Warren Barr Orland Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Orland Park, Illinois.
- Location
- 14601 South John Humphrey Dr, Orland Park, Illinois 60462
- CMS Provider Number
- 145899
- Inspections on file
- 29
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Warren Barr Orland Park during CMS and state inspections, most recent first.
Two residents experienced undignified and non–preference-consistent dining care. One resident with Parkinson’s disease, dysphagia, and moderate cognitive impairment had an active order for a puree diet but was repeatedly served non-pureed food, including whole fish fillet, bun, and vegetables, despite a meal ticket marked for puree and the resident’s statements that he needed pureed or cut-up food. The same resident reported asking daily to be transferred to a chair for meals so he could feed himself, but staff left him in bed, limiting his ability to self-feed, while a care card in his closet listed him as an independent feeder. Another resident with significant cardiac and renal conditions was observed being fed in bed by a CNA who stood over him, and both CNAs reported they stand when feeding, contrary to the DON’s expectation that staff sit at the resident’s level. These actions and inactions failed to respect resident dignity, self-determination, and reasonable accommodation of needs and preferences during dining.
A resident with glaucoma and multiple comorbidities did not consistently receive ordered dorzolamide 2% eye drops three times daily, as documented by multiple early morning doses marked as "sleeping" on the MAR without subsequent administration. The resident reported frequent missed doses, especially at night and early morning, and stated she had previously self-administered the drops reliably when they were kept at bedside. The physician order allowed the drops to be kept at bedside for self-administration, and the DON confirmed that the resident was permitted to self-administer and that medications marked as "sleeping" should be given upon awakening, but these practices were not consistently followed, resulting in failure to provide treatment as ordered.
A resident with severe mobility impairments and morbid obesity, who required extensive assistance for bed mobility, was being turned in bed by a CNA working alone. During the process, the resident's leg slid off the bed and she rolled onto the floor, resulting in a right femur fracture. Staff interviews confirmed that proper procedures, such as rolling the resident toward the caregiver and ensuring support on both sides of the bed, were not followed.
A resident with severe cognitive impairment had their debit card taken by a newly assigned CNA, who attempted to use it at a gas station. The incident was confirmed through video evidence and the CNA's admission, revealing a failure to safeguard the resident's personal property and finances.
Surveyors identified multiple deficiencies in food storage, sanitation, and documentation, including a leaking coffee station drainpipe, unclean equipment, expired and unlabeled food items, missing temperature and cleaning logs for refrigerators and ice machines, and improperly stored dry goods. The Dietary Director and other staff confirmed lapses in maintenance, cleaning, and adherence to facility policies.
The facility did not have documentation showing that staff were educated about or offered the COVID-19 vaccine, nor did it maintain records of staff vaccination status. The Infection Control Nurse and Administrator were unable to provide evidence of education, offers, or a vaccination tracker, despite facility policy requiring promotion and documentation of COVID-19 vaccination.
Multiple residents with impaired mobility and cognitive conditions did not receive necessary assistance with ADLs, including hair washing, shaving, and nail care. Residents were observed with greasy hair, long and dirty fingernails, and foul odors, and some reported that staff did not fulfill requests for personal hygiene. Family members sometimes performed nail care themselves due to staff inaction. Staff and policy confirmed that regular hygiene and grooming should be provided, but these standards were not met.
The facility did not obtain or document required pacemaker information, such as make, model, and serial number, in the medical records of several residents with cardiac pacemakers. Additionally, physician orders for pacemaker checks were missing or incomplete, and care plans lacked details on when the devices were last assessed, contrary to facility policy.
Expired food items, including yogurt, gelatin, cheese, and beverages, were found in the personal refrigerators of four cognitively intact residents with complex medical conditions. Facility staff, including housekeeping and nursing, had inconsistent understanding of their responsibilities for removing expired food, and there was no documentation to show that regular checks were performed, despite facility policy requiring timely removal of such items.
Staff failed to follow infection prevention protocols by not performing hand hygiene between resident contacts, using the same gloves for dirty and clean tasks, and not wearing required PPE when caring for residents on isolation or enhanced barrier precautions. These lapses occurred during feeding, toileting, incontinence care, and when entering COVID-19 isolation rooms, affecting multiple residents with complex medical needs.
