Smith Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2320 West 113th Place, Chicago, Illinois 60643
- CMS Provider Number
- 145904
- Inspections on file
- 27
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Smith Village during CMS and state inspections, most recent first.
A resident who was alert, oriented, and able to communicate clearly had multiple personal checks written from his bank account to a CNA regularly assigned to his care, with the checks later found to have been mobile deposited into a personal account. After the resident’s death, his daughter discovered the suspicious checks while closing his bank estate and notified facility leadership, who confirmed through bank records that several checks labeled as “rent” in varying amounts had been issued to and deposited by the CNA. These events show that the facility failed to prevent misappropriation of the resident’s money in accordance with its abuse policy prohibiting exploitation and wrongful use of resident property.
The facility failed to ensure that two licensed nurses consistently completed and documented shift-to-shift controlled substance counts for medication carts containing narcotics for multiple residents. Review of controlled substance count forms for two medication carts showed missing "Nurse Off" initials at morning shift changes, despite staff statements that both incoming and outgoing nurses are required to count all narcotics together and initial the form, and that the DON should be notified of any missing initials or discrepancies. Facility policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, but this process was not consistently documented as completed.
Surveyors found that dietary staff failed to consistently label and date fresh produce and leftover foods, and did not discard items past their discard dates, including overripe bananas and unlabeled trays of fish and other foods in dry and cold storage. Multiple boxes of bananas lacked delivery-date labels, and some bananas had split peels with exposed flesh. During preparation of pureed sloppy joe sandwiches for residents on puree diets, a cook repeatedly washed hands for less than the required 20 seconds between tasks, despite facility policy and staff statements that 20-second handwashing is necessary to prevent cross-contamination. At the time, all but one resident were receiving oral diets, and the facility’s HACCP, dry storage, and hand hygiene policies required proper dating, discarding of expired foods, and thorough handwashing.
Staff failed to follow hand hygiene and respiratory etiquette requirements during direct care and dining. One CNA provided care to a resident without hand hygiene or gloves, carried a soiled napkin from that resident’s room into another resident’s room, placed it on the second resident’s dresser, then handled the shared ice machine without cleaning hands. Another CNA donned gloves and assisted with repositioning a resident without performing hand hygiene. During 1:1 feeding of a cognitively impaired resident on a mechanical soft diet, a CNA coughed into her scrub shirt and later sneezed into her elbow while seated next to the resident, did not perform hand hygiene, continued feeding, and used a bare hand to handle and feed a piece of the resident’s ice cream sandwich. These actions were inconsistent with the facility’s infection control, hand hygiene, and respiratory hygiene policies.
A resident requiring two-person assistance for transfers was improperly transferred by a single CNA, resulting in a leg laceration requiring 18 sutures. Despite clear documentation and staff awareness of the resident's needs, the CNA did not follow the care plan, leading to the injury.
A resident sustained a laceration requiring 18 sutures after being improperly transferred by a CNA, who did not follow the care plan requiring two-person assistance. The injury occurred when the resident's leg made contact with a loose bed frame that was not adjusted to match the mattress size. The facility lacked a system to ensure bed frames were properly secured, contributing to the safety hazard.
The facility failed to properly label, date, and store food items, risking foodborne illness for residents. Observations revealed uncovered beef patties, unlabeled pepperoni, and open tilapia fish, among other improperly stored items. The Dietary Manager acknowledged these practices were against facility policies, which require proper food handling to prevent cross-contamination.
The facility failed to ensure garbage dumpster lids were closed, as observed by a surveyor. A Dining Service Manager was seen closing the lids and acknowledged they should not be open, noting that CNAs also use the dumpsters. The Environment Service Director confirmed that lids should be closed. Facility policy requires garbage containers to be covered when not in use.
The facility staff failed to complete the controlled substance shift-to-shift count forms, leading to missing initials for several shifts in September. This deficiency was observed on both the second and first floors, affecting the accountability of controlled substances. Interviews revealed confusion among nurses about the procedure, which requires two nurses to count and verify the substances together. The DON highlighted the importance of this process to ensure all narcotics are accounted for.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, potentially affecting 27 residents. Staff were observed performing high-contact care without proper PPE. Interviews revealed confusion about EBP requirements, despite facility policy mandating EBP for residents with significant wounds. The resident's care plan indicated the need for EBP, but it was not followed, leading to a deficiency in infection control.
