Radford Green
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincolnshire, Illinois.
- Location
- 960 Audubon Way, Lincolnshire, Illinois 60069
- CMS Provider Number
- 146136
- Inspections on file
- 22
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Radford Green during CMS and state inspections, most recent first.
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.
A resident's credit card was stolen and used by a CNA, who accessed the card from the resident's nightstand and made unauthorized purchases at a local liquor store. The theft was discovered after the resident noticed an unfamiliar charge and reported it to both the facility and police. Investigation confirmed the CNA's involvement, leading to criminal charges for theft and unlawful use of the credit card.
A resident suffered second-degree burns from hot coffee served at 187.2°F, exceeding the facility's policy of 180°F. The coffee machine's temperature was not regularly checked. Another resident, at high risk for falls, lacked consistent fall prevention measures, such as floor mats and a low bed position, despite a care plan specifying these interventions.
The facility failed to consistently monitor food temperatures before serving meals to all 76 residents. The Dining Director stated that temperatures should be taken in the kitchen and again on the floors before serving, but records showed multiple instances of missing temperature logs. The facility's policy requires temperatures to be recorded three times per meal service, but this was not followed, leading to a deficiency in food safety and quality.
The facility failed to properly dispose of controlled substances for three residents. A resident with joint replacement had a Tramadol tablet taped back into the medication card, while another with a femur fracture had an Oxycodone pill similarly mishandled. Additionally, a resident with Alzheimer's had a diphenoxylate/atropine pill taped back into the card. The facility's policy requires destruction of such medications if not administered, witnessed by two nurses, which was not followed.
A facility failed to ensure proper PPE use for a resident on droplet precautions for COVID-19. An RN exited the resident's room, removing only her gown and gloves, but continued to wear her face shield and N95 mask in the hallway, risking cross-contamination. The facility's policy requires full PPE removal after leaving the room to prevent germ spread.
A resident at risk for pressure injuries did not receive weekly skin assessments, resulting in full-thickness wounds on the buttocks. Despite being identified as at risk, the facility failed to perform assessments for three weeks, only discovering the injuries after the resident reported pain. The DON confirmed the lapse in monitoring.
A resident with no cognitive impairment experienced a delay in the repair of a broken sink faucet, resulting in no water for personal hygiene. The issue was reported on a Friday and marked as a priority, but was not resolved until the following Monday. The RN Weekend Supervisor provided buckets of water, and the maintenance staff from Assisted Living was unable to fix the faucet over the weekend due to the need for a replacement.
A resident with severe cognitive impairment and right-sided weakness fell during a shower due to inadequate supervision. Despite requiring two-person assistance, a CNA assisted the resident alone and turned away to retrieve clothing, resulting in the resident falling from the shower chair. The incident highlights a failure to adhere to the care plan and safety protocols.
A resident with chronic pain was not informed of a change in her medication from Norco to Extra Strength Tylenol, leading to potential withdrawal symptoms. The DON confirmed the resident was not notified, and the NP assumed nurses would inform her. This oversight violated the resident's rights to be informed of changes in her treatment.
A resident with severe cognitive impairment suffered a left hip fracture after being improperly transferred using a mechanical lift by a CNA without assistance. The incident was not reported immediately, delaying necessary medical evaluation and treatment. The resident's condition worsened over several days before an x-ray revealed the fracture.
A resident with severe cognitive impairment and multiple health issues sustained a femur fracture during a mechanical lift transfer due to inadequate staffing. The CNA attempted the transfer alone, contrary to facility policy requiring two staff members, resulting in the resident sliding out of the sling and being lowered to the ground. The incident led to bruising and a fracture, with the resident's poor bone quality contributing to the injury.
A cognitively impaired resident with a history of stroke and high fall risk was left unsupervised on the toilet by two staff members, resulting in a fall and severe injuries, including a basal ganglia hemorrhage and a frontal scalp hematoma. The facility's policy on resident supervision was not followed, leading to the incident.
