Montgomery Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5550 South Shore Drive, Chicago, Illinois 60637
- CMS Provider Number
- 145748
- Inspections on file
- 24
- Latest survey
- February 15, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Montgomery Place during CMS and state inspections, most recent first.
A dependent, high fall‑risk resident with multiple fractures, severe mobility limitations, poor trunk control, and generalized weakness was transferred from bed to wheelchair using a mechanical sit‑to‑stand lift by a single CNA, despite facility expectations and documentation indicating two‑person assistance was required. During the lift, the resident jerked forward, slid off the bed while still attached to the lift, and her feet came off the foot base, leading to her being lowered to the floor with her legs twisted underneath her. The resident screamed in pain, was manually lifted back to bed by two CNAs, and was later sent to the hospital, where she was diagnosed with a right periprosthetic femoral shaft/hip fracture. Staff interviews, including from CNAs, an RN, the DON, therapy director, and medical director, confirmed that two staff should have been present for mechanical lift transfers and that the event met the facility’s definition of a fall.
A resident with a urostomy did not have an individualized care plan addressing her ostomy care needs, despite documented changes in her ostomy size and repeated requests for supply changes. Staff confirmed the absence of a care plan in the electronic health record, even though physician orders and assessments indicated the need for scheduled ostomy care.
A resident with heart failure, obesity, and multiple myeloma repeatedly did not receive the correct size incontinence products due to supply shortages. Staff used smaller, uncomfortable sizes, and the resident's family had to purchase the correct size. CNAs confirmed the lack of proper supplies and were unaware of additional stock in the basement, leading to unmet resident needs.
The facility failed to maintain RN staffing for at least eight hours on weekends, as required by policy. Interviews and records showed that on several weekends, only LPNs were on duty, with no RN coverage. The DON and Administrator acknowledged the issue, citing challenges in staffing and efforts to hire more RNs. This deficiency was documented in the CMS report and the facility's policy, potentially affecting the care of all 28 residents.
The facility failed to follow its food storage and handling policies, with opened and unlabeled food items found in storage, improper hygiene practices by kitchen staff, and failure to check food temperatures before serving. These deficiencies potentially affect 26 residents receiving oral diets.
The facility failed to properly dispose of garbage, with uncovered bins and an overflowing dumpster observed during a survey. The Director of Dining Services and other staff confirmed that dumpsters should be closed to prevent pest infestations. The facility's policy requires garbage containers to be covered at all times.
The facility failed to follow infection control procedures, with staff handling clean linens without proper hand hygiene, risking cross-contamination. Additionally, there were no measures in place to prevent Legionella growth in water systems, with no testing conducted for two years.
The facility failed to implement comprehensive care plans for several residents, neglecting to address advance directives, psychotropic medication use, and specific medical conditions. This oversight affected residents with complex medical histories, including those with fractures, hypertension, intracerebral hemorrhage, and dementia.
The facility failed to follow its bed rail policy, leading to a deficiency related to accident hazards and inadequate supervision. Four residents had bed rails installed without attempts to use alternatives, assessments for entrapment risk, or informed consent. Observations showed residents with various medical conditions had bed rails up without proper documentation or care plans. Interviews with staff revealed a lack of clarity and adherence to the policy, posing potential risks of harm to residents.
The facility failed to properly account for and dispose of controlled medications, affecting 12 residents. An LPN found a compromised Tramadol blister packet and expired Hydromorphone concentrate in the medication room. The DON confirmed that medications should be checked daily, and records showed missing nurse signatures, indicating non-compliance with controlled substances policy.
The facility failed to properly store and label medications, as observed during an inspection of a medication cart and storage room. An LPN found loose, unlabeled medications in a narcotic box, and the DON confirmed that medications were improperly stored with food items in a refrigerator. The facility's policy requires medications to be stored securely, in original containers, and separately from food.
The facility failed to educate and assess four residents for pneumococcal vaccinations, as required by policy. The Infection Preventionist admitted to not providing vaccinations or obtaining consents since March 2024. Residents' EMRs lacked documentation of education, eligibility assessment, and signed consents, despite their medical conditions potentially qualifying them for vaccination.
A facility failed to document a resident's code status and advance directives, despite the resident having intact cognition and multiple health issues. Interviews with the DON and Social Services confirmed the absence of documentation, which is crucial during emergencies. The facility's policy requires discussing and documenting advance directives during admission, but this was not done for the resident.