A resident's urinary catheter drainage bag was left uncovered, visible to passersby, compromising their dignity. The resident, with intact cognition and multiple diagnoses including bladder dysfunction, had their privacy breached as the facility's policy requiring covered catheter bags was not followed.
A resident with congestive heart failure and chronic kidney disease was observed consuming both ginger ale and water during a meal, contrary to their prescribed fluid restriction diet order. The dietician confirmed the error, noting that servers need to follow diet card instructions. The facility's policy requires adherence to prescribed dietary interventions, which was not followed in this instance.
The facility failed to maintain temperature logs and provide thermometers for personal refrigerators used by residents, leading to potential safety risks. Observations showed that these refrigerators lacked necessary monitoring tools, and interviews revealed confusion among staff about responsibility for temperature checks. The Director of Nursing indicated that families are responsible, but no specific policy exists for refrigerator maintenance.
A high fall risk resident with severe cognitive impairment and multiple medical conditions was left unsupervised, resulting in a fall and head injury. Despite requiring constant supervision and having a fall alert system, the resident was found on the bathroom floor with a laceration that required hospital treatment.
Failure to Prevent Misappropriation of a Resident’s Funds by CNA
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse policy regarding misappropriation of resident property, resulting in an employee cashing multiple personal checks belonging to a resident without his knowledge or consent. The resident was admitted in late July 2025, arriving by wheelchair from another residential setting and documented as alert and oriented x3, able to communicate clearly and understand and be understood. In early September 2025, nursing notes documented that the resident was actively transitioning with hospice involvement and then became unresponsive and pulseless later that same day, with his daughter/POA present. After the resident’s death, his daughter discovered suspicious activity while closing her father’s bank estate, including several checks written from his account to a CNA employed at the facility. She contacted facility leadership to ask if this individual worked there and reported that several checks from her father’s account bore the CNA’s name and had been cashed. The facility’s own abuse report and interviews with the Assistant Executive Director, Executive Director/Administrator, and DON confirmed that the CNA had been regularly assigned to care for the resident and that the daughter provided copies of cancelled checks and bank statements showing multiple checks written to and deposited by the CNA. Record review showed a series of checks from the resident’s account, each listing the CNA as payee and referencing “rent,” with amounts ranging from $640.00 to $940.00 over multiple days in August and early September 2025. An Employee Action Form dated 10/6/25 documented that several checks were written to the CNA from the resident’s checking account and were subsequently mobile deposited into a personal account, and that the facility determined a violation of policy had occurred. The facility’s abuse policy defines misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent, and the events described constitute such misappropriation for this resident.
Failure to Complete Shift-to-Shift Controlled Substance Counts by Two Licensed Nurses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that two licensed nurses conducted and documented a shift-to-shift physical inventory of controlled substances for all medication carts as required by facility policy. Surveyors reviewed the controlled substance shift-to-shift count forms for the second-floor and third-floor medication carts for September 2025 and found missing initials in the “Nurse Off” boxes at specific morning shift-change times. On the second-floor [NAME] medication cart, the “Nurse Off” initial box was left blank for a morning shift change on September 17, 2025. On the third-floor medication cart, the “Nurse Off” initial box was left blank for a morning shift change on September 23, 2025. These documentation gaps occurred for carts that contained controlled substances prescribed for 7 residents on the 3J cart and 5 residents on the 2J cart. During interviews, an LPN stated that every nurse is responsible for ensuring the narcotic count is correct and that two nurses are to count the controlled substances in the medication cart and sign the “on” and “off” spaces on the shift-to-shift count sheet, and that nurses are to notify the DON if initials are missing. An RN explained that the controlled substance shift-to-shift count sheets are used to document that the total number of narcotics in the cart is correct at the end of each shift, and that the incoming and outgoing nurses count all narcotics together and both initial the form once they agree the count is correct, notifying the DON if there is any discrepancy. The MDS Coordinator confirmed that nurses are responsible for completing these sheets to verify that all narcotics in the cart are accounted for and that the DON should be notified if the sheets are not initialed and completed for each shift. Review of the facility’s July 2025 policy on Controlled Substance Administration & Accountability documented that two licensed nurses must account for all controlled substances and access keys at the end of each shift, which was not consistently followed as evidenced by the missing “Nurse Off” initials.
