Midway Neurological / Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeview, Illinois.
- Location
- 8540 South Harlem, Bridgeview, Illinois 60455
- CMS Provider Number
- 145778
- Inspections on file
- 41
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Midway Neurological / Rehab Center during CMS and state inspections, most recent first.
A resident with COPD and a history of acute on chronic respiratory failure was admitted with orders to maintain SpO2 above 93% using continuous O2 at 3–4 L/min via nasal cannula, but the hospital discharge paperwork lacked a specific O2 flow rate and the facility relied on nurse-to-nurse report. Earlier documentation showed the resident stable on 4 L/min with SpO2 at 97%, yet later the resident was found pale, slow to respond, and in respiratory distress on 3 L/min, with EMS recording SpO2 at 80% and the nurse unable to state the resident’s baseline O2 needs. The family reported the resident was usually on higher O2 and BiPAP, and also that the correct O2 orders and BiPAP were not available on arrival. EMS increased O2 to 6 L/min, after which the resident’s breathing, color, and SpO2 improved to 93%. The DON stated the goal was to keep SpO2 above 93% on 3–4 L/min, confirmed the order came via nurse-to-nurse report, and acknowledged the nurse did not complete an assessment or remain with the resident despite a report of chest pain, and no vitals were documented for that shift.
A resident who sustained a fall and was later observed with Battle sign and facial bruising did not receive immediate EMS activation as required by facility policy. Instead, the resident was placed on observation and allowed to leave the unit unaccompanied, leading to a second fall and subsequent acute change in mental status. EMS was only called after the resident became unresponsive, and she was later diagnosed at the hospital with a large subdural hematoma and herniation.
A resident with a history of psychosis, mood disorder, and suicidal ideation became aggressive and was sent to the hospital for a psychiatric evaluation. The facility did not notify the resident's family of the change in condition or the transfer prior to the resident leaving, and there was no documentation of family notification at the time. Staff interviews revealed confusion about notification responsibilities, and the family only learned of the transfer from the resident after the fact.
The facility did not comply with its policy requiring face-to-face physician visits within the first 30 days of admission and at least every 60 days thereafter. This affected four residents, with some not having documented visits since 2022, and others having no visits recorded at all. The DON confirmed the inconsistency in documentation practices among physicians.
A resident with COPD did not receive scheduled CT scans or a pulmonologist evaluation due to the facility's failure to schedule appointments and document actions. Insurance denial and lack of documentation contributed to the delay, leaving the resident without necessary care.
A resident with a history of schizoaffective disorder reported being sexually abused by another resident. Despite being informed of the allegation during a meeting with a health insurance case manager, the facility's management did not document the incident or report it to the appropriate authorities as required by their abuse policy. The administrator acknowledged the failure to report the incident.
The facility staff failed to follow food safety and sanitation protocols, including not wearing beard covers, maintaining improper sanitizing solution levels, and not labeling food in the refrigerator. Additionally, improper cleaning of kitchen equipment was observed, with a cook using the wrong sink for washing utensils. These actions indicate non-compliance with the facility's policies.
The facility failed to refrigerate unopened insulin medications for two residents, storing them at room temperature instead. An LPN acknowledged the error, and the DON emphasized the importance of following manufacturer guidelines for medication storage. The facility's policy requires refrigerated storage for such medications, but this was not adhered to.
A resident with multiple medical conditions experienced complications with an indwelling urinary catheter, including leakage and pain, which were not promptly addressed by the facility staff. Despite the resident's repeated requests for assistance, the staff delayed intervention, leading to the resident calling 911 and being hospitalized for urinary retention and a UTI. Interviews revealed that the staff was aware of the issue but did not treat it as an emergency.
A resident with a history of mental health disorders was hospitalized for destructive behaviors and discharged from the facility without a documented discharge summary or plan of care. The facility did not provide necessary documentation or establish a continuation of care to another LTC facility, despite the resident's need for assistance with daily living activities. The facility's policy required a transfer form and communication with the receiving facility, which was not completed.