Two residents identified as high fall risk were found with their beds and over bed tables left in elevated positions, contrary to their care plans and facility policy. One resident, with a history of cerebral infarction and muscle wasting, reported the bed was dangerous, and a PTA confirmed the risk. Another resident with a femur fracture, diabetes, and dementia was also left in a high bed position by a CNA, despite being at risk for falls.
Surveyors found that medications and biologicals were not securely stored, as several residents were observed keeping items such as pain-relieving gels and vitamin supplements at their bedside or in their rooms without physician orders or proper assessment for self-administration. Nursing staff confirmed that facility policy prohibits residents from keeping medications at bedside, and that all medications should be secured in locked storage areas.
A facility failed to follow a physician's order to collect a urinalysis for a resident with multiple diagnoses, including dementia and altered mental status. Despite an order on 06/16/24, the urine was not collected until 06/18/24, with no documentation explaining the delay. The DON admitted to not documenting a conversation with the resident's daughter, who had requested the test due to symptoms. The facility's policy required prompt action for signs of infection, which was not adhered to.
The facility failed to provide adequate ADL care to four residents, as observed and documented by surveyors. Residents were found with unshaved facial hair and dirty fingernails, despite needing assistance with personal hygiene. Staff confirmed that shaving and nail care are typically done on shower days, but these tasks were not adequately performed, leading to the noted deficiencies.
A resident experienced significant weight loss due to the facility's failure to maintain nutritional status and monitor weights as ordered. The resident, dependent on enteral feeding, did not receive the prescribed amount of feeding consistently, and weights were not obtained as required. Staff were unaware of the missing weights and incomplete feedings, contributing to the resident's weight loss.
The facility failed to provide food services in a manner that prevents foodborne illness, affecting all 166 residents. Observations included improperly labeled and dated food items, open and exposed food products, expired food items, poor sanitization practices, and undated or moldy food in the 2nd floor pantry and servery refrigerator. Additionally, staff demonstrated inadequate hand hygiene and improper use of sanitization buckets.
The facility failed to assess residents for self-administration of medications and did not obtain physician orders for residents to self-administer medications or store them in their rooms. Multiple residents were found with various medications at their bedside without proper authorization or assessment, contrary to the facility's policy.
The facility failed to ensure call lights were accessible to dependent residents, affecting four residents with varying degrees of cognitive impairment and physical dependency. Observations revealed that call lights were often out of reach, preventing residents from calling for assistance when needed.
The facility failed to maintain proper temperature logs, thermometers, and cleanliness for residents' personal refrigerators. Several residents' refrigerators lacked thermometers and contained expired or unlabeled food items. Interviews with staff revealed inconsistencies in responsibility for maintaining these refrigerators, and the facility's policies on refrigerator maintenance and food brought from outside were not followed.
The facility failed to ensure that two residents were free from physical restraints. One resident with severe cognitive impairment was observed with full-length side rails up, and another cognitively intact resident was observed with a position change alarm on her bed and chair. Both instances lacked proper assessments, care plans, or physician's orders, violating the facility's policies on restraints.
A resident did not receive her evening medications, including antibiotics and blood thinners, until nearly midnight, despite multiple requests to the staff. The medications were scheduled for 5 PM and 9 PM but were administered six and two hours late, respectively. The resident's doctor was not notified about the delay.
A facility failed to adjust a resident's bed frame, leaving exposed metal parts that posed a hazard. Despite the resident's cognitive impairment and dependency on staff, the issue was not addressed until pointed out by a surveyor. The facility's policy to ensure safety was not followed, leading to the deficiency.
The facility failed to evaluate for gradual dose reductions (GDR) for a resident receiving psychotropic medications. Despite being prescribed Prozac and trazadone hydrochloride, no GDR had been conducted since the resident's admission. The DON acknowledged the resident was overdue for a GDR, and the Nurse Practitioner confirmed that the primary care physician was responsible for the GDR, which should be completed every six months. Additionally, the nursing staff had not been documenting the resident's behaviors, essential for evaluating the medication's effectiveness.