Improper Food Labeling, Storage, and Hand Hygiene in Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper food procurement, storage, labeling, dating, and hand hygiene practices in the kitchen. During an initial kitchen tour, the surveyor and the Dietary Director observed that dry storage food items were generally labeled with orange stickers indicating delivery dates, but multiple boxes of bananas had no delivery date labels. The bananas in two of these boxes were described as yellow with black spots and emitting a noticeable odor through the surveyor’s surgical mask. The Dietary Director confirmed that the boxes should have been dated and acknowledged that staff had not labeled them. In the walk-in cooler, the surveyor observed a tray of pre-cut salmon pieces under a clear plastic cover with no label or date, and two trays of cod (one plain and one with butter and dill) without any labels or dates. A deep stainless-steel pan of chicken in liquid and an opened package of sausage bratwurst were labeled with preparation and discard dates, but both were past their discard dates. On a follow-up kitchen tour, the surveyor again observed the same two boxes of ripe bananas with yellow peels and numerous black spots still on the dry storage shelves. The cook stated that one case would be discarded and the other used for smoothies in a chef demonstration and explained that staff determine how long food is good by referring to posted storage life guidelines. A third box of bananas, described as green/yellow, had arrived that morning but also lacked a delivery date label. When the Dietary Director opened one of the older banana boxes at the prep table, some bananas were found with split peels exposing the flesh and were discarded into the garbage; the Dietary Director again confirmed that the box had not been labeled or dated. The facility’s written policy on dry storage life of foods requires use of manufacturer expiration dates or, if absent, adding specified storage times to the date the food is received, and instructs that products be discarded when quality is unacceptable. The surveyor also observed multiple instances of improper hand hygiene by the cook during preparation of pureed sloppy joe sandwiches for residents on puree diets. The cook washed hands several times at the kitchen handwashing station, but each observed handwashing episode lasted less than 20 seconds, despite the cook’s verbal description of the correct procedure as including 20 seconds of lathering. The cook washed hands briefly, donned gloves, handled bread buns, ladled heated milk over the buns, touched the milk-soaked buns with gloved hands, removed gloves, and repeatedly moved between tasks such as checking milk on the stove, wiping the prep table with a sanitizing towel while gloved, and returning to food preparation, with each handwashing episode again documented as under 20 seconds. The facility’s handwashing policy requires staff to wash hands whenever they become soiled or contaminated, upon entering or returning to the kitchen, before food preparation, when switching between raw and ready-to-eat foods, during food preparation as often as necessary to prevent cross-contamination, and when changing gloves, and specifies that hands should be scrubbed following appropriate techniques. The Assistant Dietary Director later confirmed that kitchen staff are expected to wash hands every time they change tasks, after using the bathroom, or after touching door handles, and to wash for 20 seconds to remove germs, stating that washing for less than 20 seconds could allow germs to be carried to the next task. The Assistant Dietary Director also stated that fresh fruit items must be labeled with the date received and a discard date, and that all leftover prepared foods stored in the kitchen must be labeled with the date and time prepared, discard date and time, and staff initials. The Assistant Dietary Director explained that if ripened bananas with opening peels are kept past their discard date, bacteria can grow and the odor can attract fruit flies, and that leftover foods stored past their discard date cannot be served because bacteria and other contaminants can develop. At the time of the survey, facility records showed that 61 skilled residents were in the facility, with 60 receiving oral diets and one resident receiving tube feedings and nothing by mouth, and the cycle menu documented that pureed sloppy joe sandwiches were the planned hot lunch item for residents on puree diets.
