North Aurora Living & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in North Aurora, Illinois.
- Location
- 310 Banbury Road, North Aurora, Illinois 60542
- CMS Provider Number
- 14E306
- Inspections on file
- 37
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at North Aurora Living & Rehab Ctr during CMS and state inspections, most recent first.
A gap between the exterior wall and an air conditioner unit in a resident's room allowed cold air to enter, making the room uncomfortable. The issue went unreported for about a month, as neither staff nor maintenance were aware of it, and no maintenance request was submitted. The facility lacked a formal policy for reporting or requesting repairs, and staff had stopped using the maintenance request form.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
Two residents with psychiatric and physical conditions became involved in a physical altercation after one entered a bathroom while the other was showering and ignored requests to leave. The situation escalated to physical aggression, including striking and the throwing of a urinal containing urine, resulting in a fall. Staff intervened after hearing yelling, but the altercation had already occurred, indicating a failure to prevent resident-to-resident physical abuse as required by facility policy.
A resident who was dependent on staff for transfers and required a mechanical lift fell during a transfer when the sling's worn strap ripped, resulting in multiple fractures. Two CNAs were involved in the transfer, and the sling had not been replaced since admission. The facility's policy lacked instructions for equipment checks before use, and the manufacturer's guidelines requiring inspection of sling attachments were not followed.
A resident who was dependent on staff and a mechanical lift for transfers experienced a fall when the sling's strap ripped during a transfer. Two CNAs reported the sling was old and worn out, and the DON confirmed the sling was not maintained or replaced according to manufacturer guidelines. The facility lacked a policy for lift sling maintenance, and the incident occurred due to the use of unsafe equipment.
A resident with a stress fracture of the left radius did not have a follow-up orthopedic appointment scheduled as required. The transportation scheduler, responsible for arranging appointments, was unaware of the need for a follow-up until receiving the after-visit summary late. The Program Director for ADAPT and a registered nurse were involved in handling the after-visit summary, which indicated the need for a follow-up appointment that was not scheduled.
A resident discharged with depression and cellulitis was unable to obtain complete medical records due to a transition from PCC to Sigma Care EHR system, leaving the facility without access to previous records. The resident sought her records to review treatment details, but the facility could only provide partial records, highlighting a deficiency in maintaining accurate and complete records post-discharge.
The facility failed to protect two residents from abuse by their peers, resulting in psychological harm. One resident was inappropriately touched by a female peer, while another was slapped by a male peer. Both incidents were reported, but the facility's abuse prevention policy was not effectively implemented, leaving the residents feeling scared and unprotected.
The facility did not report a physical altercation between two cognitively intact residents to local law enforcement, as required by their policy. The incident, which occurred in the TV lounge, involved one resident hitting another, leading to a mutual exchange of blows. The facility's policy mandates reporting such incidents, but the administrator failed to do so, and no investigation report or resident assessments were documented.
The facility failed to report two incidents of resident-to-resident physical abuse to the State Agency as required by their policy. In the first incident, a resident with multiple diagnoses, including schizoaffective disorder, was involved in an altercation with another resident, resulting in a reddened cheek. The second incident involved the same resident in a physical altercation with another resident, witnessed by a Restorative Aide. The Administrator admitted both incidents were not reported to the State Agency or local police.
The facility failed to investigate two incidents of resident-to-resident physical abuse as per policy. One incident involved a resident slapping another in the lounge, and another involved a physical altercation in the TV lounge. Despite acknowledgment by staff, no investigation reports were completed, violating the facility's abuse prevention policy.
The facility failed to follow proper procedures for administering eye drops and blood glucose monitoring. An LPN administered eye drops directly onto a resident's eyeball instead of into the lower eyelid pouch, causing the drops to fall onto the cheek. Another resident's blood glucose was checked incorrectly, as the LPN used an alcohol wipe to discard the first drop of blood, potentially altering the reading.
The facility failed to securely store medications and properly label insulin vials. An LPN did not label an insulin vial with an open date, and expired medications were found in a medication cart. Additionally, a pill was left unattended in a resident's room without authorization. Staff confirmed that medications should not be left at the bedside unless specifically ordered.
