Pearl Of Orchard Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Illinois.
- Location
- 2330 West Galena Boulevard, Aurora, Illinois 60506
- CMS Provider Number
- 145473
- Inspections on file
- 36
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 7 (2 serious)
Citation history
Health deficiencies cited at Pearl Of Orchard Valley during CMS and state inspections, most recent first.
Two cognitively impaired residents with documented sexually inappropriate and flirtatious behaviors were left unsupervised together in the dining room before a meal, despite one resident’s care plan specifying that unsupervised visiting with male residents should be discouraged and prevented when possible. Staff interviews and psychiatric notes showed both residents had dementia, poor insight and judgment, and lacked capacity to consent to sexual activity under facility policy. A dietary aide entered the dining room and observed one resident sucking on the other’s breast after she lifted her shirt, with no staff present; security footage reportedly showed the pair engaging in inappropriate contact whenever staff left the room. CNAs acknowledged awareness of the resident’s sexual comments but were unaware of any special monitoring requirements and stated that continuous monitoring of the dining room only occurred once meals were served, contributing to the failure to prevent the sexual contact.
A resident with multiple comorbidities and on anticoagulation reported that a CNA did not promptly return after a call light request for incontinence care, leading the resident to attempt self-transfer, fall, and sustain a forehead hematoma, skin tear, and back pain. The next morning, a pulmonary nurse found the resident confused with visible injuries and arranged EMS transfer. Although the facility’s policy requires immediate notification of the physician and resident representative, with repeated contact attempts and escalation to the medical director as needed, there was no documentation that the attending physician or medical director were actually reached after the fall, and no clear documentation that the resident’s representative was immediately notified, resulting in a failure to follow the facility’s change-in-condition notification policy.
A high fall-risk resident with multiple comorbidities, including prior fractures, atrial fibrillation on anticoagulation, and lack of coordination, required maximal assistance with toileting and had a care plan and facility policy calling for staff to anticipate and promptly address toileting and incontinence needs, conduct frequent safety rounds, and maintain bilateral safety mats. One night, the resident activated the call light for incontinence care due to a wet brief and sheets; the CNA who responded left to complete other tasks and obtain supplies instead of providing immediate care. During this delay, the resident attempted to transfer independently to reach the bathroom and fell, later found with a forehead hematoma, a left arm skin tear, confusion compared to baseline, and back pain. At the time of the fall, only one fall mat was in place instead of the ordered bilateral mats, and the DON confirmed that staff were expected to follow the resident’s fall-prevention care plan and the facility’s fall prevention policy, which included universal and high-risk fall precautions and purposeful rounding for toileting and incontinence needs.
A female resident with severe cognitive impairment was left unsupervised and exposed to sexual abuse by a male peer with a known history of wandering and inappropriate behaviors. The male resident entered her room unobserved and remained there with the door closed for several minutes, during which staff were not present in the hallway. Staff and record reviews confirmed that the male resident's behaviors were known but not adequately addressed in his care plan, and the incident was not promptly reported to the resident's family or medical providers.
The facility did not promptly report allegations of sexual and verbal abuse involving two residents with cognitive impairments. In both cases, notifications to the residents' representatives, physicians, IDPH, and local police were delayed by several days, contrary to the facility's abuse prevention policy requiring immediate reporting. The delays were attributed to the administrator being new in the position.
A facility failed to thoroughly investigate an allegation of sexual abuse after a staff member found a male resident with his pants lowered near a female resident's bed. Video confirmed the male resident was alone in the room for several minutes, and staff interviews indicated a pattern of wandering and inappropriate behavior. The investigation lacked a full assessment of the female resident, did not review surveillance footage as part of the process, and did not address the male resident's behavioral history, leading to a premature conclusion that the allegation was unsubstantiated.
A resident who needed substantial assistance for toileting was left in a soiled incontinence brief for hours after staff failed to respond to repeated call light requests. The resident reported feeling like a burden and expressed fear of urinating at night due to delayed care, while a staff member acknowledged leaving her in that condition.
A resident at risk for skin breakdown experienced redness and open areas on her buttocks after reporting prolonged exposure to urine and feces due to delayed incontinence care. The wound LPN applied a dressing but did not document the assessment or obtain treatment orders, and the wound summary lacked necessary measurements. The resident's care plan required prompt reporting and intervention for skin changes, which was not followed.
A facility failed to monitor a resident's skin, resulting in a stage 3 pressure ulcer that became infected. The resident was observed lying on a regular mattress without repositioning, despite being on isolation precautions for a MRSA/Strep A infection. The wound care nurse misclassified the ulcer and did not implement necessary interventions like using a low air-loss mattress or repositioning every two hours. The facility did not adhere to its skin prevention policies, leading to the resident's condition worsening.
The facility failed to maintain kitchen sanitation and food safety, affecting 132 residents. The dishwasher did not reach the required temperature for disinfection, and expired test strips were used. Sanitization buckets were improperly used, and food items lacked proper labeling and dating. Equipment and utensils were unclean, and dented cans were found in storage. A dietary manager did not perform hand hygiene after handling a resident's item, increasing contamination risk.
The facility failed to provide adequate assistance with ADLs for several residents, leading to deficiencies in personal hygiene and care. A resident with cognitive impairment was found with soiled clothing and poor oral hygiene, while another resident reported not receiving scheduled showers and oral care. Additional residents experienced neglect in grooming and personal hygiene, indicating a significant lapse in meeting care standards.
The facility failed to supervise residents who smoke, leading to safety hazards. Five residents were not properly assessed or supervised, with incidents including a cigarette burn on a wheelchair cushion and a resident passing a lit cigarette to a peer. The facility's policy requires regular smoking risk assessments, but several residents had outdated assessments or were not reassessed after changes in their condition. Observations showed residents smoking unsupervised, despite the need for staff presence during smoking times.
The facility failed to secure medications and obtain physician orders for medications brought from home for four residents. One resident had Tylenol, Icy-Hot, and Sooth without orders, while another had unlabeled medications including Cranberry tablets and Gas-X. Two other residents had medications like Salonpas patches and Nystatin powder without active orders. The facility's policy requires medications to be stored securely and accessible only to authorized personnel.
Two residents were involved in a physical altercation where one claimed the other stepped on her toe, leading to a push, while the other denied pushing and reported being hit with a grabber. The facility's response included a wellness check and a head-to-toe assessment, but inconsistencies in documentation and lack of thorough investigation highlight a deficiency in abuse prevention protocols.
A resident reported missing personal items and suspected a CNA of theft. The Administrator failed to document the complaint or report it to the Illinois Department of Public Health in a timely manner, as required by facility policy. The resident was cognitively intact, but the Administrator questioned the validity of her claims, leading to a delay in the investigation.