The facility failed to administer medications as ordered, resulting in a 10.34% error rate. An LPN gave Norco to a resident without verifying the order or last administration time, and another LPN crushed extended-release medications before administering them, contrary to facility policy.
The facility failed to apply PPE and perform proper hand hygiene for a resident on contact isolation for C. Diff. Staff members, including a CNA, Director of Housekeeping, and Wound Care Technicians, were observed not following infection control protocols. Another resident with respiratory failure was left without oxygen during care, and the nasal cannula was placed back on without ensuring cleanliness.
Failure to Provide Dignified, Preference-Consistent Dining Care
Penalty
Summary
The deficiency involves the facility’s failure to provide a dignified dining environment and to honor resident preferences and diet orders for two residents. One resident with multiple diagnoses including Parkinson’s disease, dysphagia (oral phase), repeated falls, spinal stenosis, orthostatic hypotension, and moderate cognitive impairment (BIMS score 12) had an active order for a regular diet with puree texture and thin liquids. Despite this order, the resident reported receiving only one pureed meal since the diet change and, on observation, was served a regular breaded fish fillet with cheese, a whole hamburger bun, and green beans. The meal ticket showed the regular diet scratched out with “puree” handwritten, but the food provided was not pureed or cut up as the resident stated was needed and as he reported was documented in his chart. On a subsequent day, the same resident was observed in bed at mealtime, with a CNA assisting to sit him up in bed and then leaving the room. The resident stated he had requested to be placed in a chair instead of eating in bed, explaining that sitting in bed restricted his ability to feed himself and caused him to spill food because his movement was restricted. He reported that staff did not listen to his request, that he asked to be put in a chair every day so he could feed himself, and that staff told him it was not their job. During another observation, while a different CNA was feeding him, the resident again stated he could feed himself if seated in a chair but could not do so in bed. A care card posted in his closet documented him as an “independent feeder,” indicating a discrepancy between posted care information and the assistance and positioning actually provided. Another resident with multiple cardiac and renal diagnoses was observed being fed lunch in bed by the same CNA, who was standing over the resident while feeding. The CNA stated that this resident was “not a feeder” but that she was helping because he was having trouble, and also stated she always stands when feeding residents. Another CNA confirmed that when feeding a resident, she stands up. The DON stated that when feeding a resident, staff are supposed to sit so they are at the same level as the resident and not hovering over them, and that if a resident asks to sit in a chair, they should be gotten up to the chair unless there is a reason they cannot. Facility policies and CNA job descriptions require that residents be treated with dignity, respect, and reasonable accommodation of needs and preferences, including during feeding and dining, but the observed practices and resident reports showed that these standards were not followed for these residents.
Failure to Administer Glaucoma Eye Drops as Ordered and Honor Self-Administration Order
Penalty
Summary
The deficiency involves the facility’s failure to administer glaucoma eye drops as ordered by the physician and in accordance with the resident’s preferences and goals. The resident, who has multiple diagnoses including glaucoma, hemiplegia/hemiparesis, COPD, atrial fibrillation, type 2 diabetes, hypertension, and mild cognitive impairment (BIMS score 11), reported that she is supposed to receive dorzolamide 2% eye drops three times daily but has frequently missed doses, particularly at night and early morning. She stated that when she previously kept the eye drops at her bedside and self-administered them at approximately 5:00 a.m., 1:00 p.m., and 9:00 p.m., she did not miss doses, but the drops were taken away and she no longer knows why. She consistently expressed that she is capable of self-administering the drops and that not receiving them as ordered is her primary concern. Record review showed a physician order and MAR entry for dorzolamide 2% eye drops, one drop in both eyes three times a day for glaucoma, with a notation that the resident may keep the eye drops at bedside for self-administration per NP. The March MAR documented the early morning dose as “S” (sleeping) on 11 of 21 days, and the DON confirmed that “S” indicates the resident was sleeping and that the medication should be administered when the resident wakes up. The DON also stated that if a resident has an order to keep medication at bedside, it should be at bedside, and that this resident is allowed to have the eye drops at bedside and self-administer if she prefers. The attending physician stated he should have been notified that the resident was not receiving the medication as ordered and confirmed that the eye drops are intended to reduce intraocular pressure and should be given three times per day; if the resident is sleeping at the scheduled time, the drops should be administered as soon as she awakens rather than omitted. These interviews and records demonstrate that the ordered three-times-daily dosing and bedside self-administration option were not consistently implemented.