The facility failed to provide influenza and pneumonia vaccines to three residents, as identified during a survey. The DON was unable to explain why the vaccines were not administered, citing a lack of clarity about whether residents requested them or if the facility offered them. The residents had significant medical histories, making them vulnerable to complications, yet the facility's policy to offer vaccinations was not effectively implemented.
A resident with full code status did not receive CPR due to confusion over their code status, resulting in their death. The facility lacked a system to ensure timely completion and accessibility of advance directives, leading to a delay in emergency response. The nurse on duty assumed the resident was a DNR based on incorrect information, highlighting systemic issues in maintaining accurate records of residents' code statuses.
The facility failed to ensure timely completion and availability of Advance Directives, leading to inconsistencies in residents' code statuses. A resident, who expressed a desire not to live, remained a full code due to lack of coordination with hospice and the guardian. Additionally, a nurse under investigation for neglect was not removed from resident contact, contrary to facility policy.
A resident with a full code status was found unresponsive, but CPR was not initiated due to confusion over advanced directives. The nurse on duty did not perform CPR, instead searching for a DNR order and contacting hospice, leading to a delay in emergency response. The facility's records confirmed the resident was a full code, and the lack of CPR was deemed neglectful.
A facility failed to implement its abuse policy by not removing a nurse from resident contact during an active neglect investigation. The nurse continued to work despite the ongoing investigation into a resident's death. Additionally, the facility did not submit a timely final investigative report to the state agency, as required by their policy, and the report lacked a final investigative summary.
A facility failed to coordinate advanced directives with hospice and a guardian for a resident with Bipolar Disorder, Dementia, and Schizoaffective Disorder. Despite the resident expressing a desire not to live, the POLST form indicated a full code status, and there was no documentation of discussions with the state guardian. The resident was admitted to hospice, but the full code status was not addressed until the resident's condition worsened, highlighting a lack of timely communication and documentation.
A resident with severe cognitive impairment fell from a wheelchair due to the absence of footrests during transport, resulting in a forehead laceration. The CNA responsible admitted to not attaching the footrests, despite the care plan's instructions to use them. The DON confirmed the requirement for footrests during transport.
The facility failed to serve substitute menu items with similar nutritional content as the main entree. Five residents received meals that did not meet the nutritional standards of the main menu items, such as sandwiches with minimal protein content compared to the main entrees. The registered dietitian confirmed that substitute items should be equivalent to the main menu entree served.
The facility failed to notify two residents in advance and provide reasons for room changes or transfers. Both residents, who have multiple medical diagnoses, were transferred to new rooms without prior notice, causing distress. The facility's policy requiring advance notice was not followed.
Failure to Repair Exterior Wall Gap and Lack of Maintenance Reporting System
Penalty
Summary
A gap was observed between the exterior wall and the air conditioner unit in a resident's room, allowing cold air to flow directly into the room and making the space chilly. The gap was large enough that the parking lot was visible through it. The resident, who was cognitively intact and had multiple diagnoses including schizophrenia, alcohol-induced psychosis, anxiety disorder, and nicotine dependence, reported that the gap had been present for about a month. The resident's roommate was also observed fully dressed and lying under blankets, indicating discomfort due to the cold. Staff members, including the housekeeper assigned to the room and the housekeeping supervisor, were unaware of the gap until it was pointed out during the survey. The maintenance director also stated he was unaware of the issue prior to being informed by staff. There was no record of a maintenance request form being completed for the gap, and the last maintenance request received by the maintenance director was dated nearly two months prior. The facility did not have a policy regarding the reporting of maintenance issues or requesting repairs, and staff had stopped using the maintenance request form for unknown reasons. The administrator confirmed that there was no formal policy in place and that staff were expected to request repairs using the form, but could not explain why this process was not being followed.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between two residents, both of whom were cognitively intact and had significant psychiatric and physical diagnoses. The incident occurred when one resident was taking a shower and another entered the bathroom, ignoring requests to leave. The situation escalated when the second resident bumped the first resident's shower chair and continued to harass him. The first resident, after drying off and attempting to leave, was confronted again by the second resident, who threw a urinal full of urine at him. In response, the first resident struck the second resident on the back of the head. The altercation continued in the hallway, with further physical aggression and the first resident slipping on urine and falling. Staff became aware of the incident after hearing yelling and observed the residents in a physical altercation. Despite staff attempts to intervene, the situation escalated, with one resident dumping urine on the other and a wheelchair being flipped. Both residents were assessed and found to have no injuries. The facility's abuse prevention policy prohibits any form of abuse, including physical or mental injury inflicted by non-accidental means. The events described demonstrate a failure to prevent resident-to-resident physical abuse as required by facility policy.
