Oak Park Oasis
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Park, Illinois.
- Location
- 625 North Harlem, Oak Park, Illinois 60302
- CMS Provider Number
- 145714
- Inspections on file
- 44
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Oak Park Oasis during CMS and state inspections, most recent first.
The facility did not ensure timely administration and documentation of medications for several residents, and failed to provide appropriate emergency response for a resident with severe hypoglycemia. Nursing staff delayed calling EMS, did not administer glucagon as required by protocol, and attempted unsafe interventions. The affected resident was hospitalized with critical hypoglycemia, sepsis, and multiple infections, with hospital staff noting poor hygiene and skin breakdown.
Two residents were involved in an incident where one directed a racially derogatory term and spat on another, despite a known history of similar behaviors and cognitive impairment. The aggressor's care plan was not updated with new interventions after repeated incidents, and the facility did not implement timely strategies to prevent further abuse, contrary to its abuse prevention policy.
Multiple residents, including those at risk for falls, were exposed to water hazards on the floor caused by leaking air conditioning vents. Staff and maintenance confirmed recurring leaks and inadequate routine maintenance of condensation pipes, resulting in puddles and slippery conditions in resident rooms. Observations included towels and buckets used to manage leaks, but these measures were insufficient to keep floors dry and safe.
A nurse called off for a day shift on a unit, but the absence was not properly communicated, resulting in no nurse coverage for approximately one to two hours. The off-going nurse left before a relief arrived, and the oncoming LPN was not notified to stay over. This left 36 residents without a licensed nurse, with CNAs unable to administer medications, in violation of facility policy requiring staff not to leave without relief.
A resident was transferred to another skilled facility without receiving discharge instructions or medications, as required by facility policy. The family transported the resident without notifying the nurse, and the nurse only learned of the departure after being contacted by the receiving facility. Documentation confirming that instructions and medications were provided and signed for was not available.
Three residents with indwelling catheters did not receive care in accordance with facility policy. Observed deficiencies included improper positioning of catheter bags, failure to secure catheters, and incomplete hygiene during catheter care, such as not cleaning the labia for a female resident and not retracting the foreskin for an uncircumcised male. Staff interviews confirmed these lapses in required catheter care procedures.
A high fall risk resident with multiple medical and cognitive conditions was not adequately supervised or provided with required fall prevention interventions, resulting in a hip fracture after attempting to clean a spill without assistance. The resident's care plan called for supervision and environmental safety measures, but staff failed to ensure these were in place, and there was a lack of consistent monitoring and follow-up after the incident.
A resident with multiple medical conditions experienced a fall and reported significant pain, but did not receive timely PRN pain medication. Nursing staff failed to document or consistently reassess pain, and there were delays in obtaining diagnostic imaging. The resident's pain remained unaddressed for 44 hours before hospitalization and surgery for a hip fracture.
A dietary aide was found in the kitchen without a required hair restraint, contrary to facility policy. The dietary supervisor acknowledged the lapse, stating the aide had removed the hairnet due to heat and perspiration. The facility's policy mandates hairnets be worn at all times in the kitchen.
A resident with multiple chronic conditions experienced a fall resulting in significant pain and immobility. Nursing staff failed to ensure a timely x-ray was performed and did not promptly report the results indicating a hip fracture. Delays in communication and follow-up led to a delay in the resident being sent to the hospital for further care.
A resident with a known history of substance abuse returned from an outing with a relative, and staff failed to conduct the required contraband search as outlined in facility policy. Shortly after, the resident was found unresponsive with a laceration and a bag of white powdery substance in his pocket, requiring Narcan administration and hospitalization for opioid overdose.
A resident with a legal guardian was administered psychotropic medications without the guardian's informed consent. Facility staff allowed the resident to sign the consent form, unaware of the guardian's status, and the guardian was not notified or consulted as required by facility policy.
A resident did not receive multiple prescribed medications on certain days, and there was no documentation on the MAR to indicate administration or reason for omission. A nurse confirmed that undocumented medications were not given, contrary to facility policy requiring complete documentation.
Two residents were found to have PRN psychotropic medication orders, including Haloperidol and Lorazepam, without required 14-day stop dates as specified by facility policy. The ADON confirmed that such medications should have a 14-day limit, but this was not followed.
The facility failed to maintain a clean and homelike environment, with issues such as missing floor tiles, lack of window curtains, and unclean bathrooms observed in several residents' rooms. Staff interviews revealed a lack of awareness and action, with housekeeping being short-staffed and maintenance acknowledging the need for repairs but lacking resources. The facility's resident rights booklet emphasizes the need for a safe, clean, and homelike environment, which was not met.
A resident with autoimmune conditions missed multiple doses of prescribed medications, including a steroid topical ointment and an immunosuppressive medication, due to the facility's failure to administer them as ordered. The staff, including a nurse and the DON, were unaware of the missed doses and did not notify the physician, contrary to facility policy. The resident reported not receiving the medication as scheduled, which is crucial for managing their condition.
A resident with autoimmune conditions missed multiple doses of a topical steroid ointment and an immunosuppressive medication over two months due to the facility's failure to administer them as ordered. Staff interviews revealed a lack of awareness about the missed doses, and the Medication Administration Record documented several instances of non-administration. The resident was hospitalized with hand ulcerations, and facility policies on medication administration were not followed.