A facility failed to promptly investigate an alleged abuse incident between two residents, where one resident reportedly stepped on another's injured toe, leading to a physical altercation. Despite the incident being reported to the Administrator, there was a delay in investigation and documentation, and inaccuracies were found in the report to the IDPH.
The facility failed to provide restorative services to two residents with contractures, resulting in severe limitations in their range of motion. Despite care plans for daily PROM exercises, the residents did not receive the necessary interventions. The Restorative Aide was unable to perform PROM due to the severity of the contractures and was also tasked with CNA duties, leading to neglect in restorative care. The residents' conditions were exacerbated by long, unkempt fingernails and a lack of contracture prevention devices.
The facility failed to provide proper catheter care to two residents with indwelling urinary catheters. A CNA did not perform catheter care for a resident after an incontinence episode, and an RN improperly cleaned another resident's catheter tubing, contrary to facility policy. The DON confirmed the expectation for staff to follow the policy.
A resident with a history of colon cancer and a fistula did not receive proper ostomy care, as their ostomy bag was observed to be full on two consecutive days without being emptied or changed by staff. The facility lacked a care plan for the resident's ostomy, and staff did not adhere to the policy of emptying the pouch when it was one-quarter to one-half full.
The facility failed to properly administer tube feedings and care for enteral tubes for two residents with gastrostomy tubes. One resident's feeding was initiated without checking for tube placement or residual, contrary to medical orders. Another resident's tube site was not cleaned or dressed as required, leading to a buildup of drainage. The facility's policy on gastrostomy tube care was not followed.
The facility exceeded the acceptable medication error rate with a 6.6% error rate during a medication pass. A resident received Ferrous Sulfate despite it being on hold, and another resident did not receive their prescribed Amiodarone Hydrochloride. The DON emphasized adherence to physician's orders and the five R's of medication administration.
A resident with dysphagia was not served his prescribed nectar-thickened liquids, receiving a thin consistency drink instead. This was confirmed by an RN, and the DON stated that staff are expected to verify meal trays against prescribed diets.
A resident with multiple health issues and high risk for pressure ulcers developed a stage 2 ulcer due to inadequate repositioning and delayed incontinence care. Despite a care plan requiring frequent turning, staff failed to reposition the resident regularly, leading to prolonged exposure to soiled briefs and the development of the ulcer.
A resident with multiple medical conditions and moderate cognitive impairment experienced delays in receiving timely incontinence care, despite being dependent on staff for toileting hygiene. The resident reported waiting over three hours on multiple occasions for soiled briefs to be changed, contrary to the facility's policies on incontinence care and supportive ADLs.
A resident with multiple chronic conditions, including respiratory failure and pleural effusions, was found with an uncapped indwelling pleural catheter, leading to fluid accumulation at the open tip. The facility's policy and manufacturer's instructions require the catheter to be capped to prevent infections, but the nurse responsible for the last dressing change did not follow these guidelines, indicating a lack of proper training or competence.
A resident with multiple diagnoses experienced a change in condition, showing unstable vital signs and requiring hospital transfer. The wound care RN and the assigned RN each assumed the other documented the change in the EMR, resulting in a lack of documentation. The resident's care plan required monitoring and recording of vital signs, but the transfer form did not reflect the observed abnormalities.
The facility failed to conduct timely care plan meetings for two residents, one with complex medical conditions and another with osteomyelitis and diabetes. Despite completed assessments, no care plan meetings were documented, leaving residents without proper planning and communication. The Social Service Director acknowledged the oversight, which contradicted the facility's policy.
A resident requiring extensive assistance for transfers was not brought to the toilet in a timely manner, despite repeated requests for help. The resident was left unattended, resulting in incontinence, contrary to the facility's policy and the resident's plan of care. The Director of Nursing confirmed that residents should receive timely assistance without waiting for therapy evaluations.
Two residents in the facility did not receive proper pressure ulcer care, leading to deficiencies. A resident with a stage 3 sacral pressure wound was found without a dressing, causing pain, and the wound care nurse was not informed. Another resident with stage 4 pressure ulcers on the hip and leg experienced delays in receiving necessary wound vacs due to a lack of communication and documentation. These failures resulted in inadequate care for their pressure ulcers.
Two residents with swallowing and eating disorders were not adequately supervised during meals, leading to deficiencies in care. An elderly male with specific dietary orders was left unsupervised, and staff were unaware of his required interventions. An elderly female consumed her food rapidly without staff prompting her to slow down, despite her care plan. The facility failed to adhere to care plans and dietary orders, compromising resident safety.
The facility failed to provide nutritional supplements as ordered for two residents with weight loss and nutritional needs. One resident, with malnutrition and dysphagia, was observed eating rapidly without prompts to slow down, and her meal tray lacked the prescribed supplement. Another resident, also with malnutrition and dysphagia, was fed by a CNA unaware of the supplement order, and her tray was missing the supplement. The Dietary Director noted that supplements are stored in unit refrigerators and should be added by nursing staff, but this was not done.
A resident with a history of heart failure and a previous femur fracture experienced significant pain and swelling in her right leg. Despite multiple attempts by an RN to contact the attending physician, there was no response, and the administration was not informed. The resident's condition worsened, and it was only after a delay that the DON and physician assistant were notified, leading to an x-ray revealing a fracture. The facility's failure to follow its notification policy resulted in a two-day delay in treatment.
A facility failed to use a gait belt during a resident's transfer, violating its policy. A CNA transferred a resident by pulling her brief and pants instead of using a gait belt. Additionally, the facility did not update the resident's care plan after a fall, despite her high fall risk and recent sensory impairments, failing to implement individualized interventions as required by their fall prevention policy.
The facility failed to have a certified Infection Preventionist (IP) responsible for the Infection Control Prevention Program, affecting all 130 residents. The DON, who took on the IP role in October 2023, had not completed the required certification. The Administrator and Regional Nurse Consultant believed the DON was certified, contrary to the facility's policy requiring specialized infection training.
The facility failed to implement its Infection Prevention and Control Program by not providing surveillance data to the Local Health Department after a confirmed case of Legionnaire's disease. The DON did not review hospital records, notify the care team, or document the positive test result in the EMR. Despite multiple attempts by the Local Health Department to obtain a complete report, the DON submitted an incomplete report and failed to respond promptly, putting other residents at risk.
