Thryve Of Burbank
Inspection history, citations, penalties and survey trends for this long-term care facility in Burbank, Illinois.
- Location
- 5400 West 87th Street, Burbank, Illinois 60459
- CMS Provider Number
- 145211
- Inspections on file
- 47
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Thryve Of Burbank during CMS and state inspections, most recent first.
The facility did not maintain required indoor temperatures of 71–81°F on one wing and in the dialysis room, resulting in multiple areas measuring around 60–63°F over several days. Staff, including the ADON, CNA, and an LPN, reported that the wing was cold and that some rooms lacked proper heat. Temperature logs and on-site readings by the Maintenance Director confirmed substandard temperatures in several rooms and hallways, as well as in the dialysis room where residents were observed wrapped in multiple blankets. Several residents receiving dialysis reported that the room was very cold, causing discomfort and body pain, and one resident stated they had to use two blankets to cover their body and head due to the lack of heat.
A resident with multiple comorbidities, including COPD, DM2, epilepsy, history of falls, lack of coordination, and altered mental status, was admitted and experienced two falls during a brief stay. The facility’s Fall Guideline Policy requires a fall risk evaluation on admission, but the admitting LPN did not complete this assessment, and the DON and Restorative Director confirmed no admission fall risk score was present. Incident reports documented one fall when the resident attempted to go to the bathroom without using the call light and another unwitnessed fall from a wheelchair while reaching for a phone, after which a later fall risk observation classified the resident as high risk for falls.
Two residents with significant cognitive and functional impairments, both care-planned and assessed via MDS as requiring two-person assistance for bed mobility and personal care, experienced falls during care when CNAs provided assistance alone instead of using the required two-person assist. In one case, a resident with morbid obesity, COPD, dementia, and dependence for ADLs slid from the bed to the floor during evening care provided by a single CNA, later becoming unresponsive and requiring EMS and CPR. In the other case, a ventilator-dependent resident with hypoxic ischemic encephalopathy and severe decision-making impairment slid from the edge of the bed to the floor during peri-care performed by one CNA, sustaining a scalp laceration that required staples and a shoulder contusion, and was transferred to the hospital. Nursing staff and leadership acknowledged that both residents should have had two-person assistance during care, but this was not followed at the time of the incidents.
A staff member failed to follow facility policy by taking a personal phone call while providing care to a resident dependent on staff for lower body care due to paraplegia and other medical conditions. The incident was observed by an LPN, who instructed the CNA to stop using her phone and reported the event to nursing leadership. The CNA admitted to using her phone and air pods during care, and documentation confirmed a formal warning was issued for unauthorized device use.
The facility did not follow its preventive maintenance policy for the chiller system, resulting in repeated equipment shutdowns due to debris and low water flow. Intake vents were found dirty, and no documentation of maintenance activities was available, despite staff claims of regular filter changes and chemical treatments. These failures led to the use of portable AC units and building temperatures exceeding 80°F, affecting all residents.
The facility did not consistently monitor or document daily temperatures, resulting in multiple days without records and prolonged periods where temperatures exceeded the required 71–81°F range. Malfunctions in the cooling system led to hot and humid conditions throughout the building, with staff and a resident reporting discomfort and the use of portable AC units and fans to address the issue. These failures affected the comfort and safety of all residents.
Two ventilator-dependent residents with severe cognitive impairments fell out of bed due to inadequate safety interventions in a facility. Despite being high fall risks, the facility lacked measures like floor mats and low beds. Both residents were on air mattresses, which contributed to movement during coughing episodes, leading to falls. The facility's failure to provide a hazard-free environment and adequate supervision resulted in these incidents.
A resident with multiple diagnoses and a high fall risk score was found on the floor after an unwitnessed fall in the facility. The care plan lacked fall prevention interventions, and the resident's call light was not activated. Staff did not observe any behaviors indicating a fall risk, but the resident's bedside table was not within reach, potentially contributing to the fall. The facility's fall prevention guidelines were not adequately followed.
The facility failed to implement its abuse prevention policies, affecting four residents identified as offenders. Care plans were not developed for these residents, and abuse/neglect screenings were incomplete upon admission. The Social Service Director was unaware of the requirement to create care plans for identified offenders, despite facility policy. The Director of Nursing and Administrator were informed of these deficiencies.