A resident with cognitive impairments was punched by another resident with a history of violent behavior after a bathroom-related altercation. The incident, witnessed by a nurse, resulted in the injured resident being transferred to a hospital for evaluation. The facility's abuse prevention policy was not effectively implemented to prevent this assault.
A facility failed to create a care plan for a resident with violent behavior, leading to multiple altercations with roommates. Despite the resident's history of aggression and hospital admission for choking a roommate, no interventions were documented in the care plan. The DON and Administrator confirmed the absence of a care plan addressing these behaviors, contrary to facility policy.
A resident with dementia and cerebrovascular disease was reported to have a bruise by a family member, which was not documented or investigated by the facility. Despite the facility's policy requiring prompt investigation of injuries of unknown origin, the DON did not notify the administrator or document the incident, resulting in a deficiency.
The facility failed to implement proper infection control protocols, with soiled linens improperly handled and staff neglecting hand hygiene. Soiled linens were found on the floor, and staff did not wear gloves while handling them. Medical equipment was not disinfected properly, and there was a lack of preventive measures for legionella in the water system.
The facility failed to ensure privacy and dignity for residents, as observed in instances where Foley catheter bags were not covered and were placed on the floor. Additionally, an LPN administered intravenous medication without providing privacy, and a resident was found without a privacy curtain. These actions were contrary to the facility's policies on resident rights and dignity.
A resident with a history of falls and an unspecified head injury experienced two unobserved falls, one resulting in a hematoma and hospital transfer, without updates to their care plan. The MDS coordinator responsible for these updates had resigned, and the facility's policy to review and update care plans after changes in condition was not followed.
A resident with multiple health issues, including reduced mobility and severe malnutrition, was found with long and dirty fingernails, indicating a failure in providing adequate nail care. Despite the facility's policy requiring CNAs to check and clean nails during personal hygiene routines, this was not done, as confirmed by an LPN. The resident required substantial assistance with ADLs, and the facility's procedures for nail care were not followed.
A resident with multiple health issues, including reduced mobility, was not provided with a physician-ordered right-hand splint. Observations revealed the resident without the splint, and the therapy department was not informed of the order. The facility's policies on carrying out physician orders and applying restorative devices were not followed.
The facility failed to maintain proper respiratory care protocols for two residents. A resident with a tracheostomy did not have a physician's order for the tube size or oxygen usage, and there was no spare tracheostomy tube at the bedside. Another resident's oxygen nasal cannula tubing was not dated, contrary to facility policy. Staff confirmed these deficiencies, highlighting a lack of adherence to respiratory care protocols.
An LPN administered IV medication to a resident without performing hand hygiene or providing privacy, and was not certified in IV administration. The DON confirmed that LPNs can administer IV medications but emphasized the need for proper hygiene and privacy. The resident had a physician's order for IV medication to treat sepsis.
A facility failed to complete an infection verification tool upon initiating antibiotics for a resident with cellulitis, as required by their Antibiotic Stewardship Program. The resident, who was alert and oriented, was prescribed Cephalexin for cellulitis, but the necessary assessment using McGeer's criteria was not conducted by the responsible nurse.
A resident with dementia and a history of wandering was not adequately monitored, leading to a potential sexual abuse incident with another resident. The incident was reported by a third resident, prompting staff intervention. The involved resident was taken to a hospital for evaluation, and a police report was filed.
A resident with dementia was transferred to a hospital for a psychological evaluation after an incident but was not allowed to return to the facility. The facility failed to document the reasons for the discharge or communicate effectively with the resident's family, leading to a deficiency. Staff interviews indicated no known history of inappropriate behavior by the resident.
A resident with advanced dementia and a history of wandering was inadequately supervised, leading to her entering another resident's room and an inappropriate incident occurring. The facility's staff responded after being alerted by another resident, but the Director of Nursing acknowledged the need for increased supervision due to the resident's condition and behavior.
The facility failed to prevent a verbal argument from escalating into a physical assault between two residents with dementia. Despite known behavioral issues, the facility did not take adequate measures to prevent the altercation, which resulted in one resident pushing the other to the floor. The incident was not classified as abuse due to the residents' cognitive impairments.
