Thryve Of Crestwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Crestwood, Illinois.
- Location
- 14255 South Cicero Avenue, Crestwood, Illinois 60445
- CMS Provider Number
- 145718
- Inspections on file
- 45
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Thryve Of Crestwood during CMS and state inspections, most recent first.
A cognitively impaired, non-ambulatory resident who required a mechanical lift for transfers was found on a floor mat after an unwitnessed fall and complained of right hip pain. An LPN assessed the resident, administered pain medication, and obtained a provider order for a STAT right hip X-ray expected to be completed and resulted within several hours, but the X-ray was never performed. The following day, the resident continued to exhibit pain, including facial grimacing and guarding of the right leg, and another LPN arranged transfer to the hospital due to unresolved right leg pain and the uncompleted STAT X-ray. At the emergency room, imaging showed a displaced comminuted intertrochanteric right femoral fracture, and the report notes that a reasonable person in this situation would have experienced psychosocial harm related to pain.
Multiple rooms and the dialysis area were recorded at temperatures above 81°F, with several residents reporting discomfort and using fans or makeshift methods to cool themselves. Staff confirmed that AC units were not functioning for several days, and temperature checks were not conducted overnight. Dialysis staff noted increased resident fatigue and fluctuating vital signs during treatments in the overheated room. Most residents were not proactively offered fans, and some were unaware they were available.
A resident with multiple health conditions, including neurogenic bladder and a sacral pressure ulcer, experienced four recurrent UTIs while having an indwelling urinary catheter. Despite ongoing complaints of discomfort and repeated infections, staff did not timely assess or consider removal of the catheter, and there was no documented outreach to the physician for reassessment. Facility policy requiring ongoing review and adjustment of care for residents with catheters and recurrent infections was not followed.
A resident with multiple complex medical conditions was admitted without a completed admission assessment, baseline care plan, or reconciliation of medications. Nursing staff did not administer medications or initiate G-tube feeding due to missing information and lack of follow-up with available resources, resulting in the resident not receiving necessary care until a code blue was called.
A facility failed to notify the attending physician about delays in urgent lab tests for a resident, resulting in a nine-hour delay. The resident, who had decreased food and fluid intake, was later hospitalized with dehydration, pneumonia, and a UTI. Incomplete documentation and lack of timely communication with the primary NP and physician contributed to the resident's deteriorating condition.
A resident with complex medical conditions, including end-stage renal disease, refused dialysis and was not properly monitored for fluid overload. The facility failed to notify the nephrologist of the refusal and abnormal X-ray results. The resident complained of shortness of breath and was later found unresponsive, leading to their death. Staff communication and adherence to policies were inadequate.
The facility failed to maintain adequate hot water temperatures in all shower rooms, affecting residents' ability to shower. The issue began when the Maintenance Director noticed dropping water temperatures, and a plumbing contractor was called. Despite efforts, the problem persisted, and residents had to use wipes or microwaved water for hygiene. Residents were not informed about repair progress, and documentation revealed inconsistencies in recording water temperatures. The deficiency highlights the facility's failure to provide a safe and comfortable environment.
The facility failed to maintain its hot water system, resulting in suboptimal water temperatures in shower rooms on multiple floors. The issue was identified on January 3rd, but delays in communication and approval processes, along with inadequate documentation and maintenance, prolonged the deficiency. A resident with spinal stenosis, fibromyalgia, and lumbar disc degeneration was affected.
A resident with a history of dialysis and low potassium levels experienced an acute change in condition, including lethargy and low oxygen saturation. Despite these symptoms, there was a delay in transporting the resident to the hospital. The nurse practitioner initially stabilized the resident with oxygen, but the condition worsened, leading to a diagnosis of severe sepsis upon hospital admission. The delay in response and transport contributed to the deficiency identified in the facility's care.
Two residents were involved in a physical altercation in an elevator, where one resident, diagnosed with schizophrenia, struck another resident with a cell phone, causing injury. The incident occurred when the second resident attempted to enter the elevator, leading to a confrontation. Staff intervened, but the facility failed to prevent the abuse, resulting in physical harm.