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 Resident from Misappropriation of Funds by CNA
Penalty
Summary
A facility failed to protect a resident from misappropriation of funds when a certified nursing assistant (CNA) stole and used a resident's credit card. The resident, who was on isolation for influenza and had limited mobility, reported his credit card missing after noticing an unauthorized charge. The card had been brought to him by his son and was kept in his nightstand, bundled with other cards. The resident discovered the theft after checking his account and immediately canceled the card and notified both the police and the facility. Investigation revealed that the CNA, who worked the day the card was stolen, confessed to using the stolen credit card at a local liquor store. Facility records and staff schedules confirmed that the CNA was present during the relevant timeframe and that no other staff member named by the CNA was working at that time. The CNA's proximity to the liquor store and her frequent visits there were corroborated by a store employee and law enforcement. The CNA initially denied the theft, blaming another staff member, but ultimately admitted to using the stolen card for personal purchases. The facility's own policies require protection of residents from misappropriation of property by staff or others. Despite these policies, the CNA was able to access the resident's personal belongings and use the credit card without authorization. The incident was substantiated by law enforcement, and the CNA was charged with multiple felonies related to the theft and misuse of the resident's credit card.
Failure to Ensure Safe Coffee Temperature and Fall Prevention
Penalty
Summary
The facility failed to ensure that resident coffee was served at a safe temperature, resulting in a resident, identified as R57, receiving second-degree burns on her right arm. The incident occurred when R57, who has severe cognitive impairment and requires substantial assistance for daily activities, spilled hot coffee on herself while in bed. The coffee was dispensed from an automatic machine, and the temperature was measured at 187.2 degrees Fahrenheit, exceeding the facility's policy of not serving hot liquids above 180 degrees. The Dietary Director, V5, admitted that the temperature of the coffee was not regularly checked, and the last service update for the machine was several months prior. Additionally, the facility failed to implement fall preventative measures for another resident, R28, who has a high risk of falls due to severe cognitive impairment and a history of falls. Despite the care plan specifying the use of floor mats and keeping the bed in the lowest position, observations revealed that these interventions were not consistently in place. R28 was found without fall mats next to her bed on multiple occasions, and the bed was not always in the lowest position, increasing the risk of injury from falls. The facility's policies on the safety of hot liquids and fall risk management were not adequately followed, leading to these deficiencies. The lack of regular temperature checks for the coffee machine and the failure to consistently implement fall prevention measures contributed to the incidents involving R57 and R28, respectively. These oversights highlight the need for adherence to established safety protocols to prevent harm to residents.
Failure to Monitor Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were consistently monitored for meals prior to service for all 76 residents. According to the Dining Director, food temperatures are initially taken by a dietary aide in the kitchen and then again on the 2nd and 3rd floors before being served to residents. However, a review of the temperature monitoring sheets for the week of February 2 to February 8 revealed multiple instances where temperatures were not recorded as required. Specifically, on the 2nd floor, there were missing temperature recordings for several meals, including no dinner temperatures on February 6, 7, and 8. Similarly, on the 3rd floor, there were missing temperature recordings for dinner on February 2, and no temperatures recorded for lunch or dinner on February 4, 6, and 8. The facility's policy from 2005 mandates that hot food temperatures be taken three times throughout each meal service: before leaving the kitchen, prior to meal service, and after meal service completion. These temperatures are to be recorded in a log form. The Dining Director emphasized the importance of taking food temperatures to ensure food is cooked properly, prevent food poisoning, and serve hot meals to residents. Despite this policy, the facility did not adhere to the required temperature monitoring procedures, leading to a deficiency in ensuring the safety and quality of food served to residents.
Improper Disposal of Controlled Substances
Penalty
Summary
The facility failed to ensure the safe disposal of controlled substances for three residents, as observed during a survey. Resident R296, admitted for aftercare following joint replacement, had a Tramadol tablet taped back into the medication card instead of being destroyed when not administered. Similarly, Resident R297, admitted for a femur fracture, had an Oxycodone pill taped back into the card. The registered nurse acknowledged that controlled medications should not be taped back into the bubble cards and should be destroyed if refused by the resident. Additionally, Resident R22, with multiple diagnoses including Alzheimer's disease, had a diphenoxylate/atropine pill taped back into the medication card. The registered nurse confirmed that the pill should have been destroyed in the presence of two nurses, who would then sign the medication count sheet. The facility's policy from November 2022 mandates that controlled substances must be destroyed if not administered, with the process witnessed and documented by two nurses. The failure to adhere to this policy was evident in the handling of controlled medications for these residents.