The facility failed to implement fall prevention measures for two high-risk residents, did not investigate or report a resident's injury, and inaccurately assessed a resident's smoking habits. Observations showed non-compliance with care plans for fall precautions, lack of documentation for an injury, and incorrect smoking assessments, indicating a breach of facility policies.
A facility failed to follow its policy for using Low Air Loss (LAL) mattresses, leading to a deficiency in pressure ulcer care for a resident with skin impairment. The resident, who had multiple diagnoses and a history of pressure ulcers, was observed with multiple layers of linen on the LAL mattress, contrary to the policy that allows only a flat sheet. The DON confirmed the policy breach and instructed the LPN to correct the issue.
The facility failed to implement its extreme high temperature policy, affecting residents' safety and comfort. A resident with multiple health conditions experienced discomfort due to a malfunctioning air conditioner, with room temperatures recorded at 84°F. The facility did not document temperature and humidity readings as required, nor did it monitor residents' fluid intake or signs of heat-related symptoms. Another resident reported feeling unwell due to a non-functioning air conditioner, with ongoing air conditioning issues since May.
A facility failed to notify a physician about a resident's lack of urine output from a urinary catheter, leading to the resident retaining 1,450 mL of urine and requiring hospital treatment for a urinary tract infection and acute kidney injury. Despite staff noticing the issue, the catheter was not changed before the resident was sent to the hospital.
A facility failed to assess, change, or flush a resident's urinary catheter after no urine output for an entire shift, leading to the resident retaining 1,450 mL of urine and requiring hospitalization for a urinary tract infection and acute kidney injury. The catheter was not changed or flushed despite orders, and staff interviews confirmed the catheter should have been addressed.
A facility failed to identify, assess, and treat a post-surgical wound site for a resident with a tracheostomy, leading to an infection that required a 10-day course of antibiotics and four weeks of wound care treatment. The embedded suture was not initially identified during daily trachea care, resulting in delayed treatment.
A facility failed to ensure a resident was seen by an eye doctor as requested by the POA. Despite multiple requests during care plan meetings, the resident's eye doctor visit was delayed. The resident was eventually diagnosed with presbyopia and given a prescription for glasses. The facility lacks a policy on vision services but expects residents to be seen upon physician's order or request.
A facility failed to ensure a resident was seen by the dentist as requested by the POA. Despite requests during two care plan meetings, the resident was only seen by the dentist after the second meeting. The resident's dental consult revealed moderate plaque and staining, mildly dry mouth, puffy tissue, and mild thrush. The facility's policy indicates that oral health services should be available to meet residents' needs, but the resident only had one dental exam since admission.
Failure to Maintain Required Indoor Temperatures on One Wing and in Dialysis Room
Penalty
Summary
The facility failed to maintain indoor temperatures within its policy range of 71–81°F, resulting in prolonged cold conditions on the XXX complex wing and in the dialysis room. During unit rounds, surveyors observed residents in the XXX complex hallway wearing multiple layers of clothing, hoodies, and zipped jackets, and staff, including the ADON, also wearing zipped sweaters and commenting that the hallway was cold. The Maintenance Director reported that the heating system on the XXX wing had been worked on in late November, which restored heat only to rooms on one side of the wing (odd-numbered rooms), while rooms on the opposite side (even-numbered rooms) continued to have heating issues. A CNA and an LPN both stated that the XXX wing was cold and that some resident rooms did not have proper heating. Temperature logs reviewed by surveyors showed multiple documented readings well below the facility’s required range, including temperatures of 63.9°F near one resident’s room, 62.1°F near another’s room, 63.2°F near a third resident’s room, and 60.1°F near two other residents’ rooms on various early-morning dates. On-site temperature checks by the Maintenance Director and surveyor in the XXX hallway and in specific resident rooms showed readings between 61.9°F and 62.2°F, which the Maintenance Director acknowledged were unacceptable and below the policy standard. In the dialysis room on the XXX complex wing, residents receiving dialysis were observed wrapped in multiple blankets, and the room temperature measured 62.2°F. Residents who received dialysis reported that the dialysis room was cold; one resident stated the cold made her body hurt and was very uncomfortable, another said it was so cold it made them angry, and another reported taking two blankets and covering their body and head because there was no heat in the dialysis room.
