Norridge Gardens
Inspection history, citations, penalties and survey trends for this long-term care facility in Norridge, Illinois.
- Location
- 7001 West Cullom, Norridge, Illinois 60634
- CMS Provider Number
- 145329
- Inspections on file
- 42
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Norridge Gardens during CMS and state inspections, most recent first.
Staff did not consistently implement fall precautions for two residents at high risk for falls, as evidenced by beds not being kept at the lowest position and call lights and personal items being out of reach. Multiple staff, including an LPN and CNA, confirmed these lapses during observations and interviews, despite care plans and fall risk assessments indicating the need for these interventions.
The facility failed to follow its Water Management Program, lacking documentation for legionella testing and monitoring in unoccupied rooms. Additionally, staff did not adhere to PPE and hand hygiene protocols, with a nurse administering medications to a resident on contact precautions for MRSA without an isolation gown, and staff not changing gloves or performing hand hygiene during resident care.
The facility failed to provide adequate grooming and hygiene care to residents dependent on staff for ADLs. Observations revealed residents with long, dirty fingernails, overgrown facial hair, and soiled incontinence briefs. Despite being present, staff did not address these issues, contradicting the facility's stated practices.
The facility failed to label and date medications properly and ensure accurate narcotic counts. Insulin and Ozempic were found opened and undated, and discrepancies were noted in narcotic logs for several residents. Staff personal items were also improperly stored in medication carts.
Two residents in a facility were not provided with appropriate splinting for their contractures as per physician orders. One resident with severe cognitive impairment and hemiplegia was found without a splint on his contracted hand, causing pain during attempts to open it. Another resident was observed multiple times without a required hand splint due to staff oversight, despite physician orders and facility policy.
The facility failed to provide safe transfer and feeding supervision to residents requiring assistance with ADLs. A resident with multiple diagnoses was assisted to the bathroom without a gait belt, contrary to the care plan. Another resident with morbid obesity and Alzheimer's was also transferred without a gait belt. Additionally, a resident with Parkinson's and dementia was left unsupervised during meals, against dietary instructions. These actions were inconsistent with care plans and standard practices.
Two residents did not receive the prescribed double protein portions during meal service. Despite physician orders and care plans indicating the need for double protein at lunch, both residents were served single portions of mechanical soft polish sausage. The dietary manager acknowledged the error, and the dietitian confirmed the double protein recommendation due to food preference and history of weight loss.
The facility failed to offer the PCV20 vaccine to three residents who were eligible, despite having received the PCV13 vaccine. The residents, with various chronic conditions, were not documented as having been offered or refused the additional vaccine, contrary to the facility's policy and CDC guidelines.
The facility failed to make survey results readily available for residents, affecting all 206 residents. During a resident council meeting, attendees reported never seeing a binder with survey results. Observations confirmed the absence of such a binder in common areas. The administrator was unable to locate the binder, confirming the deficiency.
Two residents in the facility did not receive showers twice a week as per policy. One resident, with multiple health conditions, was scheduled for baths twice weekly but reported only receiving them once due to staff time constraints. Documentation inaccurately showed refusals, with no nursing notes to confirm. Another resident, requiring substantial assistance, also reported staff being too busy to provide showers, with documentation incorrectly indicating refusals. Both residents expressed that staff claimed they had no time or it was not their scheduled day, contrary to facility policy.
A resident with moderately impaired cognition was found with medications left at their bedside, contrary to facility policy requiring staff to remain until all medications are taken. The incident involved typical morning medications, and the responsible RN claimed to have observed the resident taking them, despite evidence to the contrary.
The facility failed to provide timely incontinent care to two residents with cognitive impairments, resulting in them being found with heavily soiled and discolored briefs. The care plans for both residents included interventions for the risk of impaired skin integrity, which were not followed.
A nurse and a CNA were observed performing a straight catheterization on a resident without cleaning the labia area and without using sterile gloves. The resident had a history of UTIs and required catheterization every four hours. The Director of Nursing confirmed that the staff did not follow the proper guidelines for catheter care.
The facility failed to provide timely incontinence care for three residents requiring extensive assistance. Residents were found with saturated incontinence briefs and wet sheets, indicating that care was not provided as per the care plans and facility policy, which required checks every two hours.