Improper PPE Use Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) to prevent cross-contamination for a resident on droplet precautions due to COVID-19. On February 18, 2025, signs on the resident's door indicated the need for full PPE, including gowns, gloves, face shields, and N95 masks, with instructions for proper donning and doffing. However, on February 19, 2025, a registered nurse (RN) exited the resident's room and removed her gown and gloves at the room door but continued to wear her face shield and N95 mask down the hallway, potentially contaminating the environment outside the isolation room. The Director of Nurses confirmed that full PPE is required when entering a room of a resident on isolation for COVID-19 and that PPE should be removed upon exiting to prevent the spread of germs. The facility's policy, revised in May 2023, states that disposable respirators and eye protection should be removed and discarded after leaving the resident's room. The RN's failure to remove all PPE as per the facility's policy and the potential for cross-contamination were identified as deficiencies in infection control practices.
Failure to Conduct Regular Skin Assessments Leads to Pressure Injuries
Penalty
Summary
The facility failed to conduct regular skin assessments for a resident, leading to the development of full-thickness pressure injuries on the resident's buttocks. The resident, who was admitted with diagnoses including pancreatic cancer, Type 2 diabetes, and chronic kidney disease, was identified as being at risk for pressure injuries according to the Braden scale. Despite this risk, the facility did not perform weekly skin assessments as required, with no assessments documented for three consecutive weeks following the initial assessment upon admission. The deficiency was discovered when the resident complained of pain, prompting a wound nurse to assess and identify open areas on the resident's buttocks. The wounds were subsequently assessed by a wound physician, who documented full-thickness injuries. The Director of Nursing confirmed the lapse in weekly skin assessments, acknowledging that the open areas were only discovered during a progress note on January 9th. This oversight in regular skin monitoring contributed to the progression of the resident's pressure injuries.
Delayed Repair of Resident's Sink Faucet
Penalty
Summary
The facility failed to ensure that a resident's sink faucet was in working order, affecting one resident who was reviewed for environmental services. The resident, who had no cognitive impairment, reported that it took several days for the staff to fix the broken sink faucet in their room, which resulted in no water being available for personal hygiene tasks such as brushing teeth. The issue was initially reported on a Friday, and despite being marked as a priority for same-day repair, the faucet remained unfixed over the weekend. The Registered Nurse Weekend Supervisor was informed of the issue on Saturday and provided buckets of water to the resident for use during care. The Assistant Director of Nursing was also notified, and the maintenance staff from the Assisted Living unit was called to address the problem. However, the maintenance staff member who responded on Sunday was unable to fix the faucet due to the need for a complete replacement. The faucet was eventually replaced and fixed on the following Monday morning. The facility's maintenance policy requires the maintenance department to maintain equipment in a safe and operable manner, which was not adhered to in this instance.
Inadequate Supervision During Shower Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident during showering, leading to a fall. The resident, a male with severe cognitive impairment, right-sided weakness, and a history of falls, was dependent on staff for bathing. On the day of the incident, a CNA was assisting the resident alone, despite the care plan indicating the need for two-person assistance due to the resident's weakness and instability. The CNA turned away to retrieve clothing, leaving the resident unattended, which resulted in the resident leaning forward and falling from the shower chair. The CNA involved in the incident was aware that the resident required two-person assistance but proceeded alone, believing he could manage the task. The resident's care plan and the facility's falls protocol emphasized the need for close supervision and appropriate equipment, such as a reclining shower chair, which was not used. The CNA's decision to turn away from the resident without ensuring items were within reach contributed to the fall, highlighting a lapse in following established safety protocols for residents at risk of falls.