Failure to Complete Admission Fall Risk Evaluation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Guideline Policy by not completing a Fall Risk Evaluation upon admission for a newly admitted resident. The resident, an older female with multiple diagnoses including COPD with acute exacerbation, acute respiratory failure with hypercapnia, type 2 diabetes mellitus, asthma with acute exacerbation, epilepsy with status epilepticus, chronic fatigue, history of falling, lack of coordination, altered mental status, abnormal EEG, supraventricular tachycardia, and hypertension, was admitted on 6/5/2025 and discharged on 6/6/2025. The facility’s policy, revised 8/2024, requires that a fall risk evaluation be completed upon admission, quarterly, annually, and with significant change in condition, and that if the evaluation finds the resident at risk, resident-specific interventions and precautions are implemented. The Restorative Director, the admitting LPN, and the DON all confirmed through interview that the admitting nurse is responsible for completing the initial fall risk assessment on the day of admission and that no such assessment was found for this resident on the admission date. During the resident’s short stay, two falls were documented. On 6/5/2025 at 3:15 PM, an incident report completed by the admitting LPN documented that the resident was found sitting on the floor in her room after stating she needed to go to the bathroom and had not used the call light because she forgot and urgently needed to use the bathroom. On 6/6/2025 at 1:00 PM, another incident report documented that the resident was observed on the floor after an unwitnessed fall, with a knot noted on the left side of the head and no active bleeding; the resident reported she had been sitting in her wheelchair, reached down to grab her phone, and lost her balance. A Fall Risk Observation completed later on 6/6/2025 at 2:56 PM categorized the resident as high risk for falls with a score of 13. Staff interviews confirmed that the initial fall risk evaluation, which should have been completed upon admission, was not done, and that failure to complete this assessment places a resident at risk of falling.
Failure to Follow Two-Person Assist Requirements During Care Resulting in Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during care in accordance with residents’ assessed needs and care plans, resulting in falls for two residents. The first resident (R1), an older adult with morbid obesity, lack of coordination, COPD, dementia, and hypertension, had an MDS dated 09/15/2025 indicating moderate cognitive impairment (BIMS 10/15) and dependence on staff for toileting hygiene, rolling, showering, dressing, and bed mobility, requiring the assistance of two or more helpers. On the evening of the incident, a CNA (V8) provided routine evening care to R1 alone, positioning the resident on her side. During this care, V8 observed R1’s leg moving downward and R1 sliding toward the edge of the bed, ultimately sliding to the floor into a seated position while holding the side rail. Following the fall, an LPN (V4) responded to the room after being called and found R1 on the floor, not very responsive. V4 instructed one nursing assistant to call 911 and another to call the supervisor, assessed R1 on the floor and again after R1 was assisted back to bed with a mechanical lift, and noted that R1’s vital signs were lower than initially but that R1 was still breathing. EMS arrived, and when V4 returned to the room after printing paperwork, paramedics had initiated CPR, which V4 estimated lasted about 20 minutes before R1 was pronounced deceased. R1’s roommate recalled that staff helped R1 right away after the fall, and a family member reported having spoken with R1 earlier that evening while staff were in the room assisting, later being called to the facility after the event. The family member stated that R1 fell because only one CNA provided care when two were required and expressed questions about how R1 was assessed and when CPR was initiated. The facility was awaiting the coroner’s report, and the relationship between the fall and R1’s death could not be determined at the time of review. The second resident (R2), an older adult with hypoxic ischemic encephalopathy, respiratory failure on a ventilator/tracheostomy, acute embolism and thrombosis of the femoral vein, thoracic aortic aneurysm, bowel and bladder incontinence, and receiving enteral nutrition, had an MDS indicating severely impaired decision-making and dependence on staff for toileting hygiene, rolling, showering, oral care, dressing, and bed mobility, requiring the assistance of two or more helpers. During rounds, a CNA (V13) provided peri-care to R2 alone, with R2 positioned at the edge of the bed. V13 reported that when turning R2, the resident slid out of bed toward the door, despite the care plan requiring two-person assistance; V13 stated that R2 required two-person assist but that she believed she could handle the care by herself and had been doing so. Nursing notes by an RN (V12) documented that R2 was found lying on his back on the floor next to the bed with a laceration to the left scalp with active bleeding and a scratch on the left side of the neck. R2 was treated at the facility for bleeding control and then transferred via 911 to a local hospital, where records showed a scalp laceration requiring three staples and a left shoulder contusion. The Restorative Director and the DON acknowledged that both R1 and R2 required two-person assistance during care based on MDS assessments, but each was being cared for by a single CNA at the time of their falls, contrary to their care plans and the facility’s fall prevention policy.