The facility failed to develop an individualized care plan for a resident at risk for aspiration, resulting in the resident becoming unconscious and being admitted to the hospital due to complications of choking. The resident was discharged from speech therapy before meeting short-term goals, and staff were inconsistent in their knowledge of the resident's needs during meals.
A resident experienced significant unplanned weight loss due to the facility's failure to implement and document prescribed dietary interventions. The resident's meal tickets did not reflect the physician's orders for double portions at breakfast and a sandwich at night, and the dietary staff did not communicate missed meals to the nursing staff. The care plan and dietary progress notes indicated necessary interventions, but these were not consistently followed, leading to continued weight loss.
The facility failed to prevent incidents of staff-to-resident verbal and mental abuse, affecting four residents. Multiple residents reported that a nurse, V20, made derogatory comments, laughed at patients, and refused to help them. Despite these complaints being raised during a resident council meeting, the facility did not document or thoroughly investigate the allegations, leading to a failure in protecting residents from abuse.
The facility failed to report allegations of abuse by a registered nurse, affecting four residents. Despite residents raising concerns about the nurse's derogatory and disrespectful behavior during a council meeting, the Director of Nursing did not document or investigate the allegations properly, and the Administrator did not report the incident as required by the facility's abuse prevention policy.
The facility failed to enforce its smoking and contraband policies, resulting in a visually impaired resident with multiple mental health diagnoses bringing unauthorized smoking materials into the facility. The resident, who required supervision while smoking, dropped a lit cigarette into a garbage can, causing a fire in the bathroom. This incident had the potential to affect 84 residents on the fifth floor.
A resident with multiple diagnoses, including Bipolar Disorder and Suicidal Ideations, was moved to a different unit due to disruptive behavior without receiving prior written notice. The facility's policy requires written notice before room changes, but the Social Services Director confirmed that this practice was not followed.
A resident with multiple diagnoses reported $800 missing from an envelope after a room change. The resident alleged that a social worker returned the envelope with less money and claimed the facility did not provide proof of the missing funds. Interviews with staff revealed inconsistencies, and the police were called. The facility's investigation found no proof of the amount of money, and a resolution was agreed upon to provide the resident with $400 in retail purchases over four months.
Failure to Maintain Ordered Oxygen Saturation and Flow for Resident With COPD
Penalty
Summary
The deficiency involves the facility’s failure to maintain ordered oxygen saturation parameters for a resident with COPD and chronic respiratory needs. The resident’s hospital discharge paperwork documented a principal problem of acute on chronic respiratory failure with hypoxia and hypercapnia and COPD with acute exacerbation, with an increased oxygen demand in the emergency department and eventual weaning back to baseline supplemental oxygen needs. The discharge medication list did not specify the oxygen amount to be administered upon discharge, and the facility relied on nurse-to-nurse report to obtain oxygen orders. The physician order sheet at the facility documented that oxygen saturation was to be checked every shift and kept above 93%, with oxygen at 3–4 L/min via nasal cannula continuously. On the morning of the incident, a nurse’s note documented the resident as alert and oriented, with non-labored breath sounds, oxygen at 4 L/min via nasal cannula, head of bed elevated, and SpO2 at 97%. Later, EMS was dispatched for breathing problems. The EMS run sheet documented that upon arrival, the crew found the resident pale, with labored, tachypneic breathing, in respiratory distress, and on 3 L/min of oxygen via nasal cannula, with an SpO2 of 80%. The EMS crew reported that the RN stated the resident was on 3 L/min of supplemental oxygen but was not aware of the resident’s baseline oxygen status or whether 3 L/min was the baseline amount. The family at bedside reported the resident was usually on 6 L/min via nasal cannula and 10 L/min of BiPAP, and also indicated that when the resident arrived the previous day, the facility did not have the resident’s medications, BiPAP, or correct oxygen orders. The complainant reported that when the resident was assessed, the resident was slow to respond, pale, and had difficulty breathing, and that an unnamed nurse confirmed the resident was on 3 L/min of oxygen. The complainant stated the resident was then placed on 6 L/min of oxygen and improved immediately. The EMS run sheet documented that after the crew increased the oxygen to 6 L/min, the resident’s breathing rate and effort normalized, skin color returned to normal, SpO2 increased to 93%, and responsiveness improved. The DON stated that the resident’s oxygen order was not sent with the discharge paperwork but was given in nurse-to-nurse report, that the resident was to be on 3–4 L/min via nasal cannula with a goal to maintain oxygen level above 93%, and that the orders were verified with the physician and entered into the computer. The DON also stated that the nurse did not assess the resident because the resident refused, and that if a resident complained of chest pain, he would expect the nurse to stay with the resident. The nurse identified as the discharging nurse reported that the resident had oxygen via nasal cannula but could not recall the liter flow, stated that vitals were within normal limits but could not recall them, and that the resident was not in distress, while the electronic record contained no documented vitals for that shift. The facility’s oxygen administration policy stated that oxygen is to be provided to maintain saturation levels as needed and as ordered by the attending physician.