The facility failed to follow its abuse prevention policy, resulting in a resident-to-resident physical assault. A resident with severely impaired cognitive skills was assaulted by another resident, causing significant injuries. Staff failed to adhere to protocols requiring constant supervision and immediate reporting of abuse incidents.
A facility failed to supervise a resident with physical aggression and dementia, leading to the resident assaulting a peer. The injured resident sustained severe injuries, including multiple lacerations and a nasal bone fracture, requiring hospital treatment. The incident occurred in a locked unit left unattended by staff despite clear signage requiring constant supervision.
A resident developed an unstageable, necrotic pressure ulcer due to the facility's failure to identify, assess, and treat a change in skin condition. Despite being at risk for pressure ulcers, the resident's sacral wound was not addressed until it showed signs of infection, leading to hospitalization. Staff interviews highlighted the importance of early identification and documentation of skin changes to prevent such deterioration.
Two residents experienced verbal abuse from a CNA who used profanity and loud behavior during an interaction. Both residents, who have no cognitive impairments, confirmed the incident. The facility's investigation corroborated the residents' accounts, and the CNA admitted to the inappropriate conduct.
A resident's medications, specifically Adderall XR and Adderall, were not administered as ordered due to availability issues and documentation gaps. The resident was discharged to the hospital multiple times, and the nurse indicated that the facility's locked medication dispensing system required supervisor access, which hindered timely administration. The facility's policy for handling unavailable medications was not effectively followed.
Failure to Carry Out STAT Hip X-Ray Order After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement a physician’s STAT order for a right hip X-ray after an unwitnessed fall involving a cognitively impaired, non-ambulatory male resident who required a mechanical lift for transfers and was dependent for all ADLs. Following the fall, the resident was found on a floor mat next to a low bed by a CNA, who summoned the nurse. The LPN in charge performed a head-to-toe assessment, during which the resident complained of right hip pain. The LPN medicated the resident for pain and obtained a provider order for a STAT right hip X-ray, with an expectation that results would be available within 4–6 hours. The resident’s record later documented ongoing right hip pain, facial grimacing, and guarding of the right leg the following morning. Despite the STAT order and the provider’s and DON’s stated expectations that such X-rays be completed and resulted within hours, the ordered X-ray was never performed. The LPN who later transferred the resident to the hospital reported that the transfer occurred because the resident continued to complain of right leg pain and the previously ordered STAT X-ray had not been done. The resident was ultimately sent to a local emergency room approximately eighteen hours after the unwitnessed fall, where imaging revealed a superior laterally displaced comminuted intertrochanteric right femoral fracture. The report states that a reasonable person in the resident’s position would have experienced psychosocial harm related to pain, including facial grimacing and guarding of the right leg, as a result of the failure to carry out the STAT X-ray order.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable room temperatures for residents, with multiple resident rooms and the dialysis room recorded at temperatures ranging from 82 to 85 degrees Fahrenheit, exceeding the recommended maximum of 81 degrees. Observations revealed that residents expressed discomfort due to the heat, with some using fans or fanning themselves with paper, and others requesting additional fans. Staff interviews confirmed that the air conditioning units were not functioning properly, and parts had to be ordered and replaced, resulting in several days of elevated indoor temperatures. The maintenance director reported that temperature checks were conducted hourly during the day but not overnight, and that fans were provided only upon request. Some residents were unaware that fans were available. Dialysis staff reported that residents undergoing treatment in the dialysis room, which was also affected by the heat, appeared more fatigued and had more fluctuating vital signs than usual. Staff provided cold water, popsicles, and monitored for signs of heat-related illness, but did not check on residents during dialysis sessions. The facility's temperature logs confirmed that room temperatures remained above 81 degrees for extended periods. The deficiency affected 53 out of 54 sampled residents, with both residents and staff acknowledging the uncomfortable and potentially unsafe conditions caused by the inadequate temperature control.
