Pearl Of Montclare, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2833 North Nordica Avenue, Chicago, Illinois 60634
- CMS Provider Number
- 145844
- Inspections on file
- 32
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pearl Of Montclare, The during CMS and state inspections, most recent first.
A resident with multiple comorbidities and moderate cognitive deficits developed a new sacral deep tissue pressure injury that was identified by therapy staff and assessed by the wound care LPN. Although the wound was documented in a wound summary, there were no corresponding physician orders or treatments on the POS or TAR, and no documented notification of the physician or the resident’s representative. The LPN later stated she must have forgotten to carry out physician orders and acknowledged that facility practice and written policy require notifying the physician and family and documenting the change in condition and any new treatment plan.
A resident with multiple comorbidities, including CVA, diabetes, malnutrition, and reduced mobility, was identified as at risk for pressure ulcers and later developed a sacral DTPI noted by therapy staff and assessed by the wound care nurse. However, no corresponding physician orders, TAR entries, or care plan problem, goals, or interventions were documented for the wound. An LPN caring for the resident reported only assessing the resident’s front side and not turning the resident, and was unaware of the sacral wound. The wound care nurse stated she notified the physician but there was no documentation of physician or family notification or implementation of treatment orders, despite facility policy requiring physician-directed wound care and multidisciplinary oversight.
Surveyors identified that two residents received incorrect medications or dosages due to staff administering products that did not match physician orders, resulting in a medication error rate of 9.09%. In one case, a nurse gave a resident the wrong formulation and dose of Senna and Folic Acid, while in another, a nurse administered Calcium Carbonate without the required Vitamin D. These actions did not comply with facility policy or prescribed orders.
A resident with severe cognitive impairment was found with unexplained discoloration under the eye after admission. The resident reported that something fell on her head during ambulance transport, but the administrator did not report the incident to IDPH, as the resident stated it was unintentional and the ambulance company denied any incident. The facility's reportable binder lacked documentation of the event, contrary to policy requiring reporting of such allegations.
A resident with a history of falls and cognitive impairment fell and sustained a subdural hematoma due to the facility's failure to apply a soft head helmet as per the care plan. Despite being at moderate risk for falls, the resident was found attempting to walk without assistance and fell, hitting her head. Staff interviews confirmed the helmet was not applied while the resident was in bed, contrary to physician orders.
The facility failed to follow its policies on food storage, labeling, and hygiene, affecting all 108 residents. Expired food items were found, and food lids were stored next to bleach solutions. A Dietary Aide handled clean dishes without changing gloves, and uncovered food was left under an air conditioning unit. In the refrigerator, spoiled cucumbers and freezer-burned ice were found, and food temperatures were not checked before serving.
The facility failed to set low air loss mattresses to the correct weight settings for residents with pressure ulcers or at risk of developing them. Observations showed incorrect settings for four residents, compromising the intended pressure relief and potentially affecting skin integrity. The Wound Care LPN confirmed the importance of correct settings as per facility policy.
The facility failed to provide proper respiratory care for residents, with issues including undated and improperly stored oxygen and nebulization tubing, and missing physician orders for BiPAP and CPAP use. Four residents were affected, with conditions such as heart failure, sleep apnea, and COPD. Staff confirmed the need for weekly changes and proper storage to prevent infection.
The facility failed to ensure proper use and evaluation of side rails for several residents, leading to a deficiency in accident prevention. Observations showed residents using side rails without care plans or recent assessments. The Director of Nursing confirmed that assessments should be quarterly, but this protocol was not followed, violating the facility's policy on bedrail management.
The facility failed to provide prescribed High Calorie Frozen Desserts to several residents as part of their therapeutic diets. Despite having sufficient stock, the dietary staff did not distribute these supplements, which are crucial for residents at nutritional risk, such as those experiencing weight loss or needing extra calories for wound healing. Observations and interviews confirmed the absence of these supplements on meal trays, contrary to physician orders and facility policies.
The facility failed to follow infection control protocols by not using appropriate PPE for residents under Enhanced Barrier Precautions and Contact Isolation. Staff provided care without gowns and gloves, and signage was missing, leading to unawareness of necessary precautions. These actions risked cross-contamination and infection transmission.
A resident was found with medications at their bedside without a physician's order or a self-administration safety assessment. Staff confirmed that medications should not be left at a resident's bedside without proper authorization. The facility's policy requires physician authorization for self-administration, which was not documented in the resident's records.