Failure to Recognize and Respond to Critical Head Injury Following Resident Fall
Penalty
Summary
The facility failed to accurately assess a critical clinical sign (Battle sign) and did not implement its change in condition policy by failing to immediately activate EMS for a resident who exhibited an acute change in mental status following a fall. The resident was first observed by an LPN with discoloration around the left eye and behind the left ear after reporting a fall during the previous night. The LPN assessed the resident, initiated neurological checks, and notified the physician, who ordered a routine facial x-ray. The resident was placed on observation, and staff were instructed not to allow her to leave the nursing unit alone. Despite these instructions, the resident was later allowed to go to the patio for a smoke break without staff accompaniment. While on the patio, the resident fell again, hitting her head. After being brought back to the nursing unit in a wheelchair, she was lethargic, had abnormal vital signs, and required supplemental oxygen. The nurse on duty called EMS only after the resident became unresponsive in her room, at which point CPR was initiated. EMS arrived to find the resident unresponsive but with a pulse, and noted significant head trauma, including Battle sign and a hematoma. The EMS report indicated that staff had observed the resident with these injuries earlier in the day, following a previous fall. Upon arrival at the hospital, the resident was minimally responsive, with fixed and dilated pupils, and was diagnosed with a large acute subdural hematoma with midline shift and herniation. The hospital record confirmed the presence of Battle sign and severe brain injury. The facility's director of nursing acknowledged that the resident should have been transferred to the hospital when the initial injuries were observed. The facility's policy required immediate EMS activation in medical emergencies, but this was not followed, resulting in a delay in treatment for the resident.
Failure to Notify Family of Resident's Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to follow its change in condition policy by not notifying a resident's family member of a significant change in the resident's condition and subsequent transfer to the hospital. The resident, who had diagnoses including psychosis, mood disorder, suicidal ideation, and anxiety disorder, became verbally and physically aggressive with staff, resulting in a behavioral code and 1:1 monitoring. The following day, the resident continued to display aggressive behavior and expressed suicidal ideation, leading to a decision to send the resident to the hospital for a psychiatric evaluation. Documentation in the medical record did not show that the family was notified of the resident's behavior or transfer prior to the resident leaving the facility. A late entry note was made several days later, stating that all responsible parties, including family, were notified, but this was not entered until after the event. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for notifying the family, with one nurse assuming another had made the call and another nurse stating that documentation was not completed due to a personal emergency. The DON confirmed that family notification and documentation are required by facility protocol, but there was no evidence that this occurred at the time of transfer. The resident's family member reported learning of the hospital transfer only after being contacted by the resident and was unable to reach the facility for confirmation despite multiple attempts. The family member also visited the facility and was not provided with information about the resident's whereabouts due to the absence of management on the weekend. The facility's policy requires prompt notification of family or representatives in the event of significant changes or transfers, but there was no documentation of such notification or completion of required forms at the time of the incident.