Failure to Implement Fall Precautions for High-Risk Residents
Penalty
Summary
Facility staff failed to implement fall precautions for two residents identified as high risk for falls. One resident was observed multiple times with her bed not in the lowest position, her call light out of reach, and personal items such as water inaccessible. This resident had a history of multiple falls and her care plan specified that her bed should be kept at the lowest position and her call light within reach. Staff, including an LPN and CNA, confirmed these deficiencies during interviews and observations. The resident was also noted to have a bandaged arm and some confusion, further increasing her vulnerability. Another resident was found sitting on her bed with her feet on the floor, unable to reach her call light, which was tied to a grab bar and hanging to the floor. She expressed the need for assistance to use the bathroom but could not call for help due to the call light's placement. Staff interviews confirmed that fall precautions for residents with a history of falls include keeping beds at the lowest position and ensuring call lights and personal items are within reach. These precautions were not consistently implemented, as evidenced by direct observation and staff acknowledgment.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its Water Management Program, which is designed to reduce the risk of Legionnaire's disease. The Maintenance Director admitted that while monthly water quality tests are performed using a TDS probe, the results are not documented, and there is no evidence of legionella testing prior to December 4, 2024. Additionally, the facility lacks documentation for daily flushing, water temperature, or chlorine level monitoring in unoccupied rooms, as required by their policy. The facility also did not follow its policy for Personal Protective Equipment (PPE) during the care of a resident in contact isolation. A nurse administered medications to a resident on contact precautions for MRSA without wearing an isolation gown, only using gloves. The nurse was unsure of the specific contact precautions required for the resident, indicating a lack of adherence to the facility's infection control protocols. Furthermore, the facility failed to comply with its hand hygiene and glove use policy during resident care. Two separate incidents were observed where staff members did not change gloves or perform hand hygiene between tasks, despite providing personal care to residents. This non-compliance with standard infection control practices poses a risk of spreading infections among residents.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate incontinence care, oral care, and grooming to residents who were dependent on staff for these activities of daily living (ADLs). Observations revealed that several residents had long, untrimmed fingernails with black or brown substances underneath, indicating a lack of regular nail care. Additionally, some residents had overgrown facial hair, which was not addressed despite being unbecoming and against the facility's grooming standards. These deficiencies were observed in residents with severe cognitive impairments and those requiring maximum assistance for self-care activities. Specific instances included a male resident with hemiplegia and dementia who was found with a heavily soiled incontinence brief and dry stool stuck to his skin, requiring extensive cleaning. His fingernails were long and dirty, and his skin was extremely dry and flaky. Another resident with Parkinson's disease and dementia was observed with long facial hair and unkempt fingernails, despite being dependent on staff for grooming. Similar issues were noted in other residents, including those with Alzheimer's disease and other cognitive impairments, who were seen with long chin hairs and dirty, jagged fingernails. The facility's policies for ADLs, including nail care and shaving, were not adhered to, as evidenced by the repeated observations of residents with poor hygiene and grooming. Staff members, including CNAs and nurses, were present during these observations but did not take action to address the deficiencies. The Director of Nursing acknowledged the facility's practice of ensuring residents are well-groomed, yet the observed conditions of the residents contradicted this practice.
Medication Labeling and Narcotic Count Deficiencies
Penalty
Summary
The facility failed to properly label and date medications, as well as ensure accurate accounting of narcotic medications. During an inspection, it was observed that a Basaglar Kwik Pen and Insulin Lispro were opened and not dated, contrary to pharmacy recommendations that require these medications to be discarded after a certain period once opened. Additionally, a vial of Ozempic was found opened and undated in the refrigerator. The facility's policy requires medications to be labeled and stored to monitor potency and expiration dates, which was not adhered to in these instances. Furthermore, discrepancies were found in the narcotic medication counts for several residents. The narcotic logs did not match the actual number of tablets present for medications such as Lorazepam, Hydrocodone/APAP, and Alprazolam. The Assistant Director of Nursing stated that staff are required to sign out narcotic medications on the narcotic sheet immediately after administration to ensure accurate counts. However, this practice was not consistently followed, leading to discrepancies in the narcotic logs. Additionally, personal belongings of staff were improperly stored in medication carts, which is against the facility's policy.
Failure to Apply Splints and Assess Contractures
Penalty
Summary
The facility failed to assess and treat a resident with a contracture of the left hand and did not apply a splint as per physician orders. One resident, a male with severe cognitive impairment and multiple diagnoses including hemiplegia and hemiparesis, was observed without a splint or positioning device on his contracted left hand. The restorative nurse was unaware of the contracture, and the occupational therapist later recommended a resting hand splint to prevent further deterioration. Despite the recommendation, the resident experienced pain when staff attempted to open his contracted hand. Another resident, with diagnoses including hemiplegia and hemiparesis, was not wearing a right hand splint as ordered by the physician. The order specified the splint should be applied in the morning and removed in the evening, with monitoring for pain. However, the resident was observed without the splint on multiple occasions, and a CNA admitted to forgetting to apply it. The facility's policy on the application of splints was not followed, contributing to the deficiency.
