Nexus At Berwyn
Inspection history, citations, penalties and survey trends for this long-term care facility in Berwyn, Illinois.
- Location
- 3601 South Harlem Avenue, Berwyn, Illinois 60402
- CMS Provider Number
- 145070
- Inspections on file
- 55
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 14 (2 serious)
Citation history
Health deficiencies cited at Nexus At Berwyn during CMS and state inspections, most recent first.
A resident who was a full code was found unresponsive, and staff actions captured on video and described in interviews showed delays and failures in initiating and maintaining CPR until EMS arrival. Multiple CNAs and LPNs intermittently entered and exited the room, focused in part on soiled linens and incontinence, while the crash cart remained at the doorway with the backboard, bag-valve-mask, oxygen, and AED not brought into the room. EMS reported finding the resident pulseless and apneic with no CPR in progress and no resuscitation equipment at the bedside, and immediately initiated full resuscitative measures. Staff accounts of having performed chest compressions conflicted with video evidence and EMS documentation, leading surveyors to determine that the facility failed to provide required BLS/CPR for a full-code resident until EMS assumed care.
A resident with dementia, muscle weakness, gait abnormalities, and other comorbidities, who required total assistance with eating and was on a mechanical soft diet with thin liquids, was observed being fed by a restorative aide who was simultaneously using a personal cell phone. The aide acknowledged knowing that cell phone use during patient care was not allowed. Facility leadership, including the DON, Human Resources, and the Asst. Administrator, confirmed that staff are informed via the employee handbook and orientation that personal cell phone use is prohibited in the building except on break in designated areas, and specifically not during resident care. This conduct conflicted with facility policies on feeding assistance and resident rights, which require qualified staff to provide hand-feeding and to maintain resident dignity and a homelike environment.
A hospice resident with multiple serious diagnoses, including chronic kidney disease, malignant pericardial disease, and COPD, experienced SOB and coughing and requested transfer to the hospital. An RN refused the request, stating the resident was on hospice and did not need hospital care, and did not contact hospice or arrange an emergency transfer, instead attempting to give cough medication. The resident then asked a roommate to call 911, and EMS transported the resident to the hospital. The DON later stated that hospice should be contacted for changes in condition and that residents have the right to insist on hospital transfer, while facility policy affirms accommodating resident needs and preferences to support dignity and well-being.
A hospice resident with multiple serious diagnoses and DNR/comfort care status reported shortness of breath and severe coughing and requested hospital transfer, but an RN assessed the issue as only a small cough, attempted to give cough medication, and did not notify hospice, the physician, or the resident’s family. The resident then had a roommate call 911 and was transported by EMS to a hospital for SOB. Facility records and interviews confirmed that policies required immediate notification of the physician, responsible party, and hospice for significant changes in condition or need for transfer, and leadership stated they expected such notifications to occur, but they were not made in this instance.
Staff left a report sheet containing PHI for two residents visible and uncovered on top of a medication cart in a hallway, where it could be seen by others. A CNA confirmed the sheet contained information on two residents and that the nurse responsible had gone to lunch, leaving it on the cart. The DON later acknowledged the information should not have been visible, and an assistant administrator stated that medical records should not be visible to residents or visitors and should be covered to maintain privacy. The exposed information related to residents with multiple complex conditions, including osteoarthritis, DM2, respiratory failure, bipolar disorder, heart failure, pneumonia, AV block, COPD, and post-stroke hemiplegia. The facility’s only HIPAA guidance was in the employee handbook, which requires confidentiality of PHI and prohibits unauthorized disclosure.
A dependent resident with Alzheimer’s disease and on hospice care was found in bed with a urine-soaked incontinence brief that was separating due to saturation, despite facility expectations and policy for q2h and PRN rounds. A CNA reported she had not yet rounded on the resident after lunch because a rehabilitation aide had done earlier care, while the aide stated she had provided incontinence care only once that morning and that rounds should occur every two hours and as needed. The DON confirmed the expectation for regular rounds for dependent residents, and the resident’s care plan called for keeping the skin clean and dry with prompt toileting/incontinence care.
A resident with dementia and high fall risk suffered first, second, and third-degree burns after falling out of bed and coming into contact with a radiator heater, which was positioned next to the bed against the wall. The bed placement was standard for the facility, and staff were unaware of the hazard posed by the radiator. The incident resulted in hospitalization for burn care.
A resident and several others reported persistent mold and uncollected wet towels in a common shower room. Observations confirmed blackish mold on all four sides of the shower and wet towels left on the floor. Staff, including an LPN and the DON, acknowledged that housekeeping was responsible for cleaning and sanitizing the area, but the issue remained unresolved due to a lack of disinfectant. Facility cleaning guidelines required regular disinfection, but the unsanitary conditions persisted for weeks.
A resident with a history of neuromuscular bladder dysfunction and moderate cognitive impairment was found with a grossly soiled indwelling catheter, cloudy urine, and poor catheter maintenance. Staff failed to follow daily cleaning protocols, and the catheter was not changed regularly. The resident was hospitalized with a catheter-associated UTI, purulent drainage, and required antibiotics.
A resident reported a missing personal phone and filed a grievance, but the facility did not resolve the issue within the required seven days or document the resident's involvement in the resolution process. The resident, who was his own responsible party and unable to leave the facility independently, was not included in the decision-making, and the grievance remained unresolved for several months, contrary to facility policy.
A resident had a mini refrigerator plugged into an unapproved, non-medical grade surge protector, which overheated and caused a small fire in the room. Both the resident and her roommate, who were alert and oriented, noticed smoke and a burning smell before evacuating. The facility's fire prevention policy prohibits the use of ganged or multiple outlet plugs, and the fire department confirmed that refrigerators should not be plugged into surge protectors. This failure to follow fire safety protocols had the potential to affect all residents on the unit.
A resident with moderate cognitive impairment was physically struck in the face by his roommate, who has severe cognitive impairment and a history of aggressive behavior, during an argument over closet space. An LPN witnessed the altercation and intervened after the physical contact occurred, resulting in a minor injury. The incident was not prevented despite known risk factors and care plan interventions requiring staff to de-escalate verbal altercations.
Two residents with significant pain needs did not receive their prescribed pain medications as ordered, resulting in unmanaged pain and psychosocial harm. Staff failed to administer medications such as Norco, gabapentin, and lidocaine patches consistently, and did not document administration in the MAR as required. Interviews and record reviews revealed missed doses, unavailable medications, and lapses in following physician orders and facility policy.
Two residents with significant pain management needs did not consistently receive their ordered pain medications, with multiple missed doses and lack of documentation for several medications. Staff interviews and record reviews revealed that medications were sometimes unavailable, not administered, or not properly documented in the MAR, resulting in unmanaged pain for the affected residents.
Multiple bathrooms were found without toilet tissue, and several residents reported going without toilet paper for days. Housekeeping staff were responsible for restocking but did not consistently do so, and nursing staff lacked access to supplies. Overflowing garbage cans and dirty clothing on the floor were also observed, with no clear policy or SOP in place to guide staff on maintaining hygiene supplies.
Surveyors observed that medication and treatment carts were left unlocked and unattended, and that medications were left at the bedsides of two residents without proper authorization or supervision. Staff confirmed these actions were against facility policy, which requires medications and carts to be locked or attended at all times and prohibits leaving medications at the bedside unless specifically ordered and assessed for self-administration.
Two residents with severe cognitive impairment and high fall risk experienced multiple falls, including one resulting in a fracture, due to the facility's failure to implement and individualize effective fall prevention interventions. Staff observations revealed lapses in supervision, improper use of safety equipment, and inadequate monitoring of wandering behaviors, despite existing care plans and policies.
The facility failed to maintain a manual resuscitator at the bedside and provide timely suctioning for two residents with tracheostomies. One resident, with chronic respiratory failure, lacked a manual resuscitator, while another resident was not suctioned promptly despite having thick secretions and a low SPO2 level. The DON and Nursing Supervisor confirmed the need for immediate suctioning, as per the facility's policy.
The facility failed to maintain infection control practices for residents with tracheostomy tubes and during medication administration. Two residents had tracheostomy tubing and drainage bags touching the floor, contrary to infection control protocols. Additionally, a nurse and an LPN did not disinfect blood pressure cuffs between resident uses, despite the facility's policy requiring disinfection to prevent infection transmission.
A resident with a history of stroke and high risk for skin impairment developed a pressure ulcer that was not properly managed. The facility failed to update the wound care plan and provide prompt incontinence care, leading to contamination of the wound dressing with feces. The Assistant Director of Nursing did not update the care plan despite the facility's policy requiring it for new wounds.
A resident at high risk for falls, with a history of stroke and requiring total care, experienced unwitnessed falls due to inadequate supervision. Despite being bed-bound and placed away from the nursing station, the facility failed to document frequent rounding as part of their fall prevention policy. The resident's falls resulted in hospital evaluations, highlighting a deficiency in the facility's adherence to its own safety protocols.
The facility failed to ensure that call lights were within reach for two residents, affecting their ability to call for assistance. One resident was found with the call light behind a curtain on a dresser, and another was unable to reach it, despite needing assistance with ADLs. The facility's policy requires call lights to be within reach at all times.
A resident with multiple medical conditions, including a stage 4 pressure ulcer, did not receive adequate nail and foot care, nor timely incontinence care. Observations showed long, dirty fingernails, thickened toenails, and a disposable brief soaked with feces, contaminating the wound dressing. The facility's policies on hygiene and care were not followed, impacting the resident's condition.
