The Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Waukegan, Illinois.
- Location
- 1615 Sunset Avenue, Waukegan, Illinois 60087
- CMS Provider Number
- 146159
- Inspections on file
- 32
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Terrace during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions was prescribed doxycycline for three days following hospital discharge, but due to an order entry error in the eMAR, only a single dose was administered. The DON confirmed the order was entered incorrectly, resulting in the resident not receiving the full course of antibiotic therapy as prescribed.
The facility did not ensure that kitchen staff followed proper hand hygiene and dish sanitization procedures. A dietary aide handled both dirty and clean dishes without washing hands, and the dishwasher was found to be operating without sanitizer. Required checks of the dishwasher's sanitizing function were not consistently documented, affecting all 77 residents.
The facility failed to properly store, prepare, and distribute food, affecting 71 residents. Observations included expired and undated food items, lack of proper labeling and covering, and absence of thermometers in refrigeration units. Food carts were delivered uncovered, exposing food to air, contrary to facility policies.
The facility failed to maintain a homelike environment, with multiple rooms and shared bathrooms exhibiting peeling paint, holes in walls, and missing baseboards. Eight residents expressed dissatisfaction with these conditions, which were acknowledged by the Maintenance Director as ongoing issues. Despite recognizing the problem, the Maintenance Director hesitated to address it due to pending remodeling plans and lack of a clear policy.
The facility failed to manage and document controlled medications properly, leading to discrepancies in medication counts and potential safety issues. An LPN did not have the incoming nurse sign the accountability log, and there was a lack of an Individual Controlled Drug Administration Record for a resident's Clonazepam. Discrepancies were noted in medication counts, and residents had medications without active orders, improperly stored with pill slots covered with tape. The DON acknowledged the need for proper accounting and disposal of controlled medications.
The facility failed to properly label and store medications for five residents, including insulins and eye drops. Observations revealed opened and undated insulin vials, improper storage of insulin pens, and an undated eye drop container without an active order. The DON confirmed that medications should be stored according to package instructions, and the facility's policy requires adherence to pharmacy recommendations and regulatory guidelines.
The facility failed to assist residents with activities of daily living, including eating and oral care. A resident with Alzheimer's and dysphagia struggled to feed herself due to a soiled mask and lack of staff assistance. Another resident with hand contractures was left unsupervised, resulting in untouched drinks and spilled food. Two residents with oral hygiene needs had unkempt teeth and food residue, despite the facility's policy for daily care. The DON acknowledged the need for staff assistance, but observations showed a failure to meet these standards.
A resident with dementia and other health issues was served thin liquids instead of the prescribed nectar-thickened liquids. The CNA corrected the error after noticing the discrepancy. The facility's policy requires dietary staff to prepare meals according to prescribed diets, with CNAs performing a final check before serving.
The facility failed to provide proper urinary catheter care for two residents, leading to increased infection risk. Staff routinely disconnected and cleaned catheter bags with a vinegar solution, contrary to best practices and without physician approval. This practice was inconsistent with the facility's policy, which contributed to the deficiency.
The facility failed to follow infection control protocols by not wearing PPE for two residents on Enhanced Barrier Precautions. Staff were observed providing care without gowns, despite knowing the requirement for PPE during high-contact activities. Both residents had orders for EBP due to their medical conditions.
A resident with dementia and a history of falls sustained an unwitnessed fall resulting in a femur fracture. The facility failed to conduct required neurological assessments at specified intervals for 72 hours post-fall, as per their policy. The resident's electronic medical record showed a lack of assessments from late morning to midnight on the day of the fall, which was confirmed by the DON.
A facility failed to implement fall interventions for a resident with a history of falls and dementia. The resident was found in bed without floor mats and the bed was not in the lowest position, contrary to the care plan. The DON confirmed the required interventions were not in place.
A resident with an acute injury experienced a delay in receiving a STAT x-ray, which was ordered due to suspected deep vein thrombosis. Despite orders being placed, the x-ray was not performed until over 24 hours later, revealing a fracture. The LPN expected the x-ray to be done the same day, and the NP advised staff to follow up with the x-ray company or send the resident to the emergency department if necessary. The facility's administrator was investigating the delay.
The facility failed to document and communicate visitor restrictions for two residents, leading to a deficiency in maintaining safety. One resident's father, who was verbally aggressive, was not properly restricted in the records, and another resident's son, who brought illegal substances, was not documented as restricted. The facility's policy requires such restrictions to be clearly posted and documented, which was not done.