Failure to Prevent Recurrent UTIs and Timely Reassess Catheter Use
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident, who had multiple diagnoses including neurogenic bladder, sacral pressure ulcer, and chronic kidney disease, was admitted with a urinary catheter and experienced ongoing discomfort and recurrent UTIs. Despite repeated complaints of pain and discomfort related to the catheter, as well as multiple documented UTIs treated with antibiotics, there was no timely or appropriate assessment for the removal of the catheter. Observations and interviews revealed that the resident repeatedly expressed discomfort and requested removal of the catheter, but staff did not act on these requests until much later. The infectious disease nurse practitioner and infection prevention nurse both indicated that there was no documented outreach to the physician to consider discontinuing the catheter, and the attending physician confirmed that there had not been any prior attempt to reassess or remove the catheter before it was eventually dislodged and removed. The resident had been treated for UTIs on several occasions, with the same bacteria recurring, and the infectious disease nurse practitioner noted that improper cleaning and contamination from a sacral wound may have contributed to the infections. Facility policies required ongoing assessment and review of residents with indwelling catheters, especially in cases of recurrent infection, but these procedures were not followed. The lack of timely reassessment and failure to consider catheter removal contributed to the resident experiencing four UTIs during her stay, with ongoing discomfort and repeated antibiotic use.
Failure to Provide Necessary Services Upon Admission
Penalty
Summary
The facility failed to provide necessary services upon admission for a resident with multiple complex medical diagnoses, including diabetes, hypertension, chronic kidney disease, and obesity. Upon admission, there was no face sheet, initial admission assessment, or baseline care plan in the resident's medical record. Nursing staff documented that the resident was non-verbal, responsive only to painful stimuli, and on 7 liters of oxygen via trach collar. Although a head-to-toe assessment and vital signs were recorded, there was no documentation of height, weight, or blood sugar. The nurse who received the resident did not reconcile medications or obtain any orders, and the subsequent nurse did not administer any medications or initiate G-tube feeding, citing lack of information and inability to reach the physician for orders. Multiple staff interviews revealed that the feeding rate for the G-tube was not obtained from the hospital report, and the nurse did not connect the feeding or administer medications, waiting for a physician's response. The nurse did not seek assistance from the supervisor, and the supervisor was unaware that the resident had not received medications or feeding. The DON stated that urgent medications could be accessed from the facility's medication system and that the feeding rate was present in the admission papers. The nurse practitioner confirmed that alternative contacts and the dietician should have been involved if the physician was unavailable. The resident did not receive necessary medications or nutrition from admission until a code blue was called later that evening.
Failure to Timely Notify Physician of Urgent Lab Delays
Penalty
Summary
The facility failed to adhere to its policy for notifying the attending physician or nurse practitioner about urgent laboratory tests not being completed within the required 4-6 hour timeframe. This oversight affected a resident who was subsequently sent to the hospital and diagnosed with dehydration, pneumonia, and a urinary tract infection. The delay in obtaining laboratory results was over nine hours, which contributed to the resident's deteriorating condition. Interviews and record reviews revealed that the resident had a history of decreased food and fluid intake, which was documented by the certified nurse aide. The resident's condition worsened, showing signs of weakness, fatigue, and dehydration. Despite the urgent need for laboratory tests, there was a lack of timely communication with the primary nurse practitioner and physician, which hindered the management of the resident's care. The facility's documentation was incomplete, with missing records of the resident's fluid intake and bladder continence episodes. The resident's medical records did not show any urinalysis conducted before hospitalization, and the medication administration record lacked documentation of an administered inhaler. These documentation gaps, along with the delay in laboratory testing, contributed to the resident's hospitalization for dehydration, pneumonia, and a urinary tract infection.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, resulting in a critical incident. The resident, who had a complex medical history including chronic respiratory failure, morbid obesity, congestive heart failure, and end-stage renal disease, refused dialysis treatment and was not adequately monitored for fluid volume overload. Despite the resident's refusal to go to the hospital as ordered by the nephrologist, the facility staff did not notify the nephrologist of the refusal or the abnormal chest X-ray results, which showed signs of fluid overload. The resident complained of shortness of breath and requested to go to the hospital, but the facility staff only provided education on breathing techniques and did not perform a thorough assessment or take further vital signs. The resident was found unresponsive later that day and expired in the facility. Interviews with staff revealed a lack of communication and follow-up on the resident's condition, with several staff members unaware of the resident's complaints or the significance of the missed dialysis treatments. The facility's policies on refusal of treatment and notification of change were not followed, as the attending physician and nephrologist were not properly informed of the resident's condition and refusal of care. The facility also failed to ensure timely completion and review of the STAT chest X-ray, which was not performed within the expected timeframe, and the results were not communicated to the physician in a timely manner. This series of inactions and communication failures contributed to the resident's deterioration and eventual death.