Failure to Administer Medications Timely and Inadequate Emergency Response for Hypoglycemia
Penalty
Summary
The facility failed to follow its own policies and procedures regarding medication administration, documentation, and emergency response for multiple residents. Specifically, three residents did not receive their prescribed medications in a timely manner, and medication administration was not properly documented. Observations revealed that medications scheduled for specific times were administered late, and staff did not consistently sign out medications as they were given. The electronic medication administration record (EMAR) showed multiple residents highlighted as overdue for medication, and staff admitted to delays and incomplete documentation due to being busy or unfamiliar with procedures. A critical incident involved a resident with multiple complex medical conditions, including diabetes, chronic respiratory failure, and a history of uncontrolled diabetic status. This resident was found unresponsive with a critically low blood sugar level. Nursing staff attempted to administer oral sugar to the unresponsive resident, which is not a safe or effective intervention, and were unable to obtain intravenous access for dextrose. Glucagon, which was available in the emergency kit per facility policy, was not administered. Emergency medical services were called, but there was a delay in both the response and the appropriate intervention for hypoglycemia. The resident was subsequently hospitalized in the ICU for severe hypoglycemia, sepsis, and multiple infections, with documentation from the hospital noting poor hygiene, extensive skin breakdown, and concerns of neglect. Interviews with staff and review of facility policies confirmed that the required protocols for hypoglycemia and change in condition were not followed. Staff acknowledged that oral administration of sugar to an unresponsive resident was inappropriate and that glucagon should have been administered. There was also a failure to change the resident's Foley catheter as required, contributing to infection risk. The facility's own policies mandate timely medication administration, proper documentation, immediate emergency response, and adherence to hypoglycemia protocols, all of which were not met in these instances.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not prevent an incident of resident-to-resident abuse involving two residents. One resident, who had a history of suspected abuse or neglect and cognitive impairment, was subjected to a racially derogatory term and was spat on by another resident while walking in the hallway. The incident was reported by the affected resident to nursing staff, and a witness confirmed hearing the altercation and intervened by instructing the aggressor to return to his room. The aggressor, who had diagnoses including delusional disorder, schizophrenia, and unspecified psychosis, was known to have a history of spitting on other residents and using offensive language toward both residents and staff. Despite these known behaviors, the care plan for the aggressor did not include updated interventions following the incidents of spitting and verbal abuse. The care plan interventions remained unchanged even after multiple documented behavioral incidents, and there were no new strategies implemented to address the ongoing risk. The facility's policies affirm the right of residents to be free from abuse and to be treated with respect and dignity, but these were not upheld in this case, as evidenced by the lack of timely and appropriate updates to the care plan and interventions for the resident exhibiting abusive behaviors.
Failure to Maintain Safe, Hazard-Free Floors Due to Ongoing Water Leaks
Penalty
Summary
The facility failed to ensure that resident floors were free from hazards, specifically water accumulating on the floor near door entryways and under air conditioning vents. Multiple observations documented water puddles in resident rooms, including one instance where a towel was placed over a puddle without a wet floor sign present. Staff interviews confirmed that leaking from ceiling air conditioning grills had been observed in several rooms over the past weeks, with maintenance staff indicating that the condensation pipes required regular cleaning to prevent clogs and leaks. Maintenance also reported that prior to their recent employment, there was no established routine for cleaning these pipes, and issues were only addressed as they were reported. Residents affected by these leaks included individuals with unsteady gait and those identified as being at risk for falls, as documented in their assessments and care plans. One resident described a situation where a bucket placed to catch leaking water was not emptied, resulting in water spilling onto the floor and creating a slippery surface. Staff acknowledged that water on the floor posed a fall risk, especially for residents who ambulate independently. Review of facility work orders revealed multiple reports of water leaks from air conditioning units in various rooms, with some instances requiring makeshift solutions such as garbage bins to catch the water.
Failure to Ensure Nurse Coverage on Unit Due to Call-Off and Lack of Relief
Penalty
Summary
The facility failed to ensure that nursing staff followed the established practice of not leaving a unit at the end of a shift without a relief nurse present. On the day in question, a nurse called off for the day shift on the second floor main unit, but the absence was not communicated in a timely manner to the appropriate supervisory staff. As a result, there was no nurse present on the unit for approximately one to two hours, leaving 36 residents without a licensed nurse available. Interviews confirmed that the off-going nurse left before a replacement arrived, and the oncoming nurse was not notified to stay over. The facility's policy requires staff to call off at least four hours before their shift and not to leave without relief, but this protocol was not followed. Review of time cards and controlled substances check forms corroborated that there was no nurse on duty for the affected shift, as no signatures were present for the day shift on the unit. The Director of Nursing was not aware of the call-off until notified by another staff member after the shift had already started. The facility assessment indicated that four nurses were expected to provide direct care on the day shift, but this standard was not met due to the absence and lack of proper handoff. Certified Nursing Assistants (CNAs) were present but are not permitted to pass medications, further impacting care delivery during the period without a nurse.
Failure to Provide Discharge Instructions and Medications During Resident Transfer
Penalty
Summary
The facility failed to follow its policy regarding the provision of discharge instructions and medications for a resident who was transferred to another skilled facility. The resident had a planned discharge, and the family was responsible for transporting her. According to staff interviews, the family took the resident without speaking to the nurse on duty, and the nurse was unaware of the resident's departure until contacted by the admitting facility. As a result, no medications or discharge instructions were sent with the resident at the time of transfer. Documentation reviewed showed that while a transfer discharge report and discharge planning review were prepared, there was no evidence of a signed discharge instruction form or confirmation that instructions and medications were provided to the resident or her representative on the day of discharge. Progress notes indicated that the resident had requested the transfer and that the family would handle transportation. However, the nurse only became aware of the resident's departure after being notified by the receiving facility, which reported that no medications had accompanied the resident. The facility's policy requires that discharge instructions, medication lists, and any necessary referrals be reviewed and sent with the resident, and that documentation be signed by the resident or their representative. These steps were not completed, and the required documentation was not presented for review.