Failure to Conduct Required Physician Visits
Penalty
Summary
The facility failed to adhere to its physician services policy, which mandates that attending physicians conduct face-to-face visits with residents within the first 30 days of admission or re-admission, and at least once every 60 days thereafter. This deficiency affected four residents. The Director of Nursing (DON) acknowledged that some physicians still use paper charting, while others document in the electronic medical record. Upon review, it was found that one resident was last seen by the attending physician in 2022, despite being admitted in 2022. Another resident, admitted in 2023, had no documented face-to-face visits. A third resident, admitted in 2022, had sporadic visits with significant gaps, and a fourth resident, admitted in 2023, also had no documented visits. The facility's policy clearly states the frequency of required visits, which was not followed in these cases.
Failure to Schedule Necessary Medical Appointments for Resident
Penalty
Summary
The facility failed to schedule necessary outside appointments and testing for a resident with chronic obstructive pulmonary disease (COPD). The resident had multiple physician orders for a CT scan with contrast of the lungs and a pulmonologist evaluation, which were not fulfilled. Despite orders dating back to November 2023, the resident had not received the CT scan or seen a pulmonologist by January 2025. The resident expressed frustration over the delay in receiving care, stating they had waited a long time for the pulmonologist appointment. The appointment scheduler indicated that the CT scan was denied by the resident's insurance due to insufficient information, and the nurse was responsible for notifying the physician and documenting any refusals or rescheduling needs. The Director of Nursing acknowledged the lack of documentation and attempts to reschedule the missed pulmonologist appointment. Despite efforts to schedule the appointments, including contacting a pulmonology office that did not accept the resident's insurance, there was no documentation in the resident's medical record to reflect these actions, and the orders remained active without resolution.
Failure to Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to adhere to its abuse policy by not reporting an alleged resident-to-resident sexual abuse incident. A female resident, who has been residing at the facility since 2022 and has a medical history including schizoaffective disorder and delusional disorders, reported that another resident forced her to have sex. The incident was brought to the attention of the facility's management during a meeting with a health insurance case manager, the administrator, the Director of Nurses (DON), and a social worker. Despite the resident's allegations, the facility did not document the meeting or initiate an investigation, and no report was made to the appropriate authorities as required by their abuse policy. The facility's administrator and DON were aware of the allegation on the day it was reported by the health insurance case manager. However, they did not take immediate action to report the incident to the state licensing and certification agency, the resident's representative, or the attending physician, as outlined in their abuse reporting policy. The administrator acknowledged that the allegation should have been reported. The facility's failure to act promptly and follow their established procedures for handling abuse allegations resulted in a deficiency being noted by the surveyors.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to adhere to proper food safety and sanitation protocols, as observed during a survey. Two staff members with beards were seen in the kitchen without wearing beard covers, which is against the facility's policy for maintaining personal hygiene. Additionally, a Certified Nursing Assistant was observed in the kitchen without a beard cover while handling water jugs. These actions indicate a lack of compliance with the facility's policy that requires food service employees to maintain good personal hygiene, including covering beards with appropriate hair restraints. The facility also failed to maintain the required sanitizing solution concentration in the three-compartment sink. During dishwashing, the sanitizing solution was tested at 100 ppm, below the required 200 ppm of Quaternary Ammonium solution. This discrepancy was noted by a Dietary Aide, who acknowledged the need for a higher concentration. Furthermore, a clear container with salad was found in the refrigerator without a label, and the Dietary Manager later confirmed it belonged to a staff member, which is against the facility's policy for labeling and dating food in storage. Improper cleaning and sanitizing practices were also observed. A cook was seen rinsing a blender and spatula used for meal preparation in the food preparation sink, which is not designated for washing dishes or utensils. The cook admitted to not using soap and acknowledged that the items should have been cleaned in the three-compartment sink. The Dietary Manager confirmed that the food preparation sink is only for rinsing vegetables and filling pans with water, not for cleaning equipment. These actions demonstrate a failure to follow the facility's procedures for cleaning and sanitizing kitchen equipment and utensils.
