Ryze At The Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 6450 North Ridge Blvd, Chicago, Illinois 60626
- CMS Provider Number
- 145832
- Inspections on file
- 42
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Ryze At The Ridge during CMS and state inspections, most recent first.
Surveyors found that multiple staff members, including CNAs, LPNs, an RN, and the Social Services Director, were not wearing required ID badges while on duty, despite facility policy mandating badges for all employees. A resident reported being unable to identify staff when attempting to file complaints because staff did not wear badges and often used nicknames. Staff interviewed acknowledged that badges are required so residents and visitors can identify who is providing care and that it is a resident right and a safety issue when staff are not properly identified.
Two cognitively intact residents with complex medical and psychiatric histories were involved in a physical altercation, during which one resident grabbed another by the throat in a hallway near the smoking area. Staff and other residents witnessed the incident, and staff intervened to separate the individuals. The only immediate response was to move the aggressor to a different room, and the event was reported to the administrator. The facility's policy prohibits abuse, but the measures in place did not prevent this occurrence.
Surveyors observed multiple instances of mouse droppings in several rooms, including between walls and bedside cabinets and under floor heat registers. Multiple residents reported seeing mice in their rooms at night, often coming from under heat registers or from the walls. The facility's pest management policy was not effectively implemented, resulting in ongoing pest issues.
A resident with a history of diabetes and a healing abdominal surgical wound experienced a re-opening of the wound, but staff failed to notify the physician, obtain a treatment order, monitor and document the wound status, or develop an individualized care plan. The wound was not included in the facility's wound tracking or care planning systems, and required protocols for assessment and documentation were not followed.
Two residents engaged in a physical altercation in the dining room, which staff failed to prevent despite witnessing the escalation from a verbal argument. One resident, with a history of aggression, hit the other, causing a head injury. Staff expressed fear and inexperience in handling the situation, contributing to the deficiency.
The facility failed to submit the Abuse Final Reportable within the mandated timeframe, affecting two residents. The initial report was made on time, but the final report was delayed by one working day. One resident had a history of aggression and was cognitively intact, while the other had auditory hallucinations and was moderately impaired. The facility's policy requires submission within five working days, which was not met.
The facility failed to ensure proper food preparation and sanitization practices, as the cook did not follow standardized recipes, using a regular soup spoon instead of a measuring tablespoon, resulting in overly salty pureed tater tots. Additionally, improper sanitization of kitchen equipment was observed, with the blender lid not submerged in sanitizing solution for the required time, risking cross-contamination.
The facility failed to properly label and date food items and did not sanitize cooking equipment according to guidelines, potentially affecting all 128 residents. Observations revealed unlabeled food items and improper sanitization of a blender lid, contrary to the facility's policies. These deficiencies could lead to foodborne illnesses.
The facility failed to conduct quarterly reassessments for residents who smoke, affecting their ability to smoke safely. One resident was observed smoking without a required apron, and the Social Service Director was unaware of this intervention. Other residents also had outdated smoking assessments, and their care plans were not updated to reflect current needs.
The facility failed to properly label and store medications, affecting seven residents. Observations revealed that multiple medications, including Risperidone solution and Albuterol inhalers, were opened without labeling the date of opening. An unopened Insulin Lispro vial was improperly stored outside refrigeration, and expired medications were found in storage. The DON emphasized the importance of labeling and proper storage to ensure medication efficacy and safety.
The facility failed to assess eligibility and offer pneumococcal vaccinations to four residents, as well as provide education on the benefits and side effects. The Infection Control Nurse provided verbal education without materials, and no immunization tracker was maintained. EHR reviews showed no documentation of vaccination status or education. Interviews with residents confirmed the lack of education and vaccination, and the Director of Nursing highlighted the importance of documentation.
The facility failed to assess eligibility and offer COVID-19 vaccinations to several residents, and did not document vaccination status or education provided. Interviews revealed that while verbal education was claimed to be given, there was no documentation in the EHRs. The Director of Nursing acknowledged that documentation should be completed, but the lack of records suggests non-compliance with the facility's policy.
A facility failed to complete a significant change in status MDS assessment for a resident admitted to hospice care. The resident's last MDS was a quarterly assessment, and the required significant change assessment was not conducted within the regulatory timeframe. Interviews confirmed that the facility's protocol mandates such assessments for hospice admissions, but it was not completed as required.
A facility failed to develop a comprehensive care plan for a resident receiving hospice services, despite the resident's complex medical history and admission to hospice care. The care plan, which should have been generated to address the resident's medical, nursing, mental, and psychosocial needs, was only added nearly two months after the resident's hospice admission.
A facility failed to properly store oxygen tubing for a resident with respiratory failure, as required by their policy. The tubing was observed on the floor instead of in a plastic bag, risking contamination. Staff confirmed the tubing was not changed as per schedule, despite the facility's policy for weekly changes and proper storage.
Two residents experienced medication administration errors, resulting in a 12.9% error rate. A nurse failed to administer a nasal spray as ordered and did not notify the physician of its unavailability. Additionally, the nurse did not follow proper procedures for administering ear drops. The facility's policies for medication administration were not adhered to, contributing to the errors.
A facility failed to protect a resident's right to manage their financial affairs, resulting in the misuse of a $10,000 check. The resident, who was cognitively intact, was instructed to sign the check over to the facility without proper authorization or explanation of charges. The facility did not provide an itemized bill until months later, and the resident's family received inconsistent explanations about the funds. The facility's documentation was outdated, and there was no evidence of the resident's agreement to private pay status.
The facility failed to maintain a clean and sanitary environment, with surveyors noting foul odors, unclean floors, and malfunctioning equipment. Residents reported missing dresser drawers, clogged toilets, and non-functioning overhead lights. The maintenance and housekeeping practices were inadequate, with issues persisting for months despite being reported. The facility's administrator was aware of these ongoing problems.
A facility failed to maintain accurate records of a resident's personal funds and did not provide financial records as required. The resident, who was alert and oriented, reported not receiving cash withdrawals listed in their account. Staff admitted to signing for withdrawals instead of the resident, despite the resident's capability to sign. Discrepancies were found between withdrawal forms and account statements, and the resident's family received conflicting explanations about the funds.
A resident with intact cognitive function experienced a delay in resolving a financial grievance involving a $10,000 check. Despite multiple attempts to contact facility staff, including the Administrator and Psychiatric Rehabilitation Services Director, the resident received inadequate communication and updates. Interviews revealed a lack of coordination and follow-up, leading to the resident's dissatisfaction and distress.
A cognitively intact resident's $10,000 check was misappropriated for room and board, leaving her with only $160. The facility failed to report the incident to the Illinois State agency within the required timeframe. The resident expressed dissatisfaction and contacted external authorities. The facility's administrator and staff were aware but did not provide timely updates or resolutions, leading to a deficiency finding.
The facility failed to protect a resident from abuse, resulting in abrasions to the face and wrist after being attacked by another resident with a history of aggression. Despite visible signs of agitation and a known history of aggressive behavior, the staff did not implement appropriate interventions, including one-to-one monitoring, leading to the altercation.
Failure to Ensure Staff Wore Identification Badges for Resident Identification
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently wore identification badges, preventing residents from knowing staff names and titles as required by facility policy. During an interview, one resident reported being unable to identify staff when wanting to make a complaint because many staff did not wear identification badges and often used nicknames. The resident stated he had spoken with the Assistant DON and nurses but could not identify which specific staff members he had reported concerns to. The facility’s employee handbook dated 1/2025 states that name badges are supplied by the facility and must be worn by all employees when on duty, and that each employee is responsible for their badge and its replacement if lost or misplaced. Surveyors observed multiple staff members across different roles and units not wearing identification badges while on duty. A CNA who identified as a new employee stated he did not have an identification badge and was observed in the hallway with towels in hand. Another CNA verified she was not wearing her badge and was seen entering resident rooms without identification, acknowledging that her badge should not be in her pocket and that badges help residents identify who is caring for them. An LPN on the second floor, an RN, the Social Services Director, another LPN on the first-floor unit, and an additional LPN on the first-floor unit were all observed without identification badges and each confirmed they were not wearing them. Several of these staff members stated that facility policy requires all staff to wear ID badges, that badges allow residents and visitors to identify staff, and that it is a resident’s right to know who is caring for them, with one LPN characterizing it as a safety issue if a resident cannot identify a staff member or another person in the building not wearing an ID badge.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two cognitively intact residents with multiple medical and psychiatric diagnoses. One resident reported being grabbed by the throat by their roommate during a confrontation in the hallway near the smoking area. Multiple interviews confirmed that the altercation occurred, with one resident admitting to grabbing the other's throat after becoming aggravated by ongoing complaints. Several witnesses, including staff and other residents, observed or heard the commotion and confirmed the physical contact. Staff responded to the incident by separating the residents and assessing for injuries, but there were no visible marks or signs of injury. The only immediate action taken was moving the resident who initiated the physical contact to a different room. The incident was reported to the facility administrator and abuse prevention coordinator, and staff acknowledged awareness that the event constituted abuse. The facility's policy affirms residents' rights to be free from abuse, neglect, and mistreatment, but the actions taken did not prevent the occurrence of physical abuse between residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on one of three resident floors, as evidenced by direct observations and resident interviews. During a facility tour, numerous mouse droppings were found in multiple resident rooms, specifically between the wall and bedside cabinet, along the top of floor heat registers, and under floor heat registers. Several residents reported frequently seeing mice in their rooms, particularly at night, with some stating the mice appeared to come from under the floor heat registers or from the walls. The facility's own Integrated Pest Management (IPM) policy outlines procedures to protect the health and safety of residents, staff, and visitors from pest hazards, and aims to eliminate significant threats caused by pests, but these procedures were not effectively implemented as evidenced by the ongoing presence of mice and droppings.
Failure to Notify Physician and Care Plan for Re-Opened Surgical Wound
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a re-opened surgical wound. Upon admission, the resident had a healing surgical wound on the abdomen following a hernia repair, and reported that the site had re-opened about a month prior. The resident stated that staff were not providing any treatment for the re-opened wound. Observation confirmed a small, open wound near the navel, with no dressing applied and no signs of infection. The registered nurse acknowledged seeing the wound previously but had not notified the physician or obtained a treatment order. Further interviews revealed that the Assistant Director of Nursing was unaware of the resident's wound and had not been notified, despite being responsible for tracking wounds in the facility. The nurse involved stated that she had only documented the issue on the communication board and did not contact the physician, as she did not observe signs of infection. The MDS Coordinator also confirmed that the wound was not included in the care plan or the facility's list of residents with current skin breakdown, and was only made aware of the wound the previous night. Record review showed no physician orders or treatment administration records for the wound, and the comprehensive care plan lacked individualized goals or interventions for the surgical wound. Facility policies required notification of the physician and updates to the care plan for changes in condition, as well as consistent monitoring and documentation of wounds, but these protocols were not followed in this case.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure residents were free from resident-to-resident physical altercations, affecting two residents involved in an incident. On January 27, 2025, a physical altercation occurred between two residents, R1 and R2, in the first-floor dining room. Witnesses, including another resident and staff members, reported that the altercation began with a verbal argument that escalated into physical violence, with R1 hitting R2's head, causing R2 to fall. Staff members present did not effectively intervene to deescalate the situation, and one staff member, V9, expressed fear and inexperience in handling such situations, which contributed to the failure to prevent the altercation. R1 has a history of aggression, as documented in their care plan and medical records, which include diagnoses of bipolar disorder and schizoaffective disorder. R1's mental status was noted as cognitively intact. R2, on the other hand, has a history of auditory hallucinations and schizoaffective disorder, with a moderately impaired mental status. Following the altercation, R2 sustained a contusion of the scalp, as documented in their medical records. The facility's abuse policy emphasizes the right of residents to be free from abuse, including abuse by other residents. The policy outlines the need for staff to be trained in handling difficult situations to prevent abuse. However, during the incident, staff failed to follow these guidelines, as they did not intervene promptly or effectively to prevent the escalation of the argument into a physical altercation. The facility's failure to protect residents from abuse by other residents constitutes a deficiency in providing a safe environment.
Failure to Timely Submit Abuse Final Reportable
Penalty
Summary
The facility failed to ensure that the Abuse Final Reportable was sent to the Survey Agency within the mandated timeframe, affecting two residents. The initial report for the abuse incident involving these residents was documented as reported to the state on December 15, 2024, at 3:38 PM. However, the final reportable was not uploaded to the Department of Public Health Incident portal until December 23, 2024, which was six working days later, exceeding the mandated five working days for submission. The administrator confirmed this timeline during an interview, acknowledging the delay in submission. The residents involved in the incident had significant medical histories. One resident had diagnoses including bipolar disorder and schizoaffective disorder, with a cognitive status documented as intact. This resident had a history of aggression towards staff. The other resident had diagnoses including auditory hallucinations and schizoaffective disorder, with a moderately impaired cognitive status. This resident was involved in an altercation that resulted in a contusion of the scalp. The facility's abuse policy mandates that a complete written report of the investigation's conclusion be sent within five working days, which was not adhered to in this case.
Inadequate Food Preparation and Sanitization Practices
Penalty
Summary
The facility failed to ensure that the cook had the appropriate competencies and skills, resulting in recipes not being followed during food preparation. This deficiency was observed when the cook, responsible for preparing pureed foods for lunch, did not adhere to the standardized recipe for pureed pork fritter and tater tots. Instead of using a standard measuring tablespoon, the cook used a regular soup spoon to scoop out chicken base, leading to an excessive amount being added to the dishes. This resulted in the pureed tater tots being too salty and inedible. Additionally, the facility's kitchen was not equipped with a second blender lid, which led to improper sanitization practices. The cook was observed washing the blender lid in a three-compartment sink but did not submerge it in the sanitizing solution for the required 60 seconds. This was noted by the Dietary Manager, who acknowledged the potential for cross-contamination and foodborne illness due to inadequate sanitization. The facility's policies and procedures, including the use of standardized recipes and proper sanitization techniques, were not followed. The Dietary Manager confirmed that the cook did not use the correct measurements, which affected the taste and quality of the food. The failure to follow recipes and proper sanitization procedures could potentially impact the residents' meal intake and nutrition, especially for those on a low-salt diet.
Deficiencies in Food Safety and Equipment Sanitization
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen, which could potentially affect all 128 residents receiving food prepared there. During an inspection, it was observed that several food items in the reach-in cooler were not labeled with an opened or use-by date, contrary to the facility's policy. For instance, a 5-pound bag of shredded mozzarella cheese was only labeled with a delivery date, and two cartons of thickened honey orange juice were not discarded after the manufacturer's recommended 7-day period post-opening. Additionally, a container of cornstarch in the spice storage area lacked an opened or use-by date, and garlic bread in the walk-in cooler was not discarded by its use-by date. The facility also failed to sanitize cooking equipment according to the manufacturer's guidelines. During the preparation of pureed food, a cook was observed improperly sanitizing a blender lid by not leaving it in the sanitizing solution for the required 60 seconds. The dietary manager intervened and corrected the process, but initially, the dietary aide also failed to sanitize the lid properly, indicating a lack of understanding of the correct procedure. The manufacturer's instructions, posted above the sink, clearly stated that items need to be submerged in the sanitizing solution for a full minute to ensure proper disinfection. The facility's policies on food safety and infection control were not adhered to, as evidenced by the improper labeling, dating, and sanitizing practices observed. These deficiencies in food handling and equipment sanitization could potentially lead to foodborne illnesses among residents. The dietary manager acknowledged the importance of these practices in preventing cross-contamination and ensuring food safety, yet the observed practices did not align with the established guidelines.
Failure to Reassess Smoking Safety and Update Care Plans
Penalty
Summary
The facility failed to ensure that residents who smoke are re-evaluated on a quarterly basis for their ability to smoke safely, and that their smoking care plans were followed. This deficiency affected four residents who were reviewed for smoking. The facility's policy requires smoking assessments to be conducted quarterly, but the assessments for these residents were not completed as required. Additionally, the care plans for these residents were not updated to reflect their current needs, and interventions specified in the care plans were not consistently implemented. One resident, identified as R41, had a history of violating the facility's smoking program and was observed smoking without a required smoking apron. Despite having a care plan that indicated the need for a smoking apron, the resident had never used one since being at the facility. The Social Service Director, V2, was unaware of the intervention requiring a smoking apron and acknowledged that the resident's care plan should reflect current needs. The last smoking assessment for this resident was completed in April 2024, and a reassessment was overdue by mid-July 2024. Other residents, including R1, R62, and R18, also had outdated smoking assessments, with the last assessments completed in April 2024. These residents were observed smoking, and their care plans indicated a need for regular reassessment to ensure safe smoking practices. The facility's failure to conduct timely reassessments and update care plans as needed contributed to the deficiency, as the residents' ability to smoke safely was not adequately monitored or managed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, affecting seven residents. During an inspection, it was observed that multiple medications, including Risperidone solution, Brimonidine solution, and Albuterol inhalers, were opened without being labeled with the date of opening. This oversight was noted across several medication carts and storage rooms. Additionally, an unopened Insulin Lispro vial was improperly stored outside of refrigeration, contrary to the pharmacy's instructions. Expired medications, such as Vitamin B6 tablets, were also found in the medication storage room, indicating a lapse in the facility's medication management practices. The Director of Nursing acknowledged the importance of labeling medications with the date of opening to ensure timely disposal and maintain their efficacy. The facility's policy mandates that medications requiring refrigeration should be stored accordingly, and expired drugs should be immediately removed from stock. The failure to comply with these protocols could result in residents receiving ineffective or potentially harmful medications. The report highlights the need for strict adherence to medication labeling and storage guidelines to ensure resident safety and medication effectiveness.
Failure to Assess and Educate on Pneumococcal Vaccinations
Penalty
Summary
The facility failed to assess eligibility and offer pneumococcal vaccinations to four residents, as well as provide education regarding the benefits and potential side effects of the vaccinations. The Infection Control Nurse, identified as V14, stated that vaccination clinics are set up for residents, and education is provided verbally without any educational materials. Consents are obtained and uploaded to the residents' electronic health records (EHR), but there is no immunization tracker maintained. The review of the EHRs for residents R128, R102, R11, and R1 revealed no documentation of their pneumococcal vaccination status, eligibility assessment, or education provided. Interviews with the residents confirmed the lack of education and vaccination. R128, who is cognitively impaired, could not recall receiving the vaccine or any education. R11, who has been in the facility for four months, stated they did not receive the vaccine or any education on immunizations. R102, who is cognitively intact, mentioned being vaccinated years ago but could not recall the specifics and expressed a desire for education on vaccines. The Director of Nursing, V3, emphasized that documentation should be completed after education is provided, and if it's not documented, it means it wasn't done. The facility's policy requires screening and offering the pneumonia vaccine within the first week of admission and annually if eligible, with documentation in the EHR.
Deficiencies in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to assess eligibility and offer COVID-19 vaccinations to four residents, and did not document the vaccination status for five residents. Additionally, the facility did not document that education regarding the benefits and potential side effects of the COVID-19 vaccination was provided to six residents. These deficiencies were identified during a review of the electronic health records (EHR) of the residents in question. Interviews with the Infection Control Nurse revealed that while vaccination clinics were set up and verbal education was provided, there was no educational material distributed, and consents were uploaded to the EHR. However, the EHRs of the residents reviewed did not contain documentation of their COVID-19 vaccination status or evidence of education provided. Interviews with the residents confirmed that they either did not receive the vaccine or were not educated about it, despite being in the facility for varying lengths of time. The Director of Nursing stated that documentation should be completed after education is provided, but the lack of documentation in the EHRs suggests this was not done. The facility's policy requires that all residents be offered the COVID-19 vaccine and that vaccination data be reported weekly, but the absence of documentation indicates a failure to adhere to this policy.
Failure to Complete Timely MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for a resident who was admitted to hospice care. The resident was admitted to hospice on June 26, 2024, but the last MDS assessment was completed on June 14, 2024, as a quarterly assessment. According to the Resident Assessment Instrument (RAI) Manual, a significant change in status assessment should have been initiated within 14 days of the hospice admission and completed by day 21. However, this assessment was not conducted within the required timeframe. Interviews with the MDS Coordinator and the Regional Director confirmed that the facility's protocol requires a significant change assessment when a resident is admitted to hospice. The MDS Coordinator acknowledged that the assessment should have been started by July 9, 2024, and completed by the 21st day. The Regional Director also stated that a new MDS assessment should be completed when a resident is put on hospice, regardless of the reason. The failure to conduct the assessment as required by the RAI Manual resulted in a deficiency in the facility's compliance with regulatory timeframes for resident assessments.
Failure to Implement Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving hospice services. This deficiency was identified during a review of the resident's electronic health record (EHR), which revealed that the resident was admitted to hospice care on June 26, 2024, but did not have a corresponding hospice care plan until August 21, 2024. The absence of a hospice care plan was confirmed by the MDS Coordinator, who acknowledged that a care plan should have been generated to inform staff that the resident was receiving specialized hospice care. The resident in question has a complex medical history, including chronic respiratory failure, unsteadiness on feet, dysphagia following cerebral infarction, and several other conditions. The facility's policy mandates the development of a comprehensive care plan that includes measurable goals and interventions tailored to the resident's medical, nursing, mental, and psychosocial needs. Despite this policy, the care plan for the resident on hospice was only added on August 21, 2024, by the Regional Director, highlighting a lapse in ensuring the resident's psychosocial needs were met in a timely manner.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the proper storage of oxygen tubing for a resident, identified as R70, who is cognitively intact and has an active physician order for continuous oxygen therapy due to acute and chronic respiratory failure with hypoxia. During an observation, a surveyor noted that R70's oxygen nasal cannula tubing was left on the floor when not in use, which was contrary to the facility's policy that requires the tubing to be stored in a plastic bag to prevent infection. A Certified Nursing Assistant (CNA) was observed picking up the tubing from the floor and placing it on the oxygen tank, indicating a lapse in following proper infection control procedures. Further interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the expectation was for the oxygen tubing to be stored in a plastic zip bag when not in use. Despite this, the RN admitted to not changing the tubing, as it was scheduled to be replaced on a specific day of the week. The facility's policy, dated January 2024, mandates weekly changes of oxygen tubing and proper storage to prevent contamination, which was not followed in this instance.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 12.9% error rate during the survey. This deficiency involved two residents, R27 and R103, out of a sample of 11. For R27, the nurse, V6, did not administer the saline nasal spray as ordered at 8 AM and 12 noon, and there was no documentation of notifying the physician about the unavailability of the medication. Additionally, V6 did not adhere to the facility's policy of waiting at least 2 minutes between puffs of nasal spray and inhaler, potentially affecting the medication's efficacy. R27's medical history includes Type 2 diabetes mellitus, chronic obstructive pulmonary disease, and other conditions. For R103, V6 administered earwax softener drops without following the proper procedure, which includes cleansing the external auditory canal, straightening the auditory canal by pulling up and back, and inserting a small cotton ball afterward. The facility's policies for medication administration, oral inhalation, and ear drops were not followed, contributing to the medication errors observed. The Director of Nursing confirmed the expectations for medication administration, emphasizing the importance of following the 5R's and notifying the physician if medications are unavailable.
Failure to Protect Resident's Financial Rights
Penalty
Summary
The facility failed to protect a resident's right to manage their financial affairs and inform them of charges imposed against their personal funds. The resident, who was cognitively intact and oriented, received a $10,000 check from a family member's estate. The resident approached the Psychiatric Rehabilitation Services Director for advice and was later instructed by the former Business Office Manager to sign the check over to the facility, under the pretense that Medicaid would refuse to pay for care if the money was kept. The resident did not provide written authorization for the check to be deposited into the Resident Fund Management Service account and was not informed of the subsequent billing process. The facility did not provide the resident with an itemized bill until several months later, despite repeated requests. The resident's family member, who held power of attorney, was also given inconsistent explanations about the whereabouts of the funds. The facility's administrator at the time acknowledged the receipt of the check but did not ensure that the resident's rights regarding personal funds were explained or that proper authorization was obtained for the deposit. The facility's documentation was outdated, reflecting an old Medicaid asset limit, and there was no evidence that the resident had declined Medicaid benefits or agreed to private pay status. The facility's policy required residents to receive receipts for deposits and to authorize withdrawals, which was not adhered to in this case. The facility also failed to update the resident's personal trust fund policy to reflect current Medicaid asset limits. The survey team found no documentation supporting the resident's agreement to the charges or a switch to private pay, and the facility did not provide any such documentation by the survey's conclusion.
Deficiencies in Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by observations of offensive odors, unclean floors, and malfunctioning equipment. During a facility tour, surveyors noted foul odors and missing drawers in bedside dressers for several residents. Additionally, one of the elevators was out of service, which affected the residents' ability to move freely within the facility. The surveyor, along with a Certified Nurse Assistant, observed a yellow liquid substance on a resident's bathroom floor, which was identified as urine. The bathroom, shared by multiple residents, was not cleaned regularly, leading to persistent strong odors. The facility also failed to ensure that furniture and equipment were functioning properly. Several residents reported missing dresser drawers, which had been an issue for months. One resident mentioned that their toilet frequently clogged and took days to be fixed, while another resident's toilet was leaking and emitting a sewage smell for over three weeks. The maintenance staff was reportedly aware of these issues but had not addressed them in a timely manner. Furthermore, the overhead lights in two residents' rooms were not functioning, despite being reported as repaired in the facility's work order log. The facility's housekeeping and maintenance practices were inadequate, as evidenced by the observations of unclean conditions and broken furniture. The Housekeeping Director acknowledged that the rooms and bathrooms needed frequent cleaning due to residents' behaviors, such as urinating on the floor and smearing feces. The Maintenance Director confirmed the widespread issue of missing dresser drawers and stated that a furniture company had been contacted for replacements. However, the timeline for repairs and replacements was uncertain, and the facility's administrator was aware of these ongoing issues.
Failure to Maintain Accurate Resident Fund Records
Penalty
Summary
The facility failed to maintain accurate and complete records of a resident's personal funds and did not provide the resident with financial records quarterly or upon request. The resident, who was cognitively intact and alert, reported receiving a $10,000 check from a family member's estate, which was handed over to the facility. Despite multiple requests for updates and billing statements, the resident was only provided with an inaccurate account statement in July. The resident claimed not to have received any of the cash withdrawals listed in the account statement for the year. Interviews with facility staff revealed inconsistencies in the process of handling the resident's funds. The Psychiatric Rehabilitation Services Director and other staff members admitted to signing for the resident's cash withdrawals instead of having the resident sign, despite the resident being capable of doing so. The process involved staff counting the money, placing it in an envelope, and delivering it to the resident's room, but the resident did not sign the withdrawal forms. The facility's Business Office Manager confirmed that this process was a continuation of the previous manager's practices. Further discrepancies were found when comparing the cash withdrawal forms with the resident's account statement, showing mismatched dates and amounts. The resident's family member, who held power of attorney, also reported being given conflicting explanations about the whereabouts of the funds. The facility's policy required residents to sign for any withdrawals, but this was not followed. Additionally, the facility failed to document the resident's check or provide quarterly statements as required.
Failure to Resolve Resident's Financial Grievance
Penalty
Summary
The facility failed to promptly resolve a grievance and keep a resident informed about the progress of the investigation. The resident, who was cognitively intact, had a $10,000 check deposited, which was not reflected in her account. The facility's follow-up documentation indicated that the issue was assigned for resolution, but the resident was not satisfied with the outcome, and there was a lack of communication regarding the status of her funds. The resident expressed concerns about the misuse of her trust funds and the lack of accountability from the facility. Despite multiple attempts to contact the facility's staff, including the Administrator and the Psychiatric Rehabilitation Services Director, the resident felt ignored and was not provided with timely updates. The resident's attempts to escalate the issue included contacting external organizations, but the facility's response remained inadequate. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's grievance. The Administrator admitted to not responding to the resident's emails and not providing updates due to a lack of concrete information. The Business Office Manager and Psychiatric Rehabilitation Services Director also failed to follow up adequately, resulting in the resident's continued dissatisfaction and distress over the unresolved financial issue.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's funds to the Illinois State agency within the required timeframe. The resident, who was cognitively intact, had a check for $10,000 that was not properly reflected in her account. The facility's documentation indicated that the funds were used for room and board, leaving the resident with only $160 from the original amount. The resident expressed dissatisfaction with the resolution and reported the issue to various authorities, including the state Medicaid office, which confirmed that her services were never interrupted and that Medicaid had covered the charges. The facility's administrator and staff were aware of the resident's concerns but failed to provide timely updates or resolutions. The administrator admitted to not responding to the resident's emails and not providing updates until concrete information was available. The resident continued to express dissatisfaction and escalated the issue by contacting external organizations. The facility's internal communication and grievance handling were inadequate, as the resident's concerns were not addressed promptly, and the misclassification of her payment status was not corrected in a timely manner. The facility's policy required immediate reporting of any allegations of misappropriation of resident property, but the administrator did not initially consider the situation as misappropriation. The administrator later acknowledged the need to report the incident after being questioned by the surveyor. The facility's failure to report the incident and address the resident's concerns in a timely manner resulted in a deficiency finding by the surveyors.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident (R4) from abuse, resulting in R4 sustaining abrasions to the face and right wrist. The incident occurred when another resident (R5), who had a history of aggressive behaviors, became agitated and attacked R4 with punches and kicks. Multiple staff members, including an Activity Aide (V8), Housekeeping Director (V12), and Certified Nurse Aide (V15), witnessed the altercation and confirmed that R5 was visibly agitated and had been pacing and slamming doors prior to the attack. Despite R5's known history of aggression and the visible signs of agitation, the staff did not intervene appropriately to prevent the altercation. Interviews with staff revealed that R5's behavior was abnormal and should have prompted immediate intervention, including one-to-one monitoring. However, the staff failed to implement these measures. The Psychiatric Rehabilitation Services Director (V16) stated that there were no social workers in the building at the time of the incident, and the staff should have attempted to talk and redirect R5. The Assistant Director of Nursing (V20) also confirmed that R5's behavior warranted one-to-one monitoring, which was not provided. R5's comprehensive care plan documented the potential for physical and verbal aggression and included interventions such as monitoring and reporting signs of danger. However, these interventions were not effectively implemented. The facility's abuse policy affirmed the right of residents to be free from abuse and required immediate interventions to assure resident safety, which were not followed in this case. The failure to provide sufficient protection and immediate intervention led to the resident-to-resident abuse incident involving R4 and R5.
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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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