Libertyville Manor Ext Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Libertyville, Illinois.
- Location
- 610 Peterson Road, Libertyville, Illinois 60048
- CMS Provider Number
- 145344
- Inspections on file
- 18
- Latest survey
- February 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Libertyville Manor Ext Care during CMS and state inspections, most recent first.
A resident with dementia sustained a distal femur fracture during a transfer using a mechanical sit-to-stand lift. The incident occurred when a CNA attempted to lower the resident into a wheelchair, but the resident began slipping off the seat. Despite assistance from other staff, they were unable to reposition the resident safely, and she was lowered to the ground, potentially causing the fracture. The facility's policy required proper use of leg straps and foot support, which were not adhered to during the incident.
A facility failed to monitor residents' weight and nutritional intake, leading to significant weight loss in a resident with a G-Tube. The resident was not weighed upon admission, and their poor oral intake was not documented or communicated to the physician or dietician. Other residents also experienced delays in weight monitoring. These failures resulted in an Immediate Jeopardy situation.
The facility failed to have an RN on duty for 8 hours a day, 7 days a week, affecting all 35 residents. A violation notice indicated non-compliance with staffing requirements from July to September. On two specific days, there were no RNs available, confirmed by the DON. The facility's staffing requirements stated an RN was needed for two shifts per day.
The facility failed to monitor food temperatures and improperly stored scoops in food bins, affecting all residents. Meals were served without temperature checks, and scoops were found inside bins, violating facility policies.
The facility failed to ensure safety and supervision for four residents, including a dementia resident who was not assessed for safe smoking, a resident at risk for aspiration left with un-thickened liquids, a high fall-risk resident transferred without a gait belt, and another resident without a reachable call light. These actions were contrary to care plans and facility policies.
A facility failed to provide a vegetarian resident with protein substitutes and did not serve residents on pureed diets the same menu items as those on regular diets. A vegetarian resident received meals without protein substitutes, and residents on pureed diets did not receive pureed versions of all menu items, contrary to facility policy.
The facility failed to follow infection control protocols, including improper medication handling by an LPN and inadequate glove use and hand hygiene by a CNA. Additionally, Enhanced Barrier Precautions were not implemented for residents with indwelling medical devices or wounds, as required by facility policy.
The facility failed to maintain the confidentiality of two residents' health information. A sign indicating a COVID-19 quarantine was placed on one resident's door, and a letter detailing another resident's Clostridium Difficile diagnosis was hung outside their room. A CNA confirmed that such information should remain private, as per the facility's policy on residents' rights.
The facility failed to provide adequate ADL assistance for two residents requiring care. A resident with traumatic brain injury was found with a saturated incontinence brief and long fingernails, indicating neglect in personal hygiene. Another resident with chronic kidney disease was left in an uncomfortable position after incontinence care, contrary to facility policy requiring regular repositioning and hygiene care.
A resident with a history of urinary tract infection and chronic kidney disease did not receive thorough incontinence care, as a CNA failed to clean stool from the resident's buttocks before applying a clean brief. This was against the facility's policy, which aims to prevent infection and ensure comfort.
A facility failed to ensure medications were administered uncrushed, resulting in a 12% error rate. A resident with multiple diagnoses, including fractures and a staph infection, was given crushed extended-release medications, contrary to physician orders and facility policy. An LPN crushed and administered these medications, believing they were crushable, despite the facility's list indicating otherwise.
A resident in an LTC facility experienced mental abuse when a CNA instructed her not to use her call light for two hours after a disagreement over changing her brief. The resident, who is alert and oriented, felt intimidated and refrained from calling for assistance. The CNA admitted to the behavior, which was confirmed by staff interviews, highlighting a failure to protect the resident from mental abuse as per the facility's policy.
The facility failed to follow its abuse policy by not investigating an allegation of theft involving a resident. Despite the resident reporting missing money to the Acting Administrator, no investigation was conducted, which is a violation of the facility's elder abuse policy that mandates investigation and reporting of such allegations.
The facility failed to investigate an allegation of theft reported by a resident, who stated that approximately $1,100 was missing from his possession. The Acting Administrator did not interview staff or other residents regarding the missing money, and the facility only provided an unusual occurrence report and a State of Illinois long-term care facility report.