Staff Cell Phone Use During Resident Care
Penalty
Summary
A staff member failed to follow the facility's employee handbook regarding cell phone usage by taking a personal phone call while providing care to a resident. The incident occurred during a shower provided to a male resident with paraplegia, diabetes mellitus type 2, convulsions, hypertension, cervical spinal cord injury, and colostomy status. The resident, who is cognitively intact and dependent on staff for lower body care, reported that the Certified Nursing Assistant (CNA) used her cell phone, including FaceTime, during his shower. The resident did not report the incident to management due to anxiety and fear of triggering seizures, but did inform a family member. A Licensed Practical Nurse (LPN) working that day confirmed observing the CNA using her personal phone and air pods while providing care to the resident. The LPN instructed the CNA to stop using her phone during patient care and reported the incident to the assistant director of nursing the following day. The CNA admitted to receiving an emergency personal phone call during the resident's shower, apologized to the resident, and acknowledged that she should not have been using her phone or air pods during patient care. The CNA denied being on FaceTime but confirmed the phone call was answered through her air pods. The Director of Nursing (DON) and the facility administrator both stated that staff are regularly informed not to use personal phones in resident areas and that staff are expected to step out of resident areas to answer personal calls. The facility's employee handbook prohibits the use of devices that obstruct or restrict hearing during working time, except for management-authorized use. Documentation confirmed that the CNA received a formal warning for unauthorized use of electronic devices on the unit during working hours.
Failure to Maintain and Document Chiller Maintenance Leads to Unsafe Temperatures
Penalty
Summary
The facility failed to maintain essential equipment, specifically the chiller (air conditioning system), in accordance with its own policies and procedures. Surveyors observed that the chiller, which was installed the previous year, repeatedly shut down due to low water flow caused by dirt and debris accumulation. Maintenance staff reported that the water filter and strainer were frequently clogged with rust-colored debris and other materials, resulting in the chiller shutting off multiple times during the inspection. Intake vents throughout the facility were also found to be completely covered in dust, debris, and cottonwood remnants. Despite the maintenance staff's efforts to clean and restart the chiller, the system continued to experience operational issues, and portable AC units were in use while building temperatures remained above 80°F. Additionally, the facility failed to document any maintenance activities related to the chiller, despite staff stating that filters were changed weekly and chemicals were added monthly as part of regular maintenance. When asked, the Maintenance Director admitted to not having any records of chiller maintenance. The facility's preventive maintenance policy requires the maintenance department to maintain a preventive maintenance program and document equipment work orders and repairs, but this was not followed. These failures affected all 108 residents in the facility at the time of the survey.
Failure to Maintain Safe and Comfortable Temperatures
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not following its own policies and procedures regarding atmospheric temperature monitoring and control. Observations and interviews revealed that the facility did not consistently monitor and document daily temperatures, particularly on weekends when maintenance staff were not present, resulting in multiple undocumented days. On several occasions, the building's temperature exceeded the required range of 71 to 81°F, with readings as high as 84.3°F in various areas, and staff and residents reported the environment as warm, humid, and uncomfortable. The facility's chiller, which is responsible for cooling, experienced repeated malfunctions, including being shut down for cleaning and tripping due to low water flow and heat sensor issues. During these periods, the temperature in resident rooms and common areas rose above the acceptable threshold, and portable AC units and fans were used in an attempt to mitigate the heat. Despite these efforts, temperatures remained elevated, and the environment was described as hot and humid by both staff and residents. One resident specifically reported opening a window for ventilation due to the heat, and others in activity rooms and halls were exposed to temperatures above 80°F. Facility guidelines required daily temperature and humidity monitoring and immediate implementation of high temperature procedures if the temperature index exceeded 80°F. However, the lack of consistent monitoring, incomplete documentation, and delayed response to equipment failures led to prolonged periods where the environment was not maintained within the required comfort and safety parameters. These failures had the potential to affect all 108 residents in the facility.