Failure to Supervise Cognitively Impaired Residents With Known Sexual Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse when a male dementia resident engaged in sexual contact with a female dementia resident’s breast in the dining room. The incident occurred when the female resident, who had a documented history of socially inappropriate and sexually oriented behaviors, including objectifying males and making crude sexual remarks, was left unsupervised with the male resident in the dining room. Her behavior care plan, in place since 2015, specifically identified her lack of boundaries, sexually oriented comments, and gestures, and included an intervention that unsupervised visiting with male residents should be discouraged and prevented when possible. Despite this, staff allowed her to remain in the dining room with a male resident without continuous supervision before the meal was served. The male resident also had a behavior care plan for socially inappropriate behavior, including flirtatious behavior toward a peer, and had diagnoses of dementia, major depressive disorder, and anxiety disorder, with documented poor insight and judgment and significant cognitive deficits. Both residents had psychiatric evaluations indicating they were oriented only to person, with significant short- and long-term memory deficits and impaired attention and concentration. The psychiatric nurse practitioner and LCSW stated that neither resident had the decision-making capacity to consent to sexual activity or make informed decisions. The facility’s own Sexual Abuse Prevention and Management of Sexual Behaviors policies defined sexual abuse as non-consensual sexual contact and stated that consent cannot be given if a resident is cognitively impaired, and that the facility must intervene when one or both individuals lack the ability to provide informed consent. On the day of the incident, a dietary aide entered the dining room while setting up for lunch and observed the male resident sucking on the female resident’s breast after she had lifted her shirt. The aide reported that no other staff were present in the dining room at that time and that security footage showed the two residents making inappropriate contact whenever staff left the dining room and stopping when someone entered. A CNA confirmed that she had placed drinks and seen the two residents sitting together, then left the dining room before food arrived, leaving no staff present. Multiple staff interviews showed that staff were aware the female resident could be sexually inappropriate, made sexual comments, and asked other residents to perform sexual acts, but CNAs reported they were unaware of any special interventions beyond separating her when she made inappropriate comments, and that continuous monitoring of the dining room only occurred once meals were served. The abuse coordinator and regional nurse consultant later stated they believed sexual abuse was unsubstantiated because both residents appeared to enjoy the act, despite the facility’s policies and professional assessments that cognitively impaired residents could not provide informed consent.
Removal Plan
- R2 continues to reside in the facility with no further incidents and suffered no negatives effects.
- R2's physician and responsible party were notified; responsible party had no concerns.
- R2 was sent to the hospital; no new findings and no new orders were received.
- R2 was moved to the secured female unit.
- R3 continues to reside in the facility with no further incidents and suffered no negative effects.
- R3's physician and daughter were notified; daughter voiced no concerns.
- R3 was sent to the hospital; no new findings and no new orders were received.
- R3 was on a 1:1 with staff until R3 left for the hospital.
- R3 was moved to the secured male unit.
- Law Enforcement was notified and concluded investigation with no findings.
- Social Services completed assessments on behavior, potential abuse and trauma for R2 and R3.
- Care plans were reviewed and updated as indicated on potential for abuse, behavior and trauma.
- Assessments and care plans will be completed per assessment schedule and as needed.
- Social Services completed and reviewed assessments on residents identified with sexually inappropriate behaviors.
- Care plans were reviewed and updated as needed for residents identified with sexually inappropriate behaviors.
- DON/ADON and/or designee communicated plan of care to staff.
- A behavior monitoring binder was created and placed at the nurses' station showing residents with behaviors and their plan of care; binder will be reviewed and updated weekly and as needed by DON/ADON/Social Services and/or designee.
- For identified residents with sexually inappropriate behaviors, behavior monitoring started every 2 hours for 2 weeks and every shift thereafter while awake by nursing staff, documented on a behavior monitoring log.
- Findings from behavior monitoring will be escalated to the abuse officer and ADON for protocol implementation immediately.
Failure to Follow Change-in-Condition Notification Policy After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy for immediate notification of a resident’s change in condition after an unwitnessed fall. The resident was admitted with multiple significant diagnoses, including COPD, atrial fibrillation, cirrhosis, bone disorders, prior fractures, and was on an anticoagulant. An MDS showed the resident was cognitively intact and required staff assistance for toileting and transfers. The resident reported that during the night she activated her call light because her incontinence brief was wet; a CNA responded, was told the resident needed to be changed, and stated she would return. The resident stated she could not wait, attempted to transfer herself to her wheelchair to go to the bathroom, and fell forward. She reported using her cell phone to call the facility to report the fall, sustaining a skin tear on her left arm, and experiencing back pain throughout the night. The next morning, a pulmonary nurse assessed the resident around 8:30 AM and found her confused, with mentation documented as alert and oriented times one, a quarter-sized hematoma on the right forehead, and a skin tear on the left upper extremity. The resident told the nurse she had fallen the previous night and had back pain, and the nurse noted the resident was on apixaban and arranged for transfer via EMS. The progress note documented notification of the Administrator and DON and that the nurse practitioner was notified, but the DON later stated that facility policy requires the nurse to immediately notify the primary physician, make at least two attempts, and if unsuccessful, escalate to the medical director, with all attempts documented. The DON reported that the nurse said she left a message with the resident’s doctor, but there was no documentation of further attempts or actual physician contact, nor documentation of medical director notification. The facility also lacked documentation that the resident’s representative was immediately notified of the fall, and the fall event assessment listed the representative as notified at 5:00 AM without clear correlation to the time of the fall, demonstrating noncompliance with the facility’s notification policy.