A facility failed to provide timely assessment and intervention for a resident with limited ROM, leading to a delay in implementing necessary care to prevent contractures. The resident, who was bed-bound and had suffered a stroke, was observed with an extension contraction in the right hand wrist without a splint. The Restorative Nurse was unaware of the resident's condition until informed by a surveyor, and only then conducted an assessment and referred the resident to OT for a splint.
A medication administration error occurred when an LPN administered Aspirin 81mg chewable and Senna 8.6mg to a resident, contrary to the physician's order for Aspirin 81mg in capsule form and two tablets of Sennosides 8.6mg. The resident had multiple diagnoses, including hemiplegia and type 2 diabetes. The facility's policy requires verifying medication orders, which was not followed in this instance.
A resident with a history of cerebral vascular accident and other medical conditions was admitted to the facility without a fall care plan, despite being assessed as high fall risk. The resident sustained significant injuries, including broken ribs and a dislocated shoulder, after being found on the floor. The facility's policy for fall risk evaluation and intervention was not followed, and the incident was not reported to the health department due to lack of hospital x-ray results.
A resident with intact cognition experienced a delay in receiving a urinalysis and culture/sensitivity test due to the facility's failure to properly label and provide a requisition for urine samples. The resident reported an odor in her urine, but the first sample was unlabeled, and the second lacked a requisition form, leading her to seek testing from her primary care provider, who diagnosed a urinary tract infection.
A resident's right to receive unopened personal mail was violated when a letter from IDPH was opened and delayed by ten days. The resident, cognitively intact, reported the issue, and the Business Office Manager confirmed the mail turnaround process should be daily. The facility's consent form did not cover personal mail, and the administrator admitted the letter was opened by mistake.
A resident missed a dermatology appointment due to the facility's failure to provide transportation. The facility's van had a broken wheelchair lift, and no alternative transportation was arranged, despite the facility's policy requiring staff to make such arrangements.
A resident with anxiety was not administered their prescribed Alprazolam dose due to a failure to reorder the medication. Despite having a medication dispensing system available, the facility did not utilize it, resulting in a missed dose. Staff interviews revealed a lack of awareness and communication regarding the missed medication.
A resident with multiple health conditions was admitted to the hospital with maggots in a foot wound, which the LTC facility failed to identify and treat. Despite daily bed baths and skin checks, staff were unaware of the wound, and no skin assessment was documented before the resident's hospital transfer. The facility's wound prevention policy was not followed, and the presence of flies was noted, potentially contributing to the wound's condition.
A facility failed to obtain informed consent before administering psychotropic medications to a resident with dementia, leading to increased lethargy and confusion. The resident's family was not informed about the medications, and concerns raised during a care plan meeting were not addressed. The facility's policy requires consent before administering such medications, but this was not followed, resulting in a deficiency.
A facility failed to initiate a discharge for a resident upon request and did not update the care plan to reflect the resident's desire for transfer. Despite the family's involvement and repeated requests, the necessary transfer information was not sent to the chosen facility. The care plan was not updated, and the facility's policy lacked a process for resident-initiated discharge.
The facility failed to follow physician orders for two residents regarding medication administration. One resident did not receive the correct dosage of aripiprazole due to a transcription error, while another resident experienced a delay in receiving tizanidine for back spasms. The errors were linked to communication and procedural lapses involving the nursing staff and the use of agency nurses.
The facility failed to label and date stock medications, eye drops, and insulins, and did not dispose of expired medications. Observations revealed undated and expired medications on multiple medication carts and rooms. LPNs and the DON confirmed that medications should be dated when opened and discarded when expired, but facility policies were not followed.
The facility failed to provide adequate shower/bed bath and grooming for residents dependent on staff for ADL care. Several residents reported not receiving regular showers or bed baths, long call light response times, and inadequate incontinence care. Staff shortages and lack of personalized interventions for residents refusing care contributed to the deficiency.
The facility failed to provide sufficient nursing coverage on the third floor, affecting 45 residents. Residents reported delays in incontinence care due to staffing shortages, with only three CNAs available instead of the required four. The administrator acknowledged the issue, but staffing schedules confirmed the inadequacy, particularly during the night shift.
The facility failed to maintain a medication error rate below 5%, resulting in a 31.03% error rate. Errors included incorrect dosages, missed medications, and administration without proper physician orders. Specific issues involved incorrect Aspirin dosage, unavailability of Lidocaine patch, and missed doses of Folic Acid and Budesonide-Formoterol Fumarate Inhalation Aerosol. Extended-release medications were also crushed without proper orders.
The facility failed to document medication administration in the EMAR for seven residents as per policy. An LPN admitted to not signing medications immediately after administration, which was confirmed by the DON and ADON. The residents involved had various medical conditions requiring multiple medications at specific times.
The facility failed to follow infection control policies, including not placing required signage, not performing hand hygiene between glove changes, and not cleaning equipment between uses. These deficiencies affected six residents.
A resident with new mental health diagnoses was not referred for a Level II PASARR assessment. The resident's medical records lacked the necessary assessment, and the facility did not have a PASARR policy in place. The Psychotropic/Falls Nurse indicated that the resident might need a different type of facility, and the administrator could not confirm the necessity of the assessment during the survey exit interview.
The facility failed to develop and implement person-centered care plan interventions for three residents with specific needs, including a resident with a history of cerebral infarction and aphasia, a resident with end-stage renal disease and nicotine dependence, and a resident with recurrent major depressive disorder and adjustment disorder. The care plans lacked personalized interventions, and progress notes did not document refusals or substance use, leading to repeated issues and safety concerns.
The facility failed to follow its policy for ensuring residents receive necessary behavioral health care and services. One resident exhibited signs of substance use without appropriate care plan interventions, and another resident with a history of depressive and adjustment disorders showed aggressive and elopement behaviors without personalized behavioral interventions. The facility's care plans did not meet the criteria of being person-centered and based on comprehensive assessments.
The facility failed to safely reposition a resident during care, resulting in a head injury, and did not adequately supervise residents with a history of aggression, leading to multiple incidents of resident-on-resident violence. Additionally, the facility did not follow its elopement policy when a resident did not return from a community pass.
The facility failed to follow its abuse prevention policy, resulting in multiple incidents of resident-to-resident abuse. One resident stabbed another with a butter knife, another threw a walker causing a bruise, and a third slapped a resident in the face. Delayed documentation and inadequate management of aggressive behavior were noted.
The facility failed to follow its abuse policy and immediately report an incident of resident-to-resident abuse involving a butter knife. The incident was not reported to the regulatory agency until over two months later, despite the residents being separated and one being sent to the hospital for psychiatric evaluation. The facility's abuse prevention policy requires immediate reporting, which was not adhered to, resulting in a significant delay.
Failure to Initiate and Maintain CPR for Full-Code Resident Until EMS Arrival
Penalty
Summary
The deficiency involves the facility’s failure to initiate and continue CPR for a resident who was a full code and found unresponsive, and to maintain resuscitative efforts until EMS assumed care. Video surveillance showed that at approximately 6:58 AM, a CNA entered the unit, went directly to the resident’s room, opened and immediately closed the door, and left the unit. At about 7:17 AM, another CNA entered the room, then exited to get an LPN; the LPN briefly looked into the room and walked away while the CNA re-entered. Over the next several minutes, multiple staff, including CNAs and LPNs, intermittently entered and exited the room, with one CNA later reporting that the resident’s brief was off and there was feces and urine in the bed. Towels were observed being brought to the room and soiled linens removed, and large plastic bags were used to collect soiled items. The crash cart was brought to the resident’s doorway at about 7:21–7:22 AM, but the video showed that the backboard, manual resuscitation bag, oxygen tank, and AED remained on the cart and were not brought into the room before EMS arrived. Between the time the crash cart was placed near the room and EMS arrival at approximately 7:29 AM, staff did not obtain a backboard, and there is no visual evidence of CPR being performed. The facility’s code blue documentation sheet attached to the crash cart for that date was requested but not provided for review. EMS documentation and paramedic interview indicated that upon arrival at the bedside, no CPR was in progress, no resuscitation equipment was in the room, and only one nurse was present speaking with the roommate. EMS immediately placed a backboard, initiated manual compressions, applied a mechanical chest compression device, and began bag-mask ventilations with oxygen. Staff interviews were inconsistent with the video and EMS findings. One CNA stated she responded to the overhead code, called 911, and waited in the lobby, but video showed her earlier entry into the unit and room and later participation in handling soiled linens. An LPN reported that she performed chest compressions and switched with another LPN, but video showed her only briefly looking into the room, later bringing the crash cart to the doorway, and not re-entering the room until shortly before EMS arrival. The night-shift LPN gave multiple conflicting accounts, initially stating he initiated CPR and called 911, then later admitting he had been “running around trying to figure out what to do,” acknowledging that compressions should not be stopped before EMS takes over, and confirming that cleaning feces and wetness does not take precedence over CPR. The RN from the adjacent unit reported that CPR was in progress and that she participated, but video showed her only very brief entries into the room and primarily handing in towels and obtaining bags and linens. EMS and hospital records documented that the resident was pulseless, apneic, in asystole, and that CPR was initiated by EMS with no return of spontaneous circulation, with signs of rigor mortis noted in the jaw and one arm while the torso remained warm. The American Heart Association adult BLS guidelines cited in the report emphasize early, high-quality CPR and prompt defibrillation, including starting compressions immediately, using a firm surface, minimizing interruptions, and continuing CPR until advanced care arrives. The surveyors concluded that the facility failed to ensure that CPR was initiated and continued for this full-code resident after she was found unresponsive and a code blue was called, and that resuscitative efforts were not maintained until EMS assumed care. This failure was determined to constitute Immediate Jeopardy and had the potential to affect all residents in the facility identified as full code.