Failure to Implement Effective Fall Prevention for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to implement effective safety interventions for two dependent, immobile, ventilator-dependent residents at high risk for falls, leading to incidents where both residents fell out of bed. Resident 1, who has severe cognitive impairment and is dependent on staff for all activities of daily living, fell from her bed and sustained a C2 fracture. Despite being identified as a high fall risk, the facility did not have adequate interventions in place to prevent the fall, such as floor mats or low beds, and the resident was found on the floor after a forceful cough and involuntary movements. Resident 3, who also has severe cognitive impairment and is dependent on staff for care, experienced a similar incident where she was found on the floor after a coughing episode. The facility's incident report noted that coughing can trigger involuntary movements, especially in residents who are physically compromised. Despite this, the facility had not implemented sufficient fall prevention measures until after the incident occurred, such as adding bed bolsters. Both residents were on air mattresses, which staff noted could contribute to movement during coughing episodes. The facility's failure to provide an environment free from hazards and adequate supervision, as outlined in their fall prevention guidelines, contributed to these incidents. Staff interviews revealed a lack of awareness and communication regarding the residents' fall risks and the potential for coughing to cause significant movement, leading to the falls.
Failure to Implement Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident identified at risk for falls. The resident, an older individual with multiple diagnoses including respiratory failure and reduced mobility, was admitted to the facility and later found on the floor after an unwitnessed fall. The resident's care plan did not include any fall risk interventions, despite a high fall risk score of 16, indicating a significant oversight in the resident's care management. On the day of the incident, the resident was last seen in bed by a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) before being found on the floor by a respiratory therapist. The CNA reported that the resident was able to move her arms and use the side rails to turn, but could not move her legs. The resident's call light was not activated at the time of the fall, and her bedside table was not within reach, which may have contributed to the fall. The CNA and LPN both noted that the resident did not exhibit any behaviors indicating distress or a fall risk during their shifts. The facility's fall prevention coordinator confirmed that the resident's fall risk assessment lacked necessary interventions, such as ensuring personal items were within reach and regular checks by staff. The facility's fall guidelines emphasize the importance of an interdisciplinary team approach to managing fall risks, which was not adequately implemented in this case. The resident was sent to the hospital following the fall, where she was diagnosed with hyperkalemia and leukocytosis.
Failure to Implement Abuse Prevention Policies for Identified Offenders
Penalty
Summary
The facility failed to implement its written policy and procedure to prohibit and prevent abuse, affecting four residents identified as offenders. During the survey, it was observed that these residents did not have care plans developed as identified offenders, contrary to the facility's policy. The Social Service Director (SSD) admitted to not being aware of the requirement to develop care plans for identified offenders, despite the facility's policy stating that care plans should incorporate security measures for such residents. Additionally, the abuse/neglect screening upon admission was not completed for these residents, with the SSD acknowledging the incomplete documentation. The facility's policy on abuse prevention and identified offenders outlines the need for a resident-sensitive and secure environment, including comprehensive care plans and regular evaluations for identified offenders. However, the survey revealed that the facility did not adhere to these policies, as evidenced by the lack of care plans and incomplete abuse assessments for the residents in question. The Director of Nursing (DON) and the Administrator were informed of these deficiencies, highlighting a systemic failure in implementing the facility's abuse prevention program.
Deficiencies in Fall Prevention, Incident Reporting, and Smoking Assessment
Penalty
Summary
The facility failed to implement fall preventive interventions for residents at high risk for falls. Observations revealed that two residents, both with a history of falls and identified as high risk, did not have their beds in the lowest position as required by their care plans. Additionally, one resident did not have bilateral floor mats as specified. The staff, including an LPN, were unsure of the fall precautions for these residents, indicating a lack of adherence to the facility's fall prevention policy. The facility also failed to investigate and report an incident involving a resident who sustained a reddened and swollen thumb after catching it in a bathroom door. The incident was not documented, and the staff, including the RN and ADON, were unaware of the injury. This lack of documentation and awareness contravenes the facility's policy on reporting and investigating accidents or incidents, which requires immediate reporting and investigation of all incidents, regardless of severity. Furthermore, the facility did not accurately assess a resident who smokes, as the smoking assessment indicated that the resident does not smoke, despite the resident keeping cigarettes and a lighter at the bedside. This oversight suggests a failure to adhere to the facility's policy on smoking assessments, which mandates that all residents desiring to smoke be assessed for safety and that these assessments be reviewed by an interdisciplinary team.