Improper Use of Sit-to-Stand Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe care during the use of a mechanical sit-to-stand lift, resulting in a resident sustaining a distal femur fracture. The incident involved a resident with dementia who was wheelchair-bound and had a history of falls due to weakness and an unsteady gait. During a transfer from her bed, the sit-to-stand lift reportedly malfunctioned, causing the resident to fall and sustain a fracture. The resident was subsequently taken to the emergency department, where imaging confirmed a displaced and angulated comminuted fracture of the distal femur, necessitating surgical intervention. The incident occurred when a CNA was using the mechanical sit-to-stand lift to provide incontinence care to the resident in the shower room. As the CNA attempted to lower the resident back into her wheelchair, the resident began slipping off the seat. The CNA sought assistance from other staff members, but they were unable to reposition the resident safely into the chair. The resident was eventually lowered to the ground, during which time her right leg was noted to be in an awkward position, potentially contributing to the fracture. Interviews with staff revealed that the resident's legs were not properly secured with the lower leg straps, and the staff did not consider using the lift to reposition the resident once she began to slip. The facility's policy required that the resident's feet remain in contact with the foot support and that the lower leg straps be used to maintain the resident's position. The Director of Nursing acknowledged that the fracture might have occurred during the lowering process and emphasized the need for two staff members to be present during sit-to-stand transfers, despite the policy stating only one was necessary.
Failure to Monitor Resident Weight and Nutritional Intake
Penalty
Summary
The facility failed to implement a system to monitor residents for weight loss, particularly affecting four residents, including one with a gastrostomy tube (G-Tube). Resident R183 was not weighed upon admission and did not have any weights recorded from December 5, 2024, to January 14, 2025. Despite having a G-Tube for supplemental feeding due to poor oral intake, R183 experienced a 3.3% weight loss over 41 days. The facility also failed to report R183's decreased oral intake to the physician before discontinuing enteral feeding and did not notify the dietician of the discontinuation. The facility's inaction led to R183 not being weighed as per physician orders, and the resident's poor oral intake was not documented or communicated effectively. The dietician was unaware of the discontinuation of enteral feedings and the resident's weight loss, which hindered the ability to provide appropriate nutritional interventions. The physician discontinued the enteral feeding based on the family's request without being informed of the resident's poor appetite and lack of weight monitoring. Additionally, other residents, R135, R10, and R86, were not weighed upon admission, with significant delays in obtaining their initial weights. R135 experienced a 13-pound weight loss over 23 days without being weighed upon admission due to being on contact isolation. These failures in monitoring and communication resulted in an Immediate Jeopardy situation, highlighting the facility's noncompliance with weight monitoring protocols.
Removal Plan
- An order for daily weights on the day shift was obtained and implemented by the V3 nurse supervisor for R183.
- V24, Dietician, will assess the resident, provide recommendations and documentation.
- V4, Director of Nursing, spoke to the R183's POA and the POA is in agreement to start the tube feedings again.
- The nursing staff will monitor all resident's oral intake and notify physician and dietician with any complications.
- V3, Nurse Supervisor, has contacted V12, R183's physician and he will be in contact with the facility.
- V5, QAPI had an emergency meeting with V25, Medical Director, V1, Administrator, V4, DON, and V3, Nurse Supervisor. The problem was discussed, identified, and a system will be put into place for monitoring the compliance with the facility weight protocol.
- The facility will follow the recommendations from the Dietician as well as any orders from V12, R183's physician, and these will be implemented.
- The staff will be in serviced by V4, DON, V3, Nurse Supervisor, and V7, Unit Manager, on the facility policy for obtaining weights on admission on all residents and the facility policy on obtaining weights for medicare and skilled residents. This will involve all nursing staff and CNA's.
- The facility will weigh all residents. Any significant weight gain or loss of 5 percent or more, the physician will be contacted and the Dietician will be consulted for an assessment.
- The Dietician currently visits twice a month, 4 hours each visit, and as needed.
- V3, Nurse Supervisor, and V7, Unit Manager, will audit all weights on their units for new admissions, weekly weights, and monthly weights, and provide the weights daily to the Director of Nursing.
- Any weights that are missing will be obtained immediately, the employee responsible for the missed weight will be in serviced to ensure compliance in the future.
- The audit will be provided to V5, QAPI, at the weekly management meeting to ensure compliance.
- The QAPI committee will be updated quarterly.
