Pearl Of Hinsdale, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Hinsdale, Illinois.
- Location
- 600 West Ogden Avenue, Hinsdale, Illinois 60521
- CMS Provider Number
- 145246
- Inspections on file
- 31
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pearl Of Hinsdale, The during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow the written menu, portion sizes, and texture requirements for pureed and mechanical soft diets. For several residents on pureed diets, the cook used an incorrect scoop size and did not prepare all menu items as specified, resulting in portions that did not match the menu spreadsheet. For multiple residents on mechanical soft diets, the chicken fajita mixture contained large, crunchy onion pieces far exceeding the 1/8-inch size required by the recipe, and it was served on tortillas even though the facility’s mechanical soft diet policy required easy-to-chew, small bite-size foods and listed tortillas as a food to avoid. The dietitian confirmed that the recipe, scoop sizes, and diet policy should have been followed for these modified diets.
Two residents with PICC or midline catheters for IV antibiotics did not receive care consistent with physician orders and facility policy, as staff used bio-patches and transparent dressings that obscured the insertion tips, assessed only the surrounding skin, and failed to document required weekly arm circumference and external catheter length measurements or insertion site assessments every shift in the EMAR/ETAR or nursing notes.
Two residents receiving hemodialysis experienced inadequate monitoring and maintenance of their dialysis access sites. One resident with an AV fistula had an undated dressing on the upper arm that was completely saturated with dried dark brown drainage and nearly falling off, despite orders and care plan directives for every-shift assessment, documentation, and reinforcement of the dressing as needed; the assigned LPN acknowledged not assessing the site and that the dressing was likely unchanged since the last dialysis session, and nursing notes lacked documentation of bleeding or provider notification. Another resident with a chest central venous catheter for weekly offsite dialysis was found with a loosely hanging gauze and the catheter site exposed, showing dry, crusted brownish material around the insertion site, even though orders and the care plan required daily checks and dressing management; the RN stated the site had been checked earlier and suggested the dressing may have come off during clothing changes. Facility dialysis protocols required every-shift checks for bleeding, infection, and thrill/bruit and allowed reinforcement of line dressings, but these were not followed for these residents.
Two residents with multiple chronic conditions did not receive wound treatments as ordered by their physicians. Documentation and staff interviews confirmed that wound care was missed on several occasions, despite facility policy requiring licensed nurses to follow and document physician orders.
Surveyors found that the facility did not maintain an adequate supply of linens and towels, resulting in multiple residents missing scheduled showers, using washcloths or blankets in place of towels, and experiencing infrequent bed linen changes. Staff and laundry personnel reported ongoing shortages and insufficient deliveries, with all available linens either in use or being laundered. Facility leadership confirmed the lack of a formal inventory system and insufficient circulating supplies.
Several residents did not receive meals consistent with their dietary orders or the posted menu, including missing double portions, incomplete trays, and inappropriate substitutions. Staff acknowledged menu adherence issues due to supply shortages and delivery delays, and resident council minutes reflected ongoing concerns about missing food items and portion sizes.
The facility failed to ensure nursing staff were trained and competent to care for residents with LVADs, affecting four residents with cardiac diagnoses. The DON and ADONs, designated as superusers, had not attended required training since March 2023, leading to insufficient training for other staff. Interviews revealed that nurses had not received LVAD training for over a year, and the facility lacked documentation of staff competency. This resulted in concerns about the care provided, prompting the hospital to remove a resident from the facility.
The facility failed to follow physician-ordered LVAD dressing changes for three residents, leading to improper sterile procedures. For one resident, the EMR had incomplete orders, and the facility lacked documentation of adherence to sterile dressing protocols. Another resident did not receive the required antimicrobial patch during dressing changes, and the staff was unaware of the complete order requirements. The third resident reported improper dressing changes and lack of sterile procedure adherence, with the facility failing to document the correct orders.
Two residents with LVADs experienced significant medication errors at the facility. One resident received another patient's Milrinone, a heart failure medication, with a higher concentration than prescribed for 27 hours. Another resident received an incorrect dosage of Torsemide, a diuretic, for 15 days due to an entry error. Despite the facility's medication administration policy, these errors occurred, raising concerns about the care of LVAD residents.
The facility failed to return heart monitor devices as per physician orders for two residents. One resident's monitor was misplaced, delaying cardiac care, while another's device was returned incomplete, causing billing issues. The facility's policy required adherence to physician orders, which was not followed in these cases.
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents who receive oral nutrition. During a kitchen tour, deficiencies such as unlabeled and expired food items, improperly stored personal food, and warm milk cartons were observed. The Dietary Manager confirmed that these practices violate the facility's food safety policies, which require proper labeling, dating, and storage to prevent foodborne illness and contamination.
The facility failed to properly contain and cover garbage in the kitchen, resulting in a fruit fly infestation. Observations showed uncovered garbage cans with fruit flies present, and the Dietary Manager confirmed the issue had persisted for months. Pest control reports documented fruit flies in the kitchen and dish room, indicating non-compliance with facility policies on garbage disposal and pest control.