A facility failed to transmit a resident's MDS records to the CMS system within the required timeframe. The resident, admitted with multiple diagnoses, had their Quarterly MDS completed but submitted late, beyond the 14-day regulatory period. The MDS manager, working remotely for an outside company, coordinated with the DON but acknowledged the delay, indicating non-compliance with the RAI manual and facility policy.
A resident with severe cognitive impairment and significant weight loss did not receive the prescribed nutritional supplement, Magic Cup, due to a lack of stock and communication failures in the facility. Despite physician orders and dietary recommendations, the resident's meal did not include the supplement, contributing to continued weight loss.
The facility failed to date and properly store respiratory equipment for two residents, potentially increasing infection risk. One resident's oxygen tubing was not dated or stored in a plastic bag, while another's nebulizer mask was undated. An LPN was unaware of the facility's policy, which was confirmed by the DON. The policy requires equipment to be dated and stored in a clean bag when not in use.
A facility failed to follow the prescribed menu for a resident on a mechanical soft diet and did not adhere to standardized recipes during pureed food preparation. A resident received a meal that did not match the facility's menu, and the support chef used unmeasured scoops, resulting in improper food consistency. The Director of Dining Services and Registered Dietician confirmed the importance of following recipes to ensure nutritional adequacy.
Failure to Use Two‑Person Assist During Sit‑to‑Stand Lift Transfer Resulting in Femoral Fracture
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident safety during a mechanical sit‑to‑stand lift transfer and to provide the required two‑person assistance for a dependent resident at high risk for falls. The resident was an older adult with a history of multiple fractures, falls, spinal stenosis, polyosteoarthritis, bilateral artificial knee joints, generalized muscle weakness, reduced mobility, and need for assistance with personal care. The resident’s MDS documented functional limitations in range of motion in one upper extremity and both lower extremities and coded the resident as dependent for transfers, meaning assistance of two or more helpers was required. The care plan and a fall risk evaluation identified the resident as high risk for falls, with impaired physical mobility and prior fall during transfer. On the morning of the incident, a CNA (V8) attempted to transfer the resident from bed to wheelchair using a mechanical sit‑to‑stand lift without a second staff member present. V8 reported that she applied the belt/sling, tightened it, attached the hooks, positioned the resident’s feet on the lift base, and locked the wheelchair nearby. As the lift began to raise the resident from the bed, the resident jerked or threw herself forward, causing her buttocks to slide off the bed while still attached to the lift, and her feet to come off the foot base. V8 attempted to lower the resident back toward the bed, but the resident’s buttocks slid off the bed and one foot came off the base, with toes touching the floor and the resident sliding forward. V8 then lowered the resident fully to the floor while the resident’s legs were twisted underneath her, with the right leg bent inward and tucked under the body as the resident came to rest seated on her buttocks. After lowering the resident to the floor, V8 left to get help and returned with another CNA (V10). Both CNAs observed the resident on the floor in a seated position with legs twisted underneath her, and the resident was screaming and complaining of pain in her leg and knee. They manually lifted and slid the resident back into bed. Nursing documentation by an LPN (V9) noted that during the sit‑to‑stand transfer the resident threw herself forward, removed her foot from the base, placed one leg behind the other, and that the CNA had to lower the mechanical lift, resulting in the resident sitting on her legs, with both feet later observed pointed outward and a small skin tear on the anterior right calf and complaints of right lower extremity pain. The resident was subsequently sent to the hospital, where the admitting diagnosis communicated to the facility was a right periprosthetic femoral shaft fracture/hip fracture, attributed by facility staff and the medical director to the fall to the floor during the sit‑to‑stand transfer. Multiple staff interviews confirmed that facility practice and expectation were that two staff members should assist with mechanical lift transfers, including sit‑to‑stand lifts, particularly for dependent residents. V8 acknowledged that staff were instructed to use two people with lifts but stated she had been using the sit‑to‑stand lift alone with this resident because help was not always available and she had not previously had problems. Other CNAs and the therapy director stated they always or usually used two staff for sit‑to‑stand transfers and believed that having a second staff member present could have helped prevent the resident from sliding off the bed or being injured. The DON reviewed the resident’s MDS coding for dependence in transfers and stated that, by definition, the resident should have had at least two staff assisting with the sit‑to‑stand lift, and that the event met the facility’s definition of a fall as a change in plane resulting in landing on the floor. The DON further stated that, based on her understanding of the incident, the resident’s feet became tangled when V8 was trying to fix their position, and when the lift was lowered, the resident’s legs buckled, likely causing the injury. The DON indicated that V8 should have pulled the sit‑to‑stand lift upward instead of downward, as lowering it placed the resident’s weight on her legs while they were tangled underneath her. The therapy director and medical director both stated that when a resident is dependent for mobility and transfers, two staff members should be present during mechanical lift transfers, and they understood that the resident’s fracture occurred when she fell to the floor during the sit‑to‑stand transfer. The facility’s Safe Lifting and Movement policy stated that it was intended to protect the safety and well‑being of staff and residents and promote quality care through appropriate lifting techniques and devices, and the facility’s fall policy defined falls as downward displacement of the body to the floor or ground, including injurious falls where physical injury occurs.