Failure to Inspect and Replace Worn Mechanical Lift Sling Results in Resident Fall and Fractures
Penalty
Summary
A resident with multiple diagnoses, including impaired mobility and generalized weakness, was dependent on staff for transfers and required the use of a mechanical lift. The resident's care plan specified the need for a mechanical lift and two-person assistance for transfers. On the day of the incident, two CNAs attempted to transfer the resident from bed to wheelchair using a mechanical lift. One CNA secured the resident's sling to the lift, while the other stood behind the wheelchair but was not within close reach of the resident. As the lift was being maneuvered, the sling's lower left strap ripped, causing the resident to fall to the floor. Both CNAs reported that the sling appeared worn out and had not been replaced since the resident's admission. The Director of Nursing confirmed that the sling's lower left and right straps were completely ripped and attributed the fall to the frayed condition of the sling. The facility's accident investigation and fall incident reports also indicated that the sling should have been inspected prior to use and that the failure to do so led to the incident. The manufacturer's instructions for the lift required that all sling attachments be checked for wear before each use, but the facility's policy did not include instructions for equipment checks before use. As a result of the fall, the resident sustained multiple fractures, including to the right hip, left pelvis, pubic bone, and lumbar vertebra, and required transfer to the hospital for evaluation and treatment. The incident was witnessed and documented in the resident's progress notes and hospital records, which detailed the injuries and the circumstances of the fall.
Failure to Maintain and Replace Mechanical Lift Sling Leads to Resident Fall
Penalty
Summary
The facility failed to follow the manufacturer's maintenance recommendations for a mechanical lift-sling transferring device, resulting in the use of worn and unsafe equipment. A resident with multiple diagnoses, including impaired mobility and generalized weakness, was dependent on staff and a mechanical lift for transfers. On the day of the incident, two CNAs attempted to transfer the resident using a mechanical lift when the sling's lower left strap ripped, causing the resident to fall to the floor. Both CNAs reported that the sling was old, worn out from overuse, and had not been replaced since the resident's admission. The Director of Nursing confirmed that the sling's straps were completely ripped and that the sling appeared worn out from overuse. The facility did not have a policy for maintaining lift sling equipment, and the DON was unaware of the manufacturer's service life recommendations. The resident's care plan indicated a risk for falls and required the use of a mechanical lift with staff assistance. Documentation from the accident investigation and fall incident reports confirmed that the fall occurred because the sling broke, and that the sling should have been inspected prior to use. The manufacturer's guidelines specified that slings should be inspected after each laundering and discarded if found to be bleached, torn, cut, frayed, or broken, with an expected service life of thirteen months. The facility's policy required providing an environment free from hazards and ensuring the use of safe assistive devices, but this was not followed in the case of the mechanical lift sling.
Failure to Schedule Follow-Up Appointment for Resident with Fracture
Penalty
Summary
The facility failed to schedule a follow-up doctor appointment for a resident diagnosed with a stress fracture of the left radius. The resident's mother reported that the facility did not arrange the necessary follow-up appointment. The transportation scheduler, responsible for scheduling such appointments, confirmed that the resident's last orthopedic visit was conducted by the facility's ADAPT staff, and no subsequent appointment was scheduled. The Program Director for ADAPT stated that the after-visit summary from the orthopedic appointment indicated a follow-up was needed the week of March 17th, and this information was given to a registered nurse. However, the registered nurse was unsure if the appointment was scheduled and had passed the after-visit summary to the transportation scheduler, who only became aware of the need for a follow-up appointment after receiving the paperwork belatedly. The orthopedic after-visit summary explicitly instructed scheduling a follow-up in three weeks, which was not done, as confirmed by the progress note entered by the registered nurse.