Improper Storage of Unopened Insulin
Penalty
Summary
The facility failed to properly store unopened medications that required refrigeration, specifically affecting two residents. During an inspection of the medication cart on the second floor, an LPN was present when it was discovered that unopened insulin medications, which were labeled to be refrigerated before opening, were stored at room temperature in the medication cart. The medications involved were Lantus pens for one resident and a Novolin R vial for another resident, both of which are used for managing diabetes. The LPN acknowledged that the medications should have been refrigerated to maintain their durability. The Director of Nursing also confirmed the importance of refrigerating unopened insulin to preserve its integrity, as per the manufacturer's recommendations. The facility's pharmacy medication storage policy requires that refrigerated products be stored in the appropriate refrigerator upon delivery, with the responsibility falling on the nurse and/or Director of Nursing to follow drug-specific guidelines. However, this protocol was not followed, leading to the deficiency.
Failure to Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide timely assessment and adequate intervention for a resident experiencing complications with an indwelling urinary catheter. The resident, a male with multiple medical diagnoses including Multiple Sclerosis and quadriplegia, was admitted to the facility and required substantial assistance for all activities of daily living. Despite being cognitively intact, the resident experienced a leaking urinary catheter, abdominal fullness, and pain, which were not promptly addressed by the facility staff. On the day of the incident, the resident reported the leaking catheter and associated pain to the nursing staff multiple times. However, the staff did not take immediate action to change the catheter or alleviate the resident's discomfort. The resident was instructed to wait until after medication pass, and when he requested emergency assistance, he was told to call 911 himself. Eventually, the resident called 911 and was taken to the hospital, where a large amount of urine was drained, and he was treated for urinary retention and a urinary tract infection. Interviews with facility staff revealed that the resident had been requesting a catheter change for several days, and the issue was known to the staff. The facility's Director of Nurses acknowledged that the situation was not treated as an emergency, and the attending physician noted that routine catheter care was not adequately performed. The facility's failure to provide timely catheter care and intervention led to the resident's hospitalization and treatment for a urinary tract infection.
Failure to Document Discharge Summary and Plan of Care
Penalty
Summary
The facility failed to adhere to its resident discharge policy by not documenting a discharge summary and plan of care for a resident who was hospitalized for destructive behaviors and did not return to the facility. This deficiency was identified during a review of the discharge procedures for a resident with a history of Schizoaffective disorder, Dementia, Attention-Deficit Hyperactivity Disorder, and bipolar disorder. The resident, who required staff assistance with activities of daily living, was admitted to the hospital for acute behaviors and subsequently discharged from the facility without proper documentation or a continuation of care plan to another long-term care facility. The facility's Director of Nursing and Administrator acknowledged the situation, indicating that the resident was sent to the hospital due to destructive behaviors and that there was a delay in deciding whether to readmit the resident. Despite the facility's stated intention to take the resident back if no other facility would, the hospital ultimately found another placement for the resident. The facility's policy required a transfer form with pertinent medical information and communication with the receiving facility to maintain continuity of care, which was not completed in this case.
Failure to Develop Individualized Care Plan for Resident at Risk for Aspiration
Penalty
Summary
The facility failed to develop an individualized plan of care for a resident identified to be at risk for aspirations and assessed to have impairments while eating. The resident, who had a history of alcohol dependence with alcohol-induced persisting dementia, heart failure, and atherosclerotic heart disease, was discharged from speech therapy before reaching the short-term goals identified in the evaluation. This failure resulted in the resident becoming unconscious, with CPR being initiated, an excessive amount of food found in the resident's airway, and the resident being admitted to the hospital where he later expired due to complications of choking. The incident occurred when the resident was observed with jerky movements in the dining room after finishing lunch. Staff initiated CPR and called paramedics when the resident became unconscious and stopped breathing. The emergency room records and fire department report confirmed that a significant amount of food was found in the resident's airway, leading to a suspected hypoxic arrest and cardiac arrest. Interviews with staff revealed inconsistencies in their knowledge of the resident's needs and the level of assistance required during meals. The speech therapy evaluation had identified several issues with the resident's swallowing and eating behaviors, including difficulties with labial closure, rapid mastication, incomplete bolus formation, and poor attention to the task. Despite these findings, the resident was discharged from speech therapy without meeting the short-term goals for improving oral clearance and bolus control. The facility's care plan did not reflect the identified issues or provide a plan to ensure safe oral intake and reduce the risk of aspiration for the resident.