Failure to Follow Urinary Catheter Care Policy
Penalty
Summary
The facility failed to follow its Urinary Catheter Care policy for three out of four residents reviewed for indwelling catheter care. One female resident with moderate cognitive impairment was observed with her indwelling catheter bag placed flat on the bed, contrary to the care plan intervention requiring the bag and tubing to be positioned below the level of the bladder. During catheter care, a CNA used soap and water to wipe down the catheter but did not clean the labia, stating it was difficult to do so while the resident was in a geriatric chair. Another female resident with mild cognitive impairment was found with an indwelling catheter that was not secured to her thigh, lacking a stat lock or tape as required by policy. A male resident with moderate cognitive impairment was observed with a urine leg bag tied to his thigh, but the catheter itself was not secured. During catheter care for this resident, staff used soap and water to clean the catheter but did not retract the foreskin to clean the catheter-meatal junction, as required for uncircumcised males. Staff interviews confirmed that proper procedures were not followed, including securing catheters to prevent tension, maintaining gravity drainage, and performing appropriate hygiene for both male and female residents. The facility's policy specifies these requirements, but observations and staff statements indicated noncompliance in multiple instances.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident hazard prevention for a high fall risk resident, resulting in a left hip fracture, hospitalization, and surgery. The resident, an older male with multiple diagnoses including ataxia, epilepsy, gait abnormalities, schizoaffective disorder, diabetes with neuropathy, and heart failure, was assessed as having moderate cognitive impairment and was identified as high risk for falls. His care plan required supervision during transfers and ambulation, prompt response to requests for assistance, and a safe, clutter-free environment with accessible call lights and personal items. On the day of the incident, the resident was found sitting on the hallway floor after attempting to clean up spilled water, without his walker and possibly without shoes. The call light was observed out of his reach, and the room was dark. Staff interviews revealed inconsistent awareness of the resident's fall risk status and required interventions. The assigned CNA was the only one on duty for the unit, despite the usual need for two, and did not recall any special monitoring or interventions for the resident. Nursing staff did not consistently reassess the resident's pain or follow up on the x-ray order after the fall, resulting in a delay in diagnosis and transfer to the hospital. Documentation and interviews indicated that the resident was not adequately supervised, and fall prevention interventions were not reliably implemented. The resident's known behaviors, such as obsessive cleaning and not using the call light, were not sufficiently addressed through increased monitoring or environmental adjustments. The facility's fall prevention policy required individualized interventions and ongoing monitoring, but these measures were not effectively carried out for this high-risk resident, directly contributing to the incident and subsequent injury.
Failure to Timely Administer PRN Pain Medication After Resident Fall
Penalty
Summary
A deficiency occurred when a resident who experienced a fall and reported significant pain did not receive timely administration of PRN pain medication. After the fall, the resident was found unable to move his left leg and expressed considerable pain, especially with movement. Although nursing staff assessed the resident and notified the physician, there was a failure to ensure that pain medication was administered and documented in a timely manner. The resident's pain persisted for 44 hours before he was ultimately hospitalized and diagnosed with a left hip fracture requiring surgery. The resident involved had multiple complex medical conditions, including ataxia, epilepsy, abnormal gait, schizoaffective disorder, hypertension, diabetes with neuropathy, and heart failure. Following the fall, staff interviews and record reviews revealed lapses in pain assessment, documentation, and follow-up. Nursing staff did not consistently reassess the resident's pain or verify the effectiveness of any pain interventions. There was also confusion regarding the x-ray order, with delays in obtaining diagnostic imaging and a lack of follow-up with the diagnostic company. Documentation in the resident's medical record and Medication Administration Record (MAR) did not show evidence of pain medication being administered between the time of the incident and the resident's transfer to the hospital. Despite the facility's pain management policy requiring prompt assessment and intervention for pain, these procedures were not followed, resulting in the resident experiencing unaddressed pain for an extended period prior to hospitalization.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
A deficiency occurred when a dietary aide was observed inside the facility's kitchen without wearing a hair restraint, in violation of the facility's own policy requiring hairnets to be worn at all times in the kitchen. The surveyor, upon entering the kitchen with the dietary supervisor, immediately noticed the aide sitting by the wall without a hair restraint. The supervisor then instructed the aide to put on a hair restraint, after which the aide briefly left the kitchen and returned wearing one. During an interview, the dietary supervisor acknowledged that the aide was not supposed to be in the kitchen without a hairnet, but allowed it because the aide reported being hot and having just wiped sweat from his brow, causing the hairnet to slip off. The facility's policy, dated 2021, clearly states that food and nutrition services employees must wear hair restraints at all times in the kitchen. No residents or their medical conditions were directly involved or mentioned in this deficiency.
Failure to Timely Obtain and Report Diagnostic X-ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a diagnostic x-ray order was carried out and the results were reported in a timely manner for a resident who had sustained an acute fracture. The resident, an older male with multiple complex medical conditions including ataxia, epilepsy, schizoaffective disorder, diabetes with neuropathy, and heart failure, experienced a fall and was found unable to move his left leg, in significant pain, and unable to recall the incident. The nurse on duty assessed the resident, notified the physician, and received an order for an x-ray, which was communicated to the external diagnostic company. However, there was no confirmation of when the x-ray would be performed, and the nurse did not follow up with the company or reassess the resident's pain before the end of the shift. The following day, another nurse discovered that the x-ray had not been completed and, upon contacting the diagnostic company, learned that no order had been received. A STAT x-ray was then ordered, and the resident was found to be immobile and in pain, with a visible bruise on the left hip. The x-ray was performed later that day, and the results, indicating an impacted transcervical fracture of the left femoral neck, were posted in the electronic medical record in the evening. However, the results were not promptly identified or reported by the nursing staff, and the Director of Nursing was not made aware of the findings until the next morning. During this period, the resident remained in bed, continued to experience pain, and was not returned to his baseline level of mobility. The delay in both obtaining the diagnostic test and reporting the results led to a delay in the resident being sent to the hospital for further evaluation and treatment. The deficiency was identified through interviews and record reviews, which confirmed lapses in communication, follow-up, and timely reporting of critical diagnostic information.