Removal Plan
- Conduct an in-service on performing CPR for full-code residents in cardiopulmonary arrest/emergency medical attention, emphasizing recognition of cardiac arrest, initiating CPR without delay, and staff roles/responsibilities during a code event; document who conducted the training and their title.
- Complete a knowledge check and competency assessment for all staff; verify nursing staff competence to initiate CPR using a questionnaire and competency test conducted by the DON/designee.
- Educate all staff currently on duty and verify competency to provide CPR prior to resuming resident care.
- Audit all residents’ code status orders to ensure they are accurate and readily available to staff.
- In-service new hires on the facility’s code blue policy by the DON/designee.
- Provide code blue policy education via telephone to staff who are on vacation or unavailable, and repeat the same education upon their return to work by the DON/designee.
- Ensure any agency staff (if used) receive the same code blue policy training as facility staff prior to the start of their shift.
- Conduct a crash cart audit by the DON/ADON/designee to ensure all resuscitation equipment (including a backboard and manual resuscitation device) is readily available.
- Have the Medical Director, Administrator, DON and RNC review facility policies including the Code Blue policy and Emergency Cart policy.
- Conduct code blue drills to identify any potential need for additional training; review drill/audit results after each drill by the DON, ADON and Administrator.
- Conduct random staff interviews with at least five employees to assess knowledge retention and determine if additional training is required.
- Address any identified concerns.
- Hold an ad-hoc QAPI meeting to review results of audits and drills and determine if additional interventions are necessary to ensure compliance.
- Have the Administrator, DON and designee monitor completion of the plan of removal.
Staff Cell Phone Use During Assisted Feeding Undermines Resident Dignity
Penalty
Summary
The deficiency involves a failure to promote care in a manner that maintains resident dignity and rights when a staff member used a personal cell phone while feeding a resident who required total assistance. On 1/27/26 at 12:55 PM, a restorative aide (V9) was observed feeding resident R5 while simultaneously using her personal cell phone. During this observation, V9 acknowledged she was feeding R5 and stated she knew she was not supposed to use a cell phone while providing patient care. R5’s record shows admission with diagnoses including unspecified dementia, abnormal posture, muscle weakness, unspecified abnormalities of gait and mobility, type 2 diabetes mellitus, essential hypertension, and dehydration. The order summary for January 2026 reflects a general diet with mechanical soft texture and thin liquids, and the care plan dated 3/21/25 identifies R5 as requiring total assistance with eating. Interviews with facility leadership confirmed that staff are not to use personal cell phones while feeding residents or providing any type of care. The DON (V2) stated staff should not be on their cell phones while feeding residents or providing care, and later clarified that the facility does not have a separate cell phone policy beyond what is in the employee handbook, but that staff are aware there is no cell phone use while in the facility. The Human Resource Director (V19) reported that staff are informed upon hire that no personal cell phone usage is allowed in the facility except during breaks in designated areas, and that this is discussed with the employee handbook, which staff sign to acknowledge. The Assistant Administrator (V3) also stated the facility has a no cell phone use policy while in the facility and while providing resident care. Facility policies on feeding assistance and resident rights emphasize that residents who cannot feed themselves are to be fed by qualified staff and that care should support dignity, independence, and a homelike environment, but the observed conduct of V9 using a cell phone while feeding R5 did not align with these expectations.
Failure to Honor Hospice Resident’s Request for Hospital Transfer and Participation in Care Decisions
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was informed about and allowed to participate in decisions regarding her care and treatment, including her right to request hospital transfer. On the reported date, the resident (R6) stated she experienced shortness of breath and coughing severe enough that her chest hurt and asked the assigned nurse (V17) to send her to the hospital. According to R6, the nurse refused, telling her she was on hospice care. R6 then had her roommate call 911. The roommate (R1) corroborated that R6 was short of breath and coughing, that R6 asked her to call 911 because the nurse would not, and that the nurse said R6 was on hospice and her condition was not bad enough to warrant hospital transfer. The nurse (V17) reported that R6 was uncooperative and refusing care, had a small cough, and wanted to be transferred to the hospital. V17 stated she informed R6 she did not need hospital transfer for a cough, did not call hospice or arrange an emergency transfer, and instead attempted to administer cough medication, after which 911 arrived and transported R6 to the hospital. The DON (V2) stated she expects hospice to be called for a change in condition, that nurses should use PRN medications and interventions, and that if a resident insists on going to the hospital it is their right to be transferred. Record review showed R6 had diagnoses including chronic kidney disease, diabetes, GERD, acute embolism and thrombosis, anxiety, malignant pericardial disease, and was on DNR/comfort care with hospice services and orders for respiratory medications for SOB. Documentation also showed a prior hospital admission for SOB and a hospital record noting acute COPD with bilateral wheezing. The facility’s Resident Rights policy states that the facility will accommodate resident needs and preferences to maintain dignity and well-being, except when it endangers health or safety.
Failure to Notify Hospice, Physician, and Family of Change in Condition for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify hospice, the physician, and the resident’s family of a change in condition for a hospice resident. The resident, who had diagnoses including chronic kidney disease, diabetes, GERD, acute embolism and thrombosis, anxiety, malignant pericardial disease, and dementia, was admitted with DNR/comfort care status and had orders for respiratory medications including ipratropium-albuterol four times a day for shortness of breath. A hospice care plan included an intervention to coordinate care and services between facility caregivers and the hospice company. On the date in question, the resident reported being short of breath and coughing until her chest hurt and requested to be sent to the hospital. The assigned nurse stated the resident had only a small cough, did not appear short of breath, and did not need hospital transfer, and attempted to administer cough medication instead. The resident then had her roommate call 911, and EMS arrived and transported her to the hospital. A progress note later documented that the resident had been admitted to a local hospital for shortness of breath, and another note indicated the resident’s son called and informed the facility that the resident had called 911 and was going to the hospital. The nurse acknowledged that, for a hospice resident with a change in condition, hospice, the physician, and family should be called, but she did not notify hospice, the physician, or initiate an emergency transfer. The DON stated an expectation that hospice, the physician, and family be notified when a resident has a change in condition. Facility policies on change in resident condition and hospice services required immediate notification of the resident’s physician and responsible party for significant changes in status and immediate notification of hospice for significant changes or need to transfer the resident, which did not occur in this case.
Failure to Protect Confidentiality of Resident Medical Information
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical information when a report sheet containing protected health information (PHI) for two residents was left visible and uncovered on top of a medication cart in the first-floor north hallway. On 1/27/26 at 12:35 PM, surveyors observed the report sheet on the cart with resident health information clearly visible. A certified nurse aide (V7) confirmed that the form contained information on two residents and stated that the nurse on duty had gone to lunch, leaving the report on the cart. V7 also indicated uncertainty about whether the report should be placed on top of the cart where it was visible to others. At 12:50 PM the same day, the Director of Nursing (V2) acknowledged that the report form on the nurse's cart contained resident information and confirmed it should not be visible on the cart in order to maintain resident privacy. On 1/29/26 at 10:39 AM, the Assistant Administrator (V3) stated that resident records containing medical information should not be visible to other residents or visitors and that all records should be covered to maintain privacy, further noting that the only HIPAA-related policy was contained in the employee handbook. The residents whose information was exposed, R9 and R10, had multiple medical diagnoses including, for R9, primary osteoarthritis, type 2 diabetes mellitus, acute and chronic respiratory failure with hypoxia, insomnia due to other mental disorder, acute bronchitis, GERD, anemia, hyperlipidemia, bipolar disorder, depression, polyneuropathy, essential hypertension, and atrial fibrillation; and for R10, heart failure, pneumonia, atrioventricular block, type 2 diabetes mellitus, essential hypertension, hemiplegia and hemiparesis following cerebral infarction, COPD, muscle weakness, abnormal posture, and dysphagia. The facility’s employee handbook policy on HIPAA requires confidentiality of PHI and prohibits unauthorized use or disclosure of such information.
Failure to Provide Timely Incontinence Care to a Dependent Resident
Penalty
Summary
Surveyors identified a failure to provide required assistance with ADLs, specifically incontinence care, to a dependent resident. On 1/28/2026 at 12:30 p.m., the surveyor, along with a rehabilitation aide and a CNA, observed the resident in bed wearing a urine-soaked incontinence brief (depend) that was so saturated it began to separate when staff attempted to remove it. The resident’s admission record documented diagnoses including Alzheimer’s disease, encounter for palliative care, and dysphagia, and the resident was described by staff as dependent on all care from staff. During interviews, the CNA assigned to the resident stated she performs resident rounds before breakfast and after lunch but had not yet made rounds for this resident because the rehabilitation aide had made rounds earlier. The rehabilitation aide reported that she had provided incontinence care to the resident only once at 7:30 a.m. that day and that resident rounds are supposed to occur every two hours and as needed, with her role limited to assisting with morning care. The DON stated she expects CNAs and nursing staff to conduct rounds every two hours and as needed, especially for dependent residents. The resident’s care plan, dated 11/7/2024, included an intervention to keep the skin clean and dry and to perform prompt toileting/incontinence care, and the facility’s August 2024 ADL policy required that dependent residents receive regular assistance with ADLs such as toileting, with all nursing staff and CNAs responsible for direct care.