Failure to Follow High-Risk Fall Interventions and Timely Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow established fall-prevention interventions and care plan directions for a resident identified as a high fall risk. The resident was admitted with multiple diagnoses including COPD, hypertension, anxiety, metabolic encephalopathy, vertebral compression fracture, bone disorders, history of falls, femur fracture, atrial fibrillation, hypothyroidism, lack of coordination, UTI, and cirrhosis. An MDS showed the resident was cognitively intact but required maximal assistance with toileting hygiene and moderate assistance with transfers. The resident’s fall risk care plan, initiated at admission and updated after a prior fall, identified her as at risk for falls related to weakness, fatigue, activity intolerance, pain, and history of falls, and included interventions such as staff assessing and anticipating ADL and toileting needs during rounds, providing timely incontinence care, making frequent safety rounds, and maintaining bilateral safety mats at the bedside. On the night of the fall, the resident activated the call light because her incontinence brief and bed sheets were wet and requested incontinence care. The CNA who responded told the resident she would return after completing another task, then proceeded to deliver ice water to another resident, obtain sheets from the linen cart, and go to another floor to obtain incontinence briefs. During this delay, the resident, who was known to be a high fall risk and required assistance with toileting and transfers, attempted to get to her wheelchair to use the bathroom independently and fell forward. The resident later reported she used her cell phone to call the facility to notify staff of the fall and that she had sustained a skin tear on her left arm and was experiencing back pain. The next morning, a pulmonary nurse assessed the resident and found her confused compared to baseline, with a protruding hematoma on the right forehead and a skin tear on the left upper extremity. The resident reported she had fallen the previous night and had back pain. The DON confirmed the fall was unwitnessed, that the resident was on high fall risk precautions, and that staff were expected to follow the care plan and immediately attend to the resident’s incontinence needs. The DON also stated that at the time of the fall, only one fall mat was in place on the right side of the bed, while the resident’s care plan called for bilateral safety mats, and the resident had fallen from the left side where no mat was present. The facility’s fall prevention policy required universal fall precautions, individualized high-risk interventions, purposeful rounding to address toileting and incontinence needs, and adherence to high-risk fall precautions, which were not followed in this incident.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Peer
Penalty
Summary
The facility failed to protect a female resident with severe cognitive impairment from abuse by another male resident with a known history of wandering and inappropriate behaviors. The male resident, who was cognitively intact but exhibited behaviors such as wandering, rummaging, and public sexual acts, entered the female resident's room without staff awareness and remained there with the door closed for approximately eight minutes. During this time, staff were not present in the hallway, and the male resident was later found standing at the head of the female resident's bed with his pants lowered and genitals exposed near her face. The female resident was asleep, unable to verbalize her needs, and fully dependent on staff for activities of daily living. Staff interviews and record reviews revealed that the male resident was known among staff for entering other residents' rooms and taking their belongings, and that staff had expressed concerns about his behavior prior to the incident. Despite these known risks, there was no individualized care plan addressing his inappropriate wandering or sexually inappropriate behaviors, aside from standard two-hour monitoring. Staff also reported that they were responsible for supervising a high number of residents, making it difficult to provide adequate supervision, and that the male resident would take advantage of moments when staff were not watching. Following the incident, it was discovered that the facility did not promptly notify the female resident's family, hospice care team, or primary physician about the alleged abuse. This delay in notification meant that appropriate medical assessments and interventions, such as evaluation for trauma or sexually transmitted infections, were not conducted in a timely manner. The facility's failure to supervise the male resident and protect the vulnerable female resident from harm constituted a significant breakdown in resident safety and resulted in an Immediate Jeopardy to health and safety.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of sexual and verbal abuse involving two residents, as required by its abuse prevention policy. In the first incident, a female resident with severe cognitive impairment and under hospice care was found in her room with a male resident who had exposed himself and remained alone with her for approximately eight minutes. The incident was observed by staff and confirmed by video surveillance. Despite the clear identification of sexual abuse, notifications to the resident's Power of Attorney (POA), physician, the Illinois Department of Public Health (IDPH), and local police were significantly delayed, with the POA and IDPH notified six to seven days after the incident and the police notified ten days later. Both the hospice and primary physicians confirmed they were not informed, which prevented timely evaluation or treatment. In the second incident, a resident with moderate cognitive impairment sustained a skin tear and bleeding after being startled by another resident's shouting during a verbal altercation. This abuse allegation was also not reported to IDPH until six days after the event. The facility administrator attributed the delays in both cases to being new in the role. The facility's abuse prevention policy explicitly requires immediate notification of the resident's representative, physician, and local police in cases of suspected criminal activity, which was not followed in these instances.
Failure to Conduct Comprehensive Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a comprehensive investigation into an allegation of sexual abuse involving two residents. Staff discovered one resident standing at the head of another resident's bed with his pants lowered to his knees, exposing his buttocks, while the other resident was asleep and facing him. The staff member who discovered the incident questioned the resident, who immediately pulled up his pants and replied that he was doing nothing. Video surveillance confirmed that the resident was alone in the other resident's room with the door closed for eight minutes, and exited the room with his pants not fully pulled up. There was no staff present in the hallway during this period. Interviews with staff revealed that the resident who entered the room was known to wander, enter other residents' rooms, and take their belongings. Staff expressed concerns that this may not have been the first such incident. The resident was described as cognitively intact, aware of boundaries, and able to converse, but continued to exhibit wandering and inappropriate behaviors. The facility did not have an individualized plan to address these behaviors beyond standard monitoring. The resident who was found in bed was severely cognitively impaired, dependent on staff for all activities of daily living, and unable to verbalize needs. The facility's investigation was incomplete. While staff checked the resident in bed for skin issues and documented this, there was no documentation of a thorough assessment for possible physical contact or environmental evidence. The investigation did not include a review of the video surveillance footage as part of the process, nor did it explore the cause of the resident's presence in the other resident's room or review the resident's wandering behavior. The facility concluded the allegation was unsubstantiated without completing all required investigative steps.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
A resident who is cognitively intact and requires substantial to maximal assistance for toileting was observed in bed wearing a hospital gown. The resident reported that the night shift staff did not respond to her call light requests for incontinence care, sometimes leaving her waiting for 5-6 hours before anyone would assist. On one occasion, a staff member entered the room, expressed frustration about having to provide care, stated she would return, but never did. As a result, the resident remained in a soiled incontinence brief containing stool and urine for several hours. The resident further stated that when she reminded the same staff member the following day about not returning to provide care, the staff member acknowledged leaving her in that condition and responded with an attitude. The resident expressed feelings of being a burden and reported being afraid to urinate at night due to the prolonged wait for assistance. The facility's policy requires care to be provided in a manner that respects resident rights, dignity, and autonomy, which was not upheld in this instance.
Failure to Document and Obtain Treatment Orders for Skin Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to document and obtain treatment orders for a resident at risk for skin breakdown who reported redness and burning to her buttock area. The resident, who was cognitively intact and required substantial assistance for toileting, complained of being left in urine and feces for extended periods during the night shift, sometimes waiting 5-6 hours for incontinence care after activating her call light. During incontinence care, redness and a dressing were observed on the resident's buttocks, and upon further inspection, three open areas surrounded by denuded skin were noted. The wound nurse acknowledged seeing redness the previous day and applying a dressing but did not document the assessment or obtain treatment orders at that time. The resident's care plan indicated she was at risk for skin breakdown and required her skin to be kept clean and dry, with any changes reported to the physician. However, the wound summary lacked measurements, and there was no documentation of the initial assessment or treatment orders prior to the surveyor's observation. Staff interviews confirmed that prolonged exposure to moisture contributed to the skin damage, and the resident's complaints about delayed care were consistent with the observed condition.