Failure to Conduct Contraband Search Results in Resident Overdose and Injury
Penalty
Summary
The facility failed to follow its policy regarding contraband searches for a resident with a known history of substance abuse. The resident had previously been found unresponsive with a rolled-up dollar bill containing a white powdery substance, and after this incident, restrictions were put in place requiring that the resident only go out with a responsible party and that his belongings be searched upon return from outings. Despite these measures, on a subsequent occasion, the resident was allowed to leave the facility with a relative and upon return, there is no evidence that the required contraband search was conducted by social services as per facility policy. Shortly after returning from the outing, the resident was found unresponsive on the floor of another resident's room, with a laceration to the right eyebrow. Staff assessed the resident, administered Narcan, and called 911 for transport to the emergency room. During this time, a bag containing a white powdery substance was found in the resident's pocket. The resident was hospitalized with a diagnosis of opioid overdose and a laceration. Interviews with staff revealed that there was confusion and lack of communication regarding who was responsible for searching the resident upon return from outings. The social services director was not present when the resident returned and was not informed of the resident's return, and it was unclear if any staff conducted the required search. The facility's policy allows for searches when there is reasonable suspicion of contraband, and in this case, the policy was not followed, resulting in the resident's overdose and injury.
Failure to Obtain Guardian Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain proper informed consent from the resident's legal guardian prior to administering psychotropic medications. The resident in question had a documented guardian, as indicated on the face sheet, but the facility allowed the resident to sign their own consent for Haloperidol and Lorazepam. The Assistant Director of Nursing, who oversees psychotropic medications, was unaware that the resident had a guardian and permitted the resident to sign the consent form. The guardian was not informed or asked for consent regarding the administration of these medications. The guardian later reported that the facility had started the resident on psychotropic medications without her knowledge or consent. When questioned, facility staff stated that the medications were necessary to manage the resident's behaviors. The facility's own policy requires that informed consent for psychotropic medications be obtained from the resident's guardian or authorized representative, not solely from the resident when a guardian is in place.
Failure to Administer and Document Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure that prescribed medications were administered as ordered for one resident. Review of the resident's Medication Administration Record (MAR) for April 2025 showed that several medications, including Benztropine Mesylate, Divalproex Sodium ER, Olanzapine, and Trazodone, were not administered on specific dates as prescribed. The MAR indicated missed doses on 4/10/25 and 4/13/25 for these medications, with no documentation to explain the omissions. A registered nurse confirmed that if there is no entry on the MAR, the medication was not given. The facility's policy requires that all medication administration be documented on the MAR with the date, time, and nurse's initials.
Lack of Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that stop dates were in place for as-needed (PRN) psychotropic medications for two of three residents reviewed for such medications. Specifically, one resident had physician orders for Haloperidol 5 mg every 6 hours as needed for behavioral disturbances and Lorazepam 1 mg every 6 hours as needed for behaviors, both lacking a documented stop date. Another resident had an order for Lorazepam Injection 0.5 ml every 8 hours as needed for agitation, also without a stop date. According to the facility's undated policy, PRN psychotropic medications should be ordered with a 14-day time limit, after which a physician must re-evaluate and reorder if necessary. The Assistant Director of Nursing confirmed that PRN psychotropic medications should have a 14-day stop date, but this was not implemented for the residents in question.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as observed during a survey. Multiple deficiencies were noted, including missing floor tiles in residents' rooms, a lack of window curtains, and a bathroom with a toilet seat smeared with a brown substance. Residents reported issues such as non-functional window curtains, insufficient hot water, and unclean rooms. These issues were observed in the rooms of nine residents, indicating a widespread problem with maintaining the facility's environment. Interviews with staff revealed a lack of awareness and action regarding these deficiencies. The Assistant Administrator acknowledged the issues but did not provide a plan for addressing them. Housekeeping staff mentioned being short-staffed and not having cleaned certain areas, while the Maintenance Director admitted to being aware of the need for tile replacements but stated that no tiles were available. The facility's resident rights booklet emphasizes the need for a safe, clean, and homelike environment, which was not met according to the observations and interviews conducted.