Failure to Prevent Severe Burns Due to Bed Placement Near Radiator
Penalty
Summary
A cognitively impaired resident with diagnoses including dementia, heart failure, and cerebrovascular disease suffered severe burns after falling out of bed and coming into contact with a radiator heater. The resident's bed had been positioned against the wall, adjacent to the radiator, which was a standard room setup for two residents in the facility. The resident had a history of falls, confusion, and required assistance with bed mobility and transfers, as documented in care plans and assessments. On the night of the incident, the resident was last seen by staff at approximately 2:30 AM and was found around 3:00 AM lying on top of the radiator after a loud noise was heard from the room. Upon assessment, the resident was found to have burns on the right cheek, right arm, and right leg, with subsequent medical evaluation confirming first, second, and third-degree burns. The burns were severe enough to require hospitalization in an intensive care unit specializing in burn care for five days. Staff interviews revealed that the bed was placed against the wall due to room size constraints and that this was a common practice. The radiator cover had become dislodged during the fall, exposing the resident to the hot surface and resulting in the burns. Maintenance staff were not routinely checking the radiators unless issues were reported, and there was no prior awareness of burn incidents related to the radiators. Documentation and interviews indicated that the resident was at high risk for falls due to cognitive impairment, impaired mobility, and a recent history of falls. The care plan included interventions such as floor mats and one-person assistance for bed mobility, but did not address the hazard posed by the proximity of the bed to the radiator. The facility's failure to identify and mitigate the environmental hazard of the radiator heater, combined with inadequate supervision and monitoring of bed placement, directly led to the resident's injuries.
Removal Plan
- Resident R2's bed was moved away from the wall and heating unit.
- The Maintenance director/Designee completed rounds to ensure that all heating units are working adequately, and all beds are moved away from the heating unit/Wall.
- All staff were provided with education by the Maintenance director/Designee, training including but not limited to ensuring the positioning of beds are away from the heating unit/Wall.
- The Medical Director, Administrator, DON and Maintenance director reviewed the facility's policies which include but are not limited to: Guidelines on preventative maintenance measures.
- New hires will be in-serviced by the Maintenance, or Designee.
- All staff members who are currently on vacation, or are not available, will also receive the same education upon their return to work.
- The facility does not utilize agency staff however the same process of providing education to ensure that Agency staff will receive the same training as the facility staff prior to the start of their shift.
- The Maintenance director/designee will conduct audits to identify any potential concerns related to this plan of removal.
- During the weekends and holidays, the Maintenance director/Designee will conduct the audits, ensuring beds are away from the heating units. Any identified concern will be addressed immediately.
- To ensure compliance, the results of the audit will be reviewed during the meeting which is attended by the leadership which includes but is not limited to the: DON, ADON, Maintenance director and the Administrator/Designee.
- The Maintenance/Designee will conduct random staff interviews for at least 5 employees to gauge knowledge for retention and determine if additional training is required.
- Any identified concern will be addressed immediately and will also be discussed during the Adhoc QAPI.
- All results of the audits and unit rounds will be reported to the QAPI committee. An Ad-hoc QAPI meeting will be held to review results of the audits and rounds to determine if additional interventions are necessary to ensure compliance.
- The Administrator, Maintenance director and Designee will monitor completion of this plan of removal.
Failure to Maintain Sanitary Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for its residents by not addressing mold buildup in a common shower room. Multiple residents reported the presence of mold and uncollected wet towels and linens in the shower area, with one resident specifically stating that the common shower room was dirty and had mold around it. Observations confirmed the presence of blackish colored mold at the bottom of all four sides of the shower, as well as wet towels left on the floor. Staff interviews revealed that housekeeping was aware of the issue but had not cleaned or sanitized the area, citing a lack of available disinfectant. The Director of Nursing and Housekeeping Director both acknowledged that the shower room should be sanitized and mold-free, and that the issue had been reported by residents but not resolved due to waiting for disinfectant supplies. Facility records included a guideline for daily cleaning procedures, which specified that restrooms, including sinks and showers, should be disinfected. Despite these guidelines, the mold and unsanitary conditions persisted for several weeks, as confirmed by staff and resident interviews. The maintenance department was also noted as responsible for replacing a broken hot water sink knob in the same shower room, but this had not been addressed at the time of the survey.
Failure to Provide Proper Catheter Care Resulting in Infection
Penalty
Summary
The facility failed to follow its Indwelling Catheter Care policy for a resident diagnosed with Neuromuscular Dysfunction of the Bladder. The resident, who had moderate cognitive impairment, had a care plan indicating the need for catheter care to prevent trauma and promote cleanliness. Despite this, observations revealed that the resident's indwelling catheter drainage tube was covered with white particles and contained cloudy urine. The resident was unable to recall when the catheter was last changed, and staff interviews confirmed that catheter changes were only performed as needed, rather than on a regular schedule. The facility's policy required daily cleaning of the catheter insertion site, but the resident's catheter and surrounding area were found to be grossly soiled, with crust and foul-smelling liquid present. The resident was sent to the hospital with a fever and was found to have a grossly soiled indwelling catheter wrapped in the gluteal fold and around the leg, with purulent drainage and tenderness noted to the penis and lower abdomen. Hospital documentation confirmed the presence of a catheter-associated urinary tract infection, requiring antibiotic treatment. The hospital also noted minimal catheter output and significant post-void residual, indicating improper catheter function. These findings demonstrate that the facility did not provide appropriate catheter care or maintain cleanliness, resulting in a preventable infection and hospitalization.
Failure to Resolve Resident Grievance Regarding Missing Personal Property
Penalty
Summary
The facility failed to follow its grievance policy and resolve a resident's grievance within the required seven-day timeframe. A resident reported that his green personal phone had been missing for several months and that he had informed staff of the loss. The resident stated that the facility had not replaced the phone, and he was unable to contact his family as all contact information was stored on the missing device. The grievance form was dated nearly six months prior to the survey, and the administrator was unaware of the grievance until it was brought to her attention during the survey. The social services director acknowledged being informed of the missing phone but did not document discussions or actions taken, including the resident's involvement in the resolution process. The resident was his own responsible party, had a BIMS score of 11 out of 15, and was not capable of independent community outings. There was no documentation in the medical record or grievance form regarding the resident's participation in the decision not to replace the phone, nor was there evidence that the grievance was resolved within the required timeframe. The facility's grievance policy requires that grievances be answered within seven days and that the department head investigate and speak with the resident regarding the concern and possible resolution. These steps were not documented or completed as required.
Failure to Prevent Fire Hazard Due to Improper Use of Surge Protector
Penalty
Summary
The facility failed to follow its fire prevention policy by not ensuring that a resident's room was free from hazardous fire conditions. Specifically, a resident had a mini refrigerator plugged into an unapproved, non-medical grade surge protector, which was not approved by the maintenance director. The surge protector, which had six outlets, showed evidence of melting and irregular shapes on three of the plug inserts, as well as a melted area near the power button and a hole on the bottom. The refrigerator and surge protector were resident-owned and not provided or approved by the facility. The fire department confirmed that refrigerators should not be plugged into surge protectors, and the facility's own policy prohibits the use of ganged or multiple outlet plugs. The incident occurred when the resident heard popping noises, smelled burning, and observed black smoke and small sparks coming from the surge protector, followed by a small flame near the refrigerator cord. Both the resident and her roommate, who were alert and oriented at the time, evacuated the room and staff responded immediately. Observations after the incident revealed black soot on the floor and a burning smell in the room. The fire department report documented that maintenance quickly unplugged the unit upon arrival. This failure to adhere to fire safety policies had the potential to affect all residents on the unit.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse during a resident-to-resident altercation. One male resident with moderate cognitive impairment and a history of traumatic brain injury reported that his roommate became upset over closet space and became physical with him. The incident was witnessed by an LPN, who observed the two residents arguing, followed by one resident swinging his hand and hitting the other in the face, resulting in an abrasion under the left eye and a small amount of blood in the mouth. The altercation was reportedly unprovoked, and there was no prior history of altercations between the two residents. The roommate involved in the altercation had severe cognitive impairment, a history of aggressive or inappropriate behavior, and diagnoses including Parkinson's disease, dementia, and schizoaffective disorder. According to staff interviews, the roommate believed his belongings were being taken and was searching the other resident's closet. The situation escalated to a physical confrontation, which was not prevented by staff despite the roommate's known behavioral history. The facility's abuse policy affirms the right of residents to be free from abuse and outlines the responsibility to prevent such occurrences. Staff responded after hearing the commotion, intervened to separate the residents, and provided immediate care for the injury. However, the incident demonstrated a failure to intervene before physical abuse occurred, despite the presence of risk factors and a care plan that included staff intervention during verbal altercations. The deficiency was identified through interviews, record reviews, and direct observation, confirming that the facility did not fully protect the resident from abuse as required.