Failure to Monitor and Prevent Pressure Ulcer Progression
Penalty
Summary
The facility failed to adequately monitor and care for a resident's skin, resulting in a pressure injury progressing to a stage 3 ulcer and becoming infected. Observations on multiple occasions showed the resident lying on a regular mattress without being repositioned, despite being on contact and droplet isolation precautions due to a MRSA/Strep A infection in the wound. The resident's skin assessment tool initially showed no concerns, but a subsequent wound assessment revealed a stage 3 sacral pressure ulcer. The wound care nurse incorrectly assessed the ulcer as stage 2 and did not implement necessary interventions such as using a low air-loss mattress or repositioning the resident every two hours. The resident, who was severely cognitively impaired and incontinent, was on a turning/repositioning program and used pressure-reducing devices. However, the facility did not follow its own policies for skin prevention and treatment, as evidenced by the lack of regular skin inspections and failure to implement recommended interventions. The Director of Nursing expected staff to check residents' skin daily and follow prevention processes, but these expectations were not met, leading to the deterioration of the resident's condition.
Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting 132 residents receiving dietary services. The dishwasher, which is supposed to disinfect dishes at 180 degrees Fahrenheit, consistently failed to reach the required temperature, with maximum temperatures recorded at 172 degrees Fahrenheit for the wash cycle and 160 degrees Fahrenheit for the final rinse cycle. The test strips used to verify the temperature were expired, and the facility did not provide a dishwasher policy. Additionally, a fan in the dishwashing area was covered with grease and dust, potentially contaminating clean dishes. The facility also failed to properly use and label sanitization buckets, with a green bucket containing sanitizer instead of soapy water, and no red sanitization bucket in use. The kitchen staff did not adhere to proper labeling and dating procedures for food items, with several items in the reach-in coolers and freezers lacking use-by dates or proper wrapping, leading to potential contamination. The facility's policy on labeling and dating was not followed, and the Regional Dietary Director acknowledged that all food items should be labeled and dated according to the facility's chart. Additional deficiencies included unclean equipment and utensils, such as a meat slicer and stand mixer with crumbs and drips, and rusty, dirty drawers containing clean utensils. Dented cans were found in dry storage, which the Regional Dietary Director stated could develop botulism. Furthermore, a dietary manager failed to perform hand hygiene after handling a resident's measuring cup, potentially contaminating meal trays. The facility's policies on handwashing and food service were not adhered to, increasing the risk of foodborne illness among residents.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents, leading to deficiencies in personal hygiene and care. Resident R109, who is severely cognitively impaired, was observed with soiled clothing and an improperly fitted incontinence brief, indicating a lack of timely incontinence care. Additionally, R109 exhibited poor oral hygiene with noticeable residue buildup on his teeth, further highlighting the neglect in providing necessary assistance with daily hygiene tasks. Resident R71, who requires substantial assistance due to a stroke, reported not receiving scheduled showers and oral care. His hair was unkempt, and his nails were long and dirty, suggesting a failure to adhere to his care plan, which mandates regular showers and hygiene assistance. Similarly, Resident R117, who is cognitively impaired, was found with overgrown facial hair, unkempt nails, and poor oral hygiene, indicating a lack of grooming and personal care support from the staff. Residents R90 and R19 also experienced neglect in personal hygiene care. R90, with severely contracted hands, had long nails causing discomfort, while R19 expressed dissatisfaction with her long, dirty nails and facial hair, which had not been addressed by the staff. The facility's policy on ADLs emphasizes maintaining residents' comfort, safety, and dignity, yet the observations and resident reports indicate a significant lapse in meeting these standards, as staff failed to provide the necessary assistance and care as outlined in the residents' care plans.
Lack of Supervision for Smoking Residents
Penalty
Summary
The facility failed to provide adequate supervision for residents who smoke, leading to potential safety hazards. Five residents were identified as not being properly assessed or supervised while smoking. One resident was found with a cigarette burn on her wheelchair cushion, and another was observed passing a lit cigarette to a peer without staff supervision. The facility's policy requires smoking risk assessments to be conducted quarterly and as needed, but several residents had outdated assessments or were not reassessed after significant changes in their condition. Additionally, a resident with a history of traumatic brain injury and cognitive impairment was not reassessed for smoking safety after admission, despite engaging in unsafe behaviors such as picking up and smoking cigarette butts. The facility's policy mandates supervision for residents who require it, but observations revealed that staff were not present during smoking times, leaving residents unsupervised and at risk of accidents. The Social Services Director acknowledged the importance of supervision but was unaware of specific incidents involving the residents.
Failure to Secure and Obtain Orders for Resident Medications
Penalty
Summary
The facility failed to obtain physician orders for medications brought from home and did not secure resident medications in locked compartments, affecting four residents. Resident R195 had a bottle of Tylenol, a tube of Icy-Hot, and a bottle of Sooth in her room without physician orders. Despite being cognitively intact, as indicated by a BIMS score of 14, there were no orders for these medications in her March Physician Order Sheet. The Director of Nursing confirmed that medications brought from home require a physician's order and should be stored securely. Resident R78 had several unlabeled medications, including Cranberry tablets, Gas-X, Fexofenadine Hydrochloride, Phenylephrine Hydrochloride, and Melatonin, in her room. There were no physician orders for these medications, except for Melatonin, which was documented in her Medication Administration Record. Resident R86 had Salonpas patches without an active order, and Resident R54 had Nystatin powder without an active order. The facility's policy requires medications to be stored securely and accessible only to authorized personnel, which was not adhered to in these cases.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents, R67 and R124. R124 reported that R67 stepped on her toe, leading her to push him, and claimed that R67 pushed her back. However, R67 denied pushing R124 and stated that R124 hit him with a grabber. The incident was reported to the facility's administrator, who documented the event and submitted a report to the department of health. Despite the conflicting accounts, the facility's response included a wellness check on R67 and a head-to-toe assessment, but there was no clear resolution or prevention of further incidents. The facility's documentation and interviews reveal inconsistencies in the handling of the incident. The Social Services Director and a Registered Nurse were instructed by the administrator on how to document the incident, but there was no clear communication or investigation into the claims of physical contact. The facility's policy on abuse prevention states that residents have the right to be free from physical abuse, yet the actions taken did not adequately address the allegations or ensure the safety of the residents involved. The lack of a thorough investigation and appropriate measures to prevent further incidents highlights a deficiency in the facility's abuse prevention and response protocols.
Failure to Timely Report Suspected Theft
Penalty
Summary
The facility failed to submit reports of suspected abuse to the Illinois Department of Public Health within the mandated timeframes. This deficiency involved a resident who reported missing personal items, including money, a debit card, an ID, and a birth certificate, from her purse. The resident, who was cognitively intact, suspected a CNA might have taken them and reported the theft to the Administrator/Abuse Coordinator. However, the Administrator did not take immediate action or document the complaint, and the initial report to the state was delayed. The Administrator acknowledged that the resident had informed him of missing money and an ID but claimed no knowledge of the other missing items. Despite the resident's cognitive intactness, the Administrator questioned the validity of her claims and failed to document the incident or initiate a timely investigation. The facility's policy requires an immediate report to the state licensing agency after an allegation of theft, but this was not followed. The initial report to IDPH was only made after the resident explicitly mentioned theft, and the facility's final report concluded that abuse was not substantiated.