Failure to Administer Medications and Notify Physician
Penalty
Summary
The facility failed to notify a physician about a resident not receiving prescribed medications, specifically a steroid topical ointment and an immunosuppressive medication, as ordered. This resulted in the resident missing 15 doses of the steroid topical ointment and 14 doses of the immunosuppressive medication. The resident, who has rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic skin ulcers, reported not receiving the medication for their autoimmune disease as scheduled, which is supposed to be administered twice daily. Interviews with facility staff, including a nurse and the Director of Nursing (DON), revealed a lack of awareness regarding the missed doses. The nurse confirmed that medications should be administered as ordered and documented in the Medication Administration Record (MAR). However, the nurse and DON were not aware of the multiple missed doses and had not been notified of the issue. The facility's policy requires physician notification when a resident misses a dose of medication, but this protocol was not followed in this case. The MAR for January and February documented several instances where the medications were not administered as ordered. Hospital records indicated that the resident presented with bilateral hand ulcerations, pain, and swelling, and the plan was to continue the prescribed medications. Despite this, the facility did not ensure the medications were administered as ordered, nor did they notify the physician of the missed doses, which is a requirement according to their policies.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer a topical steroid ointment and an immunosuppressive medication as ordered, resulting in a resident missing 15 doses of the topical steroid ointment and 14 doses of the immunosuppressive medication over a two-month period. The resident, who has rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic skin ulcers, reported not receiving the medication for their autoimmune disease as prescribed. The resident was supposed to receive the medication twice daily, but it was often given only once a day or not at all. Interviews with facility staff revealed a lack of awareness regarding the missed doses. A nurse stated that if a medication is not signed out on the Medication Administration Record (MAR), it is considered not given. The Director of Nursing (DON) and other staff members were unable to recall the specific medications the resident was taking and denied any reports of missed doses. The MAR documented multiple instances where the medications were not administered as ordered, with specific dates and times noted for both January and February. The resident was hospitalized with bilateral hand ulcerations, pain, and swelling, and the hospital records indicated the continuation of the immunosuppressive medication. The facility's policies on medication administration and physician orders emphasize the importance of administering medications as ordered and documenting them accurately. However, the facility failed to adhere to these policies, resulting in significant medication errors for the resident.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault, which affected two residents. Resident 1, who has a history of heart failure, dementia, schizophrenia, depression, and auditory hallucinations, was punched in the face by Resident 2. This incident occurred after Resident 1 repeatedly opened the bathroom door while Resident 2 was using it, leading to Resident 2 exiting the bathroom and hitting Resident 1 in the face. Resident 1 was subsequently transferred to a local hospital for evaluation due to eye pain and injury. Resident 2, who has a diagnosis of Huntington's disease and violent behavior, was described as very aggressive and angry during the incident. A nurse witnessed the assault and intervened to separate the residents. The facility's abuse prevention policy, which aims to protect residents from abuse and establish a secure environment, was not effectively implemented in this case, as the incident was not prevented. The facility's final abuse report documented the incident and the injuries sustained by Resident 1, including swelling and redness below the right eye.
Failure to Develop Care Plan for Resident with Violent Behavior
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of violent behavior, which resulted in multiple incidents of aggression. The resident, who was admitted with diagnoses including Huntington's disease, violent behavior, brief psychotic disorder, and schizoaffective disorder, was involved in several altercations with roommates. On one occasion, the resident was involved in a physical altercation with a roommate, which escalated to the point where staff intervened and were inadvertently struck. The resident was subsequently sent to the hospital due to aggressive behavior, including choking a roommate. Despite these incidents, the facility did not document any interventions or updates to the resident's care plan to address the aggressive behaviors and altercations. The Director of Nursing confirmed the absence of documented interventions following these events, and the Administrator was unable to locate any care plan addressing the resident's behaviors. The facility's policy requires a comprehensive assessment and individualized care plan for all residents, but this was not adhered to in the case of this resident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse and injury of unknown origin policy by not initiating and completing a thorough investigation of an injury of unknown origin reported by a resident's family member. This deficiency involved a resident who was admitted for respite care and had a history of cerebrovascular disease and dementia with behavioral disturbance. The resident was described as moderately impaired in cognitive status, requiring cues and supervision for decision-making. During the resident's short stay, a family member reported a bruise on the resident's arm, which was not documented upon admission or during routine care. Interviews with various staff members, including LPNs and CNAs, revealed that none had observed the bruise prior to the family's report. The Director of Nursing (DON) assessed the bruise but did not document the incident or notify the administrator, as required by the facility's policy. The family took the resident home without further communication about the bruise. The facility's policies require prompt investigation of injuries of unknown origin, including documentation, notification of the administrator, and potential initiation of an abuse investigation. However, these procedures were not followed in this case. The DON did not document the bruise in the resident's medical record, complete an incident report, or conduct a thorough investigation to determine the cause of the injury, leading to a deficiency in the facility's compliance with its own policies.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control protocols, as evidenced by multiple observations of improper handling of soiled linens. Soiled linens were found in green plastic bags on the floor in various locations, including hallways and near the therapy room. Staff members, including CNAs and housekeeping aides, were observed handling these soiled linens without wearing gloves, and using inappropriate methods such as a recliner chair to transport them. The laundry chute was found overflowing with soiled linens, and the facility's policy on linen handling was not adhered to, as soiled linens were placed on the floor and not immediately transported to the appropriate area. Additionally, the facility failed to maintain proper hand hygiene and equipment disinfection protocols. Staff members, including LPNs and CNAs, were observed not performing hand hygiene after glove removal and before exiting resident rooms, even when dealing with residents on enhanced barrier precautions. Medical equipment, such as blood pressure machines, was not properly disinfected between uses, with staff failing to adhere to the required contact time for disinfection as per the product label. The facility also lacked measures to prevent the growth of legionella and other waterborne pathogens in the building's water system. Despite having a negative legionella test result from July, the facility was unable to provide documentation of ongoing monitoring or preventive measures. This lack of documentation and preventive action poses a risk to all residents, as the facility does not have a maintenance team to address these issues.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to provide privacy and dignity to residents, affecting three residents in a sample of 24 reviewed for residents' rights. On multiple occasions, residents were observed with Foley catheter bags that were not covered with privacy bags, and in some cases, the bags were placed on the floor. Specifically, one resident was seen with a Foley catheter bag hanging visibly without a privacy cover, and another resident had their catheter bag sitting on the floor without a cover. These observations were confirmed by a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who acknowledged that the catheter bags should have been covered and not placed on the floor. Additionally, the facility failed to ensure privacy during medical procedures. An LPN administered intravenous medication to a resident without closing the room door or pulling the privacy curtain. Another resident was observed without a privacy curtain available in their room, a situation confirmed by both the LPN and the Housekeeping Supervisor. The facility's policies on resident rights and dignity, which emphasize the importance of privacy and respect, were not adhered to in these instances, leading to the identified deficiencies.