Incomplete Medical Records Post-Discharge Due to EHR Transition
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident (R2) after discharge. R2 was admitted with diagnoses of depression and cellulitis and was discharged in December. She requested her complete medical records, including doctor's notes and a list of medications, to review her treatment, particularly the antibiotics prescribed for cellulitis. However, the facility was unable to provide a complete set of records due to a change in the electronic health record (EHR) system from PCC to Sigma Care, which resulted in a lack of access to the previous records. The medical record staff (V12) and the Director of Nursing (V2) confirmed the inability to access the old EHR system, which contained essential documents such as physician order sheets, progress notes, medication administration records (MAR), minimum data set (MDS), and care plans of discharged residents. The facility's administrator (V1) acknowledged the requirement to keep records for years after discharge and mentioned that the new owner was coordinating with the previous owners to regain access to the PCC system. Despite these efforts, the resident was left without a complete set of her medical records, highlighting a deficiency in maintaining accurate and complete medical records post-discharge.
Failure to Protect Residents from Peer Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by their peers, resulting in psychological harm. One resident, R2, reported that a female peer, R1, entered his room uninvited and inappropriately touched him. Despite R2's attempts to ask R1 to leave, she continued to follow him around the facility, causing him to feel scared and uncomfortable. R2 reported the incident to the Activity Director and requested police involvement when he saw R1 again, fearing further inappropriate behavior. Another resident, R5, reported being slapped in the face by a male peer, R3, while resting in the day room. This incident left R5 feeling scared and wanting to leave the facility. The Director of Nursing documented the incident, noting a red mark on R5's cheek, but there was no further assessment of R5's injury or her request for discharge. The facility's policy on abuse prevention was not effectively implemented, as it failed to protect these residents from abuse by other residents.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to local law enforcement as required by their policy. The incident involved two residents, both of whom were cognitively intact, engaging in a physical altercation in the TV lounge. The altercation began when one resident was struck in the face by the other without any prior provocation. The resident who was hit then followed the aggressor, leading to a mutual exchange of blows. Despite the facility's policy mandating the reporting of such incidents to law enforcement, the administrator did not report the incident or provide an investigation report when requested. The medical records of both residents involved in the altercation did not contain any documentation of assessments of their physical or mental conditions following the incident. The facility's policy, titled Illinois Abuse Prevention Policy, specifies that local law enforcement should be contacted in cases of physical abuse involving injury inflicted by one resident on another. However, the facility did not adhere to this policy, as the incident was neither reported to law enforcement nor documented appropriately in the residents' medical records.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report two incidents of resident-to-resident physical abuse to the State Agency as required by their policy. The first incident involved a resident with multiple diagnoses, including schizoaffective disorder and diabetes, who was cognitively intact. This resident was involved in an altercation with another resident, resulting in a reddened cheek for the latter. The Director of Nursing confirmed there was no incident report or assessment following this event, and the Administrator admitted the incident was not reported to the State Agency. The second incident involved another resident with schizoaffective disorder and other medical conditions, who was also cognitively intact. This resident was involved in a physical altercation with the same resident from the first incident. The altercation was witnessed by a Restorative Aide, who intervened, and the resident was subsequently transferred to the hospital. However, there was no documentation of the residents' physical condition or mood following the incident, and the Administrator acknowledged that the incident was not reported to the State Agency or local police, despite recognizing it as abuse.
Failure to Investigate Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to investigate two incidents of resident-to-resident physical abuse in accordance with its policy. The first incident involved a physical altercation between two residents, R3 and R5, on December 17, 2024. R5 reported being slapped in the face by R3 while resting in the lounge. The Director of Nursing, V2, acknowledged the incident but stated there was no incident report. R3's progress notes confirmed the altercation, noting R3 had a raised hand over R5 and R5 had a reddened cheek. The second incident occurred on December 24, 2024, involving R3 and R4. R4 reported being hit in the face by R3 while in the TV lounge, which led to a physical altercation between the two. A Restorative Aide, V7, witnessed the altercation and intervened by verbally redirecting the residents. Despite these incidents, the facility did not have investigation reports for either event, as required by their Illinois Abuse Prevention Policy. This policy mandates a complete written report of the investigation within five working days of the occurrence, which was not fulfilled in these cases.
