed as outlined in their policies.
Failure to Notify Physician and Document Late Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse administered medications, including Doxycycline, Eliquis, and Amlodipine, to a resident nearly two hours after the scheduled 9:00 AM administration time. The facility's policy requires that the physician be notified of late administration of certain medications, such as antibiotics like Doxycycline, and that a note be documented explaining the delay. However, there was no documentation in the nursing progress notes regarding physician notification or an explanation for the late administration. Interviews with nursing staff and the Director of Nursing confirmed that the required notifications and documentation were not completed for this incident. The resident's medication administration record reflected the late administration, but no further action was documented as required by facility policy.
Failure to Coordinate Timely Audiology Follow-Up for Hearing Loss
Penalty
Summary
The facility failed to coordinate timely follow-up care for a resident with significant hearing loss due to hardened ear wax in both ears. The resident, who has diagnoses including Alzheimer's disease, Parkinson's disease, vascular dementia, and paraplegia, was noted by an audiologist to have severe wax buildup that was only partially removed during an initial visit. The audiologist's plan included the use of wax softening drops and a follow-up appointment for further removal, but this follow-up did not occur as scheduled. During a COVID-19 outbreak, the facility restricted outside physician visits, which delayed the resident's access to the audiologist. After the outbreak ended, staff did not reschedule the audiologist's visit for the resident, and the resident was not seen during the next available audiology visit. Staff interviews revealed a lack of awareness regarding the resident's need for further ear wax removal and the audiologist's recommendations. The resident continued to experience severe hearing impairment, with staff and family noting that hearing aids were ineffective and communication was significantly hindered. Documentation showed that the resident received wax softening drops as ordered, but the necessary follow-up for wax removal was not arranged. The care plan identified the resident's highly impaired hearing and recommended referral to an ear, nose, and throat doctor for wax removal, but this intervention was not implemented. Staff continued to use alternative communication methods, such as writing and speaking loudly, but these were ineffective due to the resident's concurrent vision impairment and lack of updated glasses.
Failure to Accurately Assess and Document Side Rail Use
Penalty
Summary
The facility failed to accurately assess and document the appropriate use and number of side rails for a resident who was observed with bolsters, quarter side rails on both the upper and lower sections of the bed, and floor mats in the room. Staff interviews revealed that the resident was dependent on staff for mobility, unable to turn or get out of bed without assistance, and had cognitive impairments including confusion and impaired decision-making. Despite these conditions, there was inconsistency among staff regarding the intended use of the side rails and bolsters, with some staff unaware of the number of rails in use or the need for an assessment for the bolsters. The care plan did not specify the number of side rails to be used or include any mention of bolsters. Documentation provided by the facility included a consent form and assessment for the use of a quarter side rail as an enabler, but it did not specify the number of rails or address the use of bolsters. The care plan was updated to reflect the use of the device for the resident's independence and psychological well-being, but lacked details on the specific devices in use. The lack of clear assessment, documentation, and communication regarding the use of side rails and bolsters led to the deficiency identified during the survey.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
Surveyors found that the facility failed to post daily Nurse Staffing Data in a prominent area accessible to residents and visitors. During a tour of the first floor, the surveyor was unable to locate the required staffing information and confirmed this with the DON, Administrator, and Receptionist. The Receptionist stated she had not seen the Nurse Staffing Data that morning, and the DON explained that the scheduler, who is responsible for posting the data, was on vacation. The Administrator further confirmed that the scheduler was on Family Medical Leave of Absence and that the Nurse Staffing Data, which should be posted at the front desk, was not posted earlier that morning. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Identify Blunt Force Injury Leads to Resident's Death
Penalty
Summary
The facility failed to determine the cause of a blunt force head injury for a resident, identified as R2, which resulted in severe consequences. R2 was admitted with multiple diagnoses, including acute heart failure, dementia, and hypertension. On the day of the incident, a CNA reported that R2 was not feeling well after a shower. Despite being awake, R2 was unresponsive to questions, prompting the staff to call 911. The ambulance report noted that R2 was found unresponsive in bed, with a primary impression of a stroke and a mechanism of injury marked as blunt force trauma, possibly from a fall. The hospital records indicated that R2 had extensive intracranial hemorrhage and edema, with a CT scan showing significant brain injuries consistent with blunt force trauma. The medical examiner attributed R2's death to complications from an intracranial hemorrhage due to a probable fall, although it was not witnessed. The report highlights that the injury was acute and likely occurred quickly, leading to R2's unresponsiveness and subsequent death. The facility's failure to promptly identify and address the injury contributed to the resident's deteriorating condition and eventual death.
Failure to Obtain Proper Authorization for Resident Outings
Penalty
Summary
The facility failed to adhere to its Community Privileges and Notice of Resident Rights and Responsibilities policies by allowing a resident diagnosed with Dementia with Lewy Bodies, Traumatic Brain Injury, and Cognitive Communication Deficit to leave the facility without obtaining a doctor's order or consent from the resident's durable Power of Attorney (POA). The resident, who was unable to complete a mental status interview due to memory problems, was taken out on pass by a surrogate decision maker without the required authorization. The facility's records indicated that the resident was not capable of going into the community independently and required a physician's order to leave with the surrogate. The deficiency was further compounded when the facility contacted the POA, who lived out of state and had never visited the facility, to inquire about the resident's return. The POA, unaware of the resident's outings, expressed concern for the resident's safety and involved the police. The facility's staff, including the Social Service Director and Administrator, acknowledged the oversight, noting that the POA should have been notified and a doctor's order should have been obtained before the resident was allowed to leave the facility. The facility's documentation, including the physician order sheet and out on pass sign-out sheet, confirmed the lack of proper authorization for the resident's outings.
Failure to Disinfect Medical Equipment Between Resident Uses
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration by not disinfecting medical equipment such as blood pressure (BP) apparatus and oximeter after each resident use. This deficiency was observed with four residents. The Registered Nurse (RN) used the same BP cuff and pulse oximeter on multiple residents without disinfecting them between uses. Specifically, the RN took vital signs of four residents consecutively without disinfecting the equipment, despite the facility's policy requiring disinfection after each use to prevent the spread of infection. The RN acknowledged forgetting to disinfect the equipment, and the Infection Control Coordinator confirmed that the equipment should be disinfected after each resident use. The facility's policy on Cleaning and Disinfection of Resident-Care Items and Equipment mandates that non-critical resident care items, such as BP cuffs, must be cleaned and disinfected before reuse by another resident. The policy also outlines the use of various germicidal detergents for intermediate and low-level disinfection of non-critical items.
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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