Failure to Update Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to update the care plan to reduce the risk of falls for a resident identified as a high fall risk. The resident, who has a history of falls and an unspecified head injury, experienced two unobserved falls on 5/25/2024 and 9/10/2024. The first fall resulted in a hematoma and required hospital transfer, while the second fall resulted in no injury. Despite these incidents, the care plan was not updated. The Director of Nursing noted that the MDS coordinator, responsible for updating the care plan after falls, had resigned the previous week. The facility's policy requires that the care plan be reviewed and updated when a change occurs in a resident's condition, but this procedure was not followed.
Failure to Provide Adequate Nail Care to Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident, identified as R110, who was dependent on staff for assistance with activities of daily living (ADLs). On two consecutive days, observations revealed that R110 had long and dirty fingernails with black matter inside them. Despite the facility's policy requiring CNAs to check and provide nail care during personal hygiene routines, this was not done for R110. The LPN acknowledged that the CNA should have cleaned and trimmed the resident's fingernails during bathing or showering and checked them weekly. R110 was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, tracheostomy status, reduced mobility, and severe protein-calorie malnutrition. The comprehensive care plan indicated that R110 required substantial to total assistance with ADLs due to self-care performance deficits. The facility's policy on nail care emphasized cleanliness, infection prevention, and safety, outlining specific procedures for nail care during bathing. However, these procedures were not followed, leading to the deficiency observed by the surveyors.
Failure to Apply Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to follow a physician's order for the application of a right-hand splint for a resident, identified as R110, who was part of a sample reviewed for the Restorative Nursing Program. The resident, who was admitted with conditions including acute respiratory failure with hypoxia, tracheostomy status, reduced mobility, and severe protein-calorie malnutrition, was observed on two consecutive days without the prescribed right-hand splint. The resident's care plan indicated a need for substantial to total assistance with activities of daily living (ADLs) due to various health issues, and the restorative nursing assessment noted a moderate loss of range of motion in the right wrist and fingers. Despite the physician's order dated 7/30/24 for the right-hand splint, the resident was not wearing it during observations, and the therapy department had not been notified to evaluate the resident for the splint. The Restorative Nurse mentioned that the splint was ordered and awaiting arrival, while the Therapy Director was unaware of the order. The facility's policies require that physician orders be carried out and that a physician's order is necessary for applying splints or restorative devices, which was not adhered to in this case.
Deficiencies in Respiratory Care Protocols
Penalty
Summary
The facility failed to maintain proper respiratory care protocols for two residents, R110 and R372, as observed during a survey. For R110, the facility did not have a physician's order for the size of the tracheostomy tube or the oxygen usage, and there was no accessible spare tracheostomy tube kit at the bedside in case of emergency or accidental decannulation. The oxygen tubing connected to R110's tracheostomy was not dated, which is against the facility's policy that requires oxygen tubing to be changed and dated weekly. R110 was admitted with acute respiratory failure with hypoxia, tracheostomy status, and other conditions, yet the facility lacked a respiratory therapist and a comprehensive policy on respiratory services. For R372, the facility also failed to date the oxygen nasal cannula tubing, as confirmed by staff members. R372 was receiving oxygen via nasal cannula without a date on the tubing, which contradicts the facility's policy. R372 was admitted with conditions including cellulitis, type 2 diabetes mellitus, and heart failure, and had a physician order for oxygen as needed for shortness of breath. The facility's failure to adhere to its own policies on respiratory care and equipment maintenance was evident in these observations.
LPN Administers IV Medication Without Proper Training and Hygiene
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to administer intravenous medications safely. During an observation, a Licensed Practical Nurse (LPN), identified as V14, administered intravenous medication to a resident, R112, without performing hand hygiene between glove changes and without providing privacy by closing the room door or pulling the privacy curtain. V14 acknowledged the oversight in hand hygiene and privacy provision during an interview. The Director of Nursing (V3) confirmed that LPNs are permitted to administer intravenous medications but emphasized the importance of hand hygiene and privacy during the process. Further investigation revealed that V14 was not certified in intravenous administration and could not recall receiving any training related to intravenous medication administration. The Director of Nursing stated that V14 should not have administered intravenous medication without the supervision of a Registered Nurse. The resident, R112, had been admitted with diagnoses including sepsis and acute cystitis with hematuria and had a physician's order for intravenous medication to treat sepsis. The facility's policy on intravenous therapy, revised in 2014, mandates that only trained personnel with demonstrated competency should administer intravenous medications, and thorough hand washing is required before and after the procedure.
Failure to Complete Infection Verification Tool for Antibiotic Use
Penalty
Summary
The facility failed to ensure the completion of an infection verification tool upon the initiation of antibiotics for a resident, as required by their Antibiotic Stewardship Program. This deficiency was identified during a survey when it was observed that the infection verification assessment was not completed using McGeer's criteria for a resident who was prescribed Cephalexin for cellulitis. The Director of Nursing and the Infection Preventionist confirmed that the assessment was not done, and it was noted that the floor nurse is responsible for completing the McGeer's criteria/Antibiotic assessment when an antibiotic order is received from the physician. The resident involved was admitted with diagnoses including cellulitis, lymphedema, and morbid obesity. At the time of the survey, the resident was alert, oriented, and able to communicate needs to the staff. The active physician order sheet indicated that the resident was prescribed Cephalexin 500mg, two tablets orally twice a day for cellulitis, starting on a specified date. The facility's policy mandates that the infection verification tool be completed by the nurse upon initiation of antibiotics using McGeer's Criteria, which was not adhered to in this case.
Failure to Monitor Resident with Wandering Behavior Leads to Potential Abuse
Penalty
Summary
The facility failed to protect a resident from potential sexual abuse by not adequately monitoring a resident with a history of wandering. The incident involved a female resident with dementia and behavioral disturbances, who wandered into another resident's room. This resident, identified as R1, was found in a compromising situation with a male resident, R2, who has a history of dementia and other medical conditions. R1's wandering behavior and lack of supervision led to an inappropriate encounter with R2, who was found with his pants off, while R1 had her dress up to her waist without her brief. The incident was reported by another resident, R3, who witnessed the event and informed the nursing staff. The staff, including a Licensed Practical Nurse (V5) and a Certified Nursing Assistant (V6), responded to the situation by separating the residents and reporting the incident. R1 was subsequently taken to a hospital for a Sexual Assault Exam, and a police report was filed. The facility's administrator and Director of Nursing acknowledged the need for increased supervision for R1 due to her dementia and wandering behavior, which was not adequately provided at the time of the incident.
Failure to Document and Communicate Involuntary Discharge
Penalty
Summary
The facility failed to adhere to its policy and procedure for involuntary discharge by not adequately documenting the reasons for a resident's transfer and discharge. The resident in question, a male with a history of vascular dementia, depression, and other medical conditions, was transferred to a hospital for a psychological evaluation following an incident involving inappropriate behavior with another resident. Despite the incident, there was no documentation in the resident's care plan or medical records indicating a history of sexually inappropriate behavior or any other behaviors that would endanger other residents. The facility did not provide the necessary documentation to justify the resident's discharge, as required by their policy and federal regulations. The Director of Nursing and the Administrator acknowledged that the resident was their responsibility, yet they did not ensure that the proper procedures were followed. The resident's family was not given the option for the resident to return to the facility, and the decision to transfer the resident to another facility was made without their input or the resident's consent. Interviews with staff members revealed that the resident was not known to engage in inappropriate behaviors, and there was no evidence of previous incidents. The facility's failure to document the reasons for the discharge and to communicate effectively with the resident's family led to the deficiency. The lack of documentation and communication highlights a significant oversight in the facility's handling of the resident's transfer and discharge process.
Inadequate Supervision of Wandering Resident Leads to Incident
Penalty
Summary
The facility failed to provide adequate supervision for a resident with dementia and a history of wandering, which resulted in the resident entering another resident's room. The resident, a female with advanced dementia and a history of behavioral disturbances, wandered into a male resident's room. This male resident, who also has dementia, was involved in an inappropriate incident with the female resident. The incident was witnessed by another resident who reported it to the nursing staff. The staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, responded to the situation after being informed by the witness. The facility's Director of Nursing acknowledged that the female resident's wandering behavior and inability to consent due to her advanced dementia required increased supervision, which was not adequately provided. The facility's policy on wanderers, which includes making visual rounds on residents every two hours or more frequently as needed, was not effectively implemented in this case.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to prevent a verbal argument from escalating into a physical assault between two residents, R1 and R2. Both residents have moderate cognitive impairments and a history of behavioral issues related to dementia. On the day of the incident, R1 attempted to enter R2's room, leading to a verbal altercation. R2 then pushed R1, causing her to fall. A Certified Nursing Assistant (CNA) witnessed the incident but did not intervene in time to prevent the physical assault. Both residents were subsequently sent to the local hospital for evaluation and did not return to the facility immediately after the incident. R1's medical history includes dementia without behaviors, a history of transient ischemic attack, depression, and heart disease. R1's care plan noted a risk for increasing confusion and aggressive behaviors. In the days leading up to the incident, R1 exhibited multiple episodes of verbal outbursts, threats, and delusions, which disturbed other residents. R2 also has moderate cognitive impairment and a history of pacing and roaming behaviors. The facility's investigation concluded that the physical altercation was not willful or intentional due to both residents' cognitive impairments. The Director of Nursing and the Administrator both acknowledged the incident but did not classify it as abuse, citing the residents' dementia as a mitigating factor. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the importance of creating a secure environment. However, the facility's response to the incident suggests a lack of adequate measures to prevent such altercations, despite the known behavioral issues of both residents involved.
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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