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to safely turn a resident in bed, resulting in the resident rolling off the bed and sustaining a right femur fracture. The resident had significant medical conditions, including functional quadriplegia, morbid obesity (BMI 50-59.9), reduced mobility, muscle wasting, and was non-ambulatory. Care plans indicated the resident required extensive assistance from two staff for mobility and transfers, and was dependent on staff for bed mobility and toileting. However, interventions related to bed mobility and transfers had not been updated in over two years, and documentation showed the resident was dependent on staff for these activities. On the day of the incident, a CNA was providing care to the resident alone and attempted to turn the resident in bed. The resident reported that her leg slid off the bed while being turned, and she subsequently rolled off the bed onto the floor. The CNA stated that the resident turned herself and that she did not touch the resident, but also confirmed she was alone during the care. Interviews with facility staff, including the Therapy Director and Assistant Director of Nursing, confirmed that staff should not roll residents away from themselves and that, given the resident's weight and immobility, there was a risk of the resident's leg sliding off the bed if not properly supported. The investigation revealed that no staff member was present on the opposite side of the bed to prevent the resident from falling, and the resident was not rolled toward the staff member as recommended. The facility's policy required care to be provided to meet residents' physical needs, including adequate assistance with activities of daily living. The failure to follow these procedures and provide adequate supervision directly led to the resident's fall and injury.
Failure to Protect Resident from Financial Exploitation by Staff
Penalty
Summary
A resident with severe cognitive impairment and multiple medical conditions, including cerebral infarction, abnormal gait, and sepsis, was admitted to the facility. The resident's son reported that his father's debit card was missing and that an attempt had been made to use the card, which was declined. The son had brought the resident's wallet to the facility, and the notification of the attempted use was received shortly after. An internal investigation and collaboration with the city police department confirmed that a newly assigned Certified Nursing Assistant (CNA), who was still in orientation and on her first day on the floor, took the resident's debit card and attempted to use it at a gas station. Video footage from the gas station corroborated the CNA's involvement, and the CNA admitted to taking the card but stated that none of the transactions were successful. The facility's records and interviews revealed that the CNA initially denied the theft when questioned by the administrator but later admitted to the attempted use of the card after being informed of the video evidence. The CNA refused to answer further questions and ended the interview abruptly. The facility's abuse and neglect policy defines financial abuse as the misappropriation or exploitation of a resident's money or property, which was substantiated in this incident. The event demonstrated a failure to protect the resident from the wrongful use of personal belongings and money.
Deficient Food Storage, Sanitation, and Documentation in Dietary Services
Penalty
Summary
The facility failed to maintain the kitchen and food service areas in a manner that would prevent foodborne illness for all 162 residents receiving dietary services. Surveyors observed a leaking coffee station drainpipe wrapped in black tape, dripping into a container with brown liquid containing a gray furry film and white unidentifiable chunks. The stand mixer was found covered in plastic but had white and yellow crusted drips, and the vents over the stove had a visible layer of dust. The Dietary Director confirmed that the vents are cleaned quarterly by an outside company and that the mixer should have been cleaned after use. The leaking drainpipe had not been previously reported to maintenance. The ice machine lacked a cleaning log, and neither the Dietary Director nor the Administrator were aware of a cleaning schedule or policy for the ice machine. The Executive Director stated that an outside company cleans the ice machines but could not provide documentation of these services. In the walk-in cooler, several food items were found past their use-by dates, including prune juice and cottage cheese, and some items were not labeled with open or use-by dates. A container of cottage cheese was found with a bubbled lid and seal, and the Dietary Director acknowledged that food should be labeled and not used past the manufacturer’s date. Unit refrigerators on all three floors lacked temperature logs, and some logs that were provided showed temperatures above the required 41 degrees Fahrenheit with no documented corrective action. In dry storage, open bags of baking cocoa and food thickener were exposed to air, and dented cans of food were present. The Dietary Director stated that dented cans should be discarded and food items should be sealed to prevent contamination. Facility policies require proper maintenance, labeling, and storage of food, but these were not consistently followed.