Failure to Follow Hand Hygiene and Respiratory Etiquette During Resident Care and Dining
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program, specifically related to hand hygiene, handling of potentially contaminated items, and respiratory hygiene/cough etiquette. On one occasion, a CNA (V7) was observed providing direct care to a resident (R1) by repositioning and fixing an underpad without performing hand hygiene or donning gloves. During the same interaction, V7 removed a soiled napkin from R1’s bed and then exited the room. V7 then entered another resident’s (R5’s) room and placed the soiled napkin from R1’s room on R5’s dresser. Without performing hand hygiene, V7 donned gloves and assisted R5 to the restroom, then removed the gloves, picked up the same soiled napkin, and walked to the dining area. V7 placed the soiled napkin in a basket and then used the shared unit ice machine to place ice in a cup, again without performing hand hygiene. On another observation, a second CNA (V8) was seen donning gloves without performing hand hygiene before entering R1’s room to assist V7 in pulling R1 up in bed. V8 later acknowledged not sanitizing hands before putting on gloves and stated that hand hygiene should have been performed. V7 also acknowledged that she should have sanitized her hands and donned gloves before caring for R1, stating she was moving too fast and that she does not like to sanitize her hands before donning gloves because it makes her hands sticky. V7 further stated that she should sanitize her hands between residents but that it is very busy and she moves fast. The MDS Coordinator (V19) stated that hand hygiene is important to prevent the spread of infection, should be done before entering and leaving a resident’s room and between tasks, and that dirty linen should not be taken from one resident’s room to another. V19 also stated that the unit’s ice machine is for all residents and that if hand hygiene is not performed after resident care and then the ice machine is used, the ice machine is considered contaminated. A separate deficiency was observed during dining involving respiratory hygiene and hand hygiene while feeding a resident (R27). During a 1:1 feeding of an ice cream sandwich, V7 sat next to R27 and was observed coughing into her scrub shirt by turning her head and bringing the neck of the scrub shirt near her mouth with her right hand. V7 did not perform hand hygiene and began feeding R27 with a spoon. After feeding two bites, V7 sneezed into her right elbow while sitting next to R27 and again did not perform hand hygiene before continuing to feed three more bites. When a piece of the ice cream sandwich fell off the spoon onto the plate, V7 used her bare left hand to touch the ice cream sandwich piece and place it back onto the spoon, then fed it to R27. V19 later stated that staff should step away from residents if they have to cough or sneeze, perform cough etiquette, and then perform hand hygiene, and that staff feeding a resident 1:1 should not touch the resident’s food with bare hands. Facility policies on Infection Control, Hand Hygiene, and Respiratory Hygiene and Cough Etiquette require staff to perform hand hygiene before and after resident contact, after coughing or sneezing, and after contact with respiratory secretions, and to adhere to proper respiratory hygiene and cough etiquette to prevent the spread of infection.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the proper number of staff were used in transferring a resident, leading to an accident hazard. A resident, who required a two-person assist for transfers due to a history of hip surgery and other medical conditions, was transferred by a single CNA. This improper transfer resulted in the resident sustaining a laceration on the left lower leg, which required hospital treatment and 18 sutures. The resident's medical records indicated a dependency on staff for transfers, with a maximum of two-person assistance required. Despite this, the CNA involved in the incident did not adhere to the care plan, which was clearly documented and accessible to staff. The incident occurred during the evening shift, and the CNA admitted to transferring the resident alone, which was against the established protocol. The CNA's actions were inconsistent with the facility's job description and training provided to staff, which emphasized the need for two-person assistance for this resident. Interviews with various staff members, including the Director of Nursing, CNAs, and therapists, confirmed that the resident's care plan required two-person assistance for transfers. The staff were aware of the resident's needs, and the facility had systems in place, such as green and yellow cards in resident rooms and a 24-hour report, to communicate these needs. However, the failure to follow the care plan resulted in the resident's injury, highlighting a lapse in adherence to established safety protocols.
Resident Injury Due to Improper Bed Frame Adjustment
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer, resulting in a significant injury. The incident involved a resident who was being transferred from a wheelchair to a bed by a CNA, who did not follow the care plan that required two-person assistance. During the transfer, the resident's left lower leg made contact with a loose bed frame, causing a laceration that required 18 sutures. The resident was subsequently sent to the hospital for treatment. The investigation revealed that the bed frame was not properly adjusted to match the size of the mattress, which contributed to the injury. The bed frame was wider than the mattress, creating a safety hazard that led to the resident's leg making contact with the frame. The maintenance department was identified as responsible for ensuring that bed frames are properly secured, but it was found that there was no regular check in place to ensure the bed frames were locked or properly adjusted. Interviews with facility staff, including the Assistant Maintenance Manager and the Director of Nursing, confirmed that the bed frame was not properly secured at the time of the incident. The facility's policy on providing a safe environment was not adhered to, as there was no system in place to regularly monitor the safety of bed frames. The lack of documentation or work orders to address this issue further highlighted the deficiency in maintaining a safe environment for residents.