Removal Plan
- All current dialysis residents were assessed for potential fluid overload, intervention in place as appropriate.
- Licensed nurses were educated by the Director of Nursing on the need to assess and implement interventions related to fluid volume overload when residents miss dialysis treatments.
- Dialysis assessment orders were updated per their physician. Their assessment order reads: Monitor for signs and symptoms of fluid volume overload, edema, bloating, headache, weight gain, shortness of breath, elevated blood pressure, JVD, lung sounds with crackles or wheezing, abdominal distention, or tachycardia. This assessment will be completed every shift and PRN.
- Licensed nurses were educated by the Director of Nursing on the importance of notifying the Attending physician and if unable to reach him/her notifying the resident's Nephrologist.
- Licensed nurses were educated by the Director of Nursing if STAT radiology orders are not able to be completed within the recommended timeframe the provider will be notified for additional instructions.
- Licensed Nurses will not work until they have been educated.
- Radiology company (All-Stat) has been notified of the expectation of timely notification of abnormal radiology results.
- Licensed nurses were educated to review their electronic health records to check and communicate the results of the radiology report.
- An additional email notification system has been implemented with the radiology company. This ensures all nursing managers receive results as they are uploaded into the electronic health record.
- All nursing managers were educated on the additional notification system.
- The Director of Nursing will audit all residents who refused dialysis to ensure they have been assessed, appropriate interventions are implemented, and that the physician was made aware.
- The Director of Nursing will complete audits to ensure any STAT radiology orders were completed within the recommended timeframe, and if the physician was notified.
Facility Fails to Maintain Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain adequate hot water temperatures in all six shower rooms, affecting five residents. The issue began when the Maintenance Director noticed dropping water temperatures on January 3rd, 2025, and a plumbing contractor was called immediately. Despite the contractor's efforts, the problem persisted, and residents were unable to take showers due to the cold water. The Maintenance Director reported that the water temperatures were below the desired range of 100-110 degrees Fahrenheit, and staff were instructed not to use the showers until further notice. Residents expressed dissatisfaction with the situation, as they were unable to take showers and had to resort to using wipes or microwaved warm water for personal hygiene. Several residents reported not being informed about the progress of the repairs or when the hot water would be restored. The Assistant Administrator was notified of the issue on January 4th, 2025, and the Site Manager was informed on January 6th, 2025. The plumbing company identified a malfunctioning heat exchanger as the cause of the problem, and a new part was ordered, but the repairs were delayed due to approval and cost issues. The facility's documentation revealed inconsistencies in recording water temperatures, with no records of the temperatures during the period when they were below the acceptable range. The Loss of Hot Water Guideline outlined procedures for managing such situations, but there was a lack of communication and timely action to resolve the issue. The deficiency highlights the facility's failure to provide a safe and comfortable environment for residents, as required by regulations.
Failure to Maintain Hot Water System
Penalty
Summary
The facility failed to maintain its hot water system, resulting in suboptimal water temperatures in the shower rooms on the second, third, and fourth floors. The issue was first noticed by the Maintenance Director on January 3rd, when the water temperatures began to drop. A plumbing contractor was called immediately, and it was identified that the heat exchanger was malfunctioning. Despite efforts to address the issue, including cleaning the heat exchanger and replacing copper piping, the water temperatures remained below the required range for several days. The Assistant Administrator was informed of the hot water issue on January 4th, and the Site Manager was notified on January 6th. However, there was a delay in communication and approval processes, which contributed to the prolonged period of inadequate water temperatures. The Site Manager expressed concern about not being informed sooner and emphasized the need for timely communication to approve necessary repairs. The plumbing company was unable to complete the repairs promptly due to the facility's not-to-exceed limit on service costs, which required further approval. Throughout this period, water temperatures were inconsistently documented, and the Maintenance Director was unable to provide maintenance logs for the water heater system. The lack of scheduled maintenance and documentation, combined with delayed communication and approval processes, led to the deficiency in maintaining adequate hot water temperatures for the residents, including a resident with spinal stenosis, fibromyalgia, and lumbar disc degeneration.