Failure to Administer and Document Physician-Ordered Pain Medications
Penalty
Summary
The facility failed to follow physician orders and ensure that as-needed pain medications were administered to residents as prescribed, affecting two residents with significant pain management needs. One resident with a complex medical history, including malignant neoplasm of bone, osteomyelitis, and a lumbar vertebrae fracture, reported that his pain was not managed well due to inconsistent administration of his prescribed medications. Documentation showed that several medications, such as lidocaine patches and gabapentin, were either not signed out as given or not available, despite being delivered by the pharmacy. The resident described experiencing excruciating pain and stated that staff did not understand his needs, with records confirming missed doses and incomplete documentation in the medication administration record (MAR). Another resident, admitted after knee surgery and with diagnoses including osteoarthritis and muscle weakness, also did not receive pain medications as ordered. The resident reported not receiving Norco consistently and rated his pain as severe. Review of the MAR confirmed that Norco was not administered for several days, and there was no documentation of tramadol administration, despite a physician order. Staff interviews revealed confusion regarding medication availability, lack of documentation, and failure to reorder medications in a timely manner. The nurse practitioner confirmed that orders were given, but the medications were not documented as administered, and the DON acknowledged lapses in documentation and medication management. Facility policies required that all medications be administered as ordered, with proper documentation in the MAR, and that pain management be based on resident reports and physician orders. However, the facility did not adhere to these policies, resulting in residents experiencing unmanaged pain and psychosocial harm. The failure to document medication administration and ensure medication availability directly contributed to the deficiency, as evidenced by resident statements, staff interviews, and review of medical records.
Failure to Administer and Document Pain Medications as Ordered
Penalty
Summary
The facility failed to ensure that staff administered ordered pain medications to residents according to their needs and as outlined in their care plans, and also failed to ensure that residents' medications were readily available. Two residents with significant pain management needs were affected, resulting in multiple missed doses of approximately nine different pain medications. These failures were identified through observation, interviews, and record reviews, and had the potential to affect all residents on the first floor. One resident with diagnoses including malignant neoplasm of bone, osteomyelitis, and a lumbar vertebrae fracture reported unmanaged pain due to inconsistent administration of pain medications. The resident stated that staff frequently told him he was not due for his medication and that alternative pain relief was not provided. Medication administration records showed that several pain medications, including lidocaine patches, hydrocodone, acetaminophen, and gabapentin, were either not signed as given or not available. Staff interviews confirmed that medications were sometimes not administered or documented, and that some medications were not on hand despite being ordered and delivered. Another resident, admitted post-knee surgery with a history of osteoarthritis and mobility issues, also reported inadequate pain control and inconsistent receipt of prescribed pain medications. The resident stated that he had not received his prescribed pain medication for several days and rated his pain as severe. Review of medication records revealed missed doses and lack of documentation for several pain medications, including hydrocodone, gabapentin, and tramadol. Staff interviews indicated that medication orders were not always entered or documented in the medication administration record, and that medications were not always available when needed.
Failure to Provide Consistent Access to Toilet Tissue in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident bathrooms were consistently stocked with toilet tissue, affecting four residents reviewed for personal hygiene equipment. Observations on multiple occasions revealed that several resident bathrooms lacked toilet paper, with no extra rolls available in the rooms. Residents reported going without toilet paper for days, and one resident expressed not knowing how to maintain personal hygiene without it. Additionally, dirty clothing was found on the floor due to the absence of plastic bags, and overflowing garbage cans with used adult incontinent diapers were observed in some rooms. Staff interviews confirmed that housekeeping was responsible for restocking supplies, but there were lapses in this process, and nursing staff did not have access to the necessary supplies to address shortages promptly. Housekeeping staff and supervisors acknowledged inconsistencies in stocking procedures, citing issues such as staff arriving late, budget constraints, and lack of access to storage areas for non-housekeeping staff. There was no standard policy or SOP provided by the company for housekeeping, and the only guidance available was a daily checklist. The Housekeeping Director admitted that sometimes only one roll was provided per room depending on the budget, and on weekends, supplies were left for staff to use in the absence of housekeeping. The lack of a clear policy and restricted access to supplies contributed to the ongoing issue of residents being left without essential hygiene items.
Failure to Secure Medication Carts and Improper Medication Administration
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled and securely stored in accordance with professional standards and facility policy. On multiple occasions, surveyors observed a treatment cart left unlocked and unattended in the hallway, as well as a crash cart in front of the elevator with broken plastic locks and an easily turned gray lock, making the contents accessible. Staff interviews confirmed that facility policy requires these carts to be locked when not in direct visual contact, and that the observed lapses were contrary to established procedures. Additionally, the facility's own policies specify that medication carts and supplies must be locked or attended by authorized personnel at all times. Surveyors also found that individual medications were not securely managed during administration. Two residents were observed with medication cups containing multiple pills left at their bedsides, with one resident unable to identify the pills and another stating that the nurse had left the medications for later consumption. Staff interviews revealed that medications should not be left at the bedside unless there is a physician's order and an assessment for self-administration, and that medications should not be signed as administered until the nurse has observed the resident take them. Facility policies reviewed by surveyors confirmed these requirements, but staff failed to adhere to them during the survey period.
Failure to Implement Effective Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to implement effective, individualized fall prevention interventions for residents identified as high risk for falls, particularly those with severe cognitive impairment and poor safety awareness. One resident with hemiplegia, muscle weakness, abnormal gait, and a history of falls experienced multiple incidents of self-transfer attempts resulting in falls. Despite being care planned for high fall risk, the resident was observed wearing regular socks instead of non-skid socks and was able to access and wear an AFO brace independently, contrary to staff instructions that it should only be used at night. Staff confirmed that the resident required minimal assistance with transfers and that the AFO brace was being kept in a drawer to prevent unsupervised use, but the resident had previously been able to put it on without supervision. Another resident with a history of falls, dementia, and wandering behavior was also identified as high risk for falls. This resident was found on the floor near a stairwell exit door after a fall, having sustained a fracture of the left humerus. The resident had a baseline of wandering and confusion, often requiring redirection to find her room or bathroom. Staff interviews confirmed that the resident was typically monitored in the dining room for safety, but on the day of the incident, she was able to access the exit door, which had an alarm and a delayed opening mechanism. The resident was found on the stairs with her wheelchair nearby, and staff responded to the alarm after the fall had already occurred. The facility's fall prevention and management policy required identification and evaluation of residents at risk for falls, with care plans updated and interventions implemented based on root cause analysis after each fall. However, the care plans and interventions in place for these high-risk residents were not sufficiently individualized or effectively implemented to prevent repeated falls and injuries, as evidenced by the incidents described and staff observations regarding supervision, use of safety equipment, and monitoring of wandering behaviors.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to maintain an available manual resuscitator and provide timely suctioning care for two residents with tracheostomies. For one resident, the manual resuscitator was not available at the bedside, which was confirmed by the Director of Nursing (DON). The resident, who is nonverbal and has a history of chronic respiratory failure, was observed with a tracheostomy attached to an oxygen concentrator. The Licensed Practical Nurse (LPN) noted that the resident had been having a lot of secretions and required frequent suctioning, yet the manual resuscitator, essential for emergencies, was missing. Another resident, also nonverbal and with a tracheostomy, was observed with thick secretions at the entrance of the trach tube. Despite the presence of secretions and a physician's order for suctioning as needed, the LPN did not suction the resident promptly. The resident's SPO2 level was found to be 89%, indicating a need for immediate suctioning, which was not performed in a timely manner. The Nursing Supervisor and DON both affirmed that the resident should have been suctioned immediately, as per the facility's tracheostomy care policy.
Infection Control Deficiencies in Tracheostomy Care and Equipment Disinfection
Penalty
Summary
The facility failed to maintain appropriate infection control practices for residents with tracheostomy tubes and during medication administration. Observations revealed that two residents, both non-verbal and requiring total assistance with activities of daily living, had their tracheostomy corrugated tubing and drainage collection bags touching the floor, which is against infection control protocols. The Director of Nursing and Assistant Director of Nursing acknowledged that the tubing and bags should not be in contact with the floor. The facility was unable to provide a policy regarding this issue. Additionally, the facility did not ensure proper disinfection of medical equipment between resident uses. A registered nurse and a licensed practical nurse were observed performing blood pressure checks on multiple residents without disinfecting the blood pressure cuffs between uses. The Director of Nursing and the Infection Preventionist confirmed that all medical equipment should be disinfected between resident uses to prevent infection transmission. The facility's policy on equipment cleaning, revised in October 2024, outlines the procedure for disinfecting equipment, but staff failed to adhere to these guidelines.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to implement adequate measures to prevent a resident from acquiring a pressure ulcer and did not update the wound care plan intervention. A resident, who has been bed-bound since July 2024 due to a stroke, developed a pressure ulcer on the sacral area that has not healed since last year. During an observation, the resident was found with a disposable brief soaked with feces, which had leaked onto the bottom sheet, contaminating the sacral wound dressing. This indicates a lack of prompt incontinence care, which is crucial for preventing skin impairment and promoting wound healing. The Assistant Director of Nursing, who also serves as the Wound Care Director, acknowledged that the resident's Braden scale/skin assessment indicated a high risk for skin impairment. Despite this, the wound care plan was not updated when a new pressure ulcer was acquired. The facility's policy requires that each new wound identified should lead to an updated care plan intervention after assessment and informing physicians for new treatment orders. The resident's comprehensive care plan included interventions for keeping the skin dry and providing prompt incontinence care, which were not adequately followed, contributing to the deficiency.