The facility failed to implement fall precautions for three residents at risk for falls. A resident dependent on staff for transfers was found with her bed in a high position, contrary to her care plan. Another resident's bed was left elevated due to a CNA's lack of awareness about fall precautions. A third resident, with impaired balance, was also observed with his bed in a high position after a PT left the room. The facility's policies on fall prevention were not followed, compromising resident safety.
The facility failed to document accurate post-dialysis weights for residents undergoing dialysis, affecting several residents with conditions like end-stage renal disease and cardiac diseases. Staff interviews revealed confusion over responsibility for post-dialysis weighing, with some relying on estimated weights rather than actual measurements. The DON was unaware of this issue, indicating a lapse in policy adherence.
The facility failed to provide adequate ADL care for three residents who required assistance with daily living activities. A resident was observed with long, dirty fingernails and dry skin, and was not assisted with hand cleaning before meals. Another resident had similar issues with nail care and was not offered help with hand hygiene. A third resident requested the removal of chin and nose hairs, which was not addressed despite her discomfort and a diagnosis of dementia. The facility's ADL policy was not followed, leading to these deficiencies.
The facility failed to properly store and secure medications for two residents, leading to deficiencies in medication management. One resident was found with albuterol sulfate and an unidentified pill at the bedside without an order to self-medicate, while another resident had duo-neb ampules without a current order or assessment for self-administration. Facility policies requiring physician orders and skill assessments for self-medication were not followed.
The facility failed to meet the dietary needs and preferences of two residents, one with celiac disease and allergies to gluten and red dye, and another with gastrointestinal sensitivities. The first resident was served meals containing allergens, while the second resident did not receive a follow-up from the dietician despite an order for re-evaluation. The facility's policy on supporting nutritional well-being was not adhered to, leading to these deficiencies.
The facility failed to follow Enhanced Barrier Precautions and isolation policies, with staff not wearing gowns during incontinent care for residents with ESBL and allowing visitors in contact isolation rooms without PPE. Additionally, staff did not maintain effective hand hygiene, failing to change gloves or wash hands between handling soiled and clean items, contrary to facility policies.
The facility failed to maintain bed equipment for two residents, resulting in safety and comfort issues. One resident had exposed wires on their bed control, while another had a non-functional bed control, impacting their ability to adjust the bed for medical needs. Despite reports, the issues were not resolved promptly, contrary to the facility's policy to maintain equipment safely.
A facility failed to perform dressing changes and obtain a vascular diagnostic test for a resident with a worsening diabetic foot ulcer. The resident, with multiple health issues, was found with only one foot offloaded, and a new deep tissue injury was discovered on the other heel. The wound care nurse admitted to missed dressing changes, and the wound nurse practitioner's recommendations were not communicated to the resident's power of attorney in a timely manner. The facility's policies on wound care and physician orders were not followed, leading to the resident's condition worsening.
A resident with multiple medical conditions, including hemiplegia and dysphagia, required 1:1 feeding assistance due to increased weakness. Despite an active order for assistance, the resident was left unsupervised during meals, with staff failing to provide necessary help. The resident was observed fatigued, with food debris on her lip, and coughing intermittently, indicating non-compliance with the feeding order.
A resident with multiple medical conditions, including an unstageable pressure ulcer, did not receive proper wound care and prevention. The facility failed to communicate effectively with the resident's family about potential interventions, and scheduled dressing changes were not consistently documented. The facility's policies on wound care and physician orders were not followed, leading to inadequate care and monitoring.
A resident with an infection did not receive timely administration of physician-ordered IV antibiotics due to a failure to start the treatment after a midline insertion. Additionally, the IV infusion bag and tubing were not labeled or dated. The nursing supervisor forgot to label the infusion, and the unit manager confirmed the delay in starting the antibiotic treatment. The DON emphasized the expectation for timely administration and proper labeling.
The facility failed to provide a clean and homelike environment for residents, as observed in multiple instances of uncleanliness and improper disposal of waste. A resident with cognitive impairment reported a urine smell and filthy shower room, while another resident was found with soiled dressings and debris in her room. Staff acknowledged these issues, and Resident Council minutes highlighted ongoing concerns about inadequate cleaning.
A facility failed to provide two-person assistance during incontinence care and did not implement a post-fall intervention, resulting in a resident falling off the bed and sustaining fractures. The resident, who was morbidly obese and dependent on staff for toileting hygiene, was repositioned by a single CNA, leading to the fall. The resident's care plan required two staff members for such activities, but this protocol was not followed.