Failure in Safe Transfer and Feeding Supervision
Penalty
Summary
The facility failed to provide safe transfer and feeding supervision to residents requiring assistance with activities of daily living (ADL). One resident, identified as R58, who has multiple diagnoses including a displaced fracture and Parkinson's disease, was assisted to the bathroom by a CNA without the use of a gait belt, despite the care plan indicating the need for extensive assistance by two staff members and the use of a gait belt during transfers. This resident was also assessed to be at risk for falls. Another resident, R24, with diagnoses including morbid obesity and Alzheimer's disease, was similarly assisted to the toilet by a CNA without a gait belt, contrary to the care plan that required two staff members and a gait belt for transfers. The resident's fall assessment indicated a risk for falls, and the Director of Nursing confirmed the standard practice of using a gait belt for residents requiring assistance. Additionally, R42, who has Parkinson's disease and dementia, was left unsupervised during meals despite requiring feeding assistance and having specific dietary instructions to avoid straws and alternate consistencies. The resident was observed eating without supervision and using a straw, which was against the care plan and dietary recommendations. The Speech Language Pathologist had previously recommended direct supervision during meals for safety and encouragement of oral intake due to the resident's swallowing difficulties and cognitive impairments.
Failure to Provide Prescribed Double Protein Portions
Penalty
Summary
The facility failed to provide the prescribed double protein portions for two residents during meal service. On December 17, 2024, during tray line service, a dietary aide served a resident a single portion of mechanical soft polish sausage instead of the double protein portion ordered by the physician. The dietary manager was informed of the discrepancy, but the resident's meal ticket only showed a single portion. The resident's care plan and physician order summary indicated a need for a therapeutic diet with double protein at lunch. Another resident also received a single portion of mechanical soft polish sausage, despite having a diet order for double protein at lunch. The dietary manager acknowledged the error and stated that the meal ticket would be updated. The resident's care plan noted nutritional problems related to weight changes and required serving the diet as ordered. The dietitian confirmed the double protein recommendation for both residents, one due to a food preference and the other due to a history of weight loss. The facility's diet spreadsheet and serving scoop chart confirmed the portion sizes, but the prescribed double protein portions were not provided.
Failure to Offer Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to adhere to its policy of offering the pneumococcal vaccine to residents, as evidenced by the cases of three residents who were not offered the PCV20 vaccine despite being eligible. Resident R63, with diagnoses including dementia and chronic obstructive pulmonary disease, was admitted to the facility and had only received the PCV13 vaccine. The facility's Infection Preventionist Nurse confirmed that R63 had not been offered the PCV20 vaccine, which should have been administered according to the facility's policy and CDC guidelines. The Immunization Audit Report for R63 did not document any offer or refusal of the additional pneumococcal vaccine. Similarly, Resident R79, with conditions such as chronic atrial fibrillation and asthma, had also only received the PCV13 vaccine and was not offered the PCV20. The Immunization Audit Report for R79 lacked documentation of any offer or refusal of the PCV20 vaccine. Additionally, Resident R118, who had type 2 diabetes mellitus and chronic kidney disease, received two doses of the PCV13 but was not offered the PCV20. The facility's policy, which follows CDC recommendations, was not followed, as the residents were not offered the PCV20 vaccine after receiving the PCV13, leading to a deficiency in the facility's immunization practices.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the survey were readily available for residents to view, which has the potential to affect all 206 residents residing in the facility. During a resident council meeting, seven attendees reported that they had never seen a book or binder containing the survey results. Observations confirmed that there was no folder or binder with the survey reports in common areas such as the lobby, library, dining hall, or theatre room. The facility administrator attempted to locate the binder with the survey results but was unable to find it, confirming the deficiency in making survey results accessible to residents.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers twice a week per its policy for two residents, R3 and R6, who were reviewed for showers. R6, diagnosed with multiple conditions including Parkinson's disease and chronic heart failure, was cognitively intact and dependent on staff for bathing. Despite being scheduled for baths every Tuesday and Friday, R6 reported only receiving baths once a week due to staff time constraints. Documentation showed R6 was marked as having refused or not applicable for several scheduled Friday baths, but there was no nursing progress note indicating R6 refused showers. R6 expressed a desire to move her bath schedule to Friday mornings to ensure consistency. Similarly, R3, with diagnoses including osteoarthritis and anxiety, required substantial assistance for bathing. R3 reported having to fight for showers as staff were often too busy, and there was no record of R3 refusing showers in the nursing progress notes. However, bathing documentation inaccurately recorded R3 as refusing showers on multiple occasions. R3 and her roommate both stated that the staff claimed they had no time or it was not R3's scheduled day for a shower, contradicting the facility's policy that residents should be offered showers twice weekly.