Ryze West
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5130 West Jackson Boulevard, Chicago, Illinois 60644
- CMS Provider Number
- 145661
- Inspections on file
- 70
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ryze West during CMS and state inspections, most recent first.
Two residents with complex medical and psychiatric histories engaged in a verbal disagreement that escalated to physical abuse in their shared room, with both parties admitting to hitting each other. Staff were aware of verbal conflicts and intervened verbally, but no staff witnessed or intervened in the physical altercation, resulting in a failure to prevent abuse as defined by facility policy.
A resident with multiple medical and behavioral diagnoses alleged physical abuse, stating someone kicked him, but retracted the claim several times. Staff, including an LPN and CNA, were aware of the allegation and their reporting responsibilities. The administrator began an internal investigation but did not report the allegation to the state agency, citing the resident's retraction, which was contrary to facility policy requiring immediate reporting of all abuse allegations.
A resident with multiple comorbidities and moderate cognitive impairment was found lying on a low air loss mattress that was not set according to their actual weight, contrary to facility policy and manufacturer instructions. Staff interviews revealed uncertainty about the correct mattress setting, and the process for updating and labeling the mattress with the resident's weight was not followed, potentially compromising pressure ulcer prevention.
A resident with multiple health conditions, including morbid obesity and a recent tracheostomy, returned from a hospital stay to find her weight loss medication missing. The medication, brought in by family and requiring refrigeration, was unaccounted for due to inconsistent staff practices and lack of documentation. Nursing staff gave conflicting reports about whether the medication was discarded or sent back to the pharmacy, and there was no policy in place for handling or documenting medications brought in by families, resulting in missed doses for the resident.
Multiple residents with complex medical needs experienced repeated exposures to lice and scabies due to the facility's failure to administer prescribed topical medications, document physician notifications, obtain and implement contact precautions, and perform required isolation assessments and deep cleaning. Staff did not consistently follow infection control policies, and there was a lack of documentation and communication regarding treatment and environmental cleaning.
A resident with intact cognition and good discharge potential was not regularly re-evaluated, referred, or provided documented referrals to local agencies for discharge planning. Despite being eligible and expressing a desire to move to assisted living, the resident received no updates or assistance after an initial referral discussion, and staff confirmed there was no record of a formal referral or updated care plan, due in part to recent staff turnover in social services.
A resident with intact cognition and nutritional risks was repeatedly served oatmeal despite documented preferences against it, leading to dissatisfaction and potential health concerns. The error was acknowledged by dietary staff as an oversight, and the facility's policy on respecting dietary preferences was not followed.
A facility failed to coordinate with the state-designated authority for a new PASRR Level I screen for a resident with severe mental disorders before the expiration of their PASRR Level II short-term approval. The resident, diagnosed with cognitive communication deficit, schizophrenia, schizoaffective disorder, and bipolar type, did not receive a new Level I screen as required by the facility's policy, leading to a deficiency in compliance with the PASRR process.
A resident with a history of mood and anxiety disorders consistently refused prescribed psychotropic medications due to distrust in staff, leading to ongoing behavioral issues. Despite the resident's verbal aggression and frequent complaints about mistreatment, the facility failed to include the medication refusal in the care plan, contrary to its policy requiring comprehensive, person-centered care plans.
A fire incident in a facility was caused by a resident's motorized wheelchair with exposed wires, leading to a dangerous situation for three residents. The facility's fire alarm system failed to function, delaying emergency response. The facility did not report the incident to the state or conduct thorough assessments of the residents involved. The maintenance of the wheelchair was left to the resident's family, who performed unauthorized repairs.
A resident involved in a fire incident in her room was not properly assessed or provided with necessary psychosocial interventions. Despite her non-verbal status, she communicated fear and distress, but the facility failed to document social service interventions or revise her care plan. The resident continued to use the same equipment involved in the fire, potentially triggering her trauma.
A facility failed to maintain a resident's motorized wheelchair, leading to a fire caused by exposed wires. The wheelchair, owned by the resident, was not routinely checked by the facility. The fire department identified the wheelchair as the fire's source, and the facility's fire alarm system did not activate, delaying staff response. The resident's son, who maintained the wheelchair, lacked formal training. The facility's policy requires monthly equipment checks, which were not followed for personal equipment.
The facility failed to ensure call light accessibility for two residents, one with paraplegia and moderate cognitive impairment, and another who is legally blind with a history of falls. The call lights were found out of reach, compromising the residents' ability to request assistance. Staff acknowledged the oversight, which contradicts the facility's policy requiring call lights to be within reach.
A resident with paraplegia and bilateral foot drop did not receive a shower since May, contrary to the facility's policy of weekly bathing. Despite being dependent on staff for ADLs, there were no records of the resident receiving a shower or bed bath after being transferred to a different floor. The resident expressed discomfort due to sticky hair, and staff acknowledged the lack of documentation, suggesting bed baths might have been given due to shingles.
A resident with severe cognitive impairment and multiple diagnoses was improperly positioned during dining, leading to a risk of choking and aspiration. The resident was observed in a low Fowler's position while eating, contrary to facility guidelines that emphasize proper positioning to prevent aspiration. Staff interviews revealed inconsistencies in understanding the correct positioning for residents during meals.
A resident with severe dental decay and pain did not have a dental appointment scheduled as ordered by a Nurse Practitioner, due to a communication breakdown in the facility. The resident's care plan and physician orders indicated the need for a dental evaluation and extraction, but the appointment was not made, resulting in continued pain and decay.
A resident with a history of epilepsy experienced a seizure, and the facility failed to follow its policy by not adequately monitoring vital signs during the medical emergency. The LPN did not document the resident's oxygen saturation post-seizure, and the resident was transported to the hospital via private ambulance instead of 911, despite low oxygen levels. The facility's policy requires frequent vital sign checks and physician notification of significant changes, which were not fully adhered to.
A resident with ADHD and depression did not receive his prescribed medication, Dextroamphetamine Sulfate, from 5/15/24 through 5/23/24. Despite the psychiatrist's assessment and prescription, the medication was not administered due to a breakdown in communication and procedure between the psychiatrist, Director of Nursing, and pharmacy. This led to the resident feeling sad, depressed, tired, and refusing care.
The facility failed to ensure proper food safety and sanitation practices, including labeling and dating food items, discarding expired food, and properly sanitizing cooking equipment. Observations revealed spoiled strawberries, dust in refrigerators, and improper sanitization of blender parts, affecting all 176 residents.
The facility failed to ensure that the dumpster was covered, leaving two of the three lids wide open and debris on the ground. The Dietary Manager and Divisional Manager for Laundry and Housekeeping Services acknowledged that the lids should be closed to prevent pests and rodents. Facility policies on garbage disposal and maintaining a clean environment were not followed.
The facility failed to provide an adequate supply of linens, affecting all 180 residents. CNAs frequently ran out of bath towels during shifts, and the par levels for linens were outdated. Despite efforts to order more linens, the issue persisted, with observations confirming a shortage of bath towels on multiple floors.
The facility failed to ensure sufficient CNAs on weekends, affecting resident care. A resident was observed with a long beard and stated that staff did not assist with shaving. The staffing coordinator confirmed frequent weekend call-offs, and records showed the facility did not meet required staffing numbers on multiple days. The DON acknowledged the challenges, and PBJ reports triggered for low weekend staffing.
The facility failed to ensure smoking materials were given to designated staff, complete timely smoking assessments, and develop comprehensive care plans for smoking. Residents were observed keeping smoking materials inside the facility, contrary to policy, and smoking assessments and care plans were either missing or outdated.
The facility failed to ensure narcotic medications were administered according to physician orders, maintain accurate narcotic counts at shift changes, and document the administration of ordered narcotic medications for two residents. Discrepancies in the amounts of Morphine Sulfate remaining in the bottles were not identified or addressed promptly by the LPNs responsible.
The facility failed to follow infection control practices, including improper hand hygiene and PPE doffing procedures, affecting residents under Enhanced Barrier Precautions. Observations revealed staff not adhering to policies, leading to potential infection risks.
The facility failed to repair a hole in the ceiling and replace missing or stained ceiling tiles in the dining room, and failed to maintain the walls in residents' rooms in good repair. Residents expressed concerns about leaks and the lack of timely repairs. The Maintenance Director acknowledged the issues and stated that repairs were ongoing due to years of neglect and limited staff.
The facility failed to follow its policy for determining and assessing a resident's ability to self-administer medications, did not obtain a physician's order, and did not implement a care plan for one resident. The resident, with multiple diagnoses, was found using medications without proper assessment or documentation.
A resident reported theft, neglect, and bullying to a surveyor, but an LPN failed to report these allegations to the administrator as required by facility policy. The administrator was unaware of the allegations until informed by the surveyor the following day, after which an investigation and report were initiated.
The facility failed to refer a resident for a required Level II PASARR evaluation despite the resident's diagnoses of Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Restlessness and Agitation. The Social Service Director admitted that the necessary PASARR Level I screen was only submitted after the surveyor's inquiry, revealing a lapse in compliance with federal and state regulations.
The facility failed to assist a resident with personal hygiene, specifically shaving, and did not provide adequate communication support in another resident's primary language. The deficiencies were identified through observations, interviews, and record reviews, revealing lapses in following care plans and facility policies.
A facility failed to identify and address a resident's skin lesions, resulting in unaddressed wounds and discomfort. The Wound Nurse was unaware of the current wounds, and despite a Bacitracin ointment order, the resident had not received the cream. The Infection Prevention Nurse confirmed the ointment should have arrived the same day it was ordered, but it had not. The facility's policy on skin care prevention was not followed.
The facility failed to provide a resident with a pressure redistribution mattress as ordered, despite the resident being at very high risk for skin breakdown. The resident, who had multiple diagnoses and a history of pressure ulcers, was observed without the required air mattress, contrary to the care plan and facility policy.
The facility failed to provide physician-ordered nutritional supplements and double portions to two residents, despite these items being in stock. Staff confirmed that the supplements and increased portions were not included on the meal trays as required, potentially impacting the residents' nutritional status and weight management.
The facility failed to provide the total volume of prescribed gastrostomy tube feeding for two residents, as observations and interviews revealed discrepancies in the administration and documentation of the tube feeding volumes, leading to a deficiency in meeting the residents' nutritional needs.
The facility failed to follow physician orders for administering the correct oxygen flow rate for two residents. One resident with multiple respiratory diagnoses was observed with oxygen set below the prescribed rate, and another resident with similar conditions also had oxygen set below the prescribed rate. Both residents denied changing the flow rate, and their records lacked orders or assessments for self-administration.
A facility failed to ensure a psychiatrist documented their assessment and completed the necessary prescription process for a resident's ADHD medication. This led to the resident not receiving the medication for nine days, causing significant distress and a decline in their condition. Interviews revealed a breakdown in communication and procedure among the psychiatrist, DON, and nursing staff.
The facility failed to follow its policy regarding psychotropic medications for three residents, including not obtaining informed consent, not ensuring PRN medications had a duration of no longer than 14 days, not attempting Gradual Dose Reduction (GDR), and not completing AIMS tests in a timely manner.
A resident was administered 4 units of Humalog Insulin one hour before the meal instead of with the meal as prescribed. The LPN acknowledged the error, and the Director of Nursing confirmed that this practice could lead to severe consequences such as hypoglycemia.
The facility failed to ensure medications were properly labeled when opened, expired medications were removed from the medication cart and medication room, and medications for discharged residents were removed from the medication cart. Expired medications were found in the fourth-floor medication cart and room, and medications without open dates were observed in the second-floor medication cart. The DON confirmed that nurses are responsible for checking expiration dates daily and removing expired medications.
A resident with legal blindness and schizophrenia became agitated and inadvertently scratched another resident in a wheelchair, leading to an altercation. The facility's measures were insufficient to prevent the incident, despite known behavioral issues.
A resident with a history of stroke and other health issues was found to have a fractured arm initially misdiagnosed as cellulitis. Despite the discovery of the fracture, the facility administrator did not report the injury to the regional office, as it was not deemed suspicious. This failure to report constitutes a deficiency in following the facility's abuse policy and prevention program.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent two residents from physically abusing one another. One resident, a female with diagnoses including diabetes, COPD, schizoaffective disorder, and heart failure, reported being verbally and physically attacked by her roommate, who has diagnoses including COPD, dementia, and mood disturbance. The incident began with a verbal disagreement that escalated to physical violence, with one resident stating she was hit in the head and face by her roommate. The other resident confirmed that both parties hit each other during the altercation, which occurred in their shared room without staff present. Staff interviews revealed that although staff were aware of ongoing verbal disagreements between the two residents and intervened at least once to separate them, they did not witness the physical altercation. Staff responses included calling a nurse to the scene and sending one resident out of the facility, but no staff member reported seeing or being informed of the physical abuse at the time. The facility's abuse policy defines physical abuse as the infliction of injury by non-accidental means, including hitting, slapping, or kicking, which was not prevented in this case.
Failure to Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse made by a resident who had multiple complex diagnoses, including heart failure, diabetes, substance abuse, and schizoaffective disorder. The resident alleged that someone had kicked him, but immediately retracted the statement multiple times, both to facility staff and emergency responders. Staff members, including an LPN and a CNA, confirmed that the resident made and then retracted the allegation, and neither witnessed any abuse. Both staff members stated they were trained on abuse reporting and were aware of the procedures for reporting such incidents to the administrator. The administrator, who also serves as the abuse coordinator, was informed of the resident's escalating behaviors and the abuse allegation after the fact. She initiated an internal investigation but did not report the allegation to the state agency, citing the resident's retraction as the reason. Review of facility records confirmed that no report was made to the state agency regarding this allegation, despite facility policy requiring immediate external reporting of all abuse allegations, regardless of retraction. The deficiency centers on the facility's failure to report the initial allegation as required by policy and regulation.
Incorrect Low Air Loss Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a low air loss mattress was set to the correct setting according to the wound care prevention protocol for a resident with multiple comorbidities and moderate cognitive impairment. The resident was readmitted with diagnoses including hypertension, diabetes, subdural hemorrhage, disc degeneration, epilepsy, anemia, malnutrition, and hepatic encephalopathy, and was identified as being at moderate risk for pressure ulcers. Upon admission, the resident had moisture-associated skin damage (MASD) to the sacrum and was assessed as chairfast and incontinent, with a care plan in place for pressure relief interventions, including the use of a low air loss mattress. During observation, the resident was found lying on a low air loss mattress set at 320, which did not correspond to the resident's actual weight, which was significantly lower. Interviews with staff revealed uncertainty about the resident's weight and the correct mattress setting. The LPN was unsure of the resident's weight and acknowledged that the mattress should be set based on weight, while the wound care technician confirmed that the setting was incorrect and planned to update the label with the correct weight. The wound care nurse also stated that the mattress should be set according to the resident's weight and that the current setting was too firm, potentially compromising the intended pressure relief. Facility policy and the manufacturer's instructions both require that the low air loss mattress be set according to the resident's weight to ensure proper pressure redistribution and skin protection. The failure to set the mattress correctly was observed and confirmed by multiple staff members, and the process for ensuring correct settings, including labeling and regular checks, was not followed at the time of the survey. This lapse had the potential to affect the resident's skin integrity and the effectiveness of the pressure ulcer prevention protocol.
Failure to Document and Account for Resident's Medication Brought in by Family
Penalty
Summary
The facility failed to ensure a system was in place for the documentation and disposition of a resident's medication, resulting in the resident's weight loss medication being unaccounted for. The resident, who had a complex medical history including morbid obesity, depression, lymphedema, hypothyroidism, and a recent tracheostomy, was readmitted to the facility after a hospital stay. The resident reported that her weight loss medication, which was brought in by her family and required refrigeration, was missing upon her return. She stated that she had two doses left, but staff could not locate them, and she subsequently missed two doses. Multiple staff interviews revealed confusion regarding the handling and documentation of medications brought in by family members, with some staff stating that medications are typically sent back to the pharmacy or discarded when a resident is hospitalized, but no clear documentation or process was followed in this case. Nursing staff provided inconsistent accounts regarding the disposition of the medication. Some staff indicated that medications not classified as controlled substances, such as the resident's injectable weight loss medication, were discarded without documentation, while others were unaware of the medication's origin or storage requirements. One LPN admitted to discarding the medication after a period of time, along with other medications, but did not document this action. There was also a lack of clarity about whether the medication should have been returned to the family, kept in a secure location, or sent back to the pharmacy, and no records were maintained to track the medication's disposition. The Director of Nursing and the Administrator both acknowledged the absence of a policy regarding the handling and documentation of medications brought in by family members. The Administrator confirmed that there was no existing policy on medication disposition, and staff were not aware that the medication in question had been provided by the resident's family. The lack of a clear process and documentation led to the medication being unaccounted for and the resident missing prescribed doses.
Failure to Administer Ordered Treatments and Implement Infection Control for Lice and Scabies
Penalty
Summary
The facility failed to properly implement its infection prevention and control program in response to multiple cases and exposures of lice and scabies among residents. Specifically, the facility did not administer ordered topical medications for lice and scabies as prescribed, and there was a lack of documentation regarding the administration of these medications. In several instances, the medication was not available at the scheduled time, and there was no evidence that the responsible staff notified the physician or nurse practitioner about the delay or non-administration. Additionally, there was no documentation of required isolation assessments or infection criteria evaluations for residents exposed to or diagnosed with lice and scabies prior to May, despite multiple exposures and symptoms being reported and observed by staff and residents. The facility also failed to obtain and document physician orders for contact precautions for affected residents at the time of exposure or diagnosis. Contact precautions were not consistently implemented or documented, and staff did not always follow facility policy regarding the use of personal protective equipment (PPE) and isolation procedures. Furthermore, the facility did not ensure that deep cleaning of resident rooms was performed in conjunction with treatment, as recommended by medical providers. There were inconsistencies in the cleaning of launderable and non-launderable items, and privacy curtains with visible stains were not always removed or laundered during deep cleaning, as reported by both residents and housekeeping staff. Residents involved in these deficiencies included individuals with significant medical histories, such as immunodeficiency, chronic illnesses, and cognitive impairments. These residents experienced repeated exposures and infestations, with one resident reporting psychosocial harm due to the ongoing situation. Staff interviews revealed a lack of clarity and follow-through regarding infection control protocols, medication administration, and communication with medical providers. The facility did not have a dedicated infection preventionist for a period during which these events occurred, further contributing to lapses in infection control practices.
Failure to Re-Evaluate and Document Discharge Planning for Resident
Penalty
Summary
The facility failed to regularly re-evaluate, refer, and document referrals to local contact agencies for discharge planning and assessment for one resident. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, major depressive disorder, and osteoarthritis, was found to have intact cognition and required only supervision or minimal assistance with activities of daily living. Despite being assessed as having good discharge potential and expressing a desire to be discharged to an assisted living facility, the resident reported not receiving updates or assistance regarding discharge planning after an initial referral discussion with a previous social worker. The resident stated he had not been informed of any progress or timeline for discharge and was concerned about having nowhere to go if the facility did not assist him. Staff interviews revealed that the social services department had experienced significant turnover, with most social workers having left and a new team recently starting. The Social Services Director confirmed that there was no record of a referral for discharge assessment in the facility's referral tool, despite the resident's eligibility and readiness for community discharge. The resident's care plan and assessments had not been updated as required, and there was a lack of ongoing communication and documentation regarding discharge planning, contrary to facility policy and standard practice.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences by repeatedly serving oatmeal instead of grits, despite the resident's clear dislike and reported allergic reaction to oatmeal. The resident, who has an intact cognitive status with a BIMS score of 15, expressed dissatisfaction and concern about receiving oatmeal, which was documented as a dislike on their meal ticket and dietary preference sheet. The resident's care plan highlighted nutritional risks due to their medical conditions, including moderate protein-calorie malnutrition and a history of weight loss, necessitating careful attention to dietary preferences. During a survey, the resident reported to the surveyor that they had informed both nursing and dietary staff about their preference against oatmeal, yet the issue persisted. On the day of the survey, the resident was again served oatmeal, which was confirmed by the surveyor upon inspection of the breakfast tray. The dietary aides acknowledged the error, attributing it to an oversight during meal preparation, and corrected it by providing grits. The facility's policy mandates that resident dietary preferences be documented and respected, but this was not adhered to in this instance, leading to the deficiency.
Failure to Coordinate PASRR Screening for Resident
Penalty
Summary
The facility failed to coordinate with the appropriate state-designated authority to refer a resident with a severe mental disorder for a new PASRR Level I screen before the expiration of the resident's PASRR Level II short-term approval. This oversight affected one resident out of four reviewed for resident rights in a total sample of 20 residents. The deficiency was identified during an interview and record review, where it was revealed that the social services department, responsible for following up with the PASRR process, did not track the expiration date of the PASRR Level II approval for the resident. The resident in question, a [AGE] year-old individual, has diagnoses including cognitive communication deficit, schizophrenia, schizoaffective disorder, and bipolar type. The resident's PASRR Level II outcome document indicated a short-term approval without specialized services, which was set to end on February 27, 2025. The facility's policy requires a new Level I screen to be submitted no later than 10 days before the short-term approval ends. However, there was no documentation showing that a new Level I screen was conducted since the PASRR Level II expired, indicating a lapse in the facility's compliance with the PASRR process.
Failure to Address Medication Refusal in Resident Care Plan
Penalty
Summary
The facility failed to provide a person-centered care plan for a resident with behavioral concerns who refused psychotropic medication. The resident, who has a medical history of mood affective disorder, anxiety disorder, cocaine abuse, bipolar disorder, and manic severe disorder, was noted to have intact cognition with a BIMS score of 15. Despite being prescribed Hydroxyzine and Seroquel to manage anxiety, agitation, and bipolar disorder, the resident consistently refused these medications. The refusal was attributed to a lack of trust in the staff administering the medication. The resident's behavioral issues included verbal aggression towards staff and peers, leading to an involuntary discharge and subsequent readmission. Interviews with facility staff and the resident's case manager revealed that the resident frequently complained about mistreatment and lack of respect, although no physical abuse was reported. The Director of Nursing acknowledged the resident's verbal aggression and frequent room changes, attributing the behavior to the refusal of psychotropic medication. Upon review, it was found that the resident's care plan did not address the issue of medication refusal, which was a significant oversight given the resident's ongoing behavioral concerns. The facility's care plan policy mandates the development of a comprehensive, person-centered care plan for each resident, which was not adhered to in this case.
Fire Incident Due to Faulty Wheelchair and Alarm System Failure
Penalty
Summary
The facility failed to ensure the safety of residents by not properly assessing and maintaining a motorized wheelchair, which led to a fire incident involving three residents. The fire occurred in a resident's room, where the motorized wheelchair was suspected to have caused the fire due to exposed wires and a potential spark. The resident using the wheelchair, who had severe cognitive impairment and multiple medical conditions, was unable to move the wheelchair during the incident, resulting in a dangerous situation. The fire alarm system in the facility did not function properly during the incident, as no alarms sounded, and the fire department was not automatically notified. This failure in the alarm system delayed the response to the fire, increasing the risk to the residents involved. Staff members had to manually call 911 and evacuate the residents from the room. The facility's maintenance director initially misidentified the cause of the fire, attributing it to an electrical outlet, before later acknowledging the wheelchair as the source. The facility did not conduct a thorough investigation or report the incident to the state health department, as it was not considered an unusual occurrence by the administration. Additionally, the residents involved were not adequately assessed for potential injuries or smoke inhalation following the incident. The facility's policy on wheelchair maintenance was unclear, and the responsibility for maintaining the resident's wheelchair was left to the resident's family, who performed unauthorized repairs that may have contributed to the fire.
Failure to Address Resident's Psychosocial Needs After Fire Incident
Penalty
Summary
The facility failed to properly assess and implement interventions for a resident who experienced a fire incident in her room. The resident, who has a history of major depressive disorder and other significant medical conditions, was involved in a fire that occurred in her room. The fire was reportedly sparked by her motorized wheelchair, which was not functioning properly. Despite the resident's non-verbal status, she was able to communicate her fear and distress through gestures, indicating that she was scared during and after the incident. The facility did not adequately address the resident's psychosocial needs following the traumatic event. There was no documentation of social service interventions or monitoring of the resident's emotional state in the days following the fire. The resident's care plan was not reviewed or revised to reflect her status and needs after the incident. Additionally, the resident continued to use the same motorized wheelchair and bed that were involved in the fire, which could serve as triggers for her trauma. Interviews with facility staff, including the Social Service Director and a Licensed Clinical Social Worker, revealed that the resident's involvement in the fire was recognized as a potentially traumatizing event. However, there was no evidence that psychotherapy or other supportive measures were provided to help the resident process her emotions. The lack of timely and appropriate interventions highlights a deficiency in the facility's response to the resident's psychosocial needs after the fire incident.
Failure to Maintain Resident's Motorized Wheelchair Leads to Fire
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, specifically regarding a motorized wheelchair owned by a resident. The Director of Maintenance, V5, stated that the facility does not conduct routine checks on residents' electric wheelchairs, as they are owned by the residents and not the facility. This lack of maintenance led to a fire incident involving a resident's motorized wheelchair, which was identified as the source of the fire by the Chicago Fire Department. The fire was caused by exposed wires on the wheelchair's cord, which ignited nearby combustible materials. On the day of the incident, the resident's son, V41, had replaced the electronic charger for the wheelchair and was responsible for its maintenance. However, the son lacked formal training in wheelchair repair, relying on his experience with motorcycles. The fire occurred when the wheelchair was being charged using an extension cord, which melted and contributed to the fire. The facility's fire alarm system did not activate, delaying the staff's awareness of the fire. Emergency Medical Technicians present at the scene assisted in evacuating the resident and extinguishing the fire. The fire department's investigation confirmed that the fire was electrical in nature, likely due to the damaged cord on the wheelchair. The facility's policy requires monthly surveillance of resident rooms and equipment, but this was not adhered to for the resident's personal equipment. The report highlights the need for proper maintenance and inspection of personal equipment to prevent such incidents. The motorized wheelchair was not inspected by a qualified technician after the fire, raising concerns about its safety for future use.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light devices were within reach for two residents, leading to a deficiency in the quality of care. For one resident, the call light was found on top of three pillows on the nightstand, out of reach. This resident, who has a history of paraplegia, major depressive disorder, and moderate cognitive impairment, expressed that she could not reach her call button and felt that it had been taken away from her. A Certified Nursing Assistant confirmed that the call light was not within reach and repositioned it appropriately. Another resident, who is legally blind and has a history of falls, was found with the call light attached to the lowest part of the bed rail, making it inaccessible. On a subsequent observation, the call light was found on the floor. This resident, who is cognitively intact, expressed a need for assistance but was unable to reach the call light. A Licensed Practical Nurse acknowledged that the call light should not have been on the floor and stated that it might have slipped off the resident. The facility's policy mandates that call lights should always be within reach of residents, especially those who are vulnerable or have specific needs.
Failure to Provide Scheduled Bathing for Resident
Penalty
Summary
The facility failed to adhere to its policy of providing a shower or bath to residents at least once a week, as evidenced by the case of a resident with paraplegia and bilateral foot drop. This resident, who is dependent on staff for activities of daily living, reported not having received a shower since May, despite being scheduled for showers twice a week. Observations and interviews revealed that there were no records of the resident receiving a shower or bed bath since being transferred to a different floor of the facility. The resident expressed discomfort due to her hair being sticky and difficult to manage, indicating a lack of proper hygiene care. The facility's bathing policy requires that all residents be offered a bath or shower at least once a week, with more frequent bathing as needed. However, the records reviewed did not show any documentation of the resident receiving the required care. The staff, including the restorative nurse and the wound nurse, acknowledged the absence of shower records and suggested that bed baths might have been given due to the resident's shingles. Despite this, the necessary documentation was not completed, and the resident's hygiene needs were not adequately met, as confirmed by the facility administrator.
Improper Positioning During Dining
Penalty
Summary
The facility failed to provide proper positioning for a resident during dining, which posed a risk for choking and aspiration. The resident, who has severe cognitive impairment and multiple diagnoses including hemiplegia, aphasia, and anxiety disorder, was observed in a low Fowler's position while attempting to eat lunch. This position was inappropriate for eating, as confirmed by a Licensed Practical Nurse (LPN) who noted the potential for choking or aspiration. Despite the resident's care plan indicating a need for assistance with dining and proper positioning, the resident was left in a reclined position, leading to coughing during the meal. Staff interviews revealed inconsistencies in understanding the correct positioning for residents during meals, with some staff indicating a 90-degree upright position and others suggesting a semi-Fowler position. The facility's policy and in-service education documents emphasize the importance of proper positioning to prevent aspiration and promote optimal intake. However, these guidelines were not followed in the case of the resident, resulting in a deficiency in care during the dining experience.
Failure to Schedule Dental Appointment for Resident with Severe Decay
Penalty
Summary
The facility failed to schedule a dental appointment for a resident with severe dental decay, as ordered by a Nurse Practitioner. The resident, who is dependent and has multiple diagnoses including essential hypertension and respiratory failure, was observed expressing the need for a tooth extraction due to pain and decay. Despite the resident's care plan and physician orders indicating the need for a dental evaluation and extraction, the appointment was not scheduled, resulting in continued pain and decay for the resident. Interviews with facility staff revealed a breakdown in communication and scheduling processes. The Restorative Nurse acknowledged the presence of the dental order in the resident's chart but noted it was not scheduled due to its absence on the communication board. The staff member responsible for scheduling appointments stated that they rely on the communication board to know when to schedule appointments, indicating a lack of verbal communication or alternative methods to ensure appointments are made. The facility's policy on dental services was not adhered to, leading to the deficiency identified by the surveyors.
Failure to Monitor Vital Signs During Medical Emergency
Penalty
Summary
The facility failed to follow its policy and adequately monitor vital signs during a medical emergency involving a resident who experienced a seizure. The Licensed Practical Nurse (LPN) observed the resident shaking in bed and noted high vital signs, which was unusual given the resident's typical low blood pressure. The doctor was contacted and instructed that the resident be sent to the hospital. However, the resident was transported via private ambulance rather than 911, as the doctor was informed that the resident was stable. The LPN did not take a full set of vital signs after the seizure, as required by the facility's policy, and the resident's oxygen saturation was not documented post-seizure. The resident, who has a history of dementia, epilepsy, and traumatic brain injury, experienced a seizure that lasted approximately two minutes. The LPN noted that the resident's oxygen saturation was 90% on room air, which was lower than the resident's usual readings. The paramedics later recorded an oxygen saturation of 88% and placed the resident on oxygen. The facility's emergency management policy requires vital signs to be taken every 10-15 minutes during a medical emergency until the resident is stable or transferred, which was not adhered to in this case. Additionally, the policy mandates notifying the resident's physician of significant changes in condition, which may not have been fully communicated regarding the resident's oxygen saturation levels.
Failure to Administer Prescribed Medication for ADHD
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with ADHD, depression, and other medical conditions. The resident, a 28-year-old male, was admitted with a physician's order for Dextroamphetamine Sulfate (Adderall) to manage his ADHD. Despite the psychiatrist's assessment and prescription on 5/15/24, the medication was not administered from 5/15/24 through 5/23/24. This lapse led to the resident feeling sad, depressed, tired, and refusing care, as documented in multiple nursing notes and confirmed by the resident's own statements. The psychiatrist, who assessed the resident on 5/15/24, confirmed that the medication was necessary and completed the required forms for the pharmacy. However, the Director of Nursing assumed the psychiatrist had faxed the prescription, which did not happen. The nursing staff failed to follow up adequately with the pharmacy or the psychiatrist, resulting in the resident not receiving his medication. The resident repeatedly expressed his distress and the negative impact of not receiving his medication, but the issue remained unresolved until 5/23/24. Interviews with the psychiatrist, Director of Nursing, and nursing staff revealed a breakdown in communication and procedure. The psychiatrist was unaware that the medication had not been delivered, and the Director of Nursing did not verify the prescription's status with the pharmacy. The facility's policy on controlled substances was not followed, leading to the resident's continued suffering and refusal of care. The deficiency was evident through the resident's deteriorating mental and physical state, as well as the documented failure to administer the prescribed medication.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, which has the potential to affect all 176 residents. During an initial kitchen tour, it was observed that food items were not labeled and dated with an opened and use-by date. Specifically, an opened case of fresh strawberries was found shriveled and covered in a white, light gray fuzzy material, indicating spoilage. Additionally, black/dark gray dust-like material was observed covering the refrigerator fan covers and ceiling, which could potentially contaminate the food. An opened gallon of barbeque sauce was also found without an open or use-by date, making it difficult for staff to track its usability. The facility's policy requires all refrigerated food to be used within seven days of opening, regardless of the manufacturer's use-by date, but this was not adhered to in practice. Furthermore, the facility failed to properly sanitize cooking equipment according to the manufacturer's directions. During the preparation of pureed food items, it was observed that the blender container, lid, and blade were not submerged in the sanitizing solution for the required 60 seconds. Instead, the items were only dipped for 10 to 16 seconds, which is insufficient for proper sanitation. The Dietary Manager confirmed that the items need to be left in the sanitizing solution for a full minute to ensure they are fully sanitized. The facility's policies on labeling, dating, and sanitizing were not followed, leading to potential cross-contamination and food safety issues.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to ensure that the dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. During an observation, it was noted that two of the three lids on a large dumpster were wide open, and there was debris and trash on the ground around the dumpster. The Dietary Manager acknowledged that the lids should not be left open as it allows birds and insects to access the garbage. Additionally, the Divisional Manager for Laundry and Housekeeping Services confirmed that the lids must be closed to prevent rodents from getting into the dumpster and potentially leading a trail to the building. The facility's policies on garbage disposal and maintaining a clean and sanitary environment were not followed, as evidenced by the open dumpster lids and surrounding debris.
Inadequate Supply of Linens
Penalty
Summary
The facility failed to provide an adequate supply of linens to meet the needs of residents and staff, affecting all 180 residents. On multiple occasions, it was observed that there were no bath towels available on the CNA carts on the 2nd floor. Interviews with CNAs revealed that they often run out of towels during their shifts and have to wait for the laundry room to supply more. The laundry aides confirmed that linen carts are sent to the floors at the start of each shift, but staff sometimes have to wait for linens if the laundry has accumulated and is not yet clean. The par levels for linens were outdated, and the facility did not have enough bath towels in stock to meet the needs of the residents. The Division Manager of Laundry Services acknowledged that the par levels on the Daily Linen Delivery document were outdated and that the facility did not have enough bath towels. The manager also mentioned that linens are sometimes thrown away by staff or not sent down to the laundry room, contributing to the shortage. Observations of the linen overstock area confirmed that there were no bath towels available, only flat sheets, fitted sheets, and washcloths. The Daily Linen Delivery documents reviewed for a week showed that the facility consistently did not meet the minimum count of linens required for resident care. Despite the administrator's efforts to order additional linens and borrow from a sister facility, the issue persisted. On the following day, it was observed that the second floor had no bath towels, and the third and fourth floors had only a limited number of bath towels and washcloths. CNAs reported that residents sometimes hide towels due to the frequent shortages. The administrator was made aware of the ongoing issue but the problem remained unresolved at the time of the survey.
Inadequate CNA Staffing on Weekends
Penalty
Summary
The facility failed to ensure sufficient certified nursing assistants (CNAs) on weekends to meet the needs of the residents. This deficiency was identified through interviews, record reviews, and observations. On one occasion, a resident was observed with a long beard and stated that staff did not offer or assist him with shaving. The staffing coordinator confirmed that the facility does not use agency staff and that weekends are particularly challenging due to frequent call-offs. The facility's daily schedule and Payroll Based Journal (PBJ) reports showed that the facility did not meet the required staffing numbers on multiple days, particularly on weekends. The Director of Nursing (DON) and other staff members acknowledged the staffing challenges, especially on weekends, and mentioned that nursing managers often work on the floor to fill in gaps. Despite these efforts, the facility's staffing policy and facility assessment tool indicated that the required number of CNAs per day was not consistently met. The PBJ report for the fiscal year 2024 also triggered for excessively low weekend staffing, further highlighting the issue. The facility's census report showed 180 residents, indicating a significant impact due to the staffing deficiencies.
Failure to Manage Smoking Materials and Assessments
Penalty
Summary
The facility failed to ensure that smoking materials, including cigarettes and lighters, were given to designated staff, complete smoking assessments in a timely manner, and develop comprehensive care plans for smoking. These failures potentially affected four residents reviewed for smoking. Observations revealed that residents were keeping smoking materials with them inside the facility, contrary to the facility's smoking policy. For instance, one resident was observed with a lighter on her bed, and another resident had a pack of cigarettes in his pocket. Both residents stated they were keeping their smoking materials with them, which is against the facility's policy that prohibits residents from possessing smoking materials inside the building. The Social Service Director (SSD) confirmed that smoking assessments are supposed to be done within 48-72 hours upon admission and then quarterly or as needed. However, the review of electronic health records showed that smoking assessments and care plans were either missing or outdated for the residents involved. For example, one resident's last smoking assessment was completed several months ago, and another resident did not have a smoking assessment or care plan documented in their electronic health record. The SSD acknowledged that without timely smoking assessments, the facility could not determine if residents were safe to smoke independently or needed supervision. During a Resident Council Meeting, another resident was observed with a lighter and a carton of cigarettes in their pocket. This resident's smoking risk assessment and care plan were also outdated, and the care plan indicated that the resident had unsafe smoking issues related to behavior. The facility's smoking policy clearly states that all residents who desire to smoke must be assessed by the interdisciplinary team and that possessing smoking materials inside the building is prohibited. The failure to adhere to these policies and procedures could lead to significant safety hazards within the facility.
Narcotic Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure narcotic medications were administered in accordance with physician orders, maintain accurate narcotic counts at the change of shift, and document the administration of ordered narcotic medications for two residents. Specifically, for one resident, the narcotic reconciliation review revealed discrepancies in the amount of Morphine Sulfate Oral Solution remaining in the bottle compared to the documented amount on the narcotic sheet. The Licensed Practical Nurse (LPN) responsible for the medication cart did not notice the discrepancy during the shift change count. Similarly, for another resident, the amount of Morphine Sulfate remaining in the bottle was less than the documented quantity, and the LPN did not notice this discrepancy during the shift change count either. Both instances indicate a failure to adhere to proper procedures for narcotic administration and documentation. The Director of Nursing (DON) confirmed that narcotics are supposed to be counted at the change of shift by two nurses, and any discrepancies should be reported immediately. However, the discrepancies in the narcotic counts for the two residents were not identified or addressed promptly. The facility's policy on controlled substances requires accurate record-keeping and immediate reporting of any discrepancies, but these procedures were not followed, leading to the identified deficiencies. The facility provided updated Controlled Substances Proof of Use forms and conducted in-service education on proper medication labeling, storage, and controlled substances handling, but these actions were taken after the deficiencies were identified.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow professional standards of practice and facility policy to prevent and control infection in the provision of patient care. A CNA was observed not performing hand hygiene after handling breakfast trays in rooms with Enhanced Barrier Precautions (EBP) signage. Additionally, a resident with a PICC line did not have EBP signage on their door, and another resident's room had improper placement of a PPE disposal bin, leading to incorrect doffing procedures. The Infection Prevention Nurse confirmed that staff should don PPE before entering rooms and doff PPE in the doorway, but observations showed this was not being followed. The Infection Prevention Nurse also reported that the facility had a 4.21% healthcare-acquired infection rate last month, primarily due to UTIs and soft tissue/wound infections. The facility's policy on EBP requires gown and gloves during high-contact resident care activities and mandates hand hygiene before and after entering rooms. Despite these policies, staff were observed not adhering to proper infection control practices, such as not performing hand hygiene between rooms and doffing PPE inappropriately.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to repair a hole in the ceiling and replace missing or stained ceiling tiles in the first-floor dining room, and failed to maintain the walls in residents' rooms in good repair. During a facility tour, a missing ceiling tile and four ceiling tiles with brown stains were observed in the dining room, along with peeling plaster and a large yellow garbage can positioned to catch water from a leak. Residents expressed their concerns about the leaks and the lack of timely repairs. Additionally, holes and damaged walls were observed in the rooms of three residents, with the Maintenance Director acknowledging the issues and stating that repairs were being made floor by floor due to years of neglect and limited maintenance staff. The Maintenance Director, who started working at the facility in January, confirmed that there were seven leaks in the facility and that repairs were ongoing. However, the surveyor noted that the issues in the dining room and residents' rooms had not been addressed promptly. Work orders and the facility's preventive maintenance plan indicated that inspections and repairs should be conducted regularly, but the observed conditions suggested that these measures were not effectively implemented. The facility's failure to maintain a safe, clean, and comfortable environment for residents was evident in the observed deficiencies.
Failure to Follow Policy for Self-Administration of Medications
Penalty
Summary
The facility failed to follow its policy and procedure for determining and assessing a resident's ability to self-administer medications. Specifically, the facility did not obtain a physician's order for medication self-administration, nor did it implement a person-centered care plan addressing self-administration of medications for one resident. The resident, who has diagnoses including colon cancer, auditory hallucinations, major depressive disorder, and mild cognitive impairment, was found with wound dressings and a bottle of multivitamins in their drawer, which they stated they used daily without proper assessment or documentation by the facility staff. The Director of Nursing confirmed that the facility's process requires a nurse to assess the resident's capability to self-administer medications, provide education, and obtain a physician's order. However, a review of the resident's electronic health records showed no documentation of such an assessment, education, or physician's order. Additionally, the resident's care plan did not address medication self-administration. This oversight indicates a failure to adhere to the facility's policy titled 'Self Administration of Medications and Treatments,' which mandates a thorough assessment and documentation process before allowing residents to self-administer medications.
Failure to Report Resident's Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to follow its policy in reporting an abuse and neglect allegation made by a resident. On 05/21/24, a resident approached a surveyor and reported that money and personal items were being stolen and that they were being neglected and bullied by staff. An LPN who was present did not report the allegation to the administrator as required by the facility's policy. The administrator, when interviewed the following day, confirmed that they had not been made aware of the resident's allegations and outlined the facility's procedure for handling such reports, which includes immediate notification and investigation. The administrator was informed of the resident's allegations during the interview and subsequently initiated an investigation and reported the incident to the state within the required timeframe. The facility's policy mandates that any incident, allegation, or suspicion of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property be reported immediately to the administrator or compliance officer. The failure to report the resident's allegations promptly represents a breach of this policy. The resident reiterated their claims of missing money, unreceived checks, and bullying during a meeting with the administrator and the surveyor. The administrator then took steps to document and report the incident as per the facility's policy, but the initial delay in reporting by the LPN constituted a deficiency in the facility's adherence to its abuse prevention and reporting protocols.
Failure to Conduct Timely PASARR Level II Assessment
Penalty
Summary
The facility failed to refer a resident (R3) to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation. R3's initial screen, completed by the state-designated authority, indicated a reasonable basis for suspecting a developmental disability or mental illness. Despite this, the facility did not request a PASARR Level II assessment until prompted by the surveyor. R3's diagnoses included Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Bipolar Disorder, and Restlessness and Agitation, all of which necessitate a Level II assessment according to the facility's Social Service Director (V16). V16 admitted that the PASARR Level I screen was only submitted the day before the surveyor's inquiry, revealing a lapse in the facility's compliance with federal and state regulations regarding timely PASARR evaluations. The facility's policy mandates that Level I and Level II PASARR documents be requested prior to a resident's arrival. However, V16 acknowledged that the facility was in the process of auditing to identify residents needing Level II assessments, indicating a systemic issue. The failure to conduct timely PASARR Level II assessments was further evidenced by the fact that R3 had been living at the facility for an extended period without the necessary evaluation. This deficiency highlights a significant oversight in the facility's adherence to regulatory standards designed to ensure appropriate care for residents with mental health and developmental disabilities.