Inadequate Supervision Leads to Unwitnessed Falls
Penalty
Summary
The facility failed to provide adequate supervision to a dependent resident, identified as R108, who is at high risk for falls and has experienced several unwitnessed falls in his room. R108, who has a history of stroke and is bed-bound with a tracheostomy, requires total care for activities of daily living and transfers. Despite being at high risk for falls, as indicated in both the admission and recent fall assessments, R108 was placed at the far end of the facility, away from the nursing station, which raised concerns from family members about the adequacy of supervision. The resident experienced two unwitnessed falls, one on 12/29/24 and another on 2/1/25, both resulting in hospital evaluations. The Director of Nursing (DON), who also serves as the fall coordinator, acknowledged that after each fall, a root cause analysis is conducted, and individualized care plan interventions are developed. However, the facility did not document frequent rounding for high-risk residents, including R108, which is a part of their fall prevention management policy. The facility's policies on fall prevention and patient monitoring emphasize the importance of identifying residents at risk for falls and implementing preventive strategies, yet the lack of documentation and the placement of R108 away from the nursing station suggest a failure to adhere to these protocols effectively.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that resident call lights were within reach, affecting two residents out of a sample of 25 reviewed for accommodation of needs. On February 25, 2025, one resident was observed in bed with the call light placed behind a curtain on top of a dresser, and another resident was found in a similar situation, unable to reach the call light and stating that it is usually next to her. A restorative aide acknowledged the issue, stating that call lights should be within reach but was unsure why they were placed on the dresser. The Director of Nursing confirmed that the expectation is for call lights to be within reach at all times and answered promptly. The first resident was admitted with diagnoses including surgical aftercare, bacteremia, hyperlipidemia, diabetes type 2, and depression, requiring assistance with activities of daily living (ADLs) and an intervention to keep call lights within reach. The second resident was admitted with diagnoses including aphasia, a history of falling, hyperlipidemia, seizures, and hypertension, also requiring assistance with ADLs and an intervention to keep call lights within reach. The facility's policy, revised in September 2024, mandates that call lights be within residents' reach at all times.
Deficiency in Nail, Foot, and Incontinence Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail and foot care, as well as timely incontinence care, to a dependent resident, identified as R108. Observations revealed that R108, who is bed-bound due to a stroke and has multiple medical conditions including a stage 4 pressure ulcer, had long, dirty fingernails and thickened, discolored toenails. The CNA and Wound Care Nurse acknowledged that CNAs are responsible for nail care, while foot care is typically referred to a podiatrist. Additionally, during a wound care preparation, R108 was found with a disposable brief soaked with feces, which had leaked onto the bed sheet and contaminated the sacral wound dressing. The Director of Nursing confirmed that CNAs are responsible for nail care during daily ADLs, and social services should schedule podiatrist consultations. The facility's policies on nail, foot, and incontinence care emphasize maintaining hygiene, preventing infection, and ensuring resident comfort. However, these policies were not adhered to, as evidenced by the prolonged exposure of R108 to fecal matter, which the Director of Nursing acknowledged could impair wound healing. The comprehensive care plan for R108 indicates a need for total assistance with personal hygiene and grooming, highlighting the facility's failure to meet these care requirements.
Failure to Provide Timely Assessment and Intervention for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure ongoing assessment and appropriate care for a resident, identified as R108, who was totally dependent and had limited range of motion (ROM) to prevent contractures. R108, who suffered a stroke and was bed-bound since July 2024, was observed with an extension contraction in the right hand wrist and did not have a splint. The Restorative Nurse, V11, was unaware of R108's condition until informed by the surveyor and could not find a restorative admission assessment for R108. It was only after the surveyor's inquiry that V11 conducted an assessment and referred R108 to occupational therapy (OT) for a right hand splint. The Therapy Director, V12, evaluated R108 and recommended the use of a resting hand splint to prevent contractures. The facility's policy on Restorative Nursing Program and Splints requires residents to be screened for restorative programs upon admission and evaluated for splint use based on assessed deformities or contractures. However, these protocols were not followed for R108, leading to a delay in the implementation of necessary interventions to prevent further decline in the resident's condition.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to ensure that medication error rates were not 5 percent or greater, affecting one of four residents reviewed for medication administration. During an observation, a Licensed Practical Nurse (LPN) administered Aspirin 81mg chewable and Senna 8.6mg to a resident. However, the physician's order specified that the resident should receive Aspirin 81mg in capsule form and two tablets of Sennosides 8.6mg. The Director of Nursing was informed of these findings and acknowledged that nurses should follow physician orders when administering medications. The resident involved was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, type 2 diabetes mellitus without complications, other seizures, gastrostomy status, and muscle weakness. The facility's policy on medication administration requires checking the medication administration record for the correct medication, dose, route, patient, and time, and verifying any discrepancies between the MAR and the label before administering medications.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a fall care plan with interventions for a resident assessed as high fall risk, resulting in the resident sustaining significant injuries. The resident, a male with a history of cerebral vascular accident, hemiplegia, respiratory failure, diabetes, and clostridium difficile, was admitted without a fall care plan in place. On the evening of the incident, the resident was found on the floor with injuries including broken ribs and a dislocated shoulder. The Licensed Practical Nurse (LPN) on duty had previously observed the resident with his leg dangling off the bed but did not implement any specific fall prevention measures. The Director of Nursing (DON) did not report the incident to the Illinois Department of Health due to the absence of hospital x-ray results, despite the nurse's progress notes indicating significant injuries. The facility's policy requires a fall risk evaluation upon admission and the implementation of interventions for residents at risk, which was not followed in this case. The Restorative Director confirmed that no fall care plan was initiated or updated for the resident, and the expectation was for the admitting nurse to complete a fall evaluation and enter a basic fall care plan if the risk score was high.
Failure to Follow Laboratory Specimens Policy
Penalty
Summary
The facility failed to adhere to its Laboratory Specimens policy, resulting in the inability to process a urinalysis and culture/sensitivity test for a resident. The resident, who was admitted to the facility with intact cognition, reported an odor in her urine, prompting the need for a urine sample. The first sample collected was not labeled, leading to its cancellation by the laboratory. A second sample was collected, but it was not accompanied by the necessary requisition form, preventing the lab from processing it. Consequently, the resident decided to seek testing from her primary care provider, who diagnosed her with a urinary tract infection and prescribed antibiotics. The deficiency was further highlighted by the statements from the facility's Nurse Practitioner and Director of Nursing (DON). The Nurse Practitioner confirmed the orders for urinalysis and culture/sensitivity tests and acknowledged the issues with the labeling and requisition. The DON stated that they were unaware of the missing lab results until the resident began antibiotic treatment. The facility's policy, revised in 2017, requires proper labeling and requisition for lab specimens, which was not followed in this case, affecting the quality of care provided to the resident.
Failure to Ensure Timely and Private Delivery of Resident Mail
Penalty
Summary
The facility failed to ensure a resident's right to receive unopened personal mail in a timely manner, affecting one resident in a sample of six. The resident, who is cognitively intact, reported receiving a letter from the Illinois Department of Public Health (IDPH) that was opened and without an envelope for appeal. The letter was mailed on December 4th and handed to the resident on December 13th by a staff member who claimed it was already opened when she picked it up. The Business Office Manager, responsible for collecting mail, stated that she does not open personal mail from IDPH and that the mail turnaround process is typically daily, with a maximum of two days. However, the resident's mail was delayed for ten days, and no grievance form was completed regarding the issue. The facility's administrator confirmed that the resident had signed a consent form allowing the facility to open certain types of mail, but this did not include personal mail or correspondence from IDPH. The administrator acknowledged that the letter was opened by mistake. The facility's admission contract specifies the types of correspondence that can be opened, excluding personal mail and IDPH findings. The Long Term Care Ombudsman Program Residents Rights states that facilities must deliver and send mail promptly and may not open mail without permission.
Failure to Provide Transportation for Medical Appointment
Penalty
Summary
The facility failed to provide necessary transportation for a resident to attend a scheduled dermatology appointment. The resident, identified as R1, had an appointment on August 27, 2024, which was documented in the appointment book by the facility scheduler. However, the resident missed the appointment because the facility's van, which was supposed to transport her, had a broken wheelchair lift. The facility van driver confirmed the issue with the van, but could not recall the specific problem. The assistant administrator also acknowledged that the wheelchair lift was broken, preventing the transportation of the resident. The executive director admitted that the facility did not arrange alternative transportation for the resident, despite being aware of the transportation issue. The facility's policy on appointments and transportation requires staff to make transportation arrangements unless the resident's family chooses to do so. In this case, the facility staff failed to adhere to the policy by not arranging alternative transportation, resulting in the resident missing her medical appointment.
Failure to Administer Prescribed Medication Due to Reordering Error
Penalty
Summary
The facility failed to obtain medication from the pharmacy for one resident, identified as R2, who was prescribed Alprazolam 1 MG for anxiety. R2's Medication Administration Record (MAR) indicated that the medication was out of stock on 8/21/24, and a note by an LPN stated that the pharmacy would follow up with an insurance order for the next day. Despite the facility's policy to provide pharmaceutical services to ensure the accurate acquiring and dispensing of medications, the dose was missed because it was not reordered in time. Interviews with facility staff revealed that the Director of Nursing was unaware of the missed dose, and the Nurse Practitioner, who reordered the medication, was not informed that the morning dose was not administered. The LPN responsible for administering the medication confirmed that it was unavailable due to a failure to reorder. The facility had a medication dispensing system (cubex) that could have been used to obtain the medication, but this option was not utilized, leading to the deficiency.