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff remained with a resident until all medications were administered, as per facility policy. This deficiency was identified when medications were found at the bedside of a resident, R2, who was part of a sample of seven residents reviewed. The incident was reported on 8/25/24 when a family member observed medications at R2's bedside. R2 initially denied that the medications were hers, claiming she had already taken them. However, upon further questioning, R2 admitted she might have forgotten to take the medications provided earlier that morning. The medications included vitamins, supplements, and other typical morning medications, but no narcotics. The Minimum Data Set (MDS) indicated that R2 had moderately impaired cognition, which may have contributed to the incident. The Registered Nurse Supervisor, V4, confirmed that the medications found were R2's morning doses and should not have been left with the resident. The facility's policy, as outlined in the document 'Administering Oral Medications,' requires staff to remain with residents until all medications are taken. Despite this policy, the Registered Nurse, V5, who was responsible for administering the medications, insisted that she watched R2 take her medications that morning, contradicting the evidence found at the scene.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide personal care to dependent residents, specifically two residents with cognitive impairments. One resident, a [AGE] year-old female with moderate cognitive impairment, was found with a strong urine odor and a soaked, discolored incontinent brief. The LPN acknowledged that the resident had not been changed as required by the facility's guidelines, which mandate changing residents every two hours and as needed. The resident's care plan included interventions for the risk of impaired skin integrity, but these were not followed as observed on the date of the survey. Another resident, a [AGE] year-old female with mild cognitive impairment, reported that she was often not changed on time and could not recall being changed on the day of the observation. The LPN found this resident with a heavily soiled and discolored incontinent brief. Similar to the first case, the resident's care plan included interventions for the risk of impaired skin integrity, which were not adhered to. The Director of Nursing confirmed that incontinent care should be provided every two hours and as needed, as per the facility's policy revised in March 2020.
Improper Urinary Catheter Insertion Procedure
Penalty
Summary
The facility failed to ensure proper urinary catheter insertion procedures were followed, leading to potential cross-contamination. A nurse and a CNA were observed performing a straight catheterization on a resident without cleaning the left and right labia area and without using sterile gloves. The resident, a [AGE] year-old female with spina bifida, chronic idiopathic constipation, bladder dysfunction, and a history of urinary tract infections, had an order for straight urinary catheterization every four hours. The nurse admitted to not knowing the proper procedure for cleansing the labia and urethral meatus before catheter insertion. The Director of Nursing confirmed that the staff should follow the straight catheterization guidelines to avoid urinary tract infections. According to the facility's Urinary Straight Catheter policy, the labia and urethral meatus should be cleansed using separate cotton balls for each downward stroke, and the catheter should be handled with sterile gloves. The failure to adhere to these guidelines was observed and acknowledged by the staff involved, indicating a lapse in following established protocols for catheter care.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure Activities of Daily Living (ADL) assistance was provided for three residents who required extensive assistance. Resident 1 (R1) was admitted with diagnoses including Alzheimer's disease, dementia, heart failure, dermatitis, and malnutrition. R1's care plan indicated a need for total assistance with personal hygiene and dressing, and to be checked every two hours for incontinence. On April 8, 2024, R1 was found in bed with a saturated incontinence brief and wet sheets, indicating that incontinence care had not been provided in a timely manner. The dressing on R1's sacrum was also saturated, and there was a strong urine odor present. The CNA admitted it was the first time she had provided incontinence care to R1 that day, despite the care plan's requirements for frequent checks and assistance. Resident 2 (R2) and Resident 3 (R3) also experienced similar deficiencies in care. R2, with diagnoses including schizoaffective disorder, anxiety disorder, and bipolar disorder, was found with a saturated incontinence brief and wet sheets. The CNA confirmed it was the first time she had provided incontinence care to R2 that day. R3, diagnosed with Parkinson's disease, Alzheimer's disease, dementia, schizophrenia, and major depressive disorder, was found with a saturated incontinence brief and a strong urine odor. Documentation showed no incontinence care was provided to R3 prior to 11:20 AM. The facility's policy required incontinence care to be provided at least every two hours, but this was not adhered to for these residents, leading to the observed deficiencies.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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