Failure to Investigate Alleged Resident Abuse Promptly
Penalty
Summary
The facility failed to immediately initiate an investigation into allegations of abuse involving a resident, leading to a deficiency. A cognitively intact resident reported an altercation with another resident, where the latter allegedly stepped on her injured toe, prompting a physical confrontation. The resident informed the Administrator/Abuse Coordinator the day after the incident, but the facility did not promptly investigate or document the occurrence in the resident's electronic medical record. The report to the Illinois Department of Public Health (IDPH) was delayed and contained inaccuracies regarding the timing of the notification and the resident's ability to provide details about the incident. Interviews with staff revealed that the altercation was known to the CNA and LPN on duty, who reported it to the Director of Nursing. However, there was no documentation or immediate assessment of the resident following the incident. The facility's Abuse Prevention Training Program mandates immediate reporting to the state licensing agency after assessing the resident and removing the alleged perpetrator, which was not adhered to in this case. The lack of timely investigation and documentation of the incident led to the deficiency identified by the surveyors.
Failure to Provide Restorative Services for Contractures
Penalty
Summary
The facility failed to provide appropriate restorative services to residents with contractures, specifically affecting two residents. One resident, R90, was unable to extend his fingers due to severe contractures, with his hands in a fixed fist position. Despite having a care plan for daily passive range of motion (PROM) exercises, R90 could not recall the last time he received these exercises. The Restorative Aide, V12, confirmed that she was unable to perform PROM on R90's hands due to the severity of the contractures. Additionally, R90's fingernails were excessively long, causing indentations in his palms, which also had a brown substance with a foul odor. The resident's mobility assessment indicated a decline in the range of motion, contradicting the care plan's goal to maintain his current level of function. Another resident, R71, experienced similar neglect in restorative care. After suffering a stroke, R71's left side was very weak, and his left arm and hand were stiff and contracted. Although his care plan included daily PROM exercises for his left extremities, R71 reported that he no longer received these exercises. V12 attempted to demonstrate PROM on R71 but was unable to due to the severity of his contractures. R71's fingernails were also long and unkempt, with a brown substance underneath, causing indentations in his palm. V12 admitted that she could not perform PROM on all residents as she was also responsible for CNA duties, and it appeared that R71 and R90 had not been receiving their prescribed exercises. The facility's policy emphasized maintaining residents' functional levels, yet the lack of contracture prevention devices and consistent restorative care contributed to the deficiency.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care to two residents, R54 and R90, who were reviewed for urinary care. On March 19, 2025, a Certified Nurse Assistant (CNA) was observed providing incontinence care to R54, who had an indwelling urinary catheter. The CNA cleaned R54's perineal and buttock area after an incontinence episode but did not provide catheter care as required by R54's care plan, which specified that catheter care should be provided during routine perineal care. On March 20, 2025, a Registered Nurse (RN) was observed providing catheter care to R90, who also had an indwelling urinary catheter and had recently been treated for a urinary tract infection. The RN cleaned R90's catheter tubing using repeated downward and upward strokes with the same wipe, contrary to the facility's policy, which requires wiping the tubing with a downward stroke using a clean cloth. The Director of Nursing (DON) confirmed that the nursing staff is expected to provide incontinence and catheter care according to the facility's policy.
Failure to Provide Proper Ostomy Care
Penalty
Summary
The facility failed to provide appropriate care for a resident's ostomy bag, as observed during a survey. On two consecutive days, the resident's ostomy bag was noted to be almost full and not emptied or changed by the staff, despite the resident's complaints. The resident, who is cognitively intact, expressed that the ostomy bag is frequently full and takes a long time to be changed by the staff. The facility's policy requires the pouch to be emptied when it is one-quarter to one-half full, which was not adhered to in this case. The resident has a medical history of colon cancer and a fistula, with a physician order to change the colostomy pouch every three days. However, there was no care plan in place for the resident's ostomy or fistula, as confirmed by the Regional Nurse Consultant and the Director of Nursing. The lack of a care plan and the failure to follow the facility's policy on ostomy care led to the deficiency observed during the survey.
Failure to Administer and Care for Gastrostomy Tubes as Ordered
Penalty
Summary
The facility failed to administer tube feedings and care for enteral tubes as ordered for residents with gastrostomy tubes. For one resident, a registered nurse did not check for tube placement or residual before initiating a feeding infusion, contrary to the resident's medical orders. The resident's order summary specified that prior to initiating feeding, the nurse should aspirate gastric content, measure and record it, and check for placement. If the aspirate was more than 60 ml, the physician should be notified, and if no aspirate was obtained, the nurse should check for placement using auscultation. The nurse did not follow these procedures, which were clearly outlined in the resident's care plan. Another resident was found to have a gastrostomy tube site with brownish dry buildup drainage and no dressing, despite orders to cleanse the insertion site daily and cover it with gauze. The facility's policy on gastrostomy tube care emphasized the importance of daily cleaning and observing the peristomal skin for any signs of irritation or leakage. The Director of Nursing stated that nurses are expected to verify enteral feeding orders and provide site care as per the facility's policy, which was not adhered to in this case.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 6.6%, which exceeds the acceptable threshold of 5%. During a medication pass, two errors were observed among 30 opportunities. The first error involved a registered nurse administering Ferrous Sulfate 325 mg to a resident, despite the medication being on hold according to the resident's Physician Order Sheet and Medication Administration Record. The second error occurred when a licensed practical nurse failed to administer Amiodarone Hydrochloride 200 mg to another resident, despite an order for the medication to be given orally in the morning. The Director of Nursing stated that nurses are expected to follow physician's orders and adhere to the five R's of medication administration: right drug, right dose, right route, right time, and right patient. The facility's Medication Administration Policy emphasizes the importance of safe and appropriate medication administration to aid residents in overcoming illness and preventing symptoms.