Antibiotic Order Not Followed Due to Medication Entry Error
Penalty
Summary
The facility failed to ensure that an antibiotic was administered as ordered for one resident. The resident, who had multiple diagnoses including pneumonia, major depressive disorder, osteoporosis, severe protein calorie malnutrition, hypothyroidism, chronic obstructive pulmonary disease, and other conditions, was discharged from the hospital with instructions to receive doxycycline 100 mg daily for three days. However, the electronic Medication Administration Record (eMAR) showed that the order was incorrectly entered as a one-time dose rather than a daily dose for three days. As a result, the resident received only one dose of doxycycline instead of the full prescribed course. The Director of Nursing confirmed that the order was entered incorrectly and that only a single dose was administered, contrary to the hospital discharge instructions and facility policy for safe medication administration.
Failure to Sanitize Dishes and Ensure Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to ensure proper kitchen sanitation practices, specifically regarding the use of the dishwasher and hand hygiene among dietary staff. On observation, a dietary aide was seen unloading clean dishes, loading dirty dishes, and then handling clean dishes again without washing hands in between, which could lead to cross contamination. Additionally, the sanitizer bucket connected to the dishwasher was found to be empty, and test strips confirmed that no sanitizing agent was present in the dishwasher at the time of inspection. The dietary manager acknowledged that the dishwasher should be checked three times daily to ensure proper function and sanitizer levels, and that handwashing is required when moving from dirty to clean dishes. Record review revealed that the facility's dishwasher sanitizer check sheet had missing entries for several meal periods, indicating that required checks were not consistently performed. The facility's policy requires dish machines to be checked prior to meals and mandates handwashing before handling clean dishes after touching dirty ones. The infection control nurse confirmed the importance of proper dish sanitization to prevent the spread of foodborne illnesses and gastrointestinal viruses. These failures applied to all 77 residents in the facility.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in a manner that would prevent foodborne illnesses, affecting 71 residents who consumed food from the kitchen. During an initial tour of the kitchen, several deficiencies were observed in the dry food storage area, including expired tomato juice, and various food items such as mashed potatoes and tortillas that lacked 'received on' or expiration dates. Additionally, an opened box of instant food thickener and long grain rice were left exposed to air without 'opened on' dates. The milk refrigerator lacked a thermometer, and undated milk was served to residents despite staff acknowledging the absence of dates. The kitchen cooler contained staff personal items and uncovered food items like juice cups, cheese, bologna, and cut vegetables, all without proper dating or covering. Further inspection revealed improper storage in the kitchen freezers, with raw pork chops stored above tator tots, and various undated and uncovered food items such as sausages, pancakes, and chicken. A second freezer contained improperly covered and undated cooked enchiladas, corn, and ice cream with a broken lid. Food carts delivered to dining halls were uncovered, exposing trays and open cups to air. The facility's policies on food receiving, storage, and preparation were not adhered to, as evidenced by the lack of proper labeling, dating, and covering of food items, as well as the absence of functioning thermometers in refrigeration units.
Facility Fails to Maintain Homelike Environment Due to Peeling Paint and Structural Issues
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as observed during a survey. Multiple rooms and shared bathrooms were found with peeling paint, holes in the walls, and missing baseboards. These conditions were noted in the rooms and shared bathrooms of eight residents, all of whom expressed dissatisfaction with the state of their living environment. The residents' cognitive statuses varied, with some being moderately impaired and others cognitively intact, yet all were aware of and concerned about the environmental deficiencies. The Maintenance Director acknowledged the ongoing issues with the facility's physical environment, including paint and wallpaper peeling, holes in walls, and missing baseboards. Despite recognizing the problem, the Maintenance Director expressed hesitation in addressing these issues due to potential future remodeling plans, which were pending approval from corporate. The lack of a clear policy or immediate plan to rectify the environmental deficiencies contributed to the ongoing neglect of the residents' right to a safe, clean, and homelike environment.