RN Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to comply with the requirement of having a Registered Nurse (RN) on duty for 8 hours a day, 7 days a week, affecting all 35 residents. This deficiency was identified through observation, interview, and record review. The CMS-671 application dated January 14, 2025, confirmed the presence of 35 residents in the facility. A violation notice was posted on the facility's entrance, indicating non-compliance with staffing requirements from the Illinois Department of Public Health for the period of July 1, 2024, to September 30, 2024. Specifically, on July 4, 2024, and September 2, 2024, there were no RNs available in the facility. The Director of Nursing confirmed the absence of RN coverage on these two days. The facility's minimum staffing requirements indicated that an RN was needed for two shifts per day, 24 hours per day.
Food Temperature Monitoring and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper food temperature monitoring and storage practices, affecting all 35 residents. On January 13, 2025, a Dietary Aide did not place food in the steam table, and the Nurse Manager served meals without checking food temperatures. The Cook admitted to not logging food temperatures, and the facility could not provide any temperature logs. The facility's policy requires food temperatures to be checked and logged at various stages, but this was not adhered to. Additionally, on January 13, 2025, scoops were found lying inside bins of sugar, flour, and oatmeal, contrary to the facility's policy that requires scoops to be stored with handles extending out of the food to avoid manual contact. The facility's policies on food safety and scoop storage were not followed, leading to potential contamination risks.
Safety and Supervision Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure the safety and supervision of four residents, leading to multiple deficiencies. A resident with dementia, who was a smoker, was not assessed for safe smoking practices, despite being on supplemental oxygen and having difficulty holding cigarettes. The facility's policy did not require safe smoking assessments, and staff were unaware of the resident's dementia diagnosis. Another resident, also with dementia and at risk for aspiration, was not provided with the appropriate consistency of fluids as per her care plan. The resident was left unsupervised with un-thickened coffee, contrary to her dietary requirements for thickened liquids due to dysphagia. Additionally, a resident at high risk for falls was transferred without the use of a gait belt, contrary to her care plan instructions. The staff member used improper techniques, increasing the risk of injury. Another resident, with a history of falls and fractures, was found without her call light within reach, despite her care plan indicating the need for it to be accessible. The facility's fall prevention policy was not adhered to, as interventions to reduce fall risk were not implemented effectively.
Failure to Provide Adequate Dietary Substitutes and Pureed Menu Items
Penalty
Summary
The facility failed to meet the nutritional needs of a resident who follows a vegetarian diet and residents on pureed diets. A resident on a vegetarian diet was not provided with any protein substitutes during meals on January 13 and 14, 2025. The Nurse Manager and Cook confirmed that the resident received meals without meat but did not receive any alternative protein sources. The Dietician was unaware of what protein substitutes were being provided, indicating a lack of communication and planning for the resident's dietary needs. Additionally, the facility did not ensure that residents on pureed diets received the same menu items as those on regular diets. On January 14, 2025, four residents on pureed diets were served Salisbury steak and mashed potatoes but did not receive pureed corn, garden salad, or peaches, despite the facility's policy allowing for these items to be pureed. The Cook stated he did not puree these items, mistakenly believing that corn could not be pureed. The Dietician confirmed that corn can be pureed, highlighting a gap in the implementation of the facility's puree policy.