Improper Medication and Blood Glucose Monitoring Procedures
Penalty
Summary
The facility failed to adhere to proper administration guidelines for eye drops and blood glucose monitoring, affecting two residents. A resident was observed receiving eye drops incorrectly, as the LPN administered the drops directly onto the eyeball instead of into the lower eyelid pouch as per the facility's procedure. This resulted in the drops falling onto the resident's cheek, indicating a deviation from the established protocol for eye drop administration. Another resident, diagnosed with type 2 diabetes, had their blood glucose level checked improperly. The LPN used an alcohol wipe to discard the first drop of blood and did not allow the alcohol to dry before collecting the blood sample. This practice can alter the blood glucose reading, as confirmed by the LPN and the DON. The facility's failure to follow proper procedures for both eye drop administration and blood glucose monitoring led to these deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to securely store medications and properly label and date insulin vials after initial use. A Licensed Practical Nurse (LPN) was unable to locate an insulin vial for a resident with type 2 diabetes and opened a new vial without labeling it with an open date, contrary to the facility's policy. Additionally, expired medications were found in the medication cart, including eye drops that were past their 28-day usage period. The Director of Nursing acknowledged that the insulin vial should have been labeled with an open date and that expired medications should have been discarded. Furthermore, a medication was found at the bedside of a resident's room without proper authorization or documentation. A yellow pill was observed on a bookshelf in a resident's room over several days, and the resident's records did not show any assessment or order allowing medications to be stored at the bedside. Staff members confirmed that residents were not allowed to keep medications at the bedside unless there was a specific order, and medications should not be left unattended in residents' rooms. The Director of Nursing reiterated that medications should be stored securely and only accessible to authorized personnel.
Failure to Administer Vaccines to Residents
Penalty
Summary
The facility failed to provide influenza and pneumonia vaccines to three residents, as identified during a survey. The Director of Nursing (DON), who also serves as the Infection Preventionist, was unable to explain why the vaccines were not administered to all residents. The DON mentioned that a vaccine day had occurred before her tenure, but she was uncertain if the residents had requested the vaccines or if the facility had offered them. This lack of clarity and follow-through resulted in the residents not receiving their vaccinations until the survey was conducted. The residents involved had significant medical histories that made them vulnerable to complications from influenza and pneumonia. One resident had chronic obstructive pulmonary disease, pneumonia, and other respiratory issues. Another resident had conditions such as hydrocephalus and diabetes, while the third resident had bipolar disorder and hypertension. Despite these conditions, the facility's policy to offer vaccinations to all residents was not effectively implemented, as evidenced by the consent forms being signed only during the survey.
Failure to Initiate CPR Due to Code Status Confusion
Penalty
Summary
The facility failed to initiate CPR for a resident with full code status, resulting in the resident's death. The resident, who had a history of bipolar disorder, dementia, and schizoaffective disorder, was found not breathing, and no CPR was initiated despite having a POLST form indicating full code status. The nurse on duty, V5, was under the impression that the resident was on hospice with a DNR order, which was incorrect. This misunderstanding led to a delay in emergency response, as V5 spent time trying to verify the resident's code status instead of initiating CPR. The facility also lacked a system to ensure that advance directives were completed timely and available to direct care staff. The resident's POLST form was not easily accessible, and there was confusion among staff regarding the resident's code status. The nurse, V5, did not perform CPR and assumed the resident was a DNR based on incorrect information. This assumption was compounded by the fact that the facility's process for verifying advanced directives was not clear to the agency nurse, V5, who was unfamiliar with the facility's procedures. Additionally, the facility's failure to maintain accurate and accessible records of residents' code statuses was evident in the review of other residents' charts, which also lacked completed POLST forms. This systemic issue contributed to the immediate jeopardy situation, as it had the potential to affect all residents in the facility. The lack of a clear and efficient process for handling advance directives and code status verification was a significant factor in the deficiency.