Failure to Implement and Document Weight Loss Interventions
Penalty
Summary
The facility failed to develop, implement, evaluate, and reevaluate a plan to prevent continued unplanned weight loss for a resident (R14). This resulted in R14 experiencing a significant weight loss of 18.55% over 90 days. The deficiency was identified through observations, interviews, and record reviews. R14's family member (V25) reported that R14 had lost about 30 pounds and mentioned that R14 had complained about not being fed adequately by the facility. Observations on different dates confirmed that R14's meal tickets did not reflect the physician's orders for double portions at breakfast and a sandwich at night, which were intended to address the weight loss issue. Additionally, the dietary staff did not inform the nursing staff if a resident missed meals, and the CNA (V47) was unaware of R14's significant weight loss and the dietary interventions required for R14. The dietary assistant (V26) and the dietitian (V48) confirmed that the diet slips did not include the prescribed double portions and sandwich at night. The dietitian acknowledged that R14 had been reviewed for unplanned weight loss and that the plan included double portions at breakfast, a sandwich at night, consultation with the psych physician, and weekly weights. However, the psych physician (V49) stated that he does not deal with weight loss and that psych medications typically result in weight gain, not loss. The dietitian could not explain why the planned weight loss interventions were not documented on the diet slips and did not respond when asked when the planned weight loss became unplanned. R14's care plan and dietary progress notes indicated that the resident had experienced significant weight loss and outlined interventions such as double portions at breakfast, a sandwich at night, and regular weight monitoring. However, these interventions were not consistently implemented or documented, leading to continued weight loss. The facility's policy on care plans emphasized the need for comprehensive assessments and individualized care plans, but this was not effectively executed for R14, resulting in a failure to prevent further weight loss.
Failure to Prevent Verbal and Mental Abuse by Staff
Penalty
Summary
The facility failed to prevent incidents of staff-to-resident verbal and mental abuse, affecting four residents. Resident R10 reported that staff, particularly V20, claimed they did not need help and made derogatory comments about their blindness. R10 has multiple diagnoses, including Schizoaffective Disorder, Schizophrenia, and Blindness, and is cognitively intact. Resident R21 stated that V20 laughed at patients, called them derogatory names, and refused to help them. R21 also has significant mental health diagnoses and is cognitively intact. Resident R22 described V20 as arrogant and problematic, and this concern was raised during a resident council meeting. R22 has multiple mental health diagnoses and is cognitively intact. Resident R23 reported that V20 talked down to residents and argued with them, which was also discussed in a resident council meeting. R23 has several chronic conditions and is cognitively intact. The facility's Director of Nursing (DON) acknowledged that concerns about V20's behavior were raised during a resident council meeting, but no formal investigation was documented. The DON believed that V20 was simply firm with residents and dismissed the complaints as a result of a specific incident involving another resident, R24, who was not listed in the meeting notes. The facility's Administrator, who is also the abuse coordinator, confirmed that verbal and mental abuse includes derogatory remarks and mocking residents. Despite being aware of the allegations, the facility did not document or thoroughly investigate the complaints, leading to a failure in protecting residents from verbal and mental abuse as per their Abuse Prevention Program Policy and Procedure.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state surveying agency, affecting four residents. Residents R21, R22, and R23 reported that a registered nurse, V20, exhibited abusive behavior, including laughing at patients, calling them derogatory names, and having a generally bad attitude. These concerns were raised during a resident council meeting, but the Director of Nursing (V13) did not document or investigate the allegations properly. V13 dismissed the concerns, attributing them to a misunderstanding and did not follow the facility's abuse prevention policy, which mandates immediate reporting and investigation of any abuse allegations. The Administrator (V5), who is the abuse coordinator, acknowledged that verbal and mental abuse includes derogatory remarks and disrespectful behavior. Despite this, V5 did not report the allegations from R24 about V20 in February 2024. The facility's abuse prevention policy requires all incidents or allegations of abuse to be documented and investigated, but this procedure was not followed. The facility's failure to document and investigate the allegations of abuse led to a deficiency in their compliance with abuse reporting regulations.
