Rivaya Care Of Des Plaines
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Plaines, Illinois.
- Location
- 9300 Ballard Road, Des Plaines, Illinois 60016
- CMS Provider Number
- 145334
- Inspections on file
- 44
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Rivaya Care Of Des Plaines during CMS and state inspections, most recent first.
A resident with type 2 DM had two unlabeled insulin pens and an unlabeled Acetaminophen 325 mg bottle stored on the bedside table, and reported currently self-administering Acetaminophen while no longer able to self-administer insulin due to hand weakness. Nursing staff stated that medications should not be left at bedside and that self-administration requires a physician order and assessment, yet record review showed no self-administration orders, no completed self-administration assessment, and no care plan interventions authorizing self-administration. This occurred despite facility policy requiring assessment, physician notification, an order to self-administer, and ongoing competency checks for any resident self-administering medications.
A resident with type 2 DM had two insulin pens (Lantus and Lispro) and an acetaminophen 325 mg bottle left on the bedside table, with no labeling for resident identification, date opened, or discard date. Staff interviews confirmed that medications should not be left at bedside and must be clearly labeled, and facility policy requires that any medications stored in a resident’s room be kept in a locked storage unit and documented on the MAR as "may keep at bedside." The observed practice did not comply with these requirements for safe medication storage and labeling.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) requirements when providing care to several residents with trachs, vents, G-tubes, urinary catheters, wounds, and histories of MDROs. A CNA repeatedly entered rooms with posted EBP signage and available PPE to reposition residents, change linens, and provide other direct care while wearing only gloves and a mask, without donning a gown as required. Multiple staff, including the wound director, RT, CNA, LPN, infection preventionist, and DON, stated that facility policy and expectations require gown, gloves, and mask for high-contact care and any direct contact with residents or their environment under EBP. Facility policies on Enhanced Barrier Precautions and the Infection Prevention and Control Program specify that gowns and gloves must be used for high-contact resident care activities and for all interactions that may involve contact with the resident or the resident’s environment, with PPE donned upon room entry and discarded before exit.
A resident with severe cognitive impairment and high fall risk, requiring supervision for ambulation, was left unsupervised and without required safety alarms, resulting in an unwitnessed fall and hip fracture. Staff interviews and records showed that individualized fall prevention interventions, including frequent monitoring and use of alarms, were not consistently implemented as outlined in the care plan.
A resident with multiple medical conditions and under state guardianship was discharged without the required notification to their legal representative. Facility staff confirmed that the guardian was not informed of the discharge planning or arrangements, and there was no documentation of such notification, despite facility policy requiring it.
A resident with complex medical and psychiatric conditions alleged that another resident touched her inappropriately in a hallway. Although the resident stated she reported the incident to staff and police, the activity assistant and administrator were unaware of the allegation, and a social worker who learned of the incident did not report it, assuming others had done so. Facility policy requiring immediate reporting of abuse allegations was not followed.
Multiple residents at risk for skin impairment did not receive timely assessment, monitoring, or wound care as ordered, with failures to update care plans, notify families, follow physician orders for wound treatments, and adhere to low air loss mattress guidelines. Staff also failed to report new wounds, document care, and maintain proper medication management and infection control practices.
A facility failed to verify and obtain the correct state guardian information for a resident, resulting in improper notification and consent procedures. Despite discrepancies in contact information, the facility did not successfully contact the state guardian, and instead, the resident's family was notified and provided consent for medical decisions. Interviews revealed that the social services department did not follow through with obtaining necessary guardian paperwork or contact the main office of the state guardian.
The facility failed to administer enteral feedings as ordered for three residents, leading to issues such as weight loss and incorrect feeding formulas. A resident experienced a seven-pound weight loss due to an incorrect feeding rate, while another was given the wrong formula and rate. Additionally, a resident received enteral feeding while eating a meal, contrary to orders, risking fluid overload.
The facility failed to follow physician orders and manufacturer guidelines in managing pressure ulcers for several residents. Observations showed improper wound care and incorrect use of low air loss mattresses, with multiple layers of linen used instead of a single flat sheet. These deficiencies affected residents with stage 4 pressure ulcers, indicating a systemic issue in the facility's wound care management.
A resident in an LTC facility was not protected from unwelcome physical contact by another resident in an elevator, leading to a deficiency in the facility's abuse prevention program. The resident who reported the incident has a complex medical history and is on medication for anxiety and depression. The resident who initiated the contact has a history of criminal behavior and poor impulse control. Despite the facility's no-tolerance policy on abuse, the incident occurred, and a misdemeanor complaint was filed.
The facility failed to implement fall precautions for two high-risk residents. Observations revealed that one resident's bed was not in the lowest position, and floor mats were not in place, posing a fall risk. An LPN corrected the bed and mat placement. Another resident's floor mats were also not in place, and a CNA admitted to forgetting to replace them after care. The Restorative Nurse confirmed the residents' high fall risk and the need for interventions to prevent injuries.
A cognitively impaired resident at high risk for falls was not adequately monitored or provided with fall preventative measures, resulting in a preventable fall and subsequent hospitalization for a femur fracture. The facility failed to implement a comprehensive care plan or educate staff on fall risk precautions, leading to delayed identification and treatment of the injury.
A resident with severe cognitive impairment experienced inadequate pain management following an unwitnessed fall. Despite complaints of pain, the resident received only one dose of Tylenol, and no further pain assessments were conducted. The facility failed to adhere to its pain management policy, resulting in a delay in diagnosing a femur fracture that required surgical intervention.
The facility failed to properly operate pressure relieving air mattresses for four residents, leading to deficiencies in pressure ulcer prevention. A resident with multiple pressure ulcers was on a static mode mattress with incorrect weight settings, while three other residents were also observed on static mode mattresses, contrary to their care plans. The wound nurse confirmed that alternating pressure is necessary for effective wound healing.
A resident with cognitive impairment and multiple medical conditions experienced an unwitnessed fall, resulting in a serious hip fracture. The facility failed to report the incident to the IDPH within the required 24-hour timeframe, as mandated by their policy. The decision not to report was based on the interpretation of x-ray results suggesting an old fracture, despite the hospital confirming the injury and performing surgery. This represents a deficiency in adhering to reporting protocols for serious injuries.
A resident with multiple diagnoses, including urinary tract infection, had abnormal urinalysis results that were not promptly communicated to a physician. Despite the results being reviewed, there was a lack of communication between nursing staff during shift handoffs, leading to a delay in notifying the nurse practitioner. The facility's process for handling lab results was not followed, as the abnormal results were not documented in the resident's electronic medical record.
A resident with brittle Type 1 diabetes and seizure disorders did not receive prescribed insulin and anti-seizure medications, leading to a critical hospital transfer. The facility failed to document medication administration and lacked a care plan for the resident's seizure disorder. Interviews revealed inconsistencies in staff documentation and adherence to physician orders.
The facility failed to protect residents from abuse and prevent a physical assault in two separate incidents involving two residents. The first incident occurred in the activity room where an argument over a television program escalated, and one resident threw a Wii console at the other. Later, during a smoke break, the same resident physically assaulted the other with a wet floor sign. Staff intervened but failed to report the first incident immediately, and there was a lack of supervision.
The facility failed to follow dietary orders for two residents on NAS diets, resulting in inappropriate meal substitutions and inadequate nutrition. One resident received hamburgers without condiments daily, while another received a hamburger patty instead of the planned meal. Conflicting information from dietary staff and non-adherence to facility policies contributed to the deficiencies.
Failure to Implement Self-Administration Medication Policy and Control Bedside Medications
Penalty
Summary
The deficiency involves the facility’s failure to implement its self-administration of medication policy for a resident who had medications stored at bedside without appropriate orders or assessment. During observation, two unlabeled insulin pens (Lantus and Lispro) and an unlabeled bottle of Acetaminophen 325 mg were found on the resident’s bedside table. The resident reported that staff were aware of these medications being kept at bedside and stated that she was currently self-administering Acetaminophen/Tylenol, while also reporting that she was no longer able to self-administer insulin since returning from a recent hospitalization due to weakness in her hands. Review of the resident’s medical record showed diagnoses including type 2 diabetes mellitus without complications and active orders for Acetaminophen 325 mg every 6 hours as needed for pain, as well as scheduled Humalog (insulin lispro) before meals and Lantus (insulin glargine) at bedtime. Interviews with nursing staff confirmed that medications should not be left at bedside and that, if a resident is to self-administer medications, there must be a physician order and an assessment in place. The RN and the Assistant DON both stated that self-administration requires an order, an assessment, and care plan documentation. Record review with facility staff revealed there was no completed self-administration of medication assessment for this resident, no orders indicating self-administration for any medications, and the care plan only noted insulin use with an intervention to modify the care plan based on patient progress and needs. The facility’s written Self-Administration & Medication Storage Policy requires assessment of residents who request to self-administer, communication of assessment results to the attending physician, obtaining an order to self-administer, and quarterly or significant-change follow-up observations to determine continued competency, none of which were documented for this resident despite medications being present at bedside and the resident’s report of self-administering Acetaminophen.
Unlabeled Insulin and Acetaminophen Left Unsecured at Bedside
Penalty
Summary
Surveyors found that the facility failed to ensure medications were safely stored and properly labeled for one resident. During an observation at 11:00 AM, two insulin pens (Lantus and Lispro) and a bottle of acetaminophen 325 mg were observed sitting on top of the resident’s bedside table. The insulin pens and acetaminophen bottle were not labeled with any resident identification, date opened, or discard date. The resident stated that staff were aware that these medications were kept at the bedside. A review of the resident’s admission record showed diagnoses including type 2 diabetes mellitus without complications and active orders for acetaminophen 325 mg by mouth every 6 hours as needed for pain, Humalog KwikPen 8 units subcutaneously before meals, and Lantus 30 units subcutaneously at bedtime. At 11:20 AM, a registered nurse (V5) stated that medications should not be left at the bedside and should be labeled with the resident’s name, date opened, and discard date. At 11:23 AM, the assistant director of nursing (V3) similarly stated that medications should not be stored at the bedside and that medications should include clear labeling. Review of the facility’s “Self-Administration & Medication Storage Policy” (effective February 2014) showed that when medications are stored in a resident’s room, all medications, both legend and over-the-counter, must be stored in a locked storage unit, and all medications/biologicals stored in the resident’s room should be written on the MAR as “may keep at bedside.” These observations and statements demonstrated that the medications at the resident’s bedside were not stored in locked compartments and were not labeled in accordance with facility policy and accepted professional principles.
Failure to Use Required PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff failure to don required personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). Four residents on EBP were involved: one with tracheostomy, ventilator dependence, gastrostomy tube, urinary catheter, and a history of carbapenem-resistant Acinetobacter baumannii; one with acute and chronic respiratory failure, ventilator dependence, pneumonia due to Klebsiella pneumoniae, tracheostomy, and gastrostomy; one with surgical aftercare needs and type 2 diabetes mellitus with complications; and one with tracheostomy, gastrostomy, cognitive communication deficit, multiple indwelling devices and wounds, and a known history of multiple multidrug-resistant organisms (MDROs) and C. difficile. All four residents were on EBP transmission-based protocols due to wounds, trachs, vents, G-tubes, urinary catheters, and/or MDRO history. On multiple observations on the same day, a CNA entered the rooms of these residents and provided direct care without wearing a gown, despite EBP signage and PPE supplies being present at the room entrances. For one resident, the CNA entered to reposition and assist without donning a gown, wearing only gloves and a mask, and had direct contact with the resident during care. After wound care for another resident, the same CNA again entered that resident’s room without a gown to reposition the resident, provide clean linens, and cover the resident with a blanket, then removed gloves and performed hand hygiene before leaving. The CNA was also observed entering another resident’s room on EBP to provide patient care, including changing linens, wearing only gloves and a mask and again not donning a gown, despite posted EBP signage and available PPE. Interviews with facility staff confirmed that the facility’s expectation and policy required staff to wear gowns, gloves, and masks when providing direct care to residents on EBP, including activities such as suctioning trachs, G-tube feedings, changing linens, changing diapers, and wound care. The wound director, respiratory therapist, CNA, LPN, infection preventionist, and DON each stated that for residents on EBP, staff must don gown, gloves, and mask for direct care or high-contact resident care activities. Facility policies titled “Enhanced Barrier Precautions” and “Infection Prevention and Control Program” specified that EBP involves the use of gown and gloves for high-contact resident care activities for residents colonized or infected with MDROs or at increased risk of MDRO acquisition, and that gowns and gloves are to be worn for all interactions that may involve contact with the resident or the resident’s environment, with PPE donned upon room entry and discarded before exiting. The observed failure of the CNA to wear gowns during direct care to residents on EBP occurred in the context of these established policies and stated staff expectations.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow its fall prevention policy and implement individualized, resident-centered interventions for a cognitively impaired resident identified as high risk for falls. The resident, who had diagnoses including end stage renal disease, unsteadiness on feet, gait abnormalities, and atherosclerotic heart disease, was assessed as having severely impaired cognitive skills and required supervision or assistance when ambulating. Despite these documented needs, the resident was able to ambulate unsupervised, resulting in an unwitnessed fall in the hallway during the night. Staff interviews and record reviews revealed that the resident was confused, unable to use the call light, and required frequent redirection and monitoring. Care plans indicated the need for staff assistance with ambulation, use of electronic alarms, and regular monitoring. However, at the time of the incident, the resident did not have a chair or bed alarm in place, and staff monitoring was not conducted at the frequency specified in the care plan. The CNA on duty was the only staff present on the resident's wing and was not actively supervising the resident when the fall occurred. The fall resulted in the resident sustaining a right intertrochanteric hip fracture with associated intramuscular hemorrhage, requiring hospital admission. Documentation and staff statements confirmed that the facility did not consistently implement the individualized interventions outlined in the care plan, such as ensuring the use of alarms and providing the required level of supervision for a resident with significant cognitive impairment and high fall risk.
Failure to Notify Resident's Representative of Discharge Planning
Penalty
Summary
The facility failed to notify a resident's legal representative of discharge planning, orders, and arrangements for post-discharge care. The resident, who was cognitively intact and had multiple medical diagnoses including anemia, COPD, heart failure, substance abuse, and anxiety disorder, had been under state guardianship since 2022. Despite this, the state guardian was not informed of the resident's discharge or the details of the discharge planning. The guardian only learned of the discharge after sending an associate to visit the resident and did not receive any court documentation regarding the revocation of guardianship. Interviews with facility staff, including the Social Service Director and the Director of Nursing, confirmed that the guardian was not notified prior to the discharge. The Social Service Director admitted to not informing the guardian and acknowledged this was a mistake. Facility policy requires notification of the resident's representative regarding discharge planning, but there was no documentation in the resident's records indicating that such notification occurred.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to identify and report an allegation of sexual abuse involving a female resident with multiple medical and psychiatric diagnoses, including end stage renal disease, depression, and bipolar disorder. The resident reported that another resident touched her inappropriately while she was in her wheelchair in the hallway. She stated that she informed staff and the police, and provided a police report number to an activity assistant. However, the activity assistant denied receiving any such report or information from the resident, and the administrator, who also serves as the abuse prevention coordinator, stated that she was unaware of the incident until informed by the surveyor. A licensed clinical social worker, who had been providing services to the resident, documented that the resident discussed the incident and a police investigation during a session. The social worker assumed that the incident had already been reported to facility staff and did not take further action to notify the administrator or other responsible parties. Facility policy requires all employees to immediately report any allegations or suspicions of abuse to the administrator or designated personnel, but this protocol was not followed, resulting in the failure to report the allegation to the appropriate authorities in a timely manner.
Failure to Assess, Monitor, and Treat Wounds per Orders and Policy
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for residents at risk for skin impairment, resulting in missed identification and documentation of new wounds, lack of timely physician notification, and failure to update care plans and notify family members. In one case, a resident with multiple comorbidities and high risk for skin breakdown developed new wounds that were not promptly addressed in the care plan, and the family was not informed of these changes. The wound care coordinator acknowledged that the care plan should have been updated and the family notified, but these actions were not taken at the time of the deficiency. There were also failures to follow physician orders for wound care treatments. For example, a resident with a stage 4 sacral pressure ulcer did not receive the correct type of dressing as ordered, with staff using gauze instead of foam dressings. Another resident with multiple wounds received foam dressings instead of the ordered gauze dressings, and a CNA failed to use proper PPE during wound care. These deviations from prescribed wound care protocols were confirmed by staff interviews and direct observation. Additionally, the facility did not adhere to manufacturer recommendations for the use of low air loss mattresses, as multiple layers of linen and blankets were placed between the resident and the mattress, contrary to guidelines. There were also lapses in medication management, such as wound care medications not being available on the treatment cart, use of another resident's medication, and leaving the treatment cart unlocked. New skin impairments were not reported to the nurse, and wound care documentation was incomplete or missing. These deficiencies affected all four residents reviewed for pressure ulcer and wound prevention and treatment management.
Failure to Verify and Notify State Guardian
Penalty
Summary
The facility failed to verify and obtain the correct state guardian information for a resident, leading to improper notification and consent procedures. The resident, who was admitted with diagnoses including respiratory failure, tracheostomy, dysphagia, and substance abuse, had a state guardian listed as the third contact on their face sheet. However, the admission paperwork indicated a different phone number for the state guardian. Despite this discrepancy, the facility did not successfully contact the state guardian, and instead, the resident's family was notified and provided consent for medical decisions. Interviews with facility staff revealed that the social services department did not follow through with obtaining the necessary guardian paperwork upon admission, nor did they contact the main office of the state guardian when initial contact attempts failed. The social service director acknowledged awareness of the issue but did not take further action to resolve it. As a result, the resident's family, rather than the state guardian, was contacted for consents and updates, which was against the facility's policy and procedures for handling residents with guardians.
Failure to Administer Enteral Feedings as Ordered
Penalty
Summary
The facility failed to administer enteral feedings as ordered for three residents, leading to significant issues. Resident R10 was observed with an enteral feeding running at 60 ml/hr, contrary to the physician's order of 65 ml/hr. This discrepancy was noted by a registered nurse who corrected the rate. R10, who is NPO and relies solely on tube feeding, experienced a weight loss of seven pounds over a month, which was attributed to the incorrect feeding rate. The nurse practitioner confirmed that the prescribed rate was necessary to prevent weight loss and provide the required nutrition and electrolytes. Resident R12 was found with an incorrect enteral feeding formula and rate, running Glucerna 1.5 at 70 ml/hr instead of the ordered Glucerna 1.2 at 80 ml/hr. The error was identified and corrected by a registered nurse, who noted that the night nurse had started the feeding incorrectly. Additionally, Resident R5 was receiving enteral feeding at 75 ml/hr while also consuming a meal, contrary to the physician's order to have the feeding off during the day. This oversight was acknowledged by a registered nurse, who admitted not knowing the feeding should have been stopped, potentially risking fluid overload for the resident.
Failure to Follow Wound Care Protocols and Mattress Guidelines
Penalty
Summary
The facility failed to adhere to physician orders and manufacturer recommendations in the management of pressure ulcers for multiple residents. Observations revealed that residents with stage 4 pressure ulcers were not provided with the appropriate wound care as per physician orders. For instance, a resident with multiple stage 4 pressure ulcers was observed to have wounds cleansed with Dakins solution and dressed with wet to dry Dakins dressing, contrary to the physician's order which specified the use of moist saline gauze after cleansing. Additionally, the resident was not provided with bilateral heel protectors as required by the care plan, and the low air loss mattress was improperly covered with multiple layers of linen, against manufacturer guidelines. The deficiency also extended to other residents who were observed with improper use of low air loss mattresses. Several residents were found with folded linens and additional bed pads over their mattresses, which contradicts the manufacturer's recommendation of using only one flat sheet. This improper use of the mattress could potentially compromise its effectiveness in preventing pressure ulcers. The facility's wound care nurse and other staff members acknowledged these discrepancies, indicating a lack of adherence to both physician orders and established care protocols. The facility's policies on wound care and specialty mattress use were not followed, as evidenced by the observations and interviews conducted. The facility's policy clearly states the need to follow physician orders and use specialty mattresses according to manufacturer guidelines, yet these were not implemented. The failure to follow these protocols affected all five residents reviewed for wound care management, highlighting a systemic issue in the facility's approach to pressure ulcer prevention and treatment.
Failure to Protect Resident from Unwelcome Physical Contact
Penalty
Summary
The facility failed to protect a resident from unwelcome physical touch by another resident, which constitutes a deficiency in their abuse prevention program. The incident involved two residents, where one resident allegedly touched the other's shoulder in an elevator. The resident who was touched later reported feeling uncomfortable, although no physical harm or skin alteration was noted. Both residents were evaluated at a hospital and returned to the facility without new orders. The facility conducted an investigation, and a misdemeanor complaint was filed against the resident who initiated the contact. The resident who reported the unwelcome touch has a complex medical history, including diagnoses of toxic encephalopathy, chronic respiratory failure, and end-stage renal disease, among others. She is also on medication for anxiety, depression, and bipolar disorder. The resident who allegedly initiated the contact has a history of criminal behavior and is identified as an offender with a behavior care plan indicating sexual preoccupation and poor impulse control. The facility's policy on abuse prevention emphasizes a no-tolerance approach to abuse, neglect, and exploitation, yet the incident highlights a failure to protect the resident from unwelcome physical contact.
Failure to Implement Fall Precautions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall precaution interventions for two residents identified as high risk for falls. During an observation, one resident's bed was not in the lowest position, and the floor mats intended to prevent falls were not in place, instead leaning against a wall. The resident, who has a tracheostomy and is able to communicate, did not recall the last time they fell. A Licensed Practical Nurse (LPN) responsible for the resident acknowledged the oversight and corrected the bed position and floor mat placement, noting the potential risk of the resident falling and injuring themselves. Similarly, another resident was observed with their floor mats not in place, leaning against a radiator and wall. A Certified Nursing Assistant (CNA) responsible for the resident admitted to forgetting to replace the floor mats after providing care. The CNA corrected the oversight by placing the mats on both sides of the bed. The Restorative Nurse/Fall Coordinator confirmed that both residents are at high risk for falls and emphasized the importance of implementing fall precaution interventions to prevent potential injuries. The facility's policy on fall prevention and management outlines the necessity of such interventions to maintain resident safety.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to adequately monitor and prevent a high-risk cognitively impaired resident from sustaining a preventable fall. The resident, identified as R57, had multiple diagnoses including End Stage Renal Disease, Major Depressive Disorder, and reduced mobility, and was assessed as being at high risk for falls. Despite this, the facility did not implement sufficient fall preventative measures or develop a comprehensive care plan tailored to the resident's needs. On the day of the incident, the resident was found on the floor by a maintenance technician who did not witness the fall but heard a loud thud. The resident was attempting to get out of bed unassisted, which led to the fall. The nursing staff's response to the fall was inadequate. The RN on duty, V8, assessed the resident without fully considering her severe cognitive impairment, and failed to complete the fall event form accurately. The RN did not verify the resident's fall risk status or ensure that appropriate interventions were in place. The resident was given Tylenol for pain, and an x-ray was ordered but not performed until the following day, delaying the identification of a significant injury. The resident was later diagnosed with a left femur fracture and required surgical intervention. Interviews with staff revealed a lack of awareness and training regarding fall risk precautions and interventions. The restorative director, V5, admitted that interventions were only put in place after a fall occurred, and there was no proactive approach to prevent falls for high-risk residents. The facility's fall prevention policy was not effectively implemented, as evidenced by the absence of necessary fall precautions and the failure to educate staff on identifying and protecting residents from falls.
Inadequate Pain Management for Cognitively Impaired Resident After Fall
Penalty
Summary
The facility failed to adequately recognize, evaluate, and manage pain for a resident with severe cognitive impairment following an unwitnessed fall. The resident, who had multiple diagnoses including End Stage Renal Disease and Major Depressive Disorder, experienced a fall and complained of pain. Despite this, the facility did not conduct timely pain assessments or provide adequate pain management. The resident was only given a single dose of Tylenol, and no further pain assessments or medications were administered until the resident was sent to the hospital two days later for a femur fracture requiring surgery. The nursing staff did not perform a thorough pain assessment following the fall. The nurse on duty did not ask the resident to indicate where the pain was or assess non-verbal indicators of pain, which is crucial given the resident's severe cognitive impairment. The nurse administered Tylenol based on a standing order but did not follow up with additional doses or assessments, despite the facility's policy requiring regular pain evaluations and management. The x-ray ordered to assess potential injuries was delayed, and the results were not communicated promptly, leading to a delay in the resident receiving appropriate medical intervention. The facility's policy on pain management was not adhered to, as evidenced by the lack of comprehensive pain assessments and timely interventions. The nurse practitioner involved was not informed of the x-ray results in a timely manner, and there was a lack of communication regarding the resident's pain management needs. This resulted in the resident experiencing unmanaged pain and a delay in receiving necessary medical treatment for a serious injury.