Deficiencies in Advance Directives and Investigation Procedures
Penalty
Summary
The administrator of the facility failed to ensure that Advance Directives were completed in a timely manner and made available to direct care staff. This deficiency was observed through the absence of completed POLST forms in the paper charts of several residents, including R5, R9, R10, R11, R16, and R17. The facility's process for obtaining POLST forms involved coordination between nursing and social services, but inconsistencies were noted, particularly with the transition to the PCC electronic medical records system. Social services staff reported ongoing issues with access to the system, which hindered their ability to correct discrepancies and ensure accurate documentation of residents' code statuses. Additionally, the facility failed to coordinate advanced directives with hospice and the guardian for a resident, R1, who had expressed a desire not to live anymore. Despite being cognitively intact and having communicated her wishes to the Medical Director, there was no documentation of discussions with R1's state guardian regarding changes to her POLST form or advanced directives. R1 was admitted to hospice care without a change in her full code status, and the hospice nurse initiated conversations about her advanced directives only after her condition declined significantly. The lack of timely communication and coordination between the facility, hospice, and the guardian resulted in R1 remaining a full code at the time of her death. Furthermore, the facility did not adhere to its Abuse Prevention Program policy by failing to remove an employee, V5, who was under investigation for neglect during an active investigation. V5, a nurse, did not implement CPR when discovering R1 deceased and spent time attempting to locate DNR paperwork instead. Despite the ongoing investigation, V5 was observed working as a floor nurse, which contradicted the facility's policy of removing employees accused of neglect from resident contact until the investigation's conclusion. The facility's final investigative report on R1's death lacked a summary and outcome, indicating incomplete documentation of the investigation process.
Failure to Initiate CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to protect a resident from neglect by not initiating cardiopulmonary resuscitation (CPR) despite the resident's Practitioner Order for Life-Sustaining Treatment (POLST) indicating a full code status. The resident, an elderly individual with diagnoses including Bipolar Disorder, Dementia, and Schizoaffective Disorder, was found unresponsive by a nursing assistant. The nurse on duty, V5, did not start CPR because she was unsure of the resident's advanced directives, despite the POLST form indicating the need for resuscitation. Instead, V5 spent time searching for a Do Not Resuscitate (DNR) order, contacting hospice, and handling another resident's issue, leading to a significant delay in emergency response. The Director of Nursing, V2, confirmed that the resident was a full code in the facility's records and that CPR should have been initiated. The Deputy Coroner also expressed concern that CPR was not started, emphasizing that without a valid DNR, the resident should have received emergency interventions. The facility's policy on abuse prevention defines neglect as the failure to provide necessary services to avoid harm, which was evident in this case as the staff did not perform CPR, resulting in the resident's death without the appropriate emergency response.
Failure to Implement Abuse Policy During Investigation
Penalty
Summary
The facility failed to implement its abuse policy during an active neglect investigation involving a resident who was found deceased. The policy mandates that any employee accused of abuse or neglect be immediately removed from resident contact until the investigation is concluded. However, the nurse involved in the incident continued to work as a floor nurse, administering medications and caring for residents, despite the ongoing investigation. This failure to remove the staff member from resident contact during the investigation is a direct violation of the facility's abuse prevention policy. Additionally, the facility did not submit a timely final investigative report to the state agency, as required by their policy. The report was undated and provided late, lacking a final investigative summary. The administrator was still investigating the circumstances surrounding the incident when the report was requested, and the report had not been submitted to the state agency by the time of the survey. This delay in reporting and lack of a conclusive investigation further highlights the facility's failure to adhere to its own policies and procedures regarding abuse prevention and investigation.