A facility failed to refer a resident for a PASRR re-evaluation after new psychiatric diagnoses were made. Initially, the resident did not require a Level II PASRR, but later received diagnoses of anxiety disorder, unspecified psychosis, and major depressive disorder, along with prescriptions for Escitalopram Oxalate and Risperidone. The Social Service Director had not reviewed the resident's PASRR, and the facility's policy lacked procedures for re-evaluation due to new diagnoses.
The facility failed to provide adequate nail care for three residents who were dependent on staff for grooming. Observations showed these residents had dirty, overgrown fingernails, which they could not manage themselves. Staff interviews confirmed that nail care should be part of the grooming routine during showers twice a week and as needed, but this was not consistently provided. The facility's DON and Administrator acknowledged that nail care is part of ADL grooming, yet there was no specific policy in place.
A facility failed to maintain a medication error rate below 5% when a nurse did not administer two scheduled medications to a resident but documented them as given. The nurse prepared and administered several medications, but the surveyor did not observe the administration of Advair Diskus and Lisinopril, which were documented as administered. This resulted in a medication error rate of 6.25%, exceeding the acceptable threshold.
The facility failed to follow its menu and cooking instructions, affecting all 108 residents receiving nutrition. Lemon meringue pies were not served as planned due to improper defrosting, and pureed mashed potatoes were prepared without following the specified instructions. Residents expressed concerns about the facility not adhering to the menu, indicating issues in food service management.
A facility failed to follow physician orders for a resident requiring nectar-thick liquids due to swallowing difficulties. Despite an active diet order and care plan specifying nectar-thick consistency, a CNA provided thin apple juice during a meal. The facility's policy requires meal accuracy checks, which were not adhered to, resulting in this deficiency.
A resident with severe cognitive impairment and a history of falls experienced nine falls after the removal of a 1:1 aide, despite being identified as a high fall risk. The facility's fall policy was not effectively implemented, leading to repeated incidents and a significant injury requiring medical attention.
A resident, who is legally blind and requires supervision, fell and fractured her femur during a transfer from the toilet to a wheelchair due to the failure of a CNA to use a gait belt. The CNA was standing in the doorway and did not provide the necessary assistance, leading to the resident's fall. Interviews with staff confirmed that gait belts are required for transfers, but the protocol was not followed in this instance.
The facility failed to respond to call lights promptly, provide adequate incontinence care, and administer medications as ordered. A resident reported waiting hours for incontinence care, while another experienced a delay in colostomy care. The call light system lacked an audible alert, and staffing issues, particularly with agency staff, contributed to these deficiencies.
The facility failed to ensure residents who depend on staff assistance for ADL care received proper grooming, showers, personal hygiene, and feeding assistance. Three residents were affected, with observations revealing unshaven beards, dry scalps, disheveled appearances, and missed meals. Facility records lacked documentation of bed baths or showers for the entire month of April.
Failure to Notify Physician and Representative of New Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician and resident representative of a significant change in condition when a new deep tissue pressure injury (DTPI) was identified for one resident (R5). R5 had multiple diagnoses, including cerebral infarction with right middle cerebral artery involvement, dysphagia, reduced mobility, polycythemia vera, elevated white blood cell count, cerebral edema, type 2 diabetes mellitus, unspecified protein calorie malnutrition, and acute respiratory issues. A Brief Interview for Mental Status (BIMS) showed a score of 12, indicating moderate cognitive deficits. On 1/19/26, the wound care nurse (V7, LPN) documented that therapy staff notified her of a skin condition on the resident’s buttocks, and her assessment identified a DTPI to the sacral region. A wound summary completed the same day recorded a newly acquired DTPI to the sacrum measuring 1.20 cm by 0.40 cm with unknown depth. Despite this documented new wound, the physician order sheet contained no orders for treatment or management of the sacral wound, and the treatment administration record for January showed no wound treatment. During interview, V7 stated she had informed the physician about the sacral wound but, upon review of the progress notes with the surveyor, there was no documentation of physician or family notification and no physician orders implemented for the DTPI. V7 acknowledged she did not carry out physician orders and stated she “must have forgot,” and also described that facility practice requires notifying the resident’s family and physician and documenting the conversation when a new wound is acquired. The occupational therapist (V16) recalled observing a reddened area on the resident’s tailbone and immediately reporting it to V7, who said she would take care of it. The DON (V2) stated she did not recall the resident having a wound and explained that when a resident acquires a wound, nurses should be aware through communication tools, wound care orders, and progress notes, and that physicians and family should be notified with documentation of the change in condition. The facility’s written policy on Notification of Change in Condition requires immediate notification of the resident, physician, and resident representative when treatment must be significantly altered or a new form of treatment commenced, and requires documentation of notifications and new orders in the medical record, which did not occur in this case.