Lack of Documentation for COVID-19 Vaccine Education and Offer to Staff
Penalty
Summary
The facility failed to maintain documentation that staff were educated about and offered the COVID-19 vaccine, as well as to record the vaccination status of staff members. During the survey, the Infection Control Nurse (RN) stated that there was no documentation available to show that staff had been offered the COVID-19 vaccine or educated on its benefits and potential side effects. The RN indicated that vaccines might be offered through an outside company and that she had not personally offered them to staff. No logbook or documentation was provided to the surveyor to confirm that staff had been offered the vaccine or educated about it. Additionally, the infection control binders lacked any records indicating staff education, acceptance, or receipt of the COVID-19 vaccine, and there was no documentation of staff vaccination status. Although the Administrator stated that the Director of Nursing enters employee COVID-19 data into a tracker, no such tracker was provided to the surveyor. The facility's policy indicated a commitment to promoting and providing COVID-19 vaccination in accordance with CMS, CDC, and state guidance, but the required documentation to demonstrate compliance was not available.
Failure to Provide Adequate ADL and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene, to multiple residents who required such care. Observations and interviews revealed that several residents were left with unwashed, greasy hair, long and dirty fingernails, and unaddressed grooming needs. In several cases, residents and their family members reported that requests for assistance with hair washing, shaving, and nail care were not fulfilled by staff, with some residents stating that CNAs cited lack of time as a reason for not providing care. Family members of one resident reported having to perform nail care themselves due to staff inaction, expressing concern about the risk of infection from long, dirty nails. Documentation review showed that the affected residents had care plans indicating the need for assistance with ADLs, including grooming, nail care, and personal hygiene, due to various medical conditions such as impaired mobility, cognitive impairment, depression, and risk for skin integrity issues. Despite these documented needs, staff failed to provide regular and necessary care, as evidenced by residents' unkempt appearance and persistent hygiene issues over multiple days. Staff interviews confirmed that nail care and hygiene should be provided regularly, especially on shower or bath days, and that failure to do so could lead to skin breakdown and infection. Additionally, one resident was observed to have been transferred using a soiled mechanical lift sling and placed in a wheelchair with a foul odor, indicating a lack of attention to cleanliness and infection control. Staff acknowledged that slings and wheelchair cushions should be cleaned regularly and replaced when soiled. Facility policies reviewed by surveyors confirmed the expectation for daily ADL care and regular nail care to maintain cleanliness and prevent infection, but these standards were not met for the residents reviewed.
Failure to Document and Maintain Pacemaker Information in Medical Records
Penalty
Summary
The facility failed to obtain and document essential information regarding residents' pacemakers, including the make, model, and serial number, as well as ensuring that this information was readily available in the residents' medical records. For five residents with pacemakers, medical records, progress notes, admission assessments, and care plans did not include the required pacemaker details. In several cases, it was also unknown when the pacemaker was last assessed, and physician orders for pacemaker checks were either missing or incomplete. The facility's own policy requires documentation of the pacemaker's make, model, serial number, date and place of insertion, and specific orders for monitoring, but these requirements were not met for the affected residents. Interviews with facility staff, including the DON, confirmed that obtaining pacemaker information is challenging, with difficulties in acquiring details from residents, families, and cardiology offices. Despite these challenges, the admission nurse and DON are responsible for attempting to gather this information, but the records reviewed showed consistent omissions. The lack of documentation and clear orders for pacemaker monitoring was observed across all five residents reviewed for this issue.