Failure to Develop Individualized Ostomy Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to provide an individualized care plan for a resident with a urostomy. The resident, who was able to clearly express her needs, had her ostomy size changed following a medical appointment. After returning, she requested frequent changes of her ostomy supplies and refused to use her old supplies, as the new supplies for the updated size had run out. Staff, including the Administrator and DON, acknowledged that Medicare Part B would not cover premature reordering of supplies and that the resident was informed of her options, including going to the hospital, which she refused. Despite these ongoing issues and repeated requests from the resident, there was no care plan in place addressing her ostomy care needs. Upon review of the electronic health record, the DON confirmed that the care plan for ostomy care was missing, even though the resident's MDS assessment documented the presence of an ostomy and physician orders specified scheduled changes. The lack of a person-centered, individualized care plan for ostomy care was not in accordance with professional standards and guidelines, as required by CMS regulations. This omission was confirmed through record review and staff interviews.
Failure to Provide Proper Size Incontinence Products
Penalty
Summary
A male resident with diagnoses including heart failure, obesity, and multiple myeloma, and with moderate cognitive impairment (BIMS 10/15), experienced repeated instances where the facility failed to provide the correct size incontinence products (3XL diapers) as needed. The resident reported that on weekends and night shifts, the proper size diapers were unavailable, resulting in staff using smaller, uncomfortable sizes. The resident's wife had to purchase the correct size diapers on several occasions due to the facility's lack of supply. This issue was corroborated by both the resident and his family member, who confirmed that the facility ran out of the required size multiple times. Multiple CNAs confirmed that they had to use smaller size diapers for the resident when the correct size was not available, and were unaware of additional supplies in the basement. Documentation from a resident concern form indicated that the resident was told the correct size was not available, and staff did not escalate the issue to supervisors or access the basement storage for additional supplies. The Director of Nursing later acknowledged that staff failed to follow the protocol of notifying security to access the basement storage for the needed supplies, resulting in the deficiency.
Failure to Maintain RN Staffing on Weekends
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was staffed for at least eight hours within a 24-hour period on weekends, as required by their policy. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have an RN on duty on certain days and weekends, particularly in the months of April, May, and June. The Director of Nursing (DON) acknowledged the issue, stating that the facility had four RNs, two of whom were as-needed, and admitted to not having an RN on duty on some days and weekends. The Administrator also confirmed the failure to meet the RN staffing requirement, noting that the facility had been using agency staff or the DON to fill in at times, but was actively seeking to hire more RNs. The facility's daily nursing schedule showed that on several weekends, only Licensed Practical Nurses (LPNs) were on duty for both the day and night shifts, without any RN coverage. This lack of RN staffing was also reflected in the CMS report, which triggered for no RN hours. The facility's policy, dated January 1, 2024, clearly stated the requirement for a minimum of one RN on duty for eight consecutive hours, seven days a week. The absence of RNs on specific dates, including November 11 and 12, 2024, was documented, highlighting the facility's non-compliance with its own staffing policy and potentially affecting the care provided to all 28 residents in the facility.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to adhere to its policies and procedures for food storage and handling, as observed during a survey. In the main cooler for meat and dairy, several opened food items were found without labels indicating when they were opened or when they should be discarded. These items included canned prunes, cottage cheese, lettuce, chicken salad, olives, coleslaw, pears, grilled chicken, tofu, various types of lettuce, cranberries, nuts, spinach, vanilla pudding, and Monterey jack cheese. Additionally, unwrapped and unlabeled items such as parmesan cheese, carrot cake, and shredded mozzarella cheese were found. In the dry storage area, an opened box of cream of wheat mix was not wrapped or labeled. In the walk-in freezer, boxes of frozen cod, bread buns, and a container of demi-glace were improperly stored on the floor. The facility also failed to ensure that kitchen staff adhered to hygiene and food safety protocols. A dietary aide was observed serving lunch without checking food temperatures, contrary to the facility's policy that requires temperature checks before serving. A cook was seen preparing food without wearing a hair restraint, and a support chef did not properly sanitize and air dry a blender after use, leaving residual food inside before using it again. These lapses in protocol have the potential to affect the 26 residents receiving oral diets at the facility. Interviews with the Director of Dining Services confirmed that the facility's policies require all opened foods to be covered, labeled, and discarded by the date on the label to ensure food safety. The director acknowledged that expired foods should not be stored or served and that food temperatures should be recorded at various stages to prevent bacterial growth. The facility's policies on meal quality, food storage, and infection control emphasize the importance of proper labeling, storage, and hygiene practices to maintain food safety and prevent contamination.