Failure to Notify Resident of Medication Change
Penalty
Summary
The facility failed to notify a resident of a change in her medication, which is a violation of her rights. The resident, who has no cognitive impairment, was not informed when her pain medication was switched from Norco to Extra Strength Tylenol. She noticed trembling after taking her pain medication and suspected a substitution. Upon inquiry, she was informed by a nurse that her medication had been changed to Tylenol without her knowledge. The resident expressed her dislike for Tylenol and reported the issue to the Director of Nursing, who then discontinued the Tylenol order per the resident's request. The Director of Nursing confirmed that the resident was not made aware of the medication change, which should have been communicated to her. The Nurse Practitioner involved assumed that the nurses would inform the resident of the new Tylenol order. The facility's policy states that residents have the right to be notified of any changes in their medical condition or treatment, which was not adhered to in this case. This oversight led to the resident experiencing potential withdrawal symptoms and a lack of informed participation in her treatment plan.
Failure to Timely Assess and Report Incident Leads to Resident Injury
Penalty
Summary
The facility failed to ensure timely assessment and notification of a physician after a resident was lowered to the ground during a mechanical lift transfer, resulting in a left hip fracture. The incident occurred when a Certified Nursing Assistant (CNA) attempted to transfer the resident using a sit-to-stand lift without the required assistance. The resident, who had severe cognitive impairment and required maximum assistance, became agitated and began to slide out of the lift sling. The CNA, who was alone, did not report the incident to the nurse, believing the resident was not hurt. Another CNA witnessed the incident and assisted in lowering the resident to the ground and transferring her to a wheelchair. Despite the resident's complaints of pain and bruising observed on her left shoulder, the incident was not reported to the nurse until the following day. The facility's Director of Nursing confirmed that the staff should have had two CNAs present for the transfer and should have reported the incident immediately for an assessment. The resident's condition worsened over the following days, with increased pain and limited range of motion observed. An x-ray eventually revealed a fracture to the left distal femur, which was linked to the incident. The facility's failure to provide ongoing nursing assessments and timely medical evaluations resulted in the resident not receiving necessary treatment until several days after the incident.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in a femur fracture that required surgery. The resident, who had severe cognitive impairment and required maximum staff assistance for mobility and transfers, was being transferred by a sit-to-stand lift for a shower. During the transfer, the resident became agitated and began to slide out of the lift sling. The CNA, who was alone during the transfer despite the facility's policy requiring two staff members, did not secure the leg band around the resident's legs, leading to the resident hanging from the sling with her arms raised and legs dangling. Another CNA intervened, assisting in lowering the resident to the ground. The incident resulted in bruising and pain, initially noted in the shoulder, but later an x-ray revealed a fracture in the left femur. The Director of Nursing confirmed that the facility's policy mandates two staff members for mechanical lift transfers to ensure resident safety. The orthopedic surgeon noted that the resident's poor bone quality could have contributed to the fracture when being lowered to the ground.
Failure to Supervise Cognitively Impaired Resident Leads to Severe Injury
Penalty
Summary
The facility failed to supervise a cognitively impaired resident (R1) while being toileted, resulting in R1 falling off the toilet and requiring emergent transport to a local hospital. R1 was admitted with a diagnosis of a basal ganglia hemorrhage and a frontal scalp hematoma. R1 had a history of cerebrovascular accident (CVA) which caused weakness in her right arm and leg, and she was nonverbal due to the stroke. R1's care plan indicated she was at risk for falls due to impaired cognition, poor safety awareness, overall weakness, and need for assistance with activities of daily living (ADLs). Despite this, on 5/7/24, two staff members (V9 CNA and V12 LPN) left R1 unsupervised in the bathroom, leading to her fall. V12 admitted to leaving R1 alone to check on a disturbance in the hallway, during which time R1 fell and sustained injuries. Interviews with staff and R1's physician confirmed that R1 was a high fall risk and should not have been left alone. The facility's Safety and Supervision of Residents policy emphasized the importance of resident supervision based on assessed needs and identified hazards. The Director of Nursing (V2) acknowledged that staff should not have left R1 unsupervised given her high fall risk. The incident highlights a failure in adhering to the facility's policy and ensuring adequate supervision for a vulnerable resident, leading to significant injury.
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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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