Improper Use of Pressure Relieving Mattresses
Penalty
Summary
The facility failed to properly operate and maintain pressure relieving air mattresses for four residents, leading to deficiencies in pressure ulcer prevention and management. Resident 54, who is cognitively impaired and has multiple pressure ulcers, was observed on a specialty air mattress set to static mode, which did not provide the necessary alternating pressure. Additionally, the mattress was under-inflated as the weight setting was incorrect, set at 80 lbs while the resident's weight was 103 lbs. This improper setting could potentially affect the healing of the resident's wounds. Similarly, residents 18, 41, and 121 were observed on low air mattresses in static mode, contrary to their care plans which required alternating pressure to prevent pressure ulcer development. Resident 18, with a history of chronic respiratory failure and quadriplegia, and resident 41, with hemiplegia and chronic kidney disease, were both observed in static mode on multiple occasions. Resident 121, who has a stage 4 sacral wound, was also found on a static mode mattress, which was not in line with the prescribed care for his condition. The wound nurse confirmed that alternating pressure is necessary for effective wound healing and that incorrect mattress settings can hinder this process.
Failure to Report Serious Injury from Unwitnessed Fall
Penalty
Summary
The facility failed to adhere to its policy on incident reporting within twenty-four hours of an unwitnessed fall that resulted in serious harm to a resident, identified as R57. The resident, who is cognitively impaired and has multiple medical conditions including End Stage Renal Disease and Major Depressive Disorder, experienced a fall while attempting to sit on the side of the bed. The fall was unwitnessed, and the resident complained of pain in both thighs. An x-ray was ordered, and the results, which indicated a fracture, were received the following day. Despite the serious nature of the injury, the facility did not report the incident to the Illinois Department of Public Health (IDPH) within the required timeframe. The facility's investigation into the fall concluded that it was accidental, and the decision not to report the incident was made collectively by the Administrator, the Restorative Nurse, the President of Operations, and the Infection Preventionist. They based their decision on the x-ray results, which suggested the fracture might be old or healing. However, the hospital's evaluation confirmed the fracture, leading to surgical intervention for the resident. The facility's policy mandates that incidents resulting in serious harm or injury be reported to IDPH within 24 hours, with a final summary completed within 7 days, which was not followed in this case. The resident was subsequently hospitalized with a diagnosis of a closed fracture of the left hip and underwent a Left Hip Arthroplasty. The facility's failure to report the incident in a timely manner represents a deficiency in following established protocols for reporting serious injuries. The decision not to report was influenced by the interpretation of the x-ray results and the belief that the fracture was not new, despite the hospital's findings and the subsequent surgery.
Failure to Notify Physician of Abnormal Urinalysis Results
Penalty
Summary
The facility failed to notify a physician of abnormal urinalysis results in a timely manner for a resident, identified as R125, who was admitted with diagnoses including hemiplegia, heart failure, retention of urine, and urinary tract infection. On observation, the resident's urine appeared dark yellow and slightly cloudy. A registered nurse, V6, acknowledged that the urinalysis was completed weeks prior due to the resident's complaints of burning upon urination, and an antibiotic was ordered based on the abnormal results. However, V6 admitted to not checking the urine results on the day of the survey until prompted by the surveyor, at which point it was confirmed that the results were abnormal and required notification to the nurse practitioner. Another registered nurse, V18, who worked with the resident the previous day, was unaware of the pending urinalysis due to a lack of communication during the handoff report. V18 stated that results are typically checked multiple times during a shift, but no results for the resident were seen before the end of the shift. The surveyor noted discrepancies in the reported date and review status of the lab results, indicating that the abnormal results were reviewed but not communicated to the physician. The Director of Nursing explained the process for handling lab results, emphasizing the importance of notifying the physician of abnormal results and documenting them in the resident's electronic medical record, which was not done in this case.