Failure to Enforce Smoking and Contraband Policies
Penalty
Summary
The facility failed to have an effective smoking policy and contraband policy to prevent unauthorized items and smoking materials. This deficiency affected two residents, one of whom, a visually impaired resident with multiple mental health diagnoses, brought unauthorized smoking materials from a home visit. The resident, who required supervision while smoking, dropped a lit cigarette into a garbage can, causing a fire in the bathroom. This incident had the potential to affect 84 residents on the fifth floor. The incident report and interviews reveal that the resident was legally blind and had auditory hallucinations, schizoaffective disorder, post-traumatic stress disorder, bipolar disorder, and anxiety. The resident admitted to smoking in the bathroom and stated that she received the cigarette and lighter from her brother during a visit. The facility's staff detected smoke, evacuated the resident, and extinguished the fire. The resident's care plan indicated that she was a supervised smoker and not capable of handling her own smoking materials. Interviews with staff members confirmed that the resident had brought smoking materials back to the facility after a visit with family. The facility's smoking policy and contraband policy were reviewed with the family upon admission, but the resident still managed to bring unauthorized items into the facility. The facility's policies stated that no lighters or matches were allowed in the building and that unsafe smokers should be supervised. Despite these policies, the resident was able to bring and use smoking materials unsupervised, leading to the fire incident.
Failure to Provide Written Notice of Room Change
Penalty
Summary
The facility failed to notify a resident (R11) in writing prior to performing a room change. R11, who has diagnoses including Chronic Pain Syndrome, Bipolar Disorder, Psychotic Disorder, Depression, and Suicidal Ideations, was cognitively intact with a score of 15 on the cognitive patterns assessment. On 12/4/23, R11 was moved to a different unit due to disruptive behavior in the common area. However, the resident was not given any written notice or paper regarding the room change. The Social Services Director confirmed that the facility does not provide residents with a copy of the written room change notice. The facility's policy states that residents have the right to receive written notice, including the reason for the change, before their room or roommate changes. The Notification of Room Change form was completed the day after the room change occurred, indicating non-compliance with the policy.
Failure to Prevent Loss of Resident's Funds During Room Change
Penalty
Summary
The facility failed to prevent the loss of a resident's funds during a room change, affecting one resident diagnosed with Chronic Pain Syndrome, Bipolar Disorder, Psychotic Disorder, Depression, and Suicidal Ideations. The resident, who was cognitively intact, reported that $800 was missing from an envelope containing $1332 after giving the locker key to a social worker. The resident alleged that the social worker returned the envelope with only $532 and claimed that the social worker said, 'you ain't getting that back.' The resident had received a $1900 check, which was cashed by the facility, and the funds were kept in an envelope in the resident's coat pocket in a locked closet. During the room change, the resident was made to stay in the dining room, and the social worker retrieved the envelope from the coat pocket. Interviews with various staff members, including the Business Office Manager, Social Services, Security Staff, and the Director of Nursing, revealed inconsistencies in their accounts of the events. The Business Office Manager confirmed that the resident managed his own funds and was only allowed $100 in cash at a time. The Social Services staff involved in the room change denied seeing or handling the envelope with the money. The Security Staff and the Director of Nursing also provided conflicting statements about the handling of the envelope and the resident's behavior during the incident. The facility's investigation found no proof of the amount of money the resident claimed to have had, and the resident was unable to provide proof of the missing funds. The police were called, and a report was filed, indicating that the resident was alert and coherent and reported $800 missing from the envelope. The facility's abuse investigation included a signed document by the Administrator, the resident, and Social Services, agreeing to a resolution of the matter by providing the resident with $400 in retail purchases over four months. The facility's Abuse Prevention Program Policy and Procedure defines misappropriation of resident property as the wrongful use of a resident's belongings or money without consent.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