Failure to Follow Low Air Loss Mattress Policy for Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to its policy regarding the use of Low Air Loss (LAL) mattresses for a resident with skin impairment, leading to a deficiency in pressure ulcer care. During an observation, it was noted that a resident, who was on a LAL mattress due to pressure ulcers, had multiple layers of linen, including a folded linen used as a draw sheet and a cloth pad, contrary to the facility's policy. The Director of Nursing (DON) confirmed that the resident should only have a flat sheet over the LAL mattress, and instructed the Licensed Practical Nurse (LPN) to inform the Certified Nursing Assistant (CNA) to remove the excess linens. The resident in question was readmitted with several diagnoses, including peripheral arterial disease, bed confinement status, severe morbid obesity, and venous insufficiency, and had a history of pressure ulcers and decreased mobility. The facility's policy, effective since January 2017, specifies that a single non-fitted sheet should be used on LAL mattresses to manage the skin's microclimate. However, the observed practice did not align with these guidelines, as confirmed by the Wound Care Nurse, who stated that the resident should only have two layers, such as an adult brief and a flat sheet or cloth pad, but not both.
Failure to Implement Extreme High Temperature Policy
Penalty
Summary
The facility failed to implement its extreme high temperature policy and procedures, affecting the safety and comfort of residents. On the 2nd floor unit, a surveyor observed warm air and noted that a resident, identified as R103, was experiencing discomfort due to the heat. R103, who has a medical history including hypertension, diabetes mellitus type 2, vascular dementia, chronic pulmonary disease, and anxiety disorder, complained of being unable to sleep and feeling exhausted due to the hot room. The air conditioner in R103's room was malfunctioning, and the room temperature was recorded at 84 degrees Fahrenheit. The facility's Director of Nursing and Maintenance Director were unaware of the situation, and there was no documentation of monitoring R103's fluid intake or signs of heat-related symptoms. The facility's policy on extreme high temperatures requires monitoring of air temperatures and humidity, as well as resident conditions, but these procedures were not followed. The Maintenance Director admitted to not documenting temperature and humidity readings, which are supposed to be taken every two hours during extreme heat. Additionally, the facility's policy mandates that residents be relocated if temperatures exceed 80 degrees Fahrenheit, but this was not done. The surveyor also noted that the dining room temperature was 86.8 degrees Fahrenheit, with residents appearing sleepy and no staff offering water to them. Another resident, R69, also experienced issues with room temperature, which was recorded at 80.6 degrees Fahrenheit. R69 reported feeling unwell, with symptoms of nausea and loss of balance, due to a non-functioning air conditioner. A concerned party mentioned that air conditioning issues had been ongoing since May, and the Administrator confirmed that the Maintenance Director was responsible for documenting temperatures and humidity, which was not done on extreme heat days. The facility's failure to adhere to its own guidelines for managing high temperatures resulted in unsafe and uncomfortable conditions for the residents.
Failure to Notify Physician of Urinary Catheter Issues
Penalty
Summary
The facility failed to notify the physician of a resident not having any urine output from the urinary catheter for an entire eight-hour shift. This failure resulted in the resident retaining 1,450 mL of urine in the bladder and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. The resident, who has a history of quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy, reported not feeling well and refused meals, but the physician was not notified of the lack of urine output or the leaking catheter in a timely manner. On the day in question, the nursing staff documented that the urinary catheter was leaking and that the resident was exhibiting confusion. Despite this, the catheter was not changed before the resident was sent to the hospital. Hospital records indicated that the resident had a palpable bladder and elevated kidney levels, confirming a kidney injury. The catheter was found to be completely dry, and upon replacement, a significant amount of urine was drained, indicating that the catheter had not been functioning properly for some time. Interviews with the staff revealed that the CNA had notified the nurse about the leaking catheter, and the nurse had received orders to change it but did not complete the task before the resident was transferred to the hospital. The Director of Nursing and other medical staff confirmed that the expectation was to notify the physician and take immediate action if there was no urine output. The facility's policies on notification of resident change in condition and catheter care were not followed, leading to the resident's severe sepsis and acute kidney injury.