Delayed Transport of Resident with Acute Medical Condition
Penalty
Summary
The facility failed to immediately transport a resident experiencing an acute change in medical condition, which was identified during a review of the resident's care. The resident, who had a history of dialysis and was noted to have low potassium levels, exhibited symptoms of lethargy, shortness of breath, and low oxygen saturation. Despite these symptoms, there was a delay in transporting the resident to the hospital. The nurse practitioner initially assessed the resident and applied oxygen, which temporarily stabilized the resident's condition, but the resident's oxygen levels later deteriorated. The nurse practitioner was not initially aware of the resident's critically low potassium levels from previous laboratory results. On the day of the incident, the resident's condition worsened, with symptoms including hypoxia and tachycardia. The nurse practitioner ordered urgent laboratory tests and administered antibiotics intramuscularly. However, the resident's oxygen saturation continued to decline, necessitating the use of a non-rebreather mask and eventually leading to the decision to transport the resident to the hospital. The documentation revealed that there was a lack of timely communication and action regarding the resident's abnormal laboratory results and acute symptoms. The resident was eventually transported to the hospital with a diagnosis of severe sepsis, but there was a significant delay from the time the resident's condition was identified as critical to the time of transport. This delay in response and transport contributed to the deficiency identified in the facility's care of the resident.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical abuse involving two residents. Resident R4, diagnosed with schizophrenia and peripheral vascular disease, displayed erratic behavior by striking Resident R5, who has a diagnosis of malignant neoplasm of the lung, chronic obstructive pulmonary disease, and Parkinsonism. The altercation occurred when R5 attempted to enter an elevator already occupied by R4, leading to R4 striking R5 in the face and hand with a cell phone, causing a laceration and pain. The incident was documented in nursing notes, a police report, and a facility incident report. Staff interviews revealed that R5 asked R4 to move forward to make room for both wheelchairs on the elevator. When R5's wheelchair accidentally bumped R4's, R4 became physically aggressive, hitting R5 with a closed fist and a cell phone. Staff intervened to separate the residents, and R5 sustained a scratch on the face and pain in the finger. The facility's care plans and assessments for both residents indicated that R4 was at risk for inappropriate responses due to schizophrenia, and R5 was at risk for abuse due to residing in a skilled facility. Despite these assessments, the facility's failure to prevent the altercation resulted in physical harm to R5, which was classified as physical abuse according to the facility's abuse prevention policy.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in a resident-to-resident physical assault. Resident R4 entered R1's room and physically assaulted R1, causing significant injuries including multiple lacerations, swelling, and a nasal bone fracture. R1, who has severely impaired cognitive decision-making skills, was transported to the hospital for treatment. The incident occurred despite signage in the men's village indicating that staff must be present at all times, and staff failed to adhere to this requirement. On the day of the incident, V4 CNA was working in the men's village and encountered combative behavior from R4. V4 attempted to redirect R4 but eventually left the men's village unattended to seek assistance from V3 LPN, who did not immediately respond. During this time, R4 entered R1's room and assaulted him. V4 and V3 only responded after hearing screams from the men's village, by which time R1 had already sustained injuries. V4 was unaware of the requirement to report the incident to the abuse coordinator. The facility's abuse prevention policy mandates staff training on assessing, preventing, and managing aggressive residents, and requires immediate reporting of any abuse incidents. However, the staff failed to follow these protocols. Additionally, R4's care plans related to his psychiatric diagnoses were not documented until after the incident, despite his history of visual delusions and hallucinations. This lack of adherence to the facility's policies and procedures contributed to the failure to prevent the assault on R1.