Failure to Administer Medications and Document Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate medical management for a resident with brittle Type 1 diabetes and a history of seizure disorders. The resident, who was admitted with multiple complex medical conditions including Type 1 Diabetes Mellitus, seizures, and end-stage renal disease, did not receive insulin and anti-seizure medications as prescribed. On June 8, 2024, the resident's insulin was not administered according to the physician's orders, and there was no documentation of blood glucose monitoring. Additionally, the resident's anti-seizure medication, Dilantin, was not administered as ordered on June 7, 2024, which was confirmed by the LPN responsible for the medication pass. The resident experienced a seizure and elevated blood glucose levels, leading to an emergency transfer to the hospital. The resident's blood glucose was recorded at 573, and the Dilantin level was critically low at 4.0, far below the reference range. The resident was hospitalized with severe hyperglycemia and dehydration, which contributed to a hyperosmolar hyperglycemic state and metabolic acidosis. The facility's failure to administer medications as prescribed and to document these actions resulted in the resident's critical condition and subsequent hospitalization. Interviews with facility staff revealed inconsistencies in medication administration and documentation. The LPNs involved admitted to potential errors in documenting the administration of insulin and anti-seizure medications. Furthermore, there was no care plan in place for managing the resident's seizure disorder, which is a critical oversight given the resident's medical history. The Director of Nursing acknowledged that the nurses should have followed the physician's orders and documented all medication administrations, highlighting a significant lapse in the facility's adherence to its medication administration and care planning policies.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse and prevent a physical assault in two separate incidents involving two residents, R5 and R6. The first incident occurred in the activity room where R6, who was watching television, got into an argument with R5 over the television program. The argument escalated, and R6 threw a Wii console at R5. Staff intervened and separated the residents, but the incident was not reported to the administrator or nursing staff immediately. Later, during a smoke break, R6 went to the first floor and heard R5 threatening to press charges. R6 then grabbed a wet floor sign and physically assaulted R5 with it. Staff intervened again, and both residents were separated and assessed for injuries. R5 had no visible injuries, and R6 was sent for a psychiatric evaluation but returned to the facility a few hours later with no new orders. R5's medical records indicate a history of generalized anxiety disorder, muscle weakness, hypertension, encephalopathy, heart failure, gait and mobility abnormalities, and a personal history of cocaine abuse. R5 was cognitively intact and had a care plan that included a potential for abuse. R5 reported the incidents to staff but felt that nothing was done about it. R6's medical records indicate a history of encephalopathy, hypertension, opioid use with withdrawal, depression, and psychoactive substance abuse. R6 had a history of verbally aggressive behavior towards staff and difficulty controlling his temper. R6's care plan did not include any orders for managing his anger or aggression. The facility's abuse prevention policy requires staff to report any incidents of abuse immediately and to protect residents from abuse, neglect, exploitation, and mistreatment. However, the staff failed to report the first incident involving the thrown console to the administrator or nursing staff, and there was a lack of supervision in the activity room and during smoke breaks. The administrator acknowledged that R6's actions were willful and that there should have been more supervision. The facility has a system in place to train staff on abuse reporting and prevention, but it was not effectively implemented in this case.
Failure to Follow Dietary Orders for Residents on NAS Diets
Penalty
Summary
The facility failed to provide adequate nutrition by not following dietary orders for two residents. One resident, a male with intact cognition, was on a No Salt Packet (NAS) diet and reported receiving hamburgers without condiments seven days a week, despite his dietary restrictions and preferences. Another resident, a female with severely impaired cognition, was observed receiving a hamburger patty on a bun instead of the planned meal of baked turkey crunch, rice pilaf, and vegetable medley, as indicated on her meal ticket. The dietary staff confirmed that the substitution was made based on their judgment rather than the resident's request or dietary order. The Dietary Director and Cook both provided conflicting information regarding the NAS diet and the reasons for meal substitutions. The Dietary Director stated that NAS diet residents should receive the same meals without additional salt packets, while the Cook indicated that certain meals, like the baked turkey crunch, were substituted due to high salt content. The facility's policies on sodium precautions and menu substitutions were not followed, leading to the observed deficiencies in meal service for the residents on NAS diets.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