Failure to Remove Expired Food from Resident Refrigerators
Penalty
Summary
The facility failed to remove expired food items from the personal refrigerators of four residents, as observed during a survey. Expired yogurts, gelatin, pepperoni, cheese, orange juice, and flavored water were found in the refrigerators of residents who were all cognitively intact and had various medical conditions, including dysphagia, prediabetes, malnutrition, diabetes, and muscle wasting. The residents were unaware that the food items were expired and expressed willingness to have them discarded when informed. Interviews with facility staff, including the DON, CNA, and housekeeping leadership, revealed inconsistent understanding and implementation of responsibilities for checking and discarding expired food. Housekeeping staff were identified as responsible for cleaning and removing expired items weekly, but there were no logs or documentation to confirm that these tasks were being performed. The facility's policy required discarding food after a set number of days and removing undated items, but this was not followed in practice, resulting in expired food remaining in resident refrigerators.
Failure to Follow Infection Control and PPE Protocols
Penalty
Summary
Multiple instances of staff failing to follow infection prevention and control protocols were observed during direct resident care. One staff member provided feeding assistance to two residents, moving between them and handling their food, utensils, and personal items without performing hand hygiene between contacts, despite facility policy and expectations requiring hand hygiene to prevent cross-contamination. Another staff member was observed assisting a resident with toileting and incontinence care, using the same gloves to handle soiled items, clean the resident, retrieve clean clothing, and assist with dressing, without changing gloves or performing hand hygiene between dirty and clean tasks. This same staff member, along with another, also failed to change gloves or perform hand hygiene when moving from soiled to clean areas during incontinence care for a different resident. Additional deficiencies were noted in the use of personal protective equipment (PPE) for residents on isolation or enhanced barrier precautions. Staff and a vendor entered a resident's COVID-19 isolation room without wearing the required N95 mask, face shield, or gown, and failed to perform hand hygiene upon exiting the room. The isolation room door was left open on multiple occasions, contrary to facility policy and staff training. Staff also failed to educate a vendor on proper PPE use before allowing entry into the isolation room. In another case, staff provided care to a resident on enhanced barrier precautions wearing only gloves, omitting the required gown and mask during high-contact activities such as incontinence care, dressing, and transferring. Facility policies reviewed indicated clear requirements for hand hygiene before and after resident contact, after handling soiled items, and when moving between dirty and clean tasks. Policies also specified the use of full PPE, including N95 masks, gowns, gloves, and face shields for COVID-19 isolation, and gowns and gloves for enhanced barrier precautions during high-contact care. Despite these policies and staff knowledge of the requirements, the observed failures to adhere to infection control protocols involved multiple staff members and affected several residents, including those with significant medical needs such as hemiplegia, cellulitis, and indwelling medical devices.
Failure to Maintain Safe Bed Heights for High Fall Risk Residents
Penalty
Summary
The facility failed to ensure that resident beds were maintained at a safe height, resulting in accident hazards for two residents identified as high risk for falls. In one instance, a resident with a history of cerebral infarction, hypertension, and muscle wasting was found with both the bed and over bed table in a very high elevated position. The resident expressed concern about the bed's safety, and the Physical Therapy Assistant confirmed the bed should not have been left in that position, noting the increased risk of injury if a fall occurred. The resident's care plan indicated a risk for falls and included interventions to provide a safe environment. In another case, a resident with a displaced femur fracture, diabetes, vertebral fracture, and dementia was also found with the bed and over bed table in a high position. A CNA acknowledged leaving the bed elevated, despite the resident being identified as a high fall risk with a care plan intervention to provide a safe environment. The facility's policy required fall interventions for those at high risk, but these were not followed in these instances.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors observed that medications and biologicals were not securely stored as required by facility policy and federal regulations. In three separate cases, residents were found with medications at their bedside or in their rooms without physician orders permitting self-administration or bedside storage. One resident, admitted with multiple musculoskeletal diagnoses, had a Biofreeze Roll On Pain Relieving Gel on her bedside table on two separate occasions, and stated she used it independently for knee pain. The resident's physician order sheet did not include an order for this medication. A registered nurse confirmed that residents were not allowed to keep medications at bedside and would remove any found. Another resident, diagnosed with multiple sclerosