Sheridan Village Nrsg & Rhb
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5838 North Sheridan Road, Chicago, Illinois 60660
- CMS Provider Number
- 145482
- Inspections on file
- 42
- Latest survey
- May 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sheridan Village Nrsg & Rhb during CMS and state inspections, most recent first.
Surveyors observed multiple failures in food safety and sanitation, including improper storage and handling of food, spoiled produce left in the cooler, unsanitary food carts, and staff not following hand hygiene or equipment sanitization protocols. The cooler was found above the required temperature, and food items were not properly labeled or discarded, increasing the risk of contamination.
The facility did not complete new Level I PASARR screenings for several residents with known mental illnesses, despite documentation of diagnoses such as schizophrenia and bipolar disorder. PASARR records were incomplete or incorrectly indicated that no further screening was needed. Staff interviews revealed confusion about PASARR requirements and inconsistent practices regarding which residents required updated screenings.
Surveyors found expired medications and enteral feeding containers stored in medication carts and storage rooms, and also observed a medication cart left unlocked and unattended by an RN. Staff confirmed these items should have been discarded and that medication carts must be locked when unattended, in accordance with facility policy.
A resident who is totally dependent and requires assistance for transfers was unable to access her call light, which was found on the floor at the foot of her bed. Despite the resident's repeated requests for staff to place the call light within reach, it remained inaccessible. Both a RN and the DON confirmed that call lights are required to be within reach according to facility policy and the resident's care plan.
The facility failed to ensure timely refills and availability of controlled substances for two residents, resulting in unmanaged pain and sleep disruption. Additionally, there were discrepancies in narcotic medication counts due to lack of documentation by an LPN, and required shift-to-shift controlled substance counts were not consistently performed or recorded, as evidenced by missing signatures on check forms.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was given psychotropic medications without discontinuing or renewing PRN orders after 14 days, and without obtaining consent from the POA as required. The resident personally signed consent forms despite documented cognitive impairment and the presence of a POA, and there was no documentation that the POA was notified or provided consent for the medications.
A medication error rate above 5% was identified when an LPN administered the incorrect dose of Acetaminophen to a resident and failed to give a scheduled dose of Bactrim DS during a medication pass. The LPN later realized the omission after reviewing the MAR and administered the missed medication at a later time, contrary to facility policy requiring verification of medication orders and adherence to the five rights of medication administration.
A resident was not offered, educated about, or given the opportunity to consent to influenza and pneumococcal vaccines, and there was no documentation of these actions in the medical record. The Infection Preventionist and DON confirmed that the required education and consent were not documented or provided, contrary to facility policy.
A resident was not offered or educated about the COVID-19 vaccine, and there was no documentation of consent or administration. The Infection Preventionist could not confirm if the vaccine was offered or given, and the DON stated that all education and consent should be documented, but the resident's record lacked this information, contrary to facility policy.
A resident with a history of delusions and false accusations made several allegations of abuse against staff members. Despite the facility's policy requiring immediate reporting of all allegations, staff failed to report these incidents to the administrator or IDPH. The registered nurse involved did not report the allegations, believing them to be false, which was against the facility's policy. This inaction led to a deficiency in handling abuse allegations.
A resident with cerebral palsy and schizoaffective disorder reported being injured during a mechanical lift transfer, alleging intentional harm by staff. Despite the resident's report and call to emergency services, the RN did not assess the injury or notify the physician and administration, violating the facility's abuse prevention policy.
The facility failed to label and date food items in the walk-in cooler, as observed with a package of chopped spinach and a box of non-dairy whipped topping. The Dietary Supervisor confirmed that labeling is essential for monitoring food usage, with a 30-day storage limit. The facility's policy mandates proper labeling and storage, which was not followed in this instance.
The facility failed to properly implement Enhanced Barrier Precautions (EBP) for residents, affecting four individuals and potentially impacting all 174 residents. Observations showed staff not using PPE when required, missing EBP signs on doors, and inadequately stocked PPE bins. The facility's policies mandate clear signage and PPE availability for high-contact care, but lapses were noted, with staff relying on in-services and verbal communication for EBP implementation.
A resident's indwelling catheter drainage bag was left uncovered, compromising their dignity. The resident, who is cognitively intact and has a history of cancer and diabetes, was observed with the drainage bag hanging from the bed frame facing the hallway. Facility staff, including an LPN, DON, and ADON, acknowledged the need for the bag to be covered for privacy. The facility's policies and Residents Rights documentation emphasize the importance of maintaining resident dignity and privacy.
A facility failed to rescreen a resident with bipolar disorder for PASRR requirements within the mandated 60-day period. The resident's PASRR Level I Screen Outcome indicated a need for rescreening if the stay exceeded 60 days, but the facility did not comply, resulting in a lapse in required evaluation. The oversight was acknowledged by the Psychiatric Rehabilitation Services Director, who confirmed the rescreening was submitted only after the deficiency was identified.
A resident's personal refrigerator was not properly cleaned or monitored for temperature, with missing log entries and a black substance found on the thermometer. The resident, with moderately impaired cognition and multiple medical conditions, reported infrequent cleaning and temperature checks, contrary to facility policy. Staff interviews revealed a lack of adherence to daily maintenance expectations.
A resident with cervical disc degeneration and quadriplegia was found using a wheelchair with broken brakes, compromising their safety and mobility. The facility's restorative staff was responsible for daily checks, but it was unclear how long the resident had been using the malfunctioning wheelchair. The facility's policy required equipment evaluation prior to use, which was not followed in this instance.
A resident with multiple diagnoses and high fall risk fell from his bed during incontinence care due to inadequate supervision. The CNA was providing care alone, contrary to the resident's care plan, resulting in a laceration that required stitches.
A resident with memory problems and a high risk for falls was inadequately supervised, resulting in a fall and a laceration to the right eyebrow that required one suture. The resident was known to wander and had a history of frequent falls, yet staff did not know the resident's whereabouts at the time of the fall. The RN on duty admitted to being preoccupied with other tasks, and the DON confirmed the need for frequent observation and assistance, which was not adequately provided.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to follow proper sanitation and food handling practices, as observed during a kitchen tour and interviews with dietary staff. Two silver baking pans containing meat loaf were found in the cooler with a pool of spilled milk on top of the foil wrapping, which the Dietary Manager acknowledged could cause contamination and pose a risk to residents with milk allergies. In the same cooler, cartons of cabbage and oranges were found with spoiled produce, including yellowing and brownish cabbages with liquid dripping out and moldy, squishy oranges. The Dietary Manager confirmed these items should have been discarded to prevent illness and cross-contamination. The cooler temperature was recorded at 51°F, above the required 41°F, and an open box of waffles in the freezer was not labeled with the date it was opened, contrary to facility policy. Additionally, unsanitary conditions were noted with two food carts that had whitish substances and black stains from food spills, which the Dietary Manager admitted had not been cleaned due to staff shortages. During dishwashing, a dietary aide was observed handling clean dishes without washing hands or wearing gloves after handling dirty dishes, which the Dietary Manager stated was not in accordance with sanitary procedures. Furthermore, the cook was seen rinsing, but not sanitizing, the puree machine between uses, despite facility policy requiring thorough washing and sanitizing. These actions and inactions contributed to the facility's failure to maintain proper food safety and sanitation standards.
Failure to Complete Required PASARR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to initiate new Level I PASARR screenings for four residents with known mental illnesses, as required for Pre-admission Screening and Resident Review (PASARR). Documentation for these residents showed diagnoses such as schizoaffective disorder, bipolar disorder, schizophrenia, major depressive disorder, and delusional disorders. However, their PASARR records were either incomplete, did not indicate a reasonable basis for suspecting mental illness or developmental delay, or incorrectly stated that no Level II PASARR was required despite the presence of qualifying diagnoses. There was no documentation to show that appropriate Level II PASARR screenings had been completed for these residents. Interviews with facility staff revealed confusion and inconsistent understanding of PASARR requirements, particularly regarding which residents required new screenings and the process for updating expired screenings. The Social Services Director and Admissions Director each described different responsibilities and procedures for ensuring PASARR compliance, with both referencing a belief that residents admitted prior to a certain date were "grandfathered" and did not require new screenings. Facility policy required compliance with federal and state PASARR standards and obtaining complete PASARR documentation from referral sources, but the observed practice did not align with these requirements.
Expired Medications and Unsecured Medication Cart Identified
Penalty
Summary
Surveyors observed that expired medications and enteral feeding containers were not removed and discarded as required. Specifically, an open bottle of Meclizine with an expiration date of 02/2025 was found in a medication cart on the third floor, and four containers of Glucerna enteral feeding with an expiration date of 04/01/2025 were found in the medication storage room. Staff confirmed that these items should have been discarded after expiration and acknowledged that expired medications and feedings should not be available for resident use. Additionally, a medication cart on the second floor was found unlocked and unattended while the responsible RN was out of sight. The RN admitted that the cart should have been locked when unattended and stated that she may have been rushing at the time. Facility policy requires that all medication storage areas be locked when not attended by authorized personnel and that expired medications be immediately removed and destroyed.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Facility staff failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. During observation, the resident was found unable to access the call light, which was hanging on the floor at the foot of the bed. The resident, who is totally dependent and requires assistance for transfers, reported being unable to find the call light and stated that she had repeatedly asked staff to place it within reach. A registered nurse confirmed the call light was not accessible and acknowledged the importance of keeping it within reach for residents to communicate their needs. The Director of Nursing also stated that call lights should always be within reach of residents. Documentation in the resident's care plan and facility policy both specify that call lights must be placed within easy reach of residents.
Failure to Refill Medications and Maintain Accurate Controlled Substance Counts
Penalty
Summary
The facility failed to ensure that medications were refilled and readily available for two residents who required controlled substances for pain management and sleep. One resident, with diagnoses including lymphedema and chronic pain, reported not receiving Tylenol with Codeine for several days due to the medication running out and not being reordered in time. The resident expressed significant pain and discomfort, stating that regular Tylenol was not sufficient. Another resident, with a history of hemiplegia and psychiatric disorders, reported repeated instances of not receiving Lunesta for sleep because the medication was not refilled before running out, resulting in sleepless nights and frustration. Inspection of the medication cart confirmed that both medications were not available at the time of the survey, and the nurse acknowledged the medications had run out and were awaiting delivery from the pharmacy. Additionally, the facility failed to maintain accurate counts of narcotic medications for two residents. During a controlled substance count, discrepancies were found between the number of pills present in the medication bingo cards and the amounts documented in the controlled drug receipt records. The LPN responsible admitted to administering the medications but forgetting to document the administration, leading to inaccurate records. The facility also did not ensure that controlled substances were counted and documented at the beginning and end of each shift as required. Review of the Controlled Substances Check Forms for multiple medication carts revealed missing signatures for several shifts, indicating that the required shift-to-shift controlled substance counts were not consistently performed or documented. Facility policy requires these counts to be conducted by two licensed nurses at each shift change, but this procedure was not followed for a number of shifts.
Failure to Discontinue PRN Psychotropics and Obtain POA Consent for Severely Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not discontinuing or obtaining an order to continue as needed (PRN) psychotropic medications after the required 14-day period. Additionally, the facility did not obtain proper psychotropic medication consent from the resident’s Power of Attorney (POA), despite the resident having severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3/15. The resident, who has diagnoses including major depressive disorder, schizophrenia, schizoaffective disorder, and anxiety disorder, was observed to be oriented to person and place but confused about time and situation, and unable to answer most questions. The review of records showed that the resident personally signed consent forms for psychotropic medications, even though the face sheet documented a POA for health and there was no documentation that the POA was notified or provided consent for these medications. The DON acknowledged that there was no documentation of POA notification or consent for the psychotropic medications. Furthermore, PRN psychotropic medication orders were found to be open-ended and not discontinued or renewed after 14 days as required by facility policy and CMS regulations.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a medication administration observation. During a medication pass, an LPN administered Acetaminophen 500 mg (2 tablets) to a resident, despite the resident's medication administration record (MAR) specifying Acetaminophen 325 mg (2 tablets) every 6 hours as needed. Additionally, the resident was scheduled to receive Bactrim DS (sulfamethoxazole-trimethoprim) 800-160 mg at 9:00 AM, but this medication was not administered during the observed medication pass. The LPN confirmed that she had completed the morning medication administration for the resident without giving the scheduled Bactrim dose. Upon later review, the LPN stated she did not initially see the Bactrim order in the MAR and only noticed it after checking the facility's 24-hour communication report. She then administered the Bactrim at approximately 10:30 AM, after the surveyor had left the area. Facility policy requires medications to be administered as prescribed, with verification of the five rights (right resident, drug, dose, route, and time) at multiple steps, and comparison of the MAR with medication labels prior to administration. The failure to follow these procedures led to the medication errors identified during the survey.
Failure to Offer, Educate, and Document Consent for Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to follow its policy regarding the offering, education, and documentation of consent for influenza and pneumococcal vaccinations for one resident. During interviews and record reviews, it was found that the resident did not recall being offered the influenza or pneumococcal vaccines. The Infection Preventionist was unable to locate any documentation of consent, education, or administration of these vaccines for the resident. The Infection Preventionist stated she was unsure why the resident had not received the vaccines or the required education, and confirmed that there was no record of these actions in the resident's file. Further review with the Director of Nursing revealed that the facility's process is to review immunizations upon admission, provide education on the importance and benefits of the vaccines, and obtain informed consent before administration. The Director of Nursing emphasized that all education and decisions regarding immunizations should be documented in the clinical record, and if not documented, it is considered not done. The resident's immunization record showed no evidence of the vaccines being offered, administered, or any education or consent being documented for the year in question, which is inconsistent with the facility's stated policy.
Failure to Offer, Educate, and Document COVID-19 Vaccination for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy regarding COVID-19 vaccination for one resident out of five reviewed for immunizations. The resident reported not recalling being offered or educated about the COVID-19 vaccine. Upon review, the Infection Preventionist was unable to locate documentation of consent, education, or administration of the COVID-19 vaccine for this resident. The Infection Preventionist stated uncertainty about whether the vaccine was offered or administered and acknowledged the absence of required documentation. Further, the Director of Nursing confirmed that the facility's process includes reviewing immunizations upon admission, providing education on the importance and benefits of the COVID-19 vaccine, and obtaining informed consent, all of which should be documented. However, the resident's immunization record lacked any indication that the COVID-19 vaccine was offered, administered, or that education and consent were provided. The facility's policy requires notification, education, and documentation of acceptance or declination of the vaccine, which was not followed in this instance.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report alleged abuse allegations to the proper authorities within the prescribed time frame for one resident. The resident, a 39-year-old with a complex medical history including cerebral palsy, schizoaffective disorder, and other conditions, made several allegations of abuse against staff members. Despite the resident's history of delusions and false accusations, the facility's policy requires all allegations to be reported to the administrator and the Illinois Department of Public Health (IDPH) within two hours. On two occasions, the resident made allegations against certified nurse assistants, claiming physical abuse and inappropriate behavior. These incidents were documented by the staff but were not reported to the administrator or IDPH as required. The registered nurse involved in these incidents did not report them, believing the allegations to be false due to the resident's history of delusional behavior. This inaction was contrary to the facility's policy, which mandates reporting all allegations regardless of their perceived validity. Interviews with staff revealed a lack of adherence to the reporting policy, with some staff assuming others would report the incidents. The administrator, who is also the abuse coordinator, was not informed of these allegations until much later. The facility's policy clearly states that it is not the responsibility of the staff to determine the truth of an allegation, but rather to report it immediately for proper investigation. This failure to report in a timely manner constitutes a deficiency in the facility's handling of abuse allegations.
Failure to Investigate Allegation of Abuse During Transfer
Penalty
Summary
The facility failed to assess and investigate an allegation of physical abuse involving a resident with multiple medical diagnoses, including cerebral palsy and schizoaffective disorder. The resident, who has intact cognitive abilities and requires substantial assistance for daily activities, reported that during a mechanical lift transfer, staff injured her knee intentionally. Despite the resident's report to a registered nurse and her call to emergency services, the nurse did not assess the resident for injuries, notify the physician, or inform the facility's administration, as required by the facility's abuse prevention policy. The Director of Nursing and the Administrator both acknowledged that the nurse should have conducted an assessment and notified the appropriate parties to investigate the allegation. The facility's policy mandates immediate reporting and investigation of any incidents or allegations of abuse, but this protocol was not followed. The failure to document and investigate the resident's report of injury during a mechanical lift transfer represents a deficiency in the facility's response to potential abuse allegations.
Failure to Label and Date Food Items in Walk-in Cooler
Penalty
Summary
The facility failed to ensure that food items stored in the walk-in cooler and freezer were labeled with the date they were placed there. During an observation, a 48-ounce package of chopped spinach and an opened box containing ten cans of non-dairy whipped topping were found in the walk-in cooler without any date labels. This lack of labeling prevents staff from monitoring the duration for which the food items have been stored, which is crucial for maintaining food safety and quality. The Dietary Supervisor (V5) confirmed that the purpose of labeling and dating food containers is to track when the food should be used, with a 30-day limit for items in the cooler and freezer. The responsibility for labeling lies with the cooks and dietary aides. The facility's policy, as outlined in the Health Technologies, Inc. Guideline & Procedure Manual, requires all stored foods to be properly labeled and dated, using a first in-first out method. The Dietary Aid Job Description also emphasizes the importance of maintaining safe food handling procedures, including proper labeling and storage.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for residents requiring such measures, affecting four residents and potentially impacting all 174 residents in the facility. Observations revealed that staff were not consistently using Personal Protective Equipment (PPE) when providing care to residents on EBP, and there were instances where EBP signs were not posted on resident doors. For example, a Certified Nursing Assistant (CNA) was observed adjusting a resident's diaper without wearing gloves or a gown, and there was no EBP sign on the resident's door, despite the resident having an indwelling Foley catheter and a pressure ulcer. Further observations indicated that PPE bins were either missing or inadequately stocked outside the rooms of residents on EBP. In one instance, a resident's room had an EBP sign, but there was no PPE bin available either inside or outside the room. The Director of Nursing confirmed the absence of PPE bins and acknowledged that EBP should be in place for residents with certain medical conditions, such as wounds or indwelling devices, to prevent infection transmission. The facility's policies on infection control and EBP require clear signage and the availability of PPE for high-contact resident care activities. However, the report highlights lapses in adherence to these policies, as evidenced by the lack of signage and PPE availability. Staff interviews revealed a reliance on in-services and verbal communication for EBP implementation, which may have contributed to the inconsistencies observed during the survey.
Failure to Cover Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of a resident by not covering the indwelling catheter drainage bag with a privacy bag. This deficiency was observed during a survey when the drainage bag of a resident, who is cognitively intact and has a history of malignant neoplasm of the colon, colorectal cancer, and diabetes, was found hanging from the bed frame facing the hallway without a privacy cover. The resident's care plan indicated the need for a urinary catheter due to the presence of urogenital implants. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), confirmed that the urinary drainage bag should be covered with a privacy bag to maintain the resident's dignity. The facility's job descriptions for LPNs and CNAs emphasize the importance of complying with policies and procedures, including ensuring resident privacy and dignity. The facility's Residents Rights documentation also highlights the right to dignity, respect, privacy, and confidentiality in medical and personal care.
Failure to Rescreen Resident for PASRR Requirements
Penalty
Summary
The facility failed to rescreen a resident, identified as R153, to determine if specialized services under the Preadmission Screening and Resident Review (PASRR) requirements were necessary. R153 had a PASRR Level I Screen Outcome that indicated a convalescence categorical approval for a 60-day stay due to a suspected or confirmed mental health disability, specifically bipolar disorder. The PASRR Level I screen stated that if the resident needed to stay beyond the approved 60 days, a new Level I screen must be submitted. However, the facility did not conduct the required rescreening within the 60-day period, as confirmed by the Psychiatric Rehabilitation Services Director (V26), who acknowledged the oversight and stated that the rescreening was only submitted after the 60-day period had expired. R153's medical records indicated a diagnosis of bipolar disorder and the use of antipsychotic medications, suggesting the need for ongoing assessment and potential specialized services. Despite the clear requirement for rescreening outlined in the PASRR documentation, the facility staff, including the Admissions Director and the Psychiatric Rehabilitation Services Director, failed to ensure that the necessary procedures were followed in a timely manner. This oversight resulted in the resident remaining in the facility without the required updated PASRR evaluation, which was only addressed after the deficiency was identified by the surveyor.
Failure to Maintain Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain proper cleaning and temperature logging for a resident's personal refrigerator. Observations revealed that the temperature log on the refrigerator was missing entries for specific dates, and a black substance was found on the thermometer inside the refrigerator. The resident stated that the staff cleaned the refrigerator and checked its temperature only once a month, which contradicts the facility's policy and the expectations set by the Maintenance Director. The resident involved has a BIMS score indicating moderately impaired cognition and has multiple medical diagnoses, including multiple sclerosis and schizoaffective disorder. Interviews with the housekeeper and Maintenance Director revealed a lack of clarity and adherence to the facility's policy, which requires daily cleaning and temperature checks of personal refrigerators. The housekeeping staff was unaware of the black substance on the thermometer and did not consistently log the refrigerator's temperature, leading to the deficiency.
Failure to Maintain Functional Wheelchair for Resident
Penalty
Summary
The facility failed to ensure that a resident's adaptive equipment, specifically a wheelchair, was functional and safe for use. On observation, the resident reported that the brakes on their wheelchair were broken, with the right brake not touching the rear wheel and the left brake being loose. This issue was confirmed when the wheelchair moved despite the brakes being engaged. The Assistant Director of Nursing acknowledged the problem and stated that the facility would provide a new wheelchair immediately. The responsibility for checking the wheelchair daily was assigned to the restorative staff, but it was unclear how long the resident had been using the malfunctioning wheelchair. The resident involved had a diagnosis of cervical disc degeneration and quadriplegia, and their mental status was documented as cognitively intact. The resident's care plan highlighted a risk for deterioration in mobility and activities of daily living, emphasizing the importance of functional mobility devices. The facility's policy required all medical equipment to be evaluated prior to use, but this was not adhered to in this case, leading to the deficiency. The failure to maintain the wheelchair could potentially limit the resident's mobility and increase the risk of falls, as noted by the Director of Nursing.
Inadequate Supervision During Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall during incontinence care for a resident (R1). R1, a male resident with multiple diagnoses including COPD, paranoid schizophrenia, heart failure, diabetes, anxiety disorder, severe depressive disorder with psychotic features, and obesity, fell from his bed while being changed by a CNA. R1's care plan indicated he required extensive or total staff assistance and was at high risk for falls due to weakness and poor safety awareness. During the incident, the CNA was providing care alone, and the resident rolled out of bed, resulting in a laceration on his forehead that required 13 stitches. The CNA reported that the mattress shifted off the edge of the bed frame, contributing to the fall. The resident had previously mentioned that the mattress on the original bed often fell off the edge, and he had almost fallen before because of that. The incident report and interviews with staff revealed that the CNA was aware that R1 typically required two-person assistance for transfers but was performing the incontinence care alone. The Assistant DON and the physician both acknowledged that while one person might be sufficient for this type of care, two people would have been better. The facility's Fall Reduction Program policy emphasizes the need for appropriate interventions and supervision to ensure resident safety, which was not adequately provided in this case. The failure to follow the care plan and provide the necessary supervision led to the resident's fall and subsequent injury.
Inadequate Supervision of High-Risk Resident
Penalty
Summary
The facility failed to adequately supervise a resident (R3) who has memory problems and is at high risk for falls. On the day of the incident, R3 was found on the floor with a laceration to the right eyebrow, which required one suture. The resident was sent to the local hospital for evaluation and returned to the facility the same day. The incident report and staff interviews indicate that R3 was known to wander and had a history of frequent falls, yet the staff did not know R3's whereabouts at the time of the fall. The RN on duty admitted to being preoccupied with other tasks and not being able to supervise R3 adequately, despite knowing R3's high fall risk status. The Director of Nursing (DON) and R3's physician both confirmed that R3 requires supervision due to dementia and confusion. The physician was not surprised by the fall, given R3's history, and emphasized the importance of staff supervision to prevent injuries. The DON stated that staff should be answering call lights promptly and conducting hourly rounds to check on residents, but it was unclear how long R3's call device had been alarming before staff responded. R3's care plan and progress notes highlighted the resident's high fall risk and the need for frequent observation and assistance with transfers. Despite these documented needs, the facility's failure to provide adequate supervision led to R3 sustaining a laceration from a fall. The facility's records show that R3 had multiple falls in the past 120 days, indicating a pattern of insufficient supervision and fall prevention measures for this high-risk resident.
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.