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. During an initial kitchen observation, three garbage bins were found uncovered and filled with waste. The Director of Dining Services acknowledged that these bins should have been covered. Additionally, an inspection of the facility's dumpsters revealed one dumpster with a lid that could not be fully closed due to overflowing garbage. This was confirmed by the Director of Dining Services, who stated that dumpsters should be fully closed to prevent pest infestations. Further interviews with the Maintenance Director and Facilities Director corroborated the issue, emphasizing the importance of keeping dumpster lids closed to prevent rodents and pests from entering the facility. The Maintenance Director noted that open lids could lead to debris flying out and attracting flies and rodents, potentially causing pest issues within the building. The Facilities Director also highlighted the safety risks to staff if lids were not closed, as items could be tossed and hit workers. The facility's policy on solid waste disposal mandates that garbage containers be clean, lined, and covered at all times, with lids closed on all outside trash receptacles.
Infection Control Deficiencies in Linen Handling and Water Management
Penalty
Summary
The facility failed to adhere to its infection control procedures, specifically in the handling of linens and the management of water systems to prevent Legionella growth. During an inspection, it was observed that clean linens were handled without proper hand hygiene by staff members, contrary to the facility's policy which requires sanitizing hands and wearing gloves. This lapse in protocol was acknowledged by the Facilities Director and the Environmental Services Manager, who confirmed that such actions could lead to cross-contamination and increase the risk of infection among residents. Additionally, the facility lacked measures to prevent the growth of Legionella and other waterborne pathogens in its water systems. The Facilities Director was unable to provide documentation or confirm any preventive measures in place, and the Administrator admitted that Legionella testing had not been conducted for the current or previous year. The absence of a policy on waterborne pathogen prevention was noted, highlighting a significant gap in the facility's infection control program.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for five residents, as required by their policy. Specifically, the care plans did not include measurable objectives and timeframes to address the residents' medical, physical, mental, and psychosocial needs. For instance, Resident 17, who was admitted with multiple diagnoses including fractures and hypertension, had no care plan for advance directives or code status despite having a Full Code order. Similarly, Resident 22, with conditions such as intracerebral hemorrhage and depression, lacked a care plan for the use of psychotropic medication. Resident 29, admitted with acute respiratory failure and other serious conditions, also had no care plan for advance directives despite having a DNR order. The Director of Nursing (V2) acknowledged that care plans should be developed by the interdisciplinary team and individualized according to each resident's needs. However, the facility's records for Residents 17, 22, and 29 did not include care plans for advance directives or psychotropic medication use. Additionally, Resident 6, who was on anticoagulant medication for stroke, and Resident 21, diagnosed with dementia, did not have care plans addressing these specific needs. The facility's policies on comprehensive care planning and psychotropic medication use were not followed, leading to these deficiencies.
Failure to Follow Bed Rail Policy and Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the use of bed rails, resulting in a deficiency related to accident hazards and inadequate supervision. Specifically, the facility did not attempt to use appropriate alternatives before installing side or bed rails, did not assess residents for the risk of entrapment from bed rails prior to installation, and did not review the risks and benefits of bed rails with the residents or their representatives to obtain informed consent. Additionally, the facility did not develop and implement a comprehensive person-centered care plan for the residents involved. The deficiency was observed in four residents, each with various medical conditions. One resident, admitted in 2019, had diagnoses including cerebral infarction and vascular dementia, while another resident, admitted in 2024, had conditions such as unspecified fracture and anemia. The third resident, also admitted in 2024, had acute respiratory failure and suicidal ideations, and the fourth resident had chronic respiratory failure and Alzheimer's disease. Observations revealed that these residents had bed rails up without proper documentation or assessment, and there was no evidence of care plans or informed consent for their use. Interviews with facility staff, including the Director of Nursing, revealed a lack of clarity and adherence to the facility's bed rail policy. The Director of Nursing admitted that side rails were used to aid in mobility and repositioning but was unsure if an order was required for their use. The facility's records lacked documentation of care plans, assessments, and consent for the use of side rails, and there was no evidence of attempts to use alternatives before resorting to bed rails. This lack of documentation and assessment posed potential risks of harm to the residents due to entrapment or other accidents.