Failure to Properly Manage and Document Controlled Medications
Penalty
Summary
The facility failed to properly manage and document controlled medications for several residents, leading to discrepancies in medication counts and potential safety issues. During an observation, it was found that a Licensed Practical Nurse (LPN) did not have the incoming morning nurse sign the accountability record log for controlled medications, and there was a lack of an Individual Controlled Drug Administration Record log for a resident's Clonazepam medication. Additionally, discrepancies were noted in the medication count for Clonazepam, with missing signatures for tablets removed on specific dates. The facility's Shift Change Accountability Record for Controlled Substances also showed multiple omitted nurses' signatures. Further observations revealed that residents had medications such as Hydrocodone and Lorazepam in their possession without active orders, and these medications were improperly stored with pill slots covered with tape or band-aids. The Director of Nursing acknowledged that all controlled medications need to be accounted for and disposed of appropriately when discontinued or not used. The facility's policy requires controlled substances to be signed out upon dispensing, with a maintained count by nurses of the off-going and oncoming shifts, and any irregularities reported to the Director of Nursing.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly label and store medications for residents receiving insulins and eye drops, affecting five residents. During an observation of medication storage, it was found that a resident's Levemir insulin vial was opened and undated, and another resident's Humulin R insulin vial was open and dated beyond the discard date. Additionally, a resident's Fiasp insulin vial was stored at room temperature despite instructions to refrigerate until opened. Another resident's insulin pens and vials were opened, unbagged, and stored in a multi-resident container, and a resident's Latanoprost eye drop container was open and undated, with no active order for the medication. The Director of Nursing acknowledged that insulin and eye drop medications should be stored according to package instructions and that multi-dose medications should be labeled when opened and discarded as indicated. The facility's policy on medication storage, dated March 2021, states that medications should be stored in accordance with pharmacy recommendations and regulatory guidelines. These observations indicate a failure to adhere to proper medication storage and labeling practices, potentially compromising medication safety administration.
Failure to Assist Residents with ADLs in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance to residents requiring help with activities of daily living, specifically in eating, oral care, and grooming. Resident 57, who has multiple diagnoses including Alzheimer's disease and dysphagia, was observed struggling to feed herself due to a soiled surgical mask and lack of consistent assistance from staff. Despite her need for substantial to maximal assistance with eating, she was left unsupervised multiple times, and her oral hygiene was neglected, as evidenced by overgrown facial hair and unkempt teeth. Resident 1, also diagnosed with Alzheimer's disease and hand contractures, was observed with untouched drinks and difficulty feeding herself due to her hand splints and a soiled surgical mask. Although she required supervision and assistance with eating and drinking, she was left unsupervised, resulting in spilled food and untouched beverages. Her care plan indicated a dependency on staff for all activities of daily living, including feeding. Residents 28 and 26, both with significant medical conditions affecting their ability to perform oral hygiene, were found with unkempt teeth and food residue. Despite the facility's policy requiring daily oral care, these residents were not adequately assisted, leading to a buildup of plaque and food residue. The Director of Nursing acknowledged the expectation for staff to assist residents with their daily living activities, including feeding and oral hygiene, but the observations indicated a failure to meet these standards.
Failure to Provide Correct Consistency of Liquids
Penalty
Summary
The facility failed to provide the correct consistency of liquids for a resident with an order for nectar-thickened liquids. The resident, identified as R60, had multiple diagnoses including dementia, muscle weakness, and respiratory infection, and required setup assistance for meals with an altered diet necessitating thickened liquids. On January 7, 2025, a Certified Nurse Assistant (CNA) served R60 lunch with drinks that were of thin liquid consistency, contrary to the nectar-thickened liquid requirement noted on the resident's meal ticket. The CNA acknowledged the error and corrected it by thickening the drinks after being prompted. The Director of Nursing (DON) confirmed that dietary staff are responsible for preparing meal trays according to prescribed diets, and CNAs are expected to perform a final check before serving meals to residents. The facility's policy on meal service emphasizes the importance of ensuring the accuracy of prescribed diets, including diet type, texture, and fluid consistency. The failure to adhere to these procedures resulted in the resident being served the incorrect type of liquids, which could potentially lead to complications such as choking and aspiration pneumonia.
Improper Urinary Catheter Care and Increased Infection Risk
Penalty
Summary
The facility failed to provide proper urinary catheter care for two residents, R44 and R67, as observed during a survey. For R44, a CNA reported changing the catheter bag from a hanging bag to a leg bag and cleaning the bags with a vinegar and water solution, despite the bag being labeled as sterile and not to be re-sterilized. The RN confirmed this practice, which was instructed during an in-service by the Infection Preventionist. The Nephrology Nurse Practitioner advised against disconnecting the catheter system due to increased infection risk, yet the facility continued this practice without physician approval. For R67, the urinary bag was observed on the floor and later placed under a blanket by a CNA. The CNA stated that the urinary bag is disconnected, cleaned with a vinegar solution, and hung to dry daily, with the cleaned bag from the previous shift being reattached. The LPN confirmed this routine, which involves switching between two bags every couple of weeks. The Infection Preventionist acknowledged that the practice of disconnecting and reusing bags increases infection risk, yet it was the facility's standard procedure. The Director of Nursing stated that the urinary bag is disconnected and cleaned twice daily to maintain cleanliness, although this practice was not approved by the facility's Medical Director or Urologist, nor was there a physician's order for it. The facility's policy on Foley catheter management indicated a different cleaning procedure, which was not being followed. This discrepancy in practice and policy contributed to the deficiency in providing appropriate catheter care and preventing urinary tract infections.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols by not wearing appropriate Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). On January 8, 2025, a Restorative Aide/CNA was observed in a resident's room without wearing a gown, despite the resident being on EBP. The aide provided incontinence care, assisted in changing clothes, and transferred the resident from the bed to a wheelchair without the required PPE. The resident had multiple diagnoses, including hemiplegia, hemiparesis, and dementia, and had an order for EBP since December 30, 2024. Similarly, another CNA was observed on the same day in a different resident's room without wearing a gown while transferring the resident and changing a catheter bag. This resident had diagnoses including Parkinson's disease and Alzheimer's disease and had an EBP order since April 18, 2024. Both staff members acknowledged the requirement to wear gowns and gloves for residents on EBP, especially during high-contact activities such as transferring and incontinence care. The facility's policy from December 2019 mandates the use of gloves and gowns for such activities, yet these protocols were not followed, leading to the deficiency.