Failure to Coordinate Advanced Directives with Hospice and Guardian
Penalty
Summary
The facility failed to coordinate advanced directives with hospice and a guardian in a timely manner for a resident who was reviewed for hospice care. The resident, who had diagnoses including Bipolar Disorder, Dementia, and Schizoaffective Disorder, was documented as cognitively intact and had expressed a desire not to live anymore to the Medical Director. Despite this, the resident's POLST form indicated a full code status, and there was no documentation of discussions with the state guardian regarding changes to the advanced directives. The Medical Director had ordered a hospice evaluation due to the resident's refusal to eat and failure to thrive, and the state guardian was informed of the clinical situation and consented to hospice services. However, there was a lack of communication and documentation regarding the resident's expressed wishes and the need to update the POLST form. The resident was admitted to hospice, but the hospice nurse noted that the resident's full code status was not addressed until the resident began declining, and the state guardian confirmed that no prior conversations about advanced directives had occurred. The facility's Director of Nursing assumed that the resident was a DNR upon hospice admission, but there was no confirmation from hospice that discussions with the guardian had taken place. The Social Service Director also did not pursue discussions about advanced directives. The hospice nurse initiated a conversation with the state guardian about the resident's code status only after the resident's condition worsened, highlighting the facility's failure to ensure timely coordination of advanced directives with hospice and the guardian.
Failure to Use Wheelchair Footrests Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the use of wheelchair footrests during transportation, resulting in a resident, identified as R4, falling from the wheelchair and sustaining a forehead laceration. R4, who was cognitively severely impaired and dependent on substantial assistance for activities of daily living, was being wheeled by a Certified Nursing Assistant (CNA) identified as V11. During the transport from the dining hall to his room, R4 placed his feet on the floor, causing the wheelchair to brake and leading to his fall. R4's care plan, revised prior to the incident, indicated the need for monitoring and intervention to reduce self-injury risks, including the use of footrests. However, V11 admitted to not attaching the footrests during the transport, acknowledging the oversight as a significant lesson. The Director of Nursing confirmed that staff should ensure residents' feet are on footrests during wheelchair transport. The incident resulted in R4 being sent to the hospital with a forehead laceration and returning with stitches and bruising.
Failure to Provide Nutritionally Equivalent Substitute Menu Items
Penalty
Summary
The facility failed to serve substitute menu items with similar nutritional content as the main entree. This deficiency was observed in five residents who received meals that did not meet the nutritional standards of the main menu items. For instance, one resident reported receiving a sandwich with minimal protein content instead of the main entree, which provided significantly more protein. Another resident, who is allergic to many foods, often received a grilled cheese sandwich or a peanut butter and jelly sandwich, both of which did not match the nutritional value of the main entree. The facility's food service supervisor provided a list of substitute items, but these items were not nutritionally equivalent to the main menu items served on the same days. The registered dietitian confirmed that substitute items should be equivalent to the main menu entree served. The facility's menu spreadsheets for specific dates showed that the main entrees provided significantly more protein compared to the substitute items. For example, the main entree on one day included a braised pork bun providing 14 grams of protein, while the substitute deli sandwich provided only 3 grams of protein from bologna and 5 grams from cheese. Similarly, the main entree on another day included Salisbury steak providing 18 grams of protein, while the substitute grilled cheese sandwich provided only 14 grams of protein. These discrepancies indicate that the facility did not ensure that substitute menu items met the nutritional content of the main entrees, leading to a deficiency in the quality of care provided to the residents.
Failure to Notify Residents of Room Transfers
Penalty
Summary
The facility failed to notify residents in advance and provide reasons for room changes or transfers. This deficiency was observed in two residents. The first resident, who has multiple medical diagnoses including Bipolar Disorder, Rheumatoid Arthritis, and Sjogren syndrome, was transferred to another bedroom without prior notice. The resident's family member and the resident herself expressed that they were not informed about the reason for the transfer. The Director of Nursing (DON) mentioned that the transfer was for deep cleaning but did not provide a truthful explanation due to confidentiality reasons. The resident's progress notes did not document any prior notification for the room transfer or the reason for the change. The resident's former roommate remained in the original room and now has a new roommate, indicating inconsistency in the reason provided for the transfer. The second resident, who has multiple medical diagnoses including Major Disorder and Panic Disorder, was also transferred to a new room without prior notification. The resident expressed that the sudden transfer was upsetting. The progress notes indicated an attempt to notify the resident's brother, but there was no documentation of prior notification to the resident herself. A Social Service progress note later documented the reason for the transfer. The Social Services Staff confirmed that residents and their families should be notified in advance of room changes, but this procedure was not followed in these cases. The facility's policy states that residents should be given notice before room or roommate changes, but this policy was not adhered to in these instances.
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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