Failure to Properly Account for and Dispose of Controlled Medications
Penalty
Summary
The facility failed to properly account for and dispose of controlled medications, which could potentially affect 12 residents assigned to the west medication cart. During an inspection, it was observed that the controlled medications were not consistently counted and signed off by outgoing and incoming nurses, as required. Specifically, a blister packet containing Tramadol for a resident was found to be compromised with transparent tape, indicating tampering. Additionally, expired Hydromorphone concentrate was found in the medication room refrigerator, which should have been returned to hospice care or discarded. The Director of Nursing confirmed that the expiration date for all medications should be checked daily to prevent the administration of expired medications, which could lead to adverse reactions. The facility's records showed multiple instances of missing nurse signatures or initials on the controlled substances record sheet, suggesting that the required counts were not being performed. The facility's policy mandates that expired controlled substances be clearly labeled and separated, but this was not adhered to, as evidenced by the expired Hydromorphone concentrate found during the inspection.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to adhere to its medication storage policy, as observed during an inspection of the west side medication cart and storage room. A Licensed Practical Nurse (LPN) who has been working at the facility since November 2018 was present during the inspection. The surveyor found approximately 20 loose yellow capsules and white tablets inside a plastic container covered with tape and without a label, stored inside the narcotic box of the medication cart. The LPN was unable to identify the medications or determine to whom they belonged, acknowledging that these medications should have been disposed of or discarded. Further inspection of the west side medication room revealed that medications requiring refrigeration, such as insulin, flu vaccine, acetaminophen suppositories, hydrocortisone suppositories, Morphine concentrate, and Hydromorphone concentrate, were stored alongside food items like a carton of Jevity 1.5 and a bottle of Ensure. The Director of Nursing (DON) confirmed that medications should be stored separately from food and that any medications without proper labeling should be discarded to prevent potential hazards. The facility's policy, dated 7/1/18, mandates that all drugs and biologicals be stored securely and in their original containers, with medications requiring refrigeration stored separately from food and properly labeled.
Failure to Provide Pneumococcal Vaccination Education and Assessment
Penalty
Summary
The facility failed to provide education and assess eligibility for pneumococcal vaccinations for four residents, as required by their policy. The electronic medical records (EMR) of these residents showed no documentation of education regarding the benefits and potential side effects of the pneumococcal vaccination, nor any assessment of their eligibility to receive it. Additionally, there were no signed consents for pneumococcal immunizations found in the EMRs of these residents. The residents involved had various medical conditions, including asthma, diabetes, spinal stenosis, and chronic kidney disease, which could potentially make them eligible for the vaccination. The Infection Preventionist (V2) admitted to not having provided any pneumococcal vaccinations, education, or obtained consents since starting in March 2024. V2 was unsure about the process of ordering the pneumonia vaccine and acknowledged that the education should be documented in the progress notes of the residents' EMRs, with consents uploaded accordingly. The facility's policy mandates that each resident or their representative should receive education about the pneumococcal immunization and that the immunization should be offered unless contraindicated or previously administered. However, this policy was not followed, leading to the deficiency noted in the report.
Failure to Document Resident's Code Status and Advance Directives
Penalty
Summary
The facility failed to determine, establish, obtain, or discuss the code status of a resident, identified as R133, who was part of a sample of 15 residents reviewed for Advance Directives. R133 was admitted with multiple diagnoses, including unspecified displaced fractures, gait and mobility issues, and a history of falling. Despite having intact cognition as per the Minimum Data Set, there was no documentation or order regarding the resident's code status or advance directives in their health record. This lack of documentation was confirmed during interviews with the Director of Nursing (V2) and Social Services (V17), who both acknowledged the importance of having a documented code status for residents, especially during emergencies. The facility's policy on advance directives, dated May 5, 2024, requires that during the admission process, the Social Services or a designee should discuss advance directives with the resident or their representative. This includes determining if the resident has a health care surrogate designation, living will, durable power of attorney, or a Do Not Resuscitate (DNR) form. However, the facility was unable to provide any documentation regarding R133's code status or advance directives, indicating a failure to adhere to their own policy and procedure.