Failure to Assist with Personal Hygiene and Provide Adequate Communication Support
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident was assisted or supervised with personal hygiene, specifically shaving. The resident, admitted with multiple diagnoses including alcohol dependence, esophagitis, and bipolar disorder, was observed with a long beard and stated that staff did not offer or assist him with shaving. The resident expressed a desire to have his beard shaved off, but the assigned CNA admitted that she did not offer to shave the resident and was not informed that he wanted to be shaved. The Director of Nursing confirmed that all residents should receive ADL care, including grooming and shaving, and that such care should be documented if provided or refused. The resident's care plan indicated a need for supervision to limited assistance with personal hygiene, but this was not followed as per the facility's policy for activities of daily living dated February 2023, which requires residents' facial hair to be shaved if necessary and appropriate per personal preference. The facility also failed to follow its policy and standards of professional practice in providing care and communication in a resident's primary language. The resident, who primarily speaks Spanish, was found to be at risk for complications with communication. Staff initially stated that the resident points to what he wants, but later mentioned the use of an app and a restorative aide for communication. The resident confirmed that he relies on a restorative aide, housekeeper, or another resident who speaks Spanish to help him communicate. The care plan for this resident included the use of communication cards/board, but no such tools were observed in the resident's room. The facility's policy on communication dated January 2023 mandates that reasonable steps be taken to ensure meaningful communication with persons with limited English proficiency (LEP). The facility's failure to assist with personal hygiene and to provide adequate communication support in the resident's primary language were identified as deficiencies. These actions and inactions affected the quality of care provided to the residents, as documented in the observations, interviews, and record reviews conducted by the surveyors.
Failure to Address Resident's Skin Lesions
Penalty
Summary
The facility failed to identify and address an alteration in skin integrity for one resident, resulting in unaddressed skin lesions and resident discomfort. On 05/21/24, the resident was observed with multiple round lesions on the left arm, upper back, and legs, some of which were open, red, and bleeding. The resident expressed discomfort due to these lesions. The Wound Nurse was unaware of the current wounds and had previously stopped following the resident's wound care. Despite a Bacitracin ointment order being placed on 05/22/24, the resident had not received the cream by the following day, and the nursing staff were unsure about the medication process. The Infection Prevention Nurse confirmed that the Bacitracin ointment should have arrived the same day it was ordered, but it had not. The Wound Nurse and Infection Prevention Nurse evaluated the resident and initiated a treatment order, including a dressing for the left arm and upper back. The facility's policy on skin care prevention requires all nursing staff to evaluate residents for changes in their skin condition, which was not adhered to in this case, leading to the deficiency.
Failure to Provide Ordered Pressure Redistribution Mattress
Penalty
Summary
The facility failed to follow the care plan for a resident (R90) by not providing a pressure redistribution mattress or low air loss mattress as ordered, and did not complete an assessment to identify the resident's risk for pressure ulcers in a timely manner. R90 was admitted with multiple diagnoses, including hemiplegia, diabetes, severe malnutrition, and a history of pressure ulcers. On observation, R90 was found lying in bed without the ordered air mattress, despite having an active order for it and being at very high risk for skin breakdown as indicated by a Braden scale score of 9. The resident's care plan also documented the need for a pressure redistribution mattress due to risk factors such as incontinence, immobility, and diabetes. The wound nurse (V17) confirmed that skin checks and assessments are done upon admission and that preventive measures, including air mattresses, should be in place if ordered. The Director of Nursing (V2) also stated that all physician orders should be followed. Despite these protocols, the resident did not have the required air mattress, which was crucial for preventing further skin breakdown. The facility's policy for skin care prevention mandates the use of pressure-reducing mattresses for residents who are bed-bound, which was not adhered to in this case.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered oral nutritional supplements and other nutrition interventions to two residents. During an initial kitchen tour, it was observed that Magic Cup supplements and whole milk were in stock. However, during meal observations, one resident did not receive double portions or the Magic Cup supplement as ordered, and another resident did not receive the Magic Cup or whole milk as specified in their meal ticket. Interviews with staff confirmed that these items should have been provided according to the residents' dietary plans, but they were not included on the meal trays during service. One resident, who has a history of weight loss and is on a mechanical soft diet with double portions and Magic Cup supplements, did not receive the required double portions or the Magic Cup during lunch. This resident's weight has been stable due to these interventions, and the failure to provide them could interfere with their weight maintenance. Another resident, who has a significantly low BMI and is on a mechanical soft diet with whole milk and Magic Cup supplements, did not receive the Magic Cup or whole milk during lunch. This resident has experienced unplanned weight loss and requires these supplements to promote weight gain. The facility's dietary policies state that supplements and increased portions should be provided as ordered by the physician or registered dietitian. The failure to adhere to these orders was confirmed through staff interviews and record reviews. The dietary director and diet technician acknowledged that the supplements and double portions were not provided as required, which could potentially impact the residents' nutritional status and weight management.
Failure to Administer Prescribed Tube Feeding Volumes
Penalty
Summary
The facility failed to provide the total volume of prescribed gastrostomy tube feeding as ordered by the physician for two residents. Observations revealed that the tube feeding bottles for both residents were hung the previous day and were not replaced or supplemented to meet the prescribed volume. Specifically, one resident's tube feeding was observed to be infusing at 65 ml per hour, but the total volume administered was less than the prescribed 1300 ml per day. Similarly, the second resident's tube feeding was infusing at 75 ml per hour, but the total volume administered was less than the prescribed 1500 ml per day. Interviews with the nursing staff confirmed that the tube feedings were turned off from 10 AM to 2 PM daily, and the bottles were not replaced or supplemented to ensure the residents received the full prescribed volume. The Director of Nursing stated that the nurses should follow the tube feed order as prescribed and document the volume infused in the Medication Administration Record (MAR). The Registered Dietitian emphasized the importance of administering the full volume to meet the residents' nutritional needs, especially since one resident was entirely dependent on tube feedings for nutrition and hydration. The MAR entries for both residents showed discrepancies in the total volume of tube feeding administered, consistently falling short of the prescribed amounts. The facility's policy on tube feeding requires continuous feedings based on individual resident needs and documentation of the intake on the MAR. However, the observations and interviews indicated that the policy was not followed, leading to the deficiency in providing the prescribed tube feeding volumes for the residents involved.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow residents' care plans and physician orders for administering the correct oxygen flow rate for two residents. Resident R39 was observed using oxygen via nasal cannula with the flow rate set to 1.5 liters per minute (LPM) on one occasion and 1 LPM on another occasion, despite having a physician order for 2-3 LPM. R39, who has diagnoses including Chronic Respiratory Failure with Hypoxia, Asthma, Obstructive Sleep Apnea, Pulmonary Hypertension, and Acute on Chronic Systolic Congestive Heart Failure (CHF), denied changing the flow rate and stated that the nurse sets it up. R39's electronic health records did not have an order or assessment for self-administration of oxygen, and the care plan indicated that oxygen should be administered per physician orders. Similarly, Resident R148 was observed receiving oxygen via nasal cannula with the flow rate set to 1.5 LPM, despite having a physician order for continuous oxygen at 2-4 LPM. R148, who has diagnoses including Unspecified Systolic (Congestive) Heart Failure, COPD, Asthma, and Dyspnea, also denied changing the flow rate and stated that the nurses set it up. R148's electronic health records did not have an order or assessment for self-administration of oxygen, and the care plan indicated that oxygen should be administered per physician orders. The facility's policy on oxygen therapy requires a physician order specifying the amount of oxygen to be administered, the route of administration, and the indication of use, which was not followed in these cases.