Failure to Assess, Document, and Treat a New Sacral Deep Tissue Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for a resident with a newly identified sacral deep tissue pressure injury (DTPI). The resident had multiple diagnoses including cerebral infarction, dysphagia, reduced mobility, diabetes, malnutrition, and other conditions, and Braden/pressure risk scales completed on several dates showed the resident was at risk for pressure ulcers. On 1/19/26, the wound care nurse documented that therapy staff notified her of a skin condition on the buttocks, and she assessed a DTPI to the sacral region measuring 1.20 cm by 0.40 cm with unknown depth. Despite this, the physician order sheet contained no orders for treatment or management of the sacral wound, the treatment administration record for the month showed no wound treatment, and the care plan contained no problem statement, goals, or interventions related to the sacral wound. Staff interviews further showed that the wound was not consistently recognized or acted upon. The LPN who was the resident’s nurse prior to transfer to the hospital stated she only assessed the resident’s front side for skin issues, did not turn the resident because she could not do so alone, and was unaware of any sacral wound. The wound care nurse stated that the occupational therapist had reported a reddened area on the tailbone, that she assessed the sacral wound, and that she informed the physician, but review of the record revealed no documentation of physician or family notification and no physician orders for the DTPI. She acknowledged she did not carry out physician orders and stated she “must have forgot,” and also stated that when a resident acquires a new wound, the family and physician should be notified and the conversation documented. The DON reported she did not recall the resident having a wound and described that, per facility practice and policy, new wounds should be communicated via the communication board, physician orders, progress notes, and assessments, with physician and family notification documented. The facility’s wound prevention and healing policy required wound care treatments under physician direction and oversight by certified wound care nurses, which was not reflected in the resident’s record for this sacral DTPI.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as required, with 3 errors identified out of 33 opportunities, resulting in a 9.09% error rate. One incident involved a nurse administering Senna 8.6 mg tablets and Folic Acid 800 mcg to a resident, instead of the prescribed Senna S (Sennosides-Docusate sodium) 8.6-50 mg and Folic Acid 1 mg. The nurse confirmed to the surveyor and the Director of Nursing that the medications given did not match the physician's orders, and documentation showed the resident had moderate cognitive impairment and multiple diagnoses, including chronic ulcers and swelling in the lower limbs. Another error occurred when a registered nurse administered Calcium Carbonate 500 mg (Alkums Antacid) to a different resident, instead of the ordered Calcium Carbonate-Vitamin D 500-200 mg. The product given did not contain vitamin D, as required by the physician's order. This resident was cognitively intact and had diagnoses including hypokalemia, hyponatremia, and hypertension. Facility policy and job descriptions require staff to administer medications as prescribed and verify medications before administration, but these procedures were not followed in the cited instances.