Improper Food Storage and Labeling in LTC Facility
Penalty
Summary
The facility failed to ensure that food items were properly labeled, dated, and stored to prevent the spread of foodborne illness to residents receiving oral nutrition. During an observation, a surveyor noted several food items in the facility's storage areas that were not covered, labeled, or dated. These included a container of uncovered beef patties, a roll of pepperoni without a received or discard date, and a bag of tilapia fish open to air. Additionally, tubs of chocolate and pecan ice cream were found with unsecured lids, and containers of bread battered cod and edamame dumplings were observed without lids and not dated. Interviews with the Dietary Manager confirmed that these practices were not in compliance with the facility's food safety policies, which require all food items to be covered and dated to prevent cross-contamination. The facility's policies, revised in March 2022 and March 2023, emphasize the importance of date marking and proper storage to ensure food safety. The failure to adhere to these policies has the potential to affect all residents receiving oral nutrition, as it increases the risk of foodborne illness due to improper food handling and storage practices.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the garbage dumpster lids were closed, as observed by a surveyor. On the specified date, the surveyor noted that a blue garbage dumpster had both lids open. The Dining Service Manager, identified as V4, was observed closing the lids and acknowledged that the lids should not be open, mentioning that CNAs also use the dumpsters. Additionally, the Environment Service Director, identified as V8, confirmed that the dumpster lids should be closed. The facility's policy on the disposal of garbage and refuse, implemented in February 2023, states that garbage and refuse containers must be covered when not in use, and containers and dumpsters should be kept covered when not being loaded. The job description for the EVS Director includes responsibilities for ensuring a safe and clean environment, adhering to regulatory requirements.
Failure to Complete Controlled Substance Count Sheets
Penalty
Summary
The facility staff failed to complete the controlled substance shift-to-shift count form, which is essential for ensuring accountability for controlled substances. This deficiency was observed during a review of the medication carts on both the second and first floors. Specifically, the forms for several shifts in September 2024 were found to have missing initials from the nurses responsible for counting and verifying the controlled substances. The missing initials were noted for the PM shift on September 8, the AM shift on September 9, and the PM shift on September 11 on the second floor, as well as the 6 PM shift on September 4 on the first floor. Interviews with the nursing staff, including two registered nurses and the Director of Nursing (DON), revealed that there was confusion among the nurses regarding the completion of the controlled substance count sheets. The process requires two nurses, one coming on shift and one going off shift, to count the controlled substances together and initial the count sheet to confirm accuracy. The DON emphasized the importance of this procedure to ensure all narcotics are accounted for and stated that nurses should notify her if the count sheets are not completed. The facility's policy, revised in August 2024, mandates that two licensed nurses verify the inventory of controlled substances at the end of each shift.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wound
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, identified as R21, which could potentially affect all 27 residents on the second floor. On observation, R21 was found in bed without an EBP sign or Personal Protective Equipment (PPE) bin in or near the room. Staff members, including a Registered Nurse (RN) and Certified Nursing Assistants (CNAs), were observed performing high-contact care activities such as wound care and hygiene assistance without wearing the appropriate PPE, specifically gowns. Interviews with staff revealed a lack of awareness and understanding regarding the necessity of EBP for residents with chronic wounds. The Wound Care Nurse, V9, acknowledged that residents with wounds require EBP but was unsure why R21 was not on EBP. The Infection Preventionist, V3, incorrectly stated that R21 did not require EBP because the wound was not chronic and lacked a history of Multidrug-Resistant Organism (MDRO). However, the Director of Nursing, V2, confirmed that residents with chronic wounds should be on EBP to prevent MDRO transmission. The facility's policy on EBP mandates the use of gowns and gloves during high-contact care activities for residents with significant wounds or indwelling medical devices, even if they are not known to be infected with MDRO. Despite this policy, R21's care plan and Physician Order Sheet indicated the need for EBP due to a chronic wound, yet these precautions were not implemented, leading to a deficiency in infection prevention and control practices.