Failure to Assess and Change Urinary Catheter
Penalty
Summary
The facility failed to assess, change, or flush a resident's urinary catheter after the resident did not have any urine output from the catheter for an entire eight-hour shift. This resulted in the resident retaining 1,450 mL of urine in the bladder and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. The resident, who has a history of quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy, reported not feeling well and had stable vital signs initially. However, the urinary catheter was noted to be leaking, and the resident exhibited confusion and low blood pressure, leading to hospitalization via 911 where severe sepsis and acute kidney injury were diagnosed. The catheter was found to be completely dry and was replaced at the hospital, resulting in a significant amount of urine being drained immediately after replacement. The Medication Administration Record (MAR) indicated that the catheter was not changed or flushed despite an order to monitor output every shift and change the catheter for blockage or leaking. Interviews with staff revealed that the catheter was leaking and the resident had no urine output, but the catheter was not changed before the resident was sent to the hospital. The Director of Nursing (DON) and other medical staff confirmed that the catheter should have been flushed or changed if there was no urine output, and failure to do so could lead to severe complications such as kidney issues, bladder rupture, or infection.
Failure to Identify and Treat Post-Surgical Wound
Penalty
Summary
The facility failed to identify, assess, and treat a post-surgical wound site for a resident who had undergone a tracheostomy and PEG tube placement. The resident was admitted to the facility with no documented wounds to the right clavicle/neck area. However, on a later date, redness and an embedded suture were noted by the respiratory therapist, which was not initially identified during daily trachea care. The wound care nurse was informed and subsequently removed the embedded suture, initiated a care plan, and started the resident on antibiotics for the infection. Despite these actions, the resident required a 10-day course of antibiotics and at least four weeks of wound care treatment due to the infection that developed from the untreated embedded suture. The resident's medical records show that the wound care nurse documented the presence of the embedded suture and the infection, and the wound care physician ordered treatments for the wound. The respiratory therapist acknowledged that the suture should have been identified during daily trachea care, and the wound care nurse confirmed that the sutures should have been removed before becoming embedded. The failure to identify and treat the embedded suture in a timely manner led to the resident developing an infection, necessitating extended medical treatment and wound care management.
Failure to Ensure Timely Vision Services
Penalty
Summary
The facility failed to ensure a resident was seen by the eye doctor as requested by the resident's Power of Attorney (POA). The resident, who was admitted to the facility, had two care plan meetings where the POA requested an eye doctor visit. Despite these requests, the Social Service Director was unsure if the resident had seen the eye doctor. The Director of Nursing confirmed that an eye doctor visits the facility monthly and that residents are seen routinely and upon request. However, the Director of Nursing was also unsure why it took so long for the resident to see the eye doctor. The resident eventually saw the eye doctor and was diagnosed with presbyopia, receiving a prescription for glasses. The facility does not have a policy on vision services but expects residents to be seen by the eye doctor upon physician's order or as requested by the resident or POA.
Failure to Ensure Timely Dental Care for Resident
Penalty
Summary
The facility failed to ensure a resident was seen by the dentist as requested by the resident's Power of Attorney (POA). The resident was admitted to the facility and had two care plan meetings where the POA requested dental services. Despite these requests, the resident was not seen by the dentist until the second care plan meeting. The Social Service Director confirmed that the POA had requested dental services at both meetings, but the resident was only seen by the dentist after the second meeting. The Director of Nursing stated that the facility has a dentist who visits monthly and that residents are seen routinely and as requested, but could not explain why the resident was not seen sooner. The resident's dental consult revealed moderate plaque and staining, mildly dry mouth, puffy tissue, and mild thrush. The facility's Dental Services Policy indicates that oral health services are available to meet residents' needs and that the Director of Nursing or their designee is responsible for notifying Social Services of a resident's need for dental services. Social Services is then responsible for assisting the resident or family in making dental appointments. Despite this policy, the resident only had one dental exam since admission, highlighting a failure in the facility's process to ensure timely dental care as requested by the POA.
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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