Failure to Identify and Treat Resident's Wound
Penalty
Summary
The facility failed to identify and treat an open wound on a resident, leading to the resident being admitted to the hospital where maggots were found in the wound. The resident, who had a history of end-stage renal disease, type 2 diabetes, heart failure, and transient ischemic attacks, was sent to the hospital for evaluation of left leg swelling. Upon admission to the hospital, a wound with maggots was discovered on the plantar surface of the resident's right foot, which had not been identified or treated by the facility prior to the transfer. Interviews with facility staff revealed inconsistencies in skin assessment practices. A CNA stated that skin checks were performed during daily bed baths, but was unaware that the resident's feet needed to be checked daily as part of the care plan. Another CNA, who worked with the resident before the hospital transfer, reported not seeing any open areas or skin concerns. A nurse claimed to have conducted a full body skin assessment before the resident left for the hospital, denying the presence of any open areas. However, the Director of Nursing and the Wound Care Coordinator were not aware of any current wounds on the resident, and there was no documentation of a skin assessment being completed before the hospital transfer. The facility's policy on wound prevention and healing requires skin inspections during showers, daily or weekly skin checks, and as needed. However, the documentation reviewed did not indicate any daily skin checks to the resident's feet, and there were no orders for wound treatments for the right foot. The care plan included interventions for skin integrity and diabetes management, such as washing and inspecting feet daily, but these were not followed. The presence of flies in the facility was noted by staff and residents, which could have contributed to the maggot infestation in the wound.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for administering psychotropic medications to a resident, identified as R2, prior to administration. R2, who has a history of dementia, osteitis, convulsions, and violent behavior, was transferred to the facility and was noted to have mild cognitive impairment. Observations and interviews revealed that R2 was experiencing increased lethargy and confusion, which raised concerns among family members. The family reported that they had not given consent for the medications being administered, and during a care plan meeting, their concerns about the medication regimen were not addressed by the facility staff. The facility's medication administration records indicated that R2 was receiving several medications, including Olanzapine, Gabapentin, Duloxetine, Cyclobenzaprine, Hydrocodone-acetaminophen, and Lorazepam. The primary physician noted that some of these medications, such as Olanzapine and Cyclobenzaprine, could contribute to R2's lethargy and were not necessarily appropriate given R2's condition. Additionally, the psychiatric PA managing R2's psychotropic medications stated that they had recommended an increase in Aripiprazole, not Olanzapine, and that consent was required before administering any new psychotropic medication. The facility's policy on psychotropic drug use requires informed consent from the resident or their representative before administering such medications. However, the facility failed to provide signed consents for the psychotropic medications administered to R2, including Olanzapine. The Director of Nursing confirmed that consent is necessary before entering medication orders into the electronic health record, but this process was not followed, leading to the deficiency.
Failure to Initiate Resident Discharge and Update Care Plan
Penalty
Summary
The facility failed to initiate a discharge for a resident upon request and did not update the discharge care plan to reflect the resident's desire for transfer. The resident, who has diagnoses including dementia and mild cognitive impairment, was transferred to the facility and expressed a desire to move to another long-term care facility. Despite the family's involvement and repeated requests since April, the facility did not send the necessary transfer information to the chosen facility. The family provided evidence of communication with the facility's Social Services Director, but the transfer documents were never sent. The Executive Director and Administrator acknowledged the oversight, with the Social Services Director unable to provide confirmation of the transfer packet being sent. The care plan for the resident was not updated to include the request for transfer, and the facility's policy on discharge did not include a process for resident-initiated discharge. This lack of action and documentation led to the deficiency noted in the survey.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to follow physician orders for two residents, R2 and R3, regarding medication administration. For R2, a psychiatric PA recommended an increase in the dosage of aripiprazole from 10mg to 15mg due to psychotic symptoms. However, this change was not transcribed into the Physician's Order Sheet, and instead, olanzapine was incorrectly ordered. The Director of Nursing and the Psychotropic Nurse were responsible for entering the medication orders into the electronic health record, but the error was not identified until the PA's follow-up visit. The Director of Nursing was unaware of the change and could not explain why the incorrect medication was ordered. For R3, the facility failed to ensure the timely ordering of tizanidine, a medication prescribed for back spasms. R3 reported that the medication was unavailable for several days in June, which was confirmed by the medication administration record showing missed doses from June 16th to 21st. The Director of Nursing acknowledged that R3 is particular about medication timing and takes the medication daily, although it is ordered as needed. Despite the use of agency nurses, the facility did not have a written policy for re-ordering medications, and no documentation was provided to show that the medication was accessed from the convenience machine during the period in question.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that stock medications, eye drops, and insulins were labeled with open and expiration dates, and failed to dispose of expired medications. These deficiencies were observed during a medication storage and labeling review on multiple medication carts and rooms. Specific instances included an undated Humalog insulin vial for a resident with diabetes, undated Cromolyn Sodium Ophthalmic Solution for another resident, and undated Levetiracetam for a resident with epileptic syndrome and cerebral infarction. Additionally, several floor stock medications such as Pro Stat, Bismuth Subsalicylate, and Acetaminophen were found open and undated. Licensed Practical Nurses (LPNs) acknowledged the lack of proper labeling and dating of these medications during the observations. Further observations revealed undated Lactulose Suspension for a resident with chronic viral hepatitis, undated multidose vials of Tuberculin, and undated eye drops and insulins for other residents. Expired medications, including Haloperidol and Scolamine gel, were also found. The Unit Manager and the Director of Nursing confirmed that medications should be dated when opened and discarded when expired. Facility policies on medication storage and administration were presented, indicating that medications should be stored securely and properly, and that the date of opening should be recorded on multi-dose containers. However, these policies were not adhered to, leading to the observed deficiencies.
Failure to Provide Adequate ADL Care and Grooming
Penalty
Summary
The facility failed to ensure staff provided adequate shower/bed bath and grooming for residents dependent on staff for Activities of Daily Living (ADL). This deficiency affected six residents, including a resident with multiple sclerosis and a history of falling, who had not had her hair washed or combed since admission, resulting in matted and painful hair. The resident also reported waiting more than four hours to be changed after sitting in urine, leading to redness on her bottom. Another resident with chronic obstructive pulmonary disease and respiratory failure reported not being changed since the previous night and not receiving showers or bed baths as scheduled. The staff confirmed that they were short-staffed, which contributed to the delay in providing care. A resident with a history of cerebral infarction and chronic kidney disease was observed with overgrown hair and beard, indicating a lack of grooming assistance. The resident stated that he had not been washed and could not remember the last time he had a shower or bed bath. Another resident with a colostomy and type 2 diabetes reported that call light response times were excessively long, and he did not receive regular showers or bed baths. The facility's Assistant Director of Nursing (ADON) acknowledged that CNAs were supposed to follow the shower schedule and provide necessary ADL care, including grooming and nail care, but this was not being consistently done. A resident with cerebral infarction and aphasia was observed with a strong urine odor and soiled linens, indicating a lack of incontinence care. The resident's family member confirmed that the resident often remained in a urine-soaked bed until late in the day. The facility's Assistant Administrator stated that the resident had a history of refusing ADL care, but the care plan did not include personalized interventions to address these refusals. Another resident with type 2 diabetes and morbid obesity reported long call light response times and inconsistent assistance with showers and bed baths. The facility's grievance policy was not effectively addressing these concerns, as the resident's complaints were not documented in the grievance records.
Insufficient Nursing Coverage on Third Floor
Penalty
Summary
The facility failed to ensure sufficient nursing coverage to adequately meet the residents' care needs on the third floor, affecting all 45 residents. On multiple occasions, residents reported not receiving timely incontinence care due to staffing shortages. For instance, one resident stated she had not been changed since the previous night, and another resident was found with a heavily soiled incontinence brief. Certified Nursing Assistants (CNAs) confirmed that they were short-staffed, with only three CNAs available instead of the required four, making it difficult to provide adequate care, especially with the new 'care in pairs' intervention requiring a female CNA to be present during incontinence care performed by a male CNA. The facility's administrator acknowledged the staffing issues but did not believe it was a problem, despite CNAs and residents expressing concerns. The staffing schedules and interviews revealed that the third floor often operated with insufficient staff, particularly during the 11 PM to 7 AM shift, where only one nurse was scheduled for 45 residents. This lack of adequate staffing led to delays in care and unmet needs, as evidenced by residents' complaints and observations of soiled briefs and unkempt appearances.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 31.03% error rate. This deficiency was observed during medication administration for six residents. Specific errors included incorrect dosages, missed medications, and the administration of medications without proper physician orders. For instance, R22 received an incorrect dose of Aspirin, and R37 did not receive a prescribed Lidocaine patch due to its unavailability. Additionally, R19's medication was held without written parameters, and R15 did not receive multiple prescribed medications, including Folic Acid and Budesonide-Formoterol Fumarate Inhalation Aerosol. Further observations revealed that R1 did not receive Flonase for seven days, and R92 was given an incorrect dose of Gabapentin. The report also highlighted that extended-release medications were crushed without proper orders, contrary to the facility's policy. Interviews with staff confirmed these discrepancies, and it was noted that the facility's policies on medication administration and crushing extended-release medications were not followed, contributing to the high error rate.