Failure to Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an abuse allegation to the Illinois Department of Public Health (IDPH) for one resident who was admitted with multiple diagnoses, including severe cognitive impairment and communication deficits. Upon a family visit, discoloration was observed under the resident's left eye, which was not present at admission. The administrator and DON assessed the resident in the presence of family, and the resident reported that something had fallen on her head during ambulance transport to the facility. The administrator contacted the ambulance company to investigate, and the resident's physician was notified, resulting in an x-ray that was negative for injury. The ambulance company later reported no incident during transport. Despite the resident's report of an object falling on her head and visible injury, the administrator did not submit an abuse allegation report to the state agency, as the resident stated the incident was unintentional and the ambulance company denied any incident. The facility's reportable binder did not contain documentation of the incident, and the administrator determined that, since the resident could explain the injury and denied intent, it did not meet the threshold for reporting to IDPH. This decision was made despite facility policy requiring investigation and reporting of unexplained injuries and abuse allegations.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adhere to a resident's fall care plan intervention and physician recommendation, which required the application of a soft head helmet while the resident was in bed. This oversight involved a resident with a history of multiple falls, moderate cognitive impairment, and a previous skull surgery. The resident, who was at moderate risk for falls, was found attempting to walk without assistance and subsequently fell, hitting her head on the floor, resulting in a left subdural hematoma. The incident occurred when the resident was in her room without the soft helmet, which was supposed to be worn while in bed as per the care plan. The resident's fall risk assessment indicated several risk factors, including inadequate vision, loss of balance, and a history of falls. Despite these risks, the helmet was not applied while the resident was in bed, contrary to the care plan and physician's orders. The resident was later found on the floor by a CNA, who noted that the resident had fallen and hit her head. Interviews with facility staff, including the Director of Nursing and the resident's physician, confirmed that the helmet was a critical intervention to minimize injury due to the resident's impulsive behavior and history of falls. The staff acknowledged that the helmet was not applied while the resident was in bed, which was a deviation from the prescribed care plan. This failure to implement the necessary fall prevention measures led to the resident sustaining a serious head injury.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to adhere to its policies regarding food storage, labeling, and hygiene practices, which were observed during a survey. In the dry goods stock room, expired food items such as maraschino cherries, soy sauce, and Caesar dressing were found, and an opened bag of brownie mix was not labeled. Additionally, food lids were stored next to bleach cleaning solutions, contrary to the facility's chemical storage guidelines. The Dietary Manager, V11, acknowledged these issues, indicating a lack of compliance with the facility's policy to check and discard expired items and to store food-related items away from cleaning solutions. During dishwashing, a Dietary Aide, V13, was observed handling clean dishes with the same gloves used for dirty dishes, without performing hand hygiene, which violates the facility's dish room safe handling policy. Furthermore, coffee grounds were left open next to sanitation buckets, posing a risk of cross-contamination. Uncovered pre-portioned pears were also left on the counter under a blowing air conditioning unit, which could lead to contamination, as acknowledged by V11. In the walk-in refrigerator, mushy and black-spotted cucumbers were found, and a large bag of ice with freezer burn was present in the freezer, which had been there for seven months without a known purpose. Additionally, the Cook, V14, did not check or record food temperatures before serving, leaving the temperature log for the current meal empty. These observations highlight a failure to follow the facility's policies on food storage, labeling, and temperature control, potentially affecting the nutrition and safety of all 108 residents receiving meals from the kitchen.
Incorrect Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that low air loss mattress devices were set to the correct weight settings for residents with current pressure ulcers and those at risk of developing them. During observations, it was noted that the weight settings on the low air loss mattresses for four residents were incorrect. For instance, one resident with a weight of 136.6 pounds had their mattress set to 400 pounds, and another resident weighing 230 pounds had their mattress set to 350 pounds. These incorrect settings were observed despite the facility's policy requiring that mattress settings be checked every shift to ensure proper functioning. Interviews with the Wound Care LPN revealed that the low air loss mattresses are intended to relieve pressure and aid in wound healing, and they must be set according to the resident's current weight. The LPN confirmed that the incorrect settings observed would not provide the intended pressure relief, potentially compromising the residents' skin integrity. The facility's policies on wound prevention and specialty mattress management emphasize the importance of using the Braden scale to assess risk and implementing appropriate interventions, including correct mattress settings, to prevent pressure injuries.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for residents, as evidenced by the lack of dated and properly stored oxygen and nebulization tubing, as well as the absence of physician orders for the use of BiPAP and CPAP machines. Four residents were affected by these deficiencies. One resident, admitted with conditions including atrial fibrillation and heart failure, had oxygen and nebulization tubing that was not dated and was improperly stored, touching the floor. The Licensed Practical Nurse (LPN) confirmed that the tubing should be changed weekly and stored in a plastic bag when not in use. The Director of Nursing (DON) reiterated the need for proper storage and physician orders for CPAP and BiPAP use. Another resident, diagnosed with obstructive sleep apnea and morbid obesity, had a BiPAP mask on the floor, not stored in a bag, and lacked a physician order for its use. A third resident, with chronic obstructive pulmonary disease and Parkinson's disease, had undated oxygen tubing and a CPAP mask not stored in a bag. The fourth resident, admitted for palliative care, had an oxygen nasal cannula that was not dated or stored in a plastic bag. The DON confirmed the expectation for weekly changes and proper storage to prevent infection.