Failure to Cover Urinary Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter drainage bag was covered with a privacy cover, which affected the resident's dignity. During an observation, the urinary catheter drainage bag was seen hanging off the lower bed frame of the resident's bed, visible to anyone passing by the open door. The bag contained yellow urine and was not covered with a privacy bag, contrary to the facility's policy. The resident involved had a diagnosis that included neuromuscular dysfunction of the bladder, retention of urine, difficulty in walking, and generalized muscle weakness. The resident's cognitive status was intact, as indicated by a BIMS score of 15. The facility's policy required that catheter drainage bags be covered at all times to maintain resident dignity, but this was not adhered to in this instance.
Failure to Adhere to Fluid Restriction Diet Order
Penalty
Summary
The facility failed to adhere to a resident's prescribed fluid restriction diet order, which was observed during a lunch meal. The resident, identified as R37, has a medical history that includes acute on chronic diastolic congestive heart failure, chronic kidney disease, and organ-limited amyloidosis. R37 also has some cognitive impairments, as indicated by a BIMS score of 10. During the observation, R37 consumed both a 7.5 oz can of ginger ale and a 6.0 oz cup of water, despite the dietary order specifying a fluid restriction of 6 oz of either water, coffee, juice, or soda, but not more than one option. The diet card and physician order sheet both documented a daily fluid restriction of 1500 mL, with specific allocations for dietary and nursing staff. The dietician, identified as V7, confirmed that R37 should not have been provided both beverages due to the fluid restriction. V7 acknowledged that the servers, who provide drinks before meals, need to read and adhere to the diet card instructions. The facility's policy on therapeutic diet orders emphasizes providing residents with foods and fluids in accordance with physician prescriptions and interdisciplinary team assessments. The failure to follow the fluid restriction order was identified as a deficiency during the survey, highlighting a lapse in the facility's adherence to prescribed dietary interventions for residents with specific medical needs.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain temperature logs and provide thermometers for personal refrigerators used by residents, specifically affecting two residents. Observations on multiple occasions revealed that the personal refrigerators of these residents lacked temperature logs and thermometers, which are necessary to ensure food safety. The facility's policy allows residents to have food brought in by family or visitors, but it requires that the food be handled safely. However, there was no clear responsibility assigned for monitoring the temperatures of these personal refrigerators, leading to potential safety risks. Interviews with staff, including a Certified Nursing Assistant, the Director of Nursing, a Registered Nurse, and the Environment Service Director, revealed confusion and lack of clarity regarding who is responsible for maintaining and monitoring the temperatures in residents' personal refrigerators. The Director of Nursing stated that the residents' families are responsible for the maintenance of these refrigerators, but acknowledged that the facility does not have a specific policy for their care and maintenance. This lack of oversight and clear policy could lead to food spoilage and potential health issues for the residents.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a confused resident (R1) who is a high fall risk. R1, who has a history of severe cognitive impairment and multiple medical conditions including a recent hip fracture and stroke, was found on the bathroom floor with a laceration to the back of the head. Despite being identified as a high fall risk and requiring constant supervision, R1 was left unsupervised, leading to the fall and subsequent injury that required hospital treatment and laceration repair with staples. R1's clinical records and care plan indicated that she had poor safety awareness and frequently attempted self-transfers and self-toileting without assistance. On the night of the incident, R1's family member had left the facility, and R1 was found by staff in the bathroom with significant bleeding from a head injury. The staff noted that R1 had a history of not using the call light and required close monitoring, which was not adequately provided at the time of the fall. Interviews with staff and family members revealed that R1 needed constant supervision due to her cognitive impairment and high fall risk. Despite having a fall alert system in place, the system failed to prevent the fall. The staff's failure to continuously monitor R1, especially after her family member left, directly contributed to the incident. The facility's policies on fall management were not effectively implemented, leading to R1's injury.
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.
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