Failure to Document and Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that the physician documented in the resident's clinical record their assessment, current condition, and medical problems for each visit. Specifically, the psychiatrist did not document their assessment of a resident who was prescribed Dextroamphetamine Sulfate for ADHD. This lack of documentation led to the resident not receiving the prescribed medication for nine days. The resident, who has a medical history including ADHD, depression, and paraplegia, reported feeling sad, depressed, tired, disorganized, and unwilling to move around due to not receiving the medication. The psychiatrist assessed the resident and prescribed the medication, but did not complete the necessary documentation or ensure the prescription was faxed to the pharmacy. The Director of Nursing believed the psychiatrist had completed the prescription and faxed it, but this was not verified. The nursing staff did not follow up adequately to ensure the medication was delivered, leading to the resident's continued lack of medication. Interviews with the resident, psychiatrist, and nursing staff revealed a breakdown in communication and procedure. The psychiatrist did not document the assessment or follow up on the prescription, and the nursing staff did not verify the prescription was received by the pharmacy. This resulted in the resident experiencing significant distress and a decline in their condition due to the lack of medication.
Failure to Follow Psychotropic Medication Policies
Penalty
Summary
The facility failed to follow its policy regarding the use of psychotropic medications for three residents. Specifically, the facility did not obtain informed consent for psychotropic medication use, ensure PRN psychotropic medications had a duration of no longer than 14 days, attempt Gradual Dose Reduction (GDR) for psychotropic medication use, or complete AIMS (Abnormal Involuntary Movement Scale) tests in a timely manner. These failures were identified during interviews and record reviews and could potentially affect residents reviewed for unnecessary psychotropic medication use in a sample of 35. One resident, admitted with multiple diagnoses including schizoaffective disorder and major depressive disorder, had active orders for FLUoxetine and QUEtiapine. However, there was no documentation of an AIMS assessment or GDR evaluation in the resident's electronic health record (EHR). The consultant pharmacist's medication regimen review recommended an AIMS test, but it was not completed until the survey date. The resident's care plan included monitoring for side effects and adverse reactions, but there was no evidence of GDR documentation. Another resident, admitted with diagnoses including unspecified dementia and bipolar disorder, had orders for Mirtazapine and Olanzapine. The resident's EHR did not contain recent consent forms for psychotropic medications, and the consultant pharmacist's medication regimen reviews did not include recommendations until the survey date. The resident's care plan included goals to remain free of drug-related complications and to consult with the pharmacy and MD for dosage reduction when clinically appropriate. A third resident, admitted with diagnoses including major depressive disorder and anxiety disorder, had multiple psychotropic medications ordered, but there was no recent GDR documentation. The consultant pharmacist's medication regimen review recommended AIMS tests and reminded that PRN psychotropic orders are only valid for 14 days unless otherwise stated.
Failure to Administer Insulin with Meals
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, a Licensed Practical Nurse (LPN) administered 4 units of Humalog Insulin to a cognitively intact resident one hour before the meal was served, instead of with the meal as prescribed. This action was observed by a surveyor, and the LPN acknowledged that the insulin should have been administered with the meal to prevent hypoglycemia, as Humalog is a fast-acting insulin. The resident's electronic Medication Administration Record (eMAR) and Physician Order Sheet (POS) both indicated that the insulin should be administered with meals. The Director of Nursing confirmed that the expectation is for nurses to administer Humalog Insulin with meals, and failing to do so is a medication error that could lead to severe consequences such as hypoglycemia, coma, or death. The resident also reported that they do not usually receive their insulin with meals, even though it is supposed to be administered that way.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled when opened, expired medications were removed from the medication cart and medication room, and medications for discharged residents were removed from the medication cart. During an inspection, expired medications were found in the top drawer of the fourth-floor medication cart and the fourth-floor medication room. Additionally, medications that were opened without an open date were observed in the second-floor medication cart. The Licensed Practical Nurses (LPNs) acknowledged the presence of expired medications and stated that they would dispose of them and notify the manager. The Director of Nursing (DON) confirmed that nurses are responsible for checking expiration dates daily and removing expired medications to prevent potential harm to residents. The report also noted that medications for discharged residents were not removed from the medication cart, contrary to the facility's policy. The DON stated that medications should be sent with the resident upon discharge and should not remain in the medication cart. The facility's policy on medication storage emphasizes the importance of storing medications safely, securely, and properly, and mandates the immediate withdrawal and disposal of outdated or deteriorated drugs. Despite these policies, the survey revealed lapses in adherence, leading to the presence of expired and improperly labeled medications in the facility.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an altercation between two residents. Resident R11, who suffers from legal blindness, schizophrenia, and altered mental status, became agitated while walking with an activity aide. During this episode, R11 began flailing his arms and inadvertently scratched Resident R12, who was seated in a wheelchair in the dining area. R12 sustained superficial scratches to the face, which were treated with first aid and monitored by the wound care team. R12 expressed that he felt safe and understood that the incident was accidental. The incident occurred when the activity aide attempted to redirect R11, who was already agitated about his trust fund. R11 started swinging his arms after nearly tripping over a cord, hitting the activity aide and then grabbing R12 by the neck. The situation escalated until other residents and staff intervened to separate the two. R11 was placed on 1:1 supervision and later sent to a community hospital for psychiatric evaluation. The facility's investigation concluded that the incident was accidental and not intentional abuse. R11's care plan documented his history of resisting care and impaired memory and decision-making abilities. Despite these known issues, the facility's actions to manage R11's behavior were insufficient to prevent the altercation. The facility's abuse prevention policy affirms residents' rights to be free from abuse, yet the measures in place failed to protect R12 from harm during R11's behavioral episode.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the regional office, affecting one resident. The resident, a male with a history of stroke, aphasia, major depressive disorder, adult failure to thrive, and anxiety, was noted to have swelling, redness, pitting edema, and warmth in his right contracted arm. Initially, the staff and nurse practitioners believed the symptoms were due to cellulitis and treated him with antibiotics. However, an x-ray later revealed a fracture of the distal humerus, leading to the resident being sent to a local hospital. Despite the discovery of the fracture, the facility administrator did not report the injury to the regional office, as it was not deemed suspicious due to the resident's poor health and history of old fractures. The investigation included statements from staff, x-ray results, and hospital findings, but the injury was not reported as required by the facility's abuse policy. The policy states that an injury should be classified as an injury of unknown source if the source was not observed or explained and is suspicious due to its extent, location, or number of injuries. The nurse practitioner and staff did not find the injury suspicious, attributing it to the resident's overall poor health and potential pathological fracture. However, the failure to report the injury to the regional office constitutes a deficiency in following the facility's abuse policy and prevention program.
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.