Deficiency in Side Rail Use and Assessment
Penalty
Summary
The facility failed to ensure the appropriate use and evaluation of side rails for four residents, leading to a deficiency in accident and hazard prevention. Observations revealed that residents were using side rails without a corresponding care plan or recent assessment. For instance, Resident 63, admitted with conditions such as Alzheimer's disease and heart failure, was observed with both upper side rails up, yet no care plan for side rail use was found in their electronic health record (EHR). Similarly, Resident 61, with diagnoses including atrial fibrillation and heart failure, also had side rails up without a care plan, and their last assessment was outdated. The deficiency was further highlighted by the lack of quarterly assessments and care plans for Residents 41 and 37, both of whom were observed with side rails up. Resident 41, with conditions like hemiplegia and diabetes, and Resident 37, with a history of cerebral infarction and rheumatoid arthritis, had not been reassessed for side rail use since late 2024. The Director of Nursing confirmed that side rail assessments should be conducted quarterly and that care plans should guide staff in their use, but these protocols were not followed. The facility's policy mandates the management of bedrails to ensure residents' well-being, yet this was not adhered to, resulting in the cited deficiency.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide oral supplements, specifically High Calorie Frozen Desserts, as part of the therapeutic diet prescribed by the physician for five residents. These residents had dietary supplement orders documented in their Order Summary Reports and meal tickets, which indicated that the Frozen Nutritional Treat should be served daily at lunch. However, observations revealed that these supplements were not consistently provided. For instance, one resident did not receive the supplement during lunch and mentioned that it was not provided every day. Another resident's guardian confirmed the absence of the supplement on the lunch tray. A dietary aide admitted to not distributing the supplements due to a perceived lack of stock, although the dietary manager confirmed that the kitchen had sufficient supplies. The dietary manager and registered dietitian acknowledged the importance of these supplements for residents at nutritional risk, such as those experiencing weight loss or requiring additional calories for wound healing. Despite having the supplements in stock, the facility staff failed to distribute them, potentially impacting the residents' nutritional status. The registered dietitian highlighted that the absence of these supplements could lead to continued weight loss or hinder wound healing. The facility's policies on fortified foods and tray line service emphasize the need for accurate meal assembly and the provision of necessary dietary items, which were not adhered to in this instance.
Inadequate PPE Use and Signage for Infection Control
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of Personal Protective Equipment (PPE) for residents under Enhanced Barrier Precautions (EBP) and Contact Isolation. On multiple occasions, staff members did not don the required gowns and gloves when providing high-contact care to residents with wounds or those under contact precautions. For instance, a Certified Nursing Assistant (CNA) provided incontinence care to a resident with a sacral wound without wearing a gown, despite the presence of EBP signage. Similarly, a Wound Care Licensed Practical Nurse and a CNA provided wound care to another resident without the appropriate PPE, acknowledging the risk of cross-contamination. Additionally, the facility failed to display EBP signage and provide accessible PPE outside a resident's room, leading to staff being unaware of the need for enhanced precautions. A nurse assigned to care for this resident was not informed of the EBP orders due to the absence of signage, resulting in the provision of care without the necessary protective measures. Furthermore, a Nursing Supervisor entered a room of a resident on Contact Isolation for Clostridium Difficile without wearing a gown or gloves, contrary to the facility's policy and the posted signage. These lapses in protocol could potentially lead to the transmission of infections among residents.
Failure to Obtain Physician Order for Self-Administration of Medications
Penalty
Summary
The facility failed to obtain a physician order and conduct a medication self-administration safety assessment for a resident who was observed with medications at their bedside. On multiple occasions, a resident was found with an inhaler and nasal spray on their bedside table without a physician's order permitting self-administration. The resident reported using the inhaler twice daily for wheezing and the nasal spray once daily for nasal congestion, even when not experiencing symptoms. Staff, including an LPN and RN, confirmed that medications should not be left at a resident's bedside without a physician's order, and the Director of Nursing stated that a safety assessment and physician order are required for self-administration. The resident's clinical records did not contain documentation of a self-administration assessment or a physician order for self-administration of medications. The facility's policy requires physician authorization for residents to self-administer medications. Additionally, another resident's records showed active orders for similar medications, but no order allowing them to be kept at the bedside. The lack of proper documentation and adherence to facility policy led to the deficiency observed by the surveyors.