Failure to Document Medication Administration in EMAR
Penalty
Summary
The facility failed to document medication administration in the Electronic Medical Record (EMAR) in accordance with acceptable clinical practice for seven residents. On the specified date, an LPN admitted to not signing the medications immediately after administration, contrary to the facility's policy. The LPN stated that they typically pass all medications first and then document them later, which was observed as a deviation from the expected practice. This practice was confirmed by the Director of Nursing and the Assistant Director of Nursing, who both emphasized that medications should be signed off immediately after administration to ensure accurate documentation and prevent errors. The residents involved had various medical conditions requiring multiple medications at specific times. For instance, one resident had diabetes and a sacral pressure ulcer, another had diabetes and acute kidney failure, and others had conditions such as atrial fibrillation, hypertension, chronic back pain, asthma, chronic obstructive pulmonary disease, and cerebral infarct. The failure to document medication administration as per the facility's policy was observed across multiple residents, indicating a systemic issue in the medication administration process on that particular unit.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow its enhanced barrier precaution policy by not placing signage with informational material on a resident's door or making personal protective equipment (PPE) available inside or outside the resident's room. Additionally, staff did not perform hand hygiene between glove changes during wound care observation, failed to clean blood pressure machines and glucose monitors after use between patients, and did not keep linen in a closed hamper with the lids closed. These failures affected six residents reviewed for infection control practices. On multiple occasions, surveyors observed staff members not adhering to infection control protocols. For instance, a Licensed Practical Nurse (LPN) was seen taking blood pressure on different residents without cleaning the blood pressure cuff in between. Another LPN was observed performing blood sugar checks and handling medications without proper hand hygiene or glove use. During a wound care observation, a wound care nurse did not perform hand hygiene between glove changes and left soiled linen hampers open in the resident's room. One resident, who had a wound on his bottom, was not placed on enhanced barrier precautions as required. There was no signage on the door, and no isolation bin was available inside or outside the room. The infection prevention nurse was unaware that the resident needed to be on any type of isolation and stated that the wound team did not communicate this information to her. The facility's policies on cleaning and disinfection, administering medications, hand hygiene, and linen management were not followed, leading to these deficiencies in infection control practices.
Failure to Refer Resident for PASARR Level II Assessment
Penalty
Summary
The facility failed to refer a resident with new mental health diagnoses for a Level II PASARR assessment. The resident, a [AGE] year-old male, was diagnosed with Recurrent Major Depressive Disorder and Adjustment Disorder with Mixed Anxiety and Depressed Mood after his admission. Despite these diagnoses, the resident's medical records did not include a PASARR Level II Assessment. The Psychotropic/Falls Nurse noted that the resident sometimes could not be calmed down or deescalated and suggested that he might belong in a different type of facility. The facility administrator confirmed that there was no PASARR policy in place, and the facility could not provide an answer regarding the necessity of a PASARR Level II Assessment for the resident during the survey exit interview.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plan interventions for three residents with specific needs. One resident, a male with a history of cerebral infarction and aphasia, was observed with a strong odor of urine and was often found in a urine-soaked bed. Despite his refusal of ADL care, his care plan did not include personalized interventions to address his refusals, and his progress notes did not document any refusals of ADL care attempts. His family member expressed concerns about his lack of attention and assistance, indicating a need for more prompting and support for his daily activities. Another resident, a male with end-stage renal disease and nicotine dependence, was observed multiple times with a strong odor of marijuana and signs of being under the influence. Despite these observations, his progress notes did not include any documentation of substance use, and his care plan lacked personalized interventions regarding substance use. The facility's staff acknowledged the issue but did not have a consistent approach to addressing it, leading to potential safety concerns and the impact on his dialysis treatment. The third resident, a male with recurrent major depressive disorder and adjustment disorder, exhibited aggressive and maladaptive behaviors, including attempts to elope and physical and verbal aggression towards staff. His care plan did not include personalized behavioral interventions to address the causes of or prevent these behaviors. Despite multiple incidents of aggression and elopement attempts documented in his progress notes, the facility did not have a comprehensive approach to managing his behaviors, leading to repeated episodes of aggression and the need for psychiatric evaluations.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to follow its policy and procedure for ensuring residents receive necessary behavioral health care and services. This deficiency was observed in two residents, one of whom was noted to have a strong odor of marijuana and exhibited signs of substance use, such as red and droopy eyes. Despite these observations, the resident's care plan did not include personalized interventions regarding substance use, and there were no progress notes documenting observations of substance use. Additionally, the social services department was not notified of the resident's substance use, contrary to the facility's stated procedures. Another resident with a history of recurrent major depressive disorder and adjustment disorder exhibited aggressive and elopement behaviors. Despite multiple incidents of aggression and attempts to leave the facility, the resident's care plan did not include personalized behavioral interventions to address or prevent these behaviors. Progress notes also lacked documentation of communication with the psychiatric care team regarding the resident's behaviors. The resident primarily engaged in self-directed activities and had limited participation in group activities, with no documentation of referrals for group or supervised outside psychosocial services activities. The facility's comprehensive care plan policy states that care plans should be person-centered, measurable, and based on comprehensive assessments. However, the care plans for the two residents in question did not meet these criteria. The facility also failed to provide a policy for substance abuse or behavioral health services when requested by the surveyors. This lack of adherence to policy and procedure resulted in the failure to provide necessary behavioral health care and services to maintain the residents' highest practicable mental and psychosocial well-being.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to safely reposition a resident during direct resident care and failed to ensure supervision of residents with a history of aggression. This affected five of six residents reviewed for supervision and safety. One resident, R9, rolled from the bed while receiving incontinence care, sustaining a laceration to the head that required treatment at a local hospital. The incident occurred because the CNA misjudged the amount of bed space available, leading to the resident falling and hitting their head on a nightstand. The resident was totally dependent on staff for all activities of daily living and had a high risk for falls due to poor trunk control, paraplegia, and seizures. The facility's falls nurse confirmed that the incident was due to improper space management during the repositioning process by the CNAs involved. Additionally, the facility failed to supervise residents with a history of aggression adequately. One resident, R4, attacked another resident, R3, with a butter knife, resulting in a head injury. Another incident involved R8 throwing a walker at R7, causing bruising to R7's left arm. Both aggressive residents had documented histories of aggressive and inappropriate behavior, with care plans indicating the need for supervision and medication management. Despite these documented needs, the facility did not provide adequate supervision to prevent these incidents. The facility also failed to follow their elopement policy by not contacting the local police when a resident, R14, did not return from an independent community pass. The resident had a history of not returning from passes, and the facility's former administrator decided not to contact the police, considering it a case of leaving against medical advice. This decision was made despite the facility's policy requiring police notification if a resident is missing. The lack of documentation and follow-up during the period the resident was missing further highlights the facility's failure to adhere to its elopement policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in multiple incidents of resident-to-resident abuse. One incident involved a resident (R4) stabbing another resident (R3) with a butter knife after a verbal disagreement over the television volume. Despite R3 reporting the incident to the former administrator and his case manager, the facility's response was delayed, and the incident was not documented in R3's medical record until nearly three months later. The assistant administrator admitted to not documenting well-being checks in a timely manner and was unaware of the details in R4's hospital record upon re-admission. Another incident involved a resident (R8) throwing a walker at another resident (R7), causing a bruise on R7's left arm. R7 reported the incident to the former administrator, and the facility's investigation noted that R8 was sent to the hospital for psychiatric evaluation. However, there was a lack of immediate intervention and documentation by the staff present during the incident. The facility's abuse investigation revealed that R8 had a history of aggressive and inappropriate behavior, which was not adequately managed. A third incident involved a resident (R6) slapping another resident (R5) in the face. The facility's investigation noted that R5 reported the incident, and R6 was placed on 1:1 monitoring until sent to the hospital for psychiatric evaluation. However, staff members interviewed during the survey had vague recollections of the incident and did not witness it directly. The facility's failure to follow its abuse prevention policy and adequately document and address these incidents resulted in multiple instances of resident-to-resident abuse.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse policy and immediately report an incident of resident-to-resident abuse to the regulatory agency. This incident involved two residents, R3 and R4, where R4 threatened R3 with a butter knife during a verbal altercation over the volume of the television. R3 reported the incident to the former administrator, and the residents were separated, with R4 being sent to the hospital for psychiatric evaluation. However, the incident was not reported to the regulatory agency until over two months later when R3's case manager informed the facility on 7/26/23. R3 was assessed to be cognitively intact with a BIMS score of 15 out of 15 and was able to make his needs known. Despite this, the assistant administrator, V2, did not document the incident in R3's medical record until nearly three months later. V2 stated that he thought it was only a verbal dispute and did not ask R3 for details about any physical contact. The facility's investigation notes that R4 had a history of aggressive behavior and was delusional at the time of the incident, which led to his hospitalization. The facility's abuse prevention policy requires immediate reporting of any allegations of abuse to the State licensing agency. However, the facility did not adhere to this policy, resulting in a significant delay in reporting the incident. The administrator, V1, confirmed that the expectation is for staff to report any allegations of abuse immediately and to intervene to prevent escalation. The failure to report the incident promptly and document it accurately in the medical records constitutes a deficiency in the facility's adherence to its abuse policy.
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.