Infection Control Deficiencies in Medication Handling and Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, leading to multiple deficiencies. A Licensed Practical Nurse (LPN) was observed preparing a resident's medications by pressing them out of bingo cards directly into her hand, contrary to the facility's policy of not touching medications when opening the bottle or unit dose. Additionally, a Certified Nursing Assistant (CNA) provided incontinence care to a resident without changing gloves or performing hand hygiene after contact with bodily fluids, which is against the facility's handwashing policy. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds. Two residents with a gastrostomy tube and a stage 3 pressure injury, respectively, did not have EBP isolation signs or carts with personal protective equipment outside their rooms, as required by the facility's policy. The Director of Nursing confirmed that residents with such conditions should be on EBP, indicating a lapse in adherence to infection control protocols.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information for two residents. For one resident, a red stop sign indicating 'STOP COVID 19' was visibly placed on the outside of the resident's door, making it visible to anyone walking in the hallway. This resident was on a COVID-19 quarantine as per physician orders. For another resident, a typed letter was hung outside the room, detailing the resident's diagnosis of Clostridium Difficile and providing information on the infection and handwashing instructions. This information was visible to anyone passing by. A Certified Nursing Assistant acknowledged that residents' information should not be visible, as it is private. The facility's policy on residents' rights assures confidential treatment of personal and medical records, which was not adhered to in these instances.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) assistance for two residents, R15 and R9, who required such care. R15, who was admitted with diagnoses including traumatic brain injury and major depressive disorder, was found with a completely saturated incontinence brief and a strong urine odor, indicating that he had not been changed since the night shift at 5:00 AM. Additionally, R15's right ring fingernail was excessively long, suggesting neglect in personal hygiene care. R9, who has diagnoses including urinary tract infection and chronic kidney disease, was observed to require substantial assistance with personal hygiene. During an observation, R9 was found laying crooked in bed after incontinence care was provided, and the CNA did not reposition him to ensure comfort. The facility's policy mandates that residents receive regular personal hygiene care, including repositioning and incontinence care every two hours, which was not adhered to in these instances.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to ensure thorough incontinence care for a resident, identified as R9, who was frequently incontinent of bowel and bladder and required substantial assistance with personal hygiene. During an observation on January 13, 2025, a CNA, V10, provided incontinence care to R9 while he was in bed. Despite the presence of stool in R9's rectum and on his buttocks, V10 placed a clean incontinence brief on R9 without thoroughly cleaning the stool from his buttocks. This action was contrary to the facility's Incontinence Care policy, which mandates correct incontinence care when continence cannot be maintained. R9's medical records indicate a history of urinary tract infection, elevated white blood cell count, and chronic kidney disease. The facility's policy, revised in April 2023, emphasizes the importance of proper incontinence care to prevent infection and ensure resident comfort. An interview with another CNA, V11, confirmed that staff should ensure all bowel movements are cleaned off residents to prevent infection and odor.
Medication Administration Error Due to Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to ensure medications were administered uncrushed, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of 5%. This deficiency was observed during a medication pass involving one resident, who had been admitted with diagnoses including humerus fracture, femur fracture, and methicillin-resistant staph infection. The resident had physician orders for potassium chloride and metoprolol succinate, both of which are extended-release medications that should not be crushed. However, on January 13, 2025, an LPN crushed all of the resident's medications and administered them mixed with pudding. The LPN later stated that she believed all medications were crushable except for potassium, despite the facility's policy and list indicating that these medications should not be crushed.
Resident Mental Abuse by CNA
Penalty
Summary
The facility failed to ensure a resident was free from mental abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, an alert and oriented female, reported that the CNA instructed her not to use her call light for two hours after a disagreement over changing her incontinent brief. The resident felt intimidated and refrained from using the call light, which she found distressing. The CNA admitted to making the statement and justified it by claiming the resident was using the call light excessively and consuming too many diapers. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Unit Manager, confirmed the resident's account of the incident. The CNA's behavior was described as abrasive and indifferent, and the Unit Manager acknowledged that the CNA needed re-education on resident rights. The facility's abuse policy emphasizes the importance of a living environment that encourages reporting concerns and protects residents from mental abuse, which includes humiliation and threats of deprivation.
Failure to Investigate Allegation of Theft
Penalty
Summary
The facility failed to follow its abuse policy by not investigating an allegation of theft/misappropriation of funds involving a resident. On April 17, 2024, a resident reported missing money to the Acting Administrator, who admitted to not conducting an investigation into the matter. The facility's elder abuse policy, dated April 11, 2023, mandates that all allegations of abuse or theft be investigated and reported to the Illinois Department of Public Health (IDPH) within 5 days. Despite this policy, the Acting Administrator did not initiate an investigation, resulting in non-compliance with the facility's established procedures for handling such allegations.
Failure to Investigate Allegation of Theft
Penalty
Summary
The facility failed to ensure an allegation of theft was investigated for one resident. The resident reported that approximately $1,100 was missing from his possession. An unusual occurrence report dated April 7, 2024, indicated that $1,000 in $100 bills, which had staples, was missing from the resident's wallet in the bedside table top drawer. The Acting Administrator stated that no one was aware the resident had the money and that the resident was advised not to keep valuables or money in the facility. The Acting Administrator did not interview staff or other residents regarding the missing money. The facility only provided an unusual occurrence report and a State of Illinois long-term care facility report, which confirmed the resident was alert and oriented and had reported the misappropriation of funds.
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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