Failure to Complete Post-Fall Assessments
Penalty
Summary
The facility failed to complete ongoing assessments for a resident who sustained a fall with injury. The resident, who had a history of repeated falls and impaired cognition due to dementia, was at high risk for falls and dependent on staff for care. After an unwitnessed fall from bed, the resident was initially assessed and found to have no immediate complaints of pain or obvious injuries. However, the resident later complained of left leg pain, and an X-ray revealed a proximal left femur fracture. Despite the injury, the resident's family did not want hospitalization, and the resident remained in the facility with orders for pain management and follow-up with an orthopedic physician. The facility's protocol required neurological assessments immediately after a fall and at specified intervals for 72 hours post-fall. However, the resident's electronic medical record showed a lack of post-fall assessments from late morning to midnight on the day of the fall. The Director of Nursing confirmed that no neurological or 72-hour post-fall assessments were completed during this period, which was a deviation from the facility's Neurological Assessment policy. This policy outlined specific intervals for monitoring key neurological checkpoints, which were not adhered to in this case.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, who had sustained a recent fall with injury, had appropriate fall interventions in place. The resident, identified as R2, had a history of repeated falls and was at high risk due to impaired cognition related to dementia. R2 was dependent on staff for care and had previously fallen out of bed, resulting in a fracture. The care plan for R2 included keeping the bed in the lowest position and providing floor mats on the sides of the bed. However, during observations on December 11, 2024, R2 was found in bed without floor mats on either side, and the bed was approximately 4 feet off the ground. The Director of Nursing confirmed that the fall interventions for R2 included frequent monitoring, ensuring the bed was in the lowest position, and placing fall mats on the floor, none of which were in place at the time of observation.
Delay in X-ray Acquisition for Resident with Acute Injury
Penalty
Summary
The facility failed to ensure timely acquisition of x-rays for a resident with an acute injury. On November 27, 2024, a resident complained of pain during care, prompting a CNA to alert the nurse on duty. Despite the administration of pain medication and an assessment by the nurse, no immediate findings were noted. Later, the resident again complained of pain, leading the CNA to inform the nurse, who then involved the DON. Suspecting a deep vein thrombosis, the DON contacted the NP, who ordered a venous doppler and a STAT x-ray. However, the x-ray was not performed until the following morning, over 24 hours later, revealing a fracture in the resident's right tibia/fibula. The delay in obtaining the x-ray was noted by the LPN who was on duty during the day shift on November 27, 2024. She expected the x-ray to be completed that evening, but it was not done until the next day. The NP, who assessed the resident later that day, instructed the nursing staff to follow up with the x-ray company and indicated that the resident should have been sent to the emergency department if the x-ray could not be performed promptly. The facility's administrator acknowledged the delay and was investigating the cause. The facility's policy requires laboratory and diagnostic testing to be performed according to the order, with oversight by the DON or a designee, but this protocol was not followed in this instance.
Failure to Document and Communicate Visitor Restrictions
Penalty
Summary
The facility failed to ensure that restricted visitor information was properly documented and communicated for two residents, leading to a deficiency in maintaining resident safety. For one resident, who had severe cognitive impairment and required total assistance for all activities of daily living, the facility did not have the necessary documentation to restrict the resident's father from visiting, despite verbal instructions and awareness among staff. The father's access was supposed to be denied due to his aggressive behavior, but the information was not present in the electronic medical records or posted at the front desk as required by the facility's policy. Similarly, another resident reported that his son was no longer allowed to visit due to bringing illegal substances during a visit. However, there was no signage or documentation at the front desk to indicate this restriction. The facility's visitation policy allows for reasonable restrictions, including denying access to disruptive visitors, but the lack of proper documentation and communication of these restrictions led to the deficiency being identified during the survey.
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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