Failure to Update PASRR After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) re-evaluation after the resident received new psychiatric diagnoses. Initially, the resident did not require a Level II PASRR as they did not have severe mental illness, intellectual disabilities, or related conditions, nor were they prescribed mental health medications. However, the resident's admission record later documented new diagnoses of anxiety disorder, unspecified psychosis, and major depressive disorder, along with medication orders for Escitalopram Oxalate and Risperidone. Interviews revealed that the facility's staff had not reviewed the resident's PASRR since the initial evaluation. The Social Service Director, responsible for reviewing current PASRRs, had not started this process, and the Admissions Director only handled initial PASRRs. The facility's policy did not include procedures for re-evaluation due to new diagnoses, contributing to the oversight in updating the resident's PASRR status.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for three residents who are dependent on staff for grooming and personal hygiene. Observations revealed that these residents had dirty, overgrown fingernails, which they were unable to manage themselves due to their conditions. One resident, who is legally blind, expressed a desire to have her nails cut but could not recall the last time this was done. Another resident was observed with long, dirty fingernails while dining, and a third resident had food debris under her nails. Interviews with staff, including CNAs and LPNs, confirmed that nail care should be part of the grooming routine during showers twice a week and as needed, but this was not consistently provided. The facility's Director of Nursing and Administrator acknowledged that nail care is part of the Activities of Daily Living (ADL) grooming, yet there was no specific policy in place for nail care. The Minimum Data Set (MDS) assessments for the involved residents indicated they required moderate to maximum assistance with personal hygiene. Despite this, the facility's failure to ensure regular nail care resulted in the observed deficiencies, as staff did not adhere to the expected grooming practices.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% during a medication administration observation for one resident. On the specified date, a registered nurse (V8) was observed administering medications to a resident (R51). The nurse prepared and administered several oral medications and a nebulizer treatment. However, the surveyor noted that two medications, Advair Diskus Aerosol Powder and Lisinopril, which were scheduled to be administered between 7:00 AM and 11:00 AM, were not observed being given to the resident during the medication pass. Despite this, the nurse documented in the Electronic Medication Administration Record (EMAR) that these medications were administered at 9:57 AM. The Director of Nursing (V2) confirmed that nurses are required to follow the five rights of medication administration: right resident, right route, right medication, right time, and right dose. The facility's policy mandates that nurses document the administration of medications accurately, including any missed or refused doses. The failure to administer the medications as per the physician's orders and the subsequent inaccurate documentation resulted in a medication error rate of 6.25%, exceeding the acceptable threshold of less than 5% for the facility.
Failure to Follow Menu and Cooking Instructions in LTC Facility
Penalty
Summary
The facility failed to adhere to its menu and cooking instructions, affecting all 108 residents receiving nutrition from the kitchen. During a kitchen tour, it was observed that the facility did not serve the planned lemon meringue pies for lunch as they did not defrost in time, and instead served a 4-ounce serving of pears. This deviation from the menu was confirmed by the Dietary Manager, who acknowledged the issue. Additionally, during a Resident Council meeting, two residents expressed concerns that the facility frequently does not follow the menus, serving different food items than what is listed. Furthermore, the facility did not follow proper cooking instructions for pureed mashed potatoes. The cook, unaware of the number of residents on a pureed diet, prepared the mashed potatoes without measuring the water or granules, contrary to the instructions on the container. The instructions specified using boiling water and specific measurements for the granules and salt, which were not followed. This lack of adherence to cooking instructions and menu planning indicates a failure in the facility's food service management, impacting the nutritional care provided to the residents.
Failure to Provide Nectar-Thick Liquids as Ordered
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring nectar-thick liquids due to swallowing and chewing difficulties. The resident had an active diet order for nectar-thick consistency liquids, documented in their Order Summary Report, and their Care Plan Report indicated the need for a mechanically altered diet with thickened liquids. Despite these orders, a Certified Nurse Aide assisted the resident with a lunch meal and provided apple juice in a thin consistency instead of the required nectar-thick consistency. The facility's policy on the Accuracy of Quality of Tray Line Service mandates that all meals be checked for accuracy against the therapeutic diet spreadsheet and meal identification card, but this protocol was not followed, leading to the deficiency.
Failure to Prevent Repeated Falls for High-Risk Resident
Penalty
Summary
The facility failed to prevent repeated falls for a resident with a known history of falls and severe cognitive impairment. The resident, who has diagnoses including unspecified dementia and muscle weakness, experienced nine falls over a period of time. Despite being identified as a high fall risk in multiple assessments, the resident did not have consistent supervision or interventions in place to prevent these incidents. Initially, a 1:1 aide was provided, which effectively prevented falls, but this support was gradually removed, leading to repeated falls. The resident's care plan acknowledged the risk of falls due to impaired mobility and other factors, yet the interventions were insufficient to prevent the incidents. The facility's fall policy emphasizes reducing fall risks and maintaining a safe environment, but the repeated falls indicate a failure to adhere to this policy. The resident sustained a significant injury from one of the falls, requiring emergency medical attention and treatment for a scalp laceration.
Failure to Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
The facility failed to utilize a gait belt during the transfer of a resident from the toilet to a wheelchair, resulting in the resident falling and sustaining a left femur fracture. The resident, who is legally blind and requires supervision with toileting and transfers, was assisted to the bathroom by a CNA. After the resident finished toileting, the CNA instructed her to stand and move towards the sink. The resident, who was severely visually impaired, missed a step and fell, sustaining a fracture. The incident report and interviews reveal that the CNA was standing in the doorway and did not use a gait belt during the transfer, which is against the facility's protocol. The resident's son reported that the resident had multiple falls in the past and required assistance in the bathroom due to her blindness. The resident herself stated that she believed someone should have been with her in the bathroom, and she was unaware if anyone helped her during the fall. Interviews with facility staff, including an LPN and the DON, confirmed that gait belts are part of the CNA's uniform and should be used during transfers. The physical therapist also noted that the resident requires contact guard assistance and the use of a gait belt during transfers. The CNA involved in the incident was not available for an interview, and the LPN who responded to the fall confirmed that the resident was left on the floor until emergency services arrived.
Deficiencies in Call Light Response, Incontinence Care, and Medication Administration
Penalty
Summary
The facility failed to monitor and respond to the call light system in a timely manner, affecting several residents. One resident reported pressing the call light at 2:00 AM for incontinence care and not receiving assistance until 6:00 AM, remaining soiled during this period. Another resident with a colostomy bag experienced a 45-minute delay in response to their call light, leading to a ruptured bag and requiring external assistance to contact the facility. Observations confirmed that the call light system lacked an audible alert, relying solely on visual cues, which staff often overlooked. In addition to the call light issues, the facility failed to provide adequate incontinence care for multiple residents. Several residents were found with soiled incontinence briefs, indicating a lack of timely assistance. One resident, who is blind and requires assistance with toileting, reported that their call light was not answered for an extended period, resulting in discomfort and unmet needs. The facility's staffing issues, particularly with agency staff, contributed to these deficiencies, as one CNA left their shift early without ensuring coverage for their assigned residents. The facility also failed to administer medications as ordered by the physician for at least one resident. This resident did not receive their prescribed medications on a specific date due to the absence of a nurse to administer them. The facility's policies on medication administration and call light use were not adhered to, leading to these deficiencies. The lack of sufficient nursing coverage further exacerbated the situation, as staff were unable to meet the residents' needs effectively.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to ensure residents who depend on staff assistance for their Activities of Daily Living (ADL) care received proper grooming care, showers, personal hygiene, and feeding assistance. This deficiency affected three residents who were reviewed for ADL care. The observations, interviews, and record reviews revealed significant lapses in the care provided to these residents. Resident 1 (R1) had multiple diagnoses including congestive heart failure, Parkinson's disease, and depression. Despite requiring substantial assistance with personal hygiene and being dependent on staff for showers, R1 was observed with an overgrown beard, dry flaky scalp, and wearing a hospital gown. R1 reported not being shaved for a month and receiving a bed bath only after complaining. Additionally, R1's meal tray was delivered late, and he was left without assistance for 45 minutes, resulting in spilled food and juice. The facility's records lacked documentation of bed baths or showers for R1 for the entire month of April. Resident 2 (R2) and Resident 3 (R3) also experienced similar neglect. R2, who had chronic obstructive pulmonary disease and dementia, reported not receiving proper showers and only getting cleaned when a friend visited. R3, with diagnoses including muscle weakness and diabetes, was observed disheveled and reported not receiving assistance with dressing or showers. The facility's records for both R2 and R3 also lacked documentation of bed baths or showers for the entire month of April. The Director of Nursing confirmed the expectation for CNAs to assist with ADLs and document the care provided, which was not met in these cases.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