Failure to Follow Menu, Portion Sizes, and Texture Requirements for Pureed and Mechanical Soft Diets
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to follow prescribed menus, portion sizes, and texture modifications for pureed and mechanical soft diets. On a specified lunch date, the posted menu and corresponding menu spreadsheet for pureed diets required pureed fajita chicken to be served with a #10 scoop, pureed peppers and onions with a #8 scoop, pureed bread with a #16 scoop, and 4 oz of seasoned cream of rice. Scoop equivalents showed #10 = 3-3/4 oz, #8 = 4 oz, and #16 = 2-3/4 oz. Instead, the cook used a #12 scoop for both the pureed chicken and pureed rice and a #8 scoop for pureed refried beans, stating the facility did not have a #10 scoop and that he compensated by using a heaped #12 scoop. The cook also did not prepare the pureed tortilla as indicated on the menu spreadsheet. As a result, four residents on pureed diets received heaped #12 scoops of pureed chicken and rice and a #8 scoop of refried beans, rather than the specified portions and items on the menu spreadsheet. For residents on mechanical soft diets, the menu spreadsheet required course ground chicken fajita with ground peppers and onions, served on bread, with the recipe directing that the prepared chicken fajita mixture be processed until no pieces were larger than 1/8 inch. Observations showed that the ground chicken mixture contained large onion pieces between 2–3 inches long that appeared crunchy, and this mixture was placed on a tortilla and served with Spanish rice and black beans to six residents on mechanical soft diets. The Regional Director of Operations acknowledged that the onion pieces should have been less than 1/8 inch and initially stated that tortillas are soft and that serving the mixture on bread would be odd. However, the facility’s mechanical soft diet policy, taken from the 2025 diet manual, specified that foods must be easy to chew, in bite-size pieces of 1/2 inch or less, with vegetables cooked to a fork-tender, mashable texture no larger than 1/2 inch, and explicitly listed tortillas as a food to avoid. The dietitian later confirmed that the recipe and policy for mechanical soft diets, as well as the specified scoop sizes for pureed diets, should have been followed to provide appropriate consistency and portions for the residents on pureed and mechanical soft diets.
Failure to Implement PICC/Midline Monitoring and Documentation Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and physician orders for management of PICC and midline catheters, including required measurements and insertion site assessments. One resident was admitted with multiple neurological and infectious diagnoses and had a right arm midline ordered for IV antibiotics. Physician orders and the care plan required midline dressing changes, measurement of arm circumference and exposed catheter length on admission and every seven days, and documentation of insertion site appearance every shift. Surveyors observed that the midline site was covered by a round dry patch (bio-patch) under a transparent dressing, preventing visualization of the insertion tip, and the dressing remained in place with the same date over multiple days. When interviewed, the RN caring for this resident stated she checked only around the area and not the actual insertion site, and she had not performed the dressing change. Review of the EMAR, ETAR, and nursing progress notes for this resident showed no documentation of arm circumference measurements, exposed catheter length, or detailed insertion site monitoring as ordered. The care plan interventions, which included maintaining a transparent dressing, changing it every seven days or as needed, and performing and documenting arm circumference and catheter length measurements after each dressing change, were not carried out or documented as required. A second resident with osteomyelitis and a left arm PICC line for IV vancomycin had similar orders and care plan interventions, including weekly PICC dressing changes, arm circumference and exposed catheter length measurements, and documentation of insertion site appearance and signs of infection every shift. Surveyors observed that this resident’s PICC site was also covered by a round dry patch under a transparent dressing, again obscuring the insertion tip. The nurse manager stated the dressing was changed weekly, and an LPN reported that the night nurse changed the dressing and that staff checked around the site for drainage, but she was unsure where insertion site and dressing change documentation was kept. Record review for this resident likewise showed no documentation of required arm circumference measurements, exposed catheter length, or insertion site assessments every shift, despite facility policy specifying weekly arm circumference and external catheter length monitoring for PICC lines.
Failure to Assess and Maintain Dialysis Access Site Dressings for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate dialysis care by not adequately assessing, documenting, or managing bleeding and dressings at dialysis access sites for two residents. One resident with end-stage renal disease, anemia in chronic kidney disease, and dependence on renal dialysis had orders for hemodialysis three times weekly and for staff to check the dialysis access site every shift for bruit and thrill, record and report abnormalities immediately, and reinforce the dressing as needed. The resident’s care plan also directed staff to check and change the dressing daily at the access site and document. When the resident’s left upper arm AV fistula site was observed, the dressing was undated, completely saturated with dried dark brown drainage, and the tape was loose and nearly falling off. The resident reported that the dressing had been bloody since the last dialysis treatment several days earlier and that she received dialysis on a Monday/Wednesday/Friday schedule. The LPN assigned to the resident that morning stated she had started her shift at 7 AM, administered morning medications, and had not assessed the dialysis access site prior to the surveyor’s observation. Upon removing the dressing, the LPN observed that it was saturated with dried dark brown drainage and acknowledged it was most likely the same dressing applied at the dialysis center on the prior treatment day. The LPN stated that the dialysis center changes the dressing and that unit nurses reinforce dressings as needed. Review of the Dialysis Communication Report for the resident showed instructions to monitor for bleeding from the access site post-treatment. However, nursing progress notes for the days surrounding the observed condition did not contain documentation of bleeding at the dialysis access site or any notification to the dialysis center or physician, despite the resident’s report that the dressing had been bloody since the prior dialysis session. A second resident with severe cognitive impairment, hemiplegia, chronic kidney disease stage 4, and dependence on renal dialysis received weekly offsite dialysis via a right chest central venous catheter. Physician orders directed staff to check the catheter site daily and upon return from dialysis, ensure caps were secure, and reinforce the dressing as needed. The resident’s care plan required staff to check and change the dressing daily at the access site and document. During observation, a gauze dressing was seen hanging loosely under the resident’s shirt, with the dialysis catheter site exposed and dry, crusted brownish substance around the insertion site. The RN present stated the site had been checked that morning and suggested the dressing may have come off when the CNA changed the resident’s clothes. The DON later stated that catheter dressings are done at the dialysis center, but if the dressing comes off it should be reinforced by the nurse on duty and that the catheter site should always be covered. The facility’s Dialysis Protocol required that dialysis sites be checked every shift for signs of infection or bleeding and monitored every shift for thrill and bruit, and allowed line dressings to be reinforced at the facility, but these expectations were not met for the two residents.
Failure to Provide Physician-Ordered Wound Treatments
Penalty
Summary
The facility failed to provide wound treatments as ordered by physicians for two residents. One resident, with diagnoses including peripheral vascular disease, osteoarthritis, chronic kidney disease, venous insufficiency, and mild protein-calorie malnutrition, had physician orders for wound treatments to be completed every Monday, Wednesday, and Friday. Documentation and staff interviews confirmed that wound treatments were missed on multiple occasions, including specific dates in March, April, and May. Staff members acknowledged that treatments were not performed as ordered, citing reasons such as being pulled in multiple directions and personal injury. Another resident, diagnosed with pleural effusion, peripheral vascular disease, protein-calorie malnutrition, and chronic obstructive pulmonary disease, also had physician orders for wound treatments to be performed three times a week. Review of the treatment administration record showed that none of the ordered wound treatments were performed on at least one specified date. Facility policy requires licensed nurses to follow physician orders and document care in a timely manner, which was not adhered to in these cases.
Inadequate Supply of Linens and Towels for Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of linens and towels to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. Multiple linen closets across all three floors were found to be nearly empty, with only a few towels, linens, and gowns available for a large number of residents. Residents reported frequent shortages, with some stating they were unable to receive scheduled showers or had to use washcloths or blankets in place of towels. Several residents also indicated that their bed linens had not been changed for extended periods, sometimes up to two or three weeks. Staff interviews corroborated these findings, with CNAs and laundry staff consistently reporting ongoing struggles to obtain enough clean linens and towels. Laundry deliveries were described as insufficient, with only a handful of towels and linens distributed per unit, despite the high number of residents. Staff described having to wait for soiled linens to be washed before new ones could be distributed, and sometimes having to go to other floors in search of supplies, which were also lacking. The laundry process was further hampered by delays in collecting soiled linens from the units, resulting in further shortages. Facility leadership acknowledged the issue, noting that while linens and towels are purchased, there is a lack of sufficient inventory in circulation and no formal inventory system in place. The Environmental Services Director and other staff confirmed that the facility did not have enough circulating linens and towels to meet resident needs, and that all available supplies were either in use or being laundered at the time of the survey. These deficiencies resulted in residents not consistently receiving basic care such as showers and regular linen changes.
Failure to Follow Menus and Dietary Orders for Residents
Penalty
Summary
The facility failed to ensure that menus and dietary orders were consistently followed to meet residents' nutritional needs. Multiple residents reported receiving meals that did not match their prescribed dietary orders or the posted menu. For example, one resident with a physician order for double portions due to weight loss did not consistently receive the correct portions, and on one occasion, was missing both milk and a beverage from his tray. Other residents reported receiving smaller portions than expected, missing menu items such as eggs or bread, and being served alternative items not aligned with their dietary needs or preferences, such as a grilled cheese sandwich instead of a ham sandwich for a lactose-intolerant resident. Observations and interviews revealed that these discrepancies were not isolated incidents but occurred across several meals and residents. The dietary manager and regional director of operations acknowledged that menu adherence was expected but cited issues such as supply shortages and delivery delays, which led to substitutions and incomplete meals. Resident council minutes also documented ongoing concerns about missing food items and portion sizes, indicating a pattern of unmet dietary needs within the facility.
Inadequate LVAD Training and Competency in Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff was adequately trained and competent to care for residents with implanted Left Ventricular Assist Devices (LVADs). This deficiency affected four residents who were admitted to the facility with LVADs due to multiple cardiac diagnoses. The facility had an agreement with a local hospital to provide initial and annual competency training for designated superusers, who would then train other staff. However, the Director of Nursing (DON) and Assistant Directors of Nursing (ADONs), identified as superusers, had not attended the required training since March 2023. Consequently, the staff caring for LVAD residents lacked the necessary training and competency. Interviews with facility staff revealed that nurses frequently assigned to LVAD residents had not received training for over a year, and some had not been trained for more than two years. The facility's annual skills fair included only a basic 10-minute training on LVADs, which was insufficient. The LVAD hospital educator confirmed that the facility's superusers had not attended the required training, and the facility did not maintain records of staff training or competency. The lack of training and competency led to concerns about the care provided to LVAD residents, prompting the hospital to remove one resident from the facility. The facility's failure to provide adequate training and maintain records of staff competency resulted in a lack of preparedness to care for LVAD residents. The DON admitted that there was no documentation to show that nursing staff were trained or competent to care for these residents. The LVAD hospital educator expressed concerns about the facility's ability to care for LVAD patients and indicated that the hospital would not send more patients to the facility until the staff received proper training.
Failure to Follow LVAD Dressing Change Orders
Penalty
Summary
The facility failed to provide proper LVAD (Left Ventricular Assist Device) dressing changes as ordered by the physician for three residents. For Resident 1, the EMR showed that the LVAD dressing orders were entered incorrectly, missing several critical steps necessary for maintaining sterile conditions. The Director of Nursing (DON) acknowledged that the orders were incomplete and not entered as scheduled treatments or as-needed treatments, which led to a lack of documentation showing that the sterile dressing orders were followed from November 7, 2024, to November 18, 2024. Additionally, upon Resident 1's return from the hospital, the facility did not document the entry of sterile dressing change orders. Resident 2's care was also deficient as the antimicrobial patch, part of the LVAD dressing change order, was not applied as required. The Assistant Director of Nursing (ADON) was unaware that the antimicrobial patch was part of the standing LVAD dressing change orders and kept the patches in her office instead of ensuring they were available in the dressing kits. When the dressing was checked, it was confirmed that the antimicrobial patch was missing, and the dressing was not dated, indicating a failure to follow the prescribed orders. For Resident 3, the facility staff failed to enter the correct LVAD dressing orders upon admission, leading to improper sterile dressing changes. The resident expressed dissatisfaction with the care, noting that the dressing was not changed on time, and the sterile procedure was not followed, such as not providing a mask or closing the door during the procedure. The hospital discharge orders specified a daily sterile dressing change, but the facility's documentation did not reflect adherence to these orders, as confirmed by the DON and the hospital LVAD educator.
Medication Errors in LVAD Residents
Penalty
Summary
The facility failed to administer medications as ordered by the physician to residents with heart failure requiring the use of implanted LVADs. For one resident, R2, a medication error occurred when the resident received another patient's Milrinone, a heart failure medication, with a higher concentration than prescribed. This error was discovered when a nurse noticed the incorrect bag was being used, and it was found that R2 had been receiving the wrong dosage for 27 hours. Despite the error, R2 remained stable with no immediate changes in condition, but the incident was reported to management and the on-call physician group. Another resident, R4, was affected by an incorrect medication order for Torsemide, a diuretic. The order was entered incorrectly as 10 mg instead of the prescribed 20 mg, and R4 received the incorrect dosage for 15 days. The error was identified by the pharmacist, who compared the hospital discharge records with the facility's orders and notified the Director of Nursing and other relevant staff via email. However, the Director of Nursing was unaware of the error until it was brought to her attention. The facility's policy on medication administration emphasizes the importance of verifying the right medication, dose, route, patient, and time before administration. Despite this policy, significant medication errors occurred, leading to potential risks for the residents involved. The LVAD educator expressed concerns about the facility's lack of education regarding the care of LVAD residents, which led to the removal of R2 from the facility for further care at the hospital.
Failure to Return Heart Monitor Devices as Ordered
Penalty
Summary
The facility failed to return heart monitor devices to the cardiology monitoring departments as per physician orders and label instructions for two residents. One resident, a female with complex cardiac conditions including congestive heart failure and atrial fibrillation, had a heart monitor patch applied due to dizziness. The monitor was supposed to be returned on a specific date, but it was found unreturned at the facility weeks later, delaying the resident's plan of care. The nurse practitioner had followed the return process but the device was misplaced, leading to a lack of results for the resident's cardiac monitoring. Another resident, a male with conditions such as congestive heart failure and acute kidney failure, was discharged home without the complete return of his heart monitoring device. The device was returned without the accompanying cell phone, resulting in a billing issue for the resident. The facility's policy required nurses to follow physician orders, but the failure to include the cell phone in the return package led to the deficiency.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting all residents who receive oral nutrition from the facility's kitchen. During a tour of the facility's kitchen, several deficiencies were observed. In walk-in cooler #1, there were unlabeled and undated pork roasts, ground beef with a past freeze-by date, expired cottage cheese, expired meatloaf, rotten tomatoes, expired marinara sauce, and expired potato salad. In walk-in cooler #3, warm milk cartons, a mushy mango, personal food items stored improperly, and expired raisin bread were found. In the dry storage area, expired rainbow sprinkle cartons, an opened bag of instant dry milk crystals, an unsealed bag of croutons, spilled rice, and unlabeled bags of brown powder were noted. In the walk-in freezer, hamburger patties were found in an unsealed bag. The Dietary Manager acknowledged that all food items in the kitchen need to be labeled and dated for food safety, as per the facility's policy. The policy requires that food stock and prepared food products be stored at safe temperature ranges, covered, labeled, and dated. The facility's policy also prohibits staff from storing personal food items in areas designated for resident food. The failure to adhere to these policies poses a risk of foodborne illness and contamination, as expired and improperly stored food items were found throughout the kitchen.
Improper Garbage Disposal Leads to Fruit Fly Infestation
Penalty
Summary
The facility failed to properly contain and cover garbage in the kitchen, leading to a fruit fly infestation. Observations revealed that large black garbage cans in the main kitchen and dish room were left uncovered, with fruit flies seen flying around them. The Dietary Manager acknowledged the issue, noting that fruit flies had been a problem for at least six months. The facility's pest control reports confirmed the presence of fruit flies in the kitchen and dish room on multiple occasions. The facility's policies on pest control and garbage disposal require that garbage containers be covered and sealed to prevent pest infestations. However, these policies were not followed, as evidenced by the uncovered garbage cans and the presence of fruit flies. The facility's failure to adhere to its own policies contributed to the ongoing issue with fruit flies in the kitchen, affecting the environment where food is prepared for residents.
Failure to Implement Fall Precautions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall precaution interventions for residents at risk for falls, affecting three residents. Resident R103, who is dependent on staff for transfers and uses a manual wheelchair, was observed with her bed and over-bed table in the highest position on multiple occasions. Despite her care plan indicating the need for a safe bed position, staff left her bed elevated after providing care, posing a fall risk. Similarly, Resident R5, who is also dependent on staff for transfers and at risk for falls, was found with her bed and over-bed table in a high position. The CNA assigned to R5 was unaware of the need to lower the bed, indicating a lack of communication and training regarding fall precautions. Resident R87, with a history of impaired balance and cognitive issues, was also observed with his bed in a high position. The physical therapist left the room without ensuring the bed was lowered, contrary to the care plan's interventions for fall risk. The facility's policies on repositioning and fall prevention were not adhered to, as staff failed to maintain a safe environment by not implementing universal fall precautions and ensuring beds were in the lowest position for residents at high risk of falls.
Failure to Document Post-Dialysis Weights
Penalty
Summary
The facility failed to complete accurate post-dialysis weights for residents undergoing dialysis treatments, affecting five out of seven residents reviewed. The facility's policy requires that post-dialysis assessments include post-dialysis weight, which should be documented by the registered nurse before the resident is discharged from the treatment area. However, observations and interviews revealed that residents were not weighed after their dialysis treatments, either at the dialysis unit or by the unit staff. This deficiency was noted for residents with diagnoses such as end-stage renal disease, cardiac diseases, diabetes, and other conditions requiring dialysis. Interviews with staff, including registered nurses and certified nursing assistants, indicated a lack of clarity and responsibility regarding who should weigh residents post-dialysis. The registered nurse responsible for dialysis acknowledged using estimated weights based on ultrafiltration goals rather than actual post-dialysis weights. The Director of Nursing was unaware of the failure to weigh residents post-dialysis, highlighting a gap in adherence to the facility's policy and the potential for complications such as hypovolemia or fluid overload due to inaccurate weight documentation.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate ADL care for three residents who were dependent on assistance for daily living activities. Resident R87 was observed with long fingernails and a brownish-black substance under them, as well as dry, flaking skin on the legs. Despite being cognitively impaired and requiring supervision or assistance with personal hygiene, R87 was not offered help to clean his hands before meals. There was no documentation of R87 refusing ADL care, including nail care, in the last 30 days of progress notes. Similarly, R123 had long, jagged fingernails with a brown substance underneath and was not assisted in cleaning his hands before eating. R123 expressed a desire for staff assistance with hand cleaning, which was not provided, despite needing partial/moderate assistance with personal hygiene. Resident R65 expressed discomfort with chin and nose hairs, which she wanted removed. Despite notifying the administrator and staff, R65's request was not fulfilled, and her chin hairs remained unaddressed. R65 has a self-care performance deficit related to decreased strength and a diagnosis of dementia. The facility's ADL policy mandates that residents receive assistance to maintain cleanliness, safety, and dignity, including nail care as needed. However, the facility did not adhere to this policy, as evidenced by the observations and resident interviews.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to appropriately store and secure medications for two residents, R19 and R93, leading to deficiencies in medication management. For R19, an unopened package of albuterol sulfate, a vial of the same medication, and a white pill were found on the resident's overbed side table. R19 reported that the nurse left the pill for her, and she was unaware of its purpose before ingesting it. Additionally, R19 stated that the nurse leaves the albuterol sulfate for her daily, and she administers the treatments herself. However, a review of R19's electronic health record revealed no order for medications to be kept at the bedside, no assessment for self-medication, and no order to self-medicate. The Assistant Director of Nursing confirmed that R19 should not have medications at her bedside due to the lack of an order to self-medicate, highlighting a safety issue and the potential for medication misuse. For R93, the resident was found with two ampules of duo-neb at his bedside, which he claimed to use for his nebulizer treatments three times a day. R93 stated that the nurses provided him with the ampules but did not follow up on his treatment administration. Upon review, it was discovered that R93 did not have a current order for duo-neb, and the last order had been discontinued in August. The Licensed Practical Nurse and Director of Nursing confirmed that R93 did not have an assessment or order to self-administer medications, and the medications should not have been in his possession. The facility's policies require a physician's order for medications to be left at the bedside and a skill assessment for residents who self-administer medications, which were not adhered to in these cases.
Failure to Address Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that residents were not served food items to which they had allergies or sensitivities, and did not adequately follow up on a resident's food preferences. This deficiency was observed in two residents. The first resident, who has celiac disease and a documented allergy to gluten and red dye, was served meals containing these allergens. On one occasion, the resident's meal included apple crisp, which contains all-purpose flour, and on another occasion, the resident was served gelatin with red dye, which led to coughing. The dietary manager and staff were aware of the resident's allergies but failed to provide appropriate substitutions or check the ingredients of the food served. The second resident, who is cognitively intact and has a history of severe protein-calorie malnutrition and gastrointestinal issues, reported receiving food items that upset her stomach, such as apple sauce, gelato, and apple juice. Despite an order for the dietician to re-evaluate her food preferences, there was no documentation of any follow-up or assessment by the dietician. The resident's family member confirmed that certain foods caused gastrointestinal distress, yet the resident continued to receive these items. The staff, including a CNA and an LPN, were unaware of the resident's sensitivities and did not document any food allergies in her chart. The facility's policy on food and nutrition emphasizes the importance of supporting residents' nutritional well-being while respecting their dietary preferences. However, the facility failed to adhere to this policy by not ensuring that the residents' dietary needs and preferences were met. The lack of communication and documentation regarding the residents' dietary restrictions and preferences contributed to the deficiency, as did the failure of the dietary staff to provide appropriate meals and substitutions for the residents with known allergies and sensitivities.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) Guidelines and isolation policy, resulting in staff not wearing gowns during incontinent care for residents on EBP and allowing visitors to enter contact isolation rooms without appropriate personal protective equipment (PPE). Specifically, a certified nursing assistant (CNA) and another CNA were observed providing incontinent care to a resident with extended-spectrum beta-lactamase (ESBL) in urine without wearing gowns, despite the EBP sign on the door indicating the need for gloves, gown, and mask. Additionally, a caregiver was seen in a contact isolation room with a resident, handling belongings without wearing gloves or a gown, contrary to the facility's isolation policy. The facility also failed to maintain effective hand hygiene during resident care. Two CNAs were observed changing soiled bed linen and providing incontinence care to a resident without changing gloves or performing hand hygiene between handling dirty and clean items. This included touching the resident's body and personal items with dirty gloves and failing to clean hands between removing soiled clothing and applying clean clothing. The facility's policies on incontinence care and hand hygiene, which require glove removal and handwashing after handling soiled items, were not followed, as confirmed by the Assistant Director of Nursing.
Failure to Maintain Bed Equipment for Residents
Penalty
Summary
The facility failed to maintain residents' bed equipment, affecting two residents. Resident R87 was observed with exposed wires on his bed control on two separate occasions. The Assistant Director of Nursing (ADON) acknowledged that exposed wires are a safety issue and expected staff to report such problems. Despite this expectation, the issue persisted, indicating a lapse in maintenance and reporting procedures. Resident R123 experienced a non-functional bed control, which had been reported multiple times by both the resident and a Certified Nurse's Assistant (CNA). The resident's bed could only be adjusted manually by staff, and attempts to repair the control were unsuccessful. R123's medical conditions, including acute pulmonary edema and end-stage renal disease, necessitated the ability to raise the head of the bed to facilitate breathing and comfort. The ADON expressed that the bed control should have been addressed promptly due to the resident's health conditions. The facility's policy mandates maintaining equipment in safe operating conditions, which was not adhered to in these cases.
Failure to Perform Wound Care and Obtain Diagnostic Test
Penalty
Summary
The facility failed to perform dressing changes and obtain a vascular diagnostic test as ordered for a resident with a known worsening diabetic foot ulcer. The resident, who had multiple diagnoses including diabetes type 2, neuropathy, and chronic kidney disease, was observed with only one foot offloaded, contrary to the care plan. The wound care nurse (V10) discovered that the dressing on the resident's left heel had adhered to the wound, which was boggy and had purulent drainage, indicating a worsening condition. Additionally, a new deep tissue injury was identified on the resident's right heel, which had not been offloaded as required. The wound care nurse (V10) acknowledged that the dressing changes were not performed as scheduled and that the floor nurses were expected to change the dressings when she did not. The wound nurse practitioner (V15) had previously recommended offloading and ordered an arterial vascular ultrasound to assess circulation due to the declining condition of the left heel wound. However, the resident's power of attorney (V16) was not informed of the ultrasound order until later and decided to wait for a physician's evaluation. The treatment administration records showed multiple omissions of scheduled dressing changes, and the wound assessment reports documented the worsening condition of the left heel ulcer and the new ulcer on the right heel. The facility's policies required wound care to be performed per physician orders and for wounds to be assessed and documented at each dressing change. Despite these policies, the facility failed to adhere to the care plan and physician orders, resulting in the deterioration of the resident's condition.
Failure to Assist Resident with Feeding
Penalty
Summary
The facility failed to provide necessary assistance to a resident (R1) who required help with eating during meal services. R1 had multiple medical conditions, including hemiplegia, hemiparesis, dysphagia, and moderate cognitive impairment, which necessitated a 1:1 feeding order due to increased weakness. Despite this order, R1 was observed in bed with her lunch tray, unsupervised and without assistance. R1 appeared fatigued, had food debris on her lip, and was chewing slowly. Staff members, including a CNA and a Nursing Supervisor, entered the room but did not assist R1 with her meal, leaving her unsupervised. R1 was observed falling asleep and coughing intermittently, indicating a lack of adherence to the feeding order. The Director of Nursing confirmed that R1 was supposed to receive 1:1 feeding assistance to ensure her safety and nutritional needs, as she had been declining recently. A progress note from a Nurse Practitioner highlighted R1's fatigue and anorexia, noting that she required frequent encouragement and assistance with meals. The facility's policy on Activities of Daily Living Support emphasized providing necessary services to maintain good nutrition for residents unable to carry out daily activities independently. However, the staff's failure to follow R1's feeding order and provide the required assistance during meals led to the deficiency.
Inadequate Pressure Ulcer Care and Communication
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident with multiple medical conditions, including diabetes type 2, neuropathy, and an unstageable pressure ulcer to the sacrum. The resident was dependent on staff for toileting and required substantial assistance with bed mobility. Despite being at risk for pressure ulcers, the resident's coccyx wound was not managed effectively, as evidenced by the worsening condition of the wound, which included new undermining and a foul odor. The wound care nurse did not pack the undermining dead space during dressing changes, contrary to the wound nurse practitioner's recommendations. The wound care nurse and wound nurse practitioner failed to communicate effectively with the resident's family regarding the potential use of an indwelling urinary catheter to protect the resident's skin from frequent incontinence. The resident's son was not informed of this recommendation until much later, despite multiple notes indicating the need to consider this intervention. Additionally, the facility's documentation showed inconsistencies, with late entries made by the wound care nurse regarding discussions with the resident's family about the catheter and other recommendations. The facility's treatment administration record revealed that scheduled dressing changes for the resident's coccyx wound were not consistently completed, with several dates lacking documentation of the procedure. The director of nursing expected nurses to perform wound care as ordered and to document it properly, but this was not adhered to. The facility's policies on wound prevention and healing, as well as physician orders, were not followed, leading to inadequate wound care and monitoring for the resident.
Failure to Administer IV Antibiotics Timely and Label IV Equipment
Penalty
Summary
The facility failed to properly label and date an intravenous fluid bag and tubing, and did not administer physician-ordered intravenous antibiotics in a timely manner for a resident with an infection. The resident had multiple diagnoses, including an unstageable pressure ulcer and a diabetic ulcer, and was ordered to receive Vancomycin due to an elevated white blood cell count. The order was to start after the insertion of a PICC line, which was completed on the afternoon of 8/30/2024. However, the initial scheduled dose was not administered as planned. On 8/31/2024, the resident was observed receiving an IV infusion, but the infusion bag and tubing were not labeled or dated. The nursing supervisor admitted to forgetting to label the infusion because the dose was taken from the facility's convenience box. The unit manager confirmed that the resident should have started the antibiotic treatment after the midline insertion on 8/30/2024, but it was unclear why this did not occur. The Director of Nursing stated that nurses are expected to administer antibiotics as ordered and to label and date the infusion for medication safety.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and resident reports. A male resident with moderate cognitive impairment reported a mild urine smell in his room and noted that the shower room was filthy, with feces on the floor and dirty clothes left unattended. Additionally, the common shower room was found with used gloves and dirty clothes in the bathtub, contrary to the facility's linen management policy, which requires dirty linens to be contained in a closed container or bag. A female resident with severe cognitive impairment was found with soiled wound dressings left in her bed, a call light on the floor, and debris scattered on the floor, including used alcohol wipes and a clean incontinence brief. Another resident's room was observed with dirty linens on the floor, and the soiled utility room had several used gloves scattered on the floor. The Director of Nursing and the Housekeeping/Laundry Director acknowledged these issues, noting that dirty linens should be bagged and used gloves disposed of properly. Resident Council minutes from previous months also documented ongoing concerns about inadequate cleaning and maintenance of resident rooms and common areas.
Failure to Provide Adequate Assistance and Implement Post-Fall Interventions
Penalty
Summary
The facility failed to provide two-person assistance during incontinence care and did not implement a post-fall intervention for a resident, resulting in the resident falling off the bed and sustaining fractures to the left femur and right shoulder. The resident, who was morbidly obese and dependent on staff for toileting hygiene, was repositioned on her left side by a single CNA during incontinence care. The CNA was unable to prevent the resident from sliding off the bed, leading to the fall and subsequent injuries. The resident's care plan required the assistance of two staff members for such activities, but this protocol was not followed at the time of the incident. The resident's electronic medical records indicated that she was sent to the emergency room following the fall, where she was diagnosed with multiple fractures and a head injury. The resident's quarterly MDS assessment showed that she was moderately impaired in cognition and dependent on staff for toileting hygiene, requiring the assistance of two or more helpers. Despite these documented needs, the CNA provided care alone, which directly contributed to the fall. Additionally, the resident was placed in a regular-sized bed that was inadequate for her size, further increasing the risk of falling. Interviews with facility staff revealed that the CNA had a history of providing incontinence care to the resident alone, contrary to the care plan requirements. The facility's policy on fall prevention and management emphasized the need for high-risk precautions and immediate post-fall interventions, but these were not adequately implemented. The resident's care plan was revised post-incident to include the use of a bariatric bed and the requirement for two staff members to assist with ADLs, but these measures were not in place at the time of the fall.
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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