Late Transmission of MDS Records
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) records to the CMS system within the regulatory timeframes for a resident, identified as R18, who was part of a sample of 15 residents reviewed for assessment. R18 was admitted on June 21, 2022, with multiple diagnoses including malignant neoplasm of the prostate, spinal stenosis, anemia, atherosclerosis, chronic kidney disease, and essential hypertension. The Quarterly MDS Assessment Reference Date (ARD) for R18 was October 4, 2024, and the assessment was completed on October 14, 2024. However, the final validation report indicated that the record was submitted late, on November 11, 2024, which is more than 14 days after the completion date. The MDS manager, V19, who works remotely for an outside company hired by the facility, stated that they coordinate with the Director of Nursing (DON), V2, to complete the MDS. V19 acknowledged that the MDS assessment should be completed within 14 days from the ARD and transmitted within 14 days from the completion date, as per the Resident Assessment Instrument (RAI) manual. Despite this, the transmission of R18's MDS was delayed, indicating non-compliance with the regulatory timeframes. The facility's policy also documented that the quarterly transmission date should be no later than 14 calendar days from the MDS completion date, which was not adhered to in this instance.
Failure to Provide Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to adhere to dietary recommendations and physician orders for a resident (R3) experiencing weight loss. R3's electronic health records indicated a physician's order for a nutritional supplement, Magic Cup, to be provided twice daily with lunch and dinner. Despite this order, observations revealed that R3 did not receive the Magic Cup during lunch, and the meal ticket did not list the supplement. Interviews with dietary staff confirmed that the facility did not have Magic Cup in stock, and there was a lack of communication regarding the need for this supplement. R3's weight records showed a decline from 159 pounds in June to 153.2 pounds in November, with no weights recorded for September and October. The resident's daughter, who holds power of attorney, expressed concerns about R3's weight loss and confirmed that R3 enjoys sweet foods like the Magic Cup. The Registered Dietitian emphasized the importance of providing the nutritional supplement as ordered to help maintain R3's weight. The facility's policies on receiving orders and nourishment supplements were not followed, contributing to the deficiency.
Improper Storage and Dating of Respiratory Equipment
Penalty
Summary
The facility failed to properly date and store respiratory equipment for two residents, which could potentially affect their health. One resident, who was admitted with respiratory failure, essential hypertension, and chronic kidney disease, was observed with oxygen tubing that was not dated or stored in a plastic bag when not in use. This resident uses oxygen daily, and the improper storage of the tubing was noted during a surveyor's visit. Another resident, admitted with chronic obstructive pulmonary disease, essential hypertension, and a nontraumatic intracerebral hemorrhage, had a nebulizer mask that was not dated. A Licensed Practical Nurse (LPN) at the facility was unaware of the policy regarding the storage and dating of oxygen tubing and nebulizer masks. The Director of Nursing confirmed the deficiencies, acknowledging that undated and improperly stored equipment could increase the risk of infection. The facility's policy requires that such equipment be dated and stored in a clean plastic bag when not in use.
Failure to Follow Prescribed Menus and Standardized Recipes
Penalty
Summary
The facility failed to adhere to the prescribed menu for a resident on a mechanical soft diet and did not follow standardized recipes during the preparation of pureed foods. Specifically, a resident with a diet order of NAS (No Added Salt) Mechanical Soft Texture was observed receiving a meal that did not match the facility's menu for that week. The menu indicated minestrone soup, ground grilled corned beef sandwich, basil roasted zucchini, and blueberry buckle, but the resident was served chicken noodle soup and ground zucchini instead. This discrepancy was noted during an observation of the resident's lunch, where the resident consumed 100% of the meal provided. Additionally, during the preparation of pureed meals, the support chef did not follow the facility's standardized recipes. The chef was observed using a scoop without measurement to puree quinoa stuffed peppers and boiled carrots, resulting in a thin consistency that did not meet the required texture standards. The facility's Director of Dining Services confirmed that recipes should be followed to ensure appropriate texture and nutritional adequacy. The Registered Dietician also emphasized the importance of following menus and recipes to meet nutritional needs. The facility's policy on modified texture foods outlines the need for a standardized process to ensure palatability, flavor, texture, and nutritional value, which was not adhered to in this instance.
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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