Failure to Supervise Aggressive Resident Results in Severe Injury
Penalty
Summary
The facility failed to effectively supervise and monitor a resident with a diagnosis of physical aggression and dementia, resulting in the resident physically assaulting a peer. This incident affected two residents, with one resident sustaining severe injuries including multiple lacerations, a swollen eye, ear redness and swelling, and a nasal bone fracture. The injured resident required hospital treatment and sutures to repair facial lacerations. The incident occurred in a locked unit known as the men's village, which was left unattended by staff for a period of time despite clear signage indicating that staff must be present at all times. On the morning of the incident, a CNA reported that a resident was being combative and attempted to redirect him. The CNA left the unit to get supplies, leaving the residents unattended. The CNA informed an LPN at the nurses' station about the combative resident, but the LPN did not immediately respond. Approximately ten minutes later, the CNA and LPN heard screaming and found the injured resident bleeding in his room. The injured resident and his roommate both reported that the aggressive resident had attacked him. The facility's Director of Nursing and Administrator were unaware that the men's village had been left unattended until after the incident occurred. The aggressive resident had a history of physical aggression and hallucinations, and his care plan included interventions to report all instances of alleged abuse. However, these measures were not effectively implemented, leading to the severe injury of a resident.
Failure to Identify and Treat Pressure Ulcer Timely
Penalty
Summary
The facility failed to identify, assess, and treat a change in skin condition for a resident, leading to the development of an unstageable, necrotic pressure ulcer. The resident, who was dependent on staff for toileting hygiene and required maximal assistance for movement, was admitted to the facility without any pressure ulcers. However, the resident was at risk for developing pressure ulcers as indicated by a Braden skin risk assessment. Despite this, the resident developed an unstageable pressure ulcer on the sacrum, which was first identified by the wound physician on November 22, 2023. The wound was initially documented as having moderate exudate, 20% slough, and 80% eschar, with no signs of infection. However, by December 6, 2023, the wound had declined, showing 100% eschar and signs of infection, including odor, necessitating hospitalization for further evaluation and treatment. Interviews with facility staff revealed that the certified nursing assistants (CNAs) are expected to report any skin changes to the floor nurse, who would then assess the resident's skin and notify the wound care nurses. However, the wound care nurse/coordinator acknowledged that the wound should have been identified before becoming necrotic. The wound care physician confirmed that the worsening of the sacral wound, with 100% eschar and possible infection, required surgical debridement and further evaluation. The registered nurse and CNA emphasized the importance of early identification and documentation of skin changes to prevent the progression to pressure ulcers. The failure to identify and address the skin condition in a timely manner resulted in the resident's wound deteriorating and requiring hospitalization.
Verbal Abuse Incident Involving Two Residents
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a staff member. On a specific date, a resident reported that a CNA entered their room and used profanity when the resident requested a specific size diaper. The resident's roommate confirmed the incident, stating that the CNA responded aggressively when asked to stop. Both residents involved were assessed to have no cognitive impairments, indicating they were aware of the situation and its impact. The facility conducted an investigation following the incident, which confirmed the CNA's use of profanity and loud behavior. The CNA admitted to using inappropriate language and acknowledged being too loud. The facility's abuse prevention policy defines verbal abuse as the use of disparaging and derogatory language, which aligns with the behavior exhibited by the CNA. The investigation was documented, and the CNA was no longer employed at the facility following the incident.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, specifically concerning the administration of Adderall XR and Adderall. The Medication Administration Record for the resident showed multiple instances where the medication was ordered and then discontinued within a short period. The resident was discharged to the hospital on three separate occasions during this time frame. On two occasions, the medication administration was marked with a '9', indicating a need to refer to the nurse's notes. However, there was no corresponding nurse's note for one of these instances, leaving a gap in documentation. The nurse involved, identified as V6, stated that if a medication is not available, they follow up with the pharmacy. The facility has a locked medication dispensing system, but the nurse indicated they were unable to access it without a supervisor. The resident had complained about not receiving their Adderall, but the nurse explained that if the medication was not available, it could not be administered. The facility's Medication Administration Policy outlines steps to be taken if a medication cannot be located, including contacting the pharmacy or using the night box/emergency kit, but it appears these steps were not effectively followed in this case.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