Failure to Serve Prescribed Diet to Resident
Penalty
Summary
The facility failed to serve a resident his prescribed diet, which was identified during an observation on 3/18/2025. The resident, who had a swallowing problem related to dysphagia, was supposed to receive nectar-thickened liquids as per his care plan and order summary report dated 3/20/2025. However, during the observation, the resident was served a thin consistency yellow drink instead of the prescribed nectar-thickened liquid. This discrepancy was confirmed by an agency registered nurse (RN) who verified that the resident was not served the correct consistency of drink. The Director of Nursing (DON) later stated that nursing staff are expected to check residents' meal tray items and tickets before serving to ensure they receive their prescribed diet.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to implement necessary interventions to prevent a resident from developing a pressure ulcer. The resident, who was admitted with multiple diagnoses including acute cystitis, acute respiratory failure, sepsis, bacteremia, heart failure, and acute kidney failure, was identified as having a high risk for pressure ulcers with a Braden Scale score of 10. Despite having a care plan that required frequent turning and repositioning, the resident developed a stage 2 pressure ulcer on the left ischium due to inadequate repositioning and prolonged exposure to soiled incontinence briefs. Observations and interviews revealed that the resident was often left in bed without being repositioned, and staff did not consistently respond to the resident's call light in a timely manner. The resident reported waiting for extended periods, sometimes over three hours, for incontinence care, which contributed to the development of the pressure ulcer. Staff interviews confirmed that the resident was not regularly repositioned, and documentation showed a lack of consistent repositioning as per the care plan. The wound nurse practitioner assessed the resident's pressure ulcer and attributed its development to prolonged sitting and exposure to stool. The facility's policies on wound prevention and ADL support were not adequately followed, as evidenced by the lack of documentation and staff actions that failed to meet the resident's care needs. The facility's failure to adhere to the care plan and provide timely incontinence care and repositioning led to the resident acquiring a pressure ulcer.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, identified as R2, who was dependent on staff for toileting hygiene due to multiple medical conditions including acute cystitis, acute respiratory failure, sepsis, bacteremia, heart failure, and acute kidney failure. R2's care plan indicated the need for frequent checks and assistance with toileting. However, on February 10, 2025, R2 was observed lying in bed with an activated call light, which had been on since 8:30 AM, waiting for his soiled incontinence brief to be changed. It was not until 10:23 AM that R2 received incontinence care from a registered nurse and a certified nursing assistant, who confirmed the presence of stool in the brief. R2 reported that on multiple occasions, including February 1, 2025, he had to wait over three hours for his soiled incontinence brief to be changed. The facility's policy on incontinence care emphasizes keeping residents dry and odor-free to prevent skin breakdown, and the policy on supportive activities of daily living requires providing necessary services for residents unable to carry out ADLs independently. Despite these policies, R2 experienced delays in receiving incontinence care, highlighting a deficiency in the facility's adherence to its own care protocols.
Failure to Properly Cap Indwelling Pleural Catheter
Penalty
Summary
The facility failed to ensure that a staff member was skilled in changing an indwelling pleural catheter dressing appropriately for a resident with respiratory conditions. The resident, who was admitted with multiple diagnoses including toxic encephalopathy, acute respiratory failure, pleural effusions, and other chronic conditions, was supposed to receive care for an indwelling pleural catheter to manage pleural effusions and shortness of breath. On a specific date, during wound care, it was observed that the resident's catheter was not capped, and fluid was present at the open catheter tip, which was noted by both the Wound Care Registered Nurse and the Wound Care Nurse Practitioner. The Director of Nursing stated that nurses are expected to change catheter dressings in a sterile manner and cap the catheter tip to prevent infections. The facility's policy and the manufacturer's instructions both emphasize the importance of capping the catheter to avoid complications such as infections. However, the nurse who last changed the dressing did not cap the catheter, indicating a lack of competence or training in handling indwelling pleural catheters, as highlighted by the Director of Nursing.
Failure to Document Change in Condition
Penalty
Summary
The facility failed to document the assessment of a resident who experienced a change in condition and required a hospital transfer due to abnormal vital signs. The resident, who had multiple diagnoses including toxic encephalopathy, acute respiratory failure, and congestive heart failure, was observed by a wound care RN to be agitated and having difficulty breathing. The resident's vital signs were unstable, with a blood pressure of 56/46 mmHg, a heart rate of 33 bpm, and an oxygen saturation of 77%. The resident was placed on 4 liters of oxygen, which improved the oxygen saturation to 99%, and was then transported to the hospital by emergency paramedics. The wound care RN assumed that the assigned RN documented the change in condition in the resident's EMR, while the assigned RN assumed the wound care RN had done so. As a result, the change in condition was not documented in the resident's medical record. The Director of Nursing stated that nurses are expected to document assessment findings when there is a change in condition. The resident's care plan required monitoring and recording of vital signs and notifying the MD of significant abnormalities, but the SNF/NF to Hospital Transfer form did not reflect the resident's change in condition or the abnormal vital signs observed.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed within 7 days after the completion of the comprehensive assessment for two residents. Resident 1 was admitted with multiple complex medical conditions, including cellulitis, atrial fibrillation, and end-stage renal disease, among others. Despite the comprehensive assessment being completed, there was no documentation of a care plan meeting or a scheduled meeting throughout the resident's stay, and the resident was eventually discharged to the hospital. Similarly, Resident 3, who was admitted with conditions such as osteomyelitis, diabetes, and hypertension, also did not have a documented care plan meeting. The resident expressed concerns about post-treatment plans and dietary options, indicating a lack of communication and planning. The Social Service Director acknowledged the responsibility for setting up care plan meetings and outlined the expected participants and process, but the facility's policy was not followed, as evidenced by the absence of documented meetings in the residents' medical records.
Failure to Provide Timely Assistance for ADLs
Penalty
Summary
The facility failed to provide timely assistance to a resident (R2) who required extensive help with activities of daily living, specifically in getting to the toilet. R2, who was admitted to the facility and had a physical therapy evaluation indicating a need for substantial assistance with transfers, was left unattended despite repeatedly requesting help to use the bathroom. On the morning of the incident, R2 activated her call light and verbally requested assistance from a Certified Nursing Assistant (CNA), who informed her that she could not be assisted until after a physical therapy evaluation. Despite R2's continued requests and the call light remaining on, she was not assisted until much later, resulting in her being incontinent of stool, which she stated was unusual for her. The Director of Nursing (V2) later clarified that call lights should be answered promptly and that residents do not need to wait for therapy evaluations to receive assistance. The facility's policy on Activities of Daily Living emphasizes the importance of maintaining residents' comfort, safety, and dignity, and ensuring they receive the necessary assistance. However, in this instance, the staff failed to adhere to these guidelines, as R2's plan of care indicated she could be transferred with one staff member using a walker and gait belt, which was not followed, leading to the deficiency.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper pressure ulcer treatment interventions for two residents, R1 and R2, leading to deficiencies in their care. R2, who had a stage 3 sacral pressure wound, was observed without a dressing during incontinence care, causing her pain. The Wound Registered Nurse, V11, confirmed that R2's wound should have had a dressing as per the treatment orders, but she was not notified by the CNAs when the dressing was missing. This lack of communication and adherence to the treatment plan resulted in inadequate care for R2's pressure ulcer. R1 was admitted to the facility with multiple wounds, including stage 4 pressure ulcers on her left hip and left lower leg. The Wound Care Registered Nurse, V11, was unaware of the need for wound vacs for R1's wounds until after admission. There was a delay in ordering and applying the necessary wound vacs, and the Treatment Administration Record (TAR) and Medication Administration Record (MAR) lacked documentation of wound care orders for R1's wounds until several days after admission. This oversight in documentation and communication led to a failure in providing timely and appropriate wound care for R1.
Failure to Supervise Residents with Eating Disorders
Penalty
Summary
The facility failed to provide adequate supervision and safe eating interventions for residents with swallowing and eating disorders, leading to deficiencies in care. One resident, an elderly male with diagnoses including anorexia, dysphagia, and anxiety, was observed feeding himself without staff supervision despite having specific dietary orders requiring supervision and a special eating plan. The staff present, including CNAs and an RN, were unaware of the resident's required interventions and failed to provide the necessary supervision. Additionally, the resident's communication board was not available, further hindering effective communication and supervision. Another resident, an elderly female with diagnoses of protein calorie malnutrition and dysphagia, was observed consuming her food rapidly without staff intervention. Despite having a care plan that required her to eat slowly and chew thoroughly, the CNAs present did not prompt her to slow down or swallow between bites. The staff's inaction in both cases demonstrates a lack of adherence to the residents' care plans and dietary orders, resulting in a failure to ensure a safe eating environment for residents with swallowing and eating disorders.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for residents with weight loss and nutritional needs. This deficiency was observed in two residents. The first resident, a female with diagnoses including protein calorie malnutrition and dysphagia, was observed eating rapidly without prompts from the CNAs to slow down or swallow between bites. Her meal tray was missing the prescribed nutritional supplement dessert. The resident's care plan included interventions for her chewing problem, but these were not followed during the observation. The second resident, who also had a diagnosis of protein calorie malnutrition and dysphagia, was observed being fed by a CNA. This resident's meal tray was also missing the nutritional supplement dessert as ordered. The CNA was unaware of the order for the supplement. The Dietary Director confirmed that the nutritional supplement dessert is stored in unit refrigerators and should be added to trays by nursing staff, but this was not done for the observed residents.
Delayed Physician Notification Leads to Treatment Delay
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition in a timely manner, resulting in a delay in treatment and pain relief. The resident, who had a history of heart failure, psychological disorders, and a previous femur fracture, was admitted to the facility and required extensive assistance with daily activities. On a particular night, the resident was found yelling and guarding her right leg, indicating pain. Despite multiple attempts by a registered nurse to contact the attending physician through an answering service, there was no response, and the administration was not informed of the lack of communication. The resident's condition worsened, with swelling and discoloration observed in the right leg and left arm. Several staff members, including CNAs and LPNs, noted the resident's complaints of pain and visible symptoms but did not escalate the issue to higher authorities or alternative contacts until the following day. It was only after a registered nurse informed the Director of Nursing and the physician assistant that the resident received medical attention, including an x-ray that revealed a supracondylar fracture of the right femur. The facility's policy required immediate notification of a physician or on-call medical personnel in the event of a significant change in a resident's condition. However, the failure to follow this protocol led to a two-day delay in addressing the resident's pain and injury. The attending physician and physician assistant were unaware of the situation until they were contacted directly, highlighting a breakdown in communication and adherence to established procedures.
Failure to Use Gait Belt and Update Care Plan After Fall
Penalty
Summary
The facility failed to utilize a gait belt during the transfer of a resident, which is a violation of their policy on gait belt usage. A Certified Nurse Assistant (CNA) admitted to transferring a resident without using a gait belt, instead opting to pull the resident's brief and pants to lift and transfer her. This action was contrary to the facility's policy, which mandates the use of gait belts to prevent injury during resident transfers. The CNA's method of transfer was not in compliance with the established procedures designed to ensure the safety of both staff and residents. Additionally, the facility did not revise the resident's care plan following a fall incident. The resident, who had a history of falls and was assessed as high risk for falls, experienced a fall on a previous date. Despite this, the care plan was not updated to address additional fall risks, such as the resident's recent hearing loss, blindness, and behaviors of hitting and swaying during care. The lack of revision in the care plan after the fall incident indicates a failure to implement individualized interventions for high-risk residents, as outlined in the facility's fall prevention policy.
Failure to Designate a Certified Infection Preventionist
Penalty
Summary
The facility failed to have a designated certified Infection Preventionist (IP) responsible for the Infection Control Prevention Program, affecting all 130 residents. The Director of Nursing (DON), who assumed the IP role in October 2023, had not completed the required certification exam despite starting an infection preventionist training course approximately six years ago. Both the Administrator and the Regional Nurse Consultant were under the impression that the DON had completed the necessary training and certification. The facility's policy, reviewed in June 2023, mandates that the IP must be a licensed professional nurse who has completed specialized infection training recommended by the CDC.
Failure to Implement Infection Prevention and Control Program for Legionnaire's Disease
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program by not providing surveillance data to the Local Health Department after a confirmed case of Legionnaire's disease was associated with the facility. The Director of Nursing (DON), who also served as the Infection Preventionist (IP), was notified by the Local Health Department about the positive test result for Legionnaire's disease. However, the DON did not review the hospital medical records, did not notify the resident's care team, and did not document the positive test result in the resident's Electronic Medical Record (EMR). This failure affected eight residents reviewed for communicable diseases of Legionnaire's. The DON admitted to not being familiar with Legionella and its symptoms and only tracked infections requiring transmission precautions, not pneumonia. Despite multiple attempts by the Local Health Department to obtain a complete Legionella Surveillance report, the DON submitted an incomplete report and failed to respond promptly to follow-up communications. The Local Health Department expressed concern over the facility's low responsiveness, emphasizing that one case of Legionnaire's disease in a long-term care facility triggers an investigation and requires cooperation to prevent potential health risks to other residents. The facility's policy on Legionella Surveillance and Detection outlined procedures for training clinical staff on symptoms, notifying physicians, and initiating active surveillance if Legionella is detected. However, the DON did not follow these procedures, resulting in incomplete data collection and delayed reporting. The facility's failure to adhere to its own policy and the Local Health Department's guidelines put other residents at risk for Legionnaire's disease, as evidenced by the identification of additional residents with healthcare-associated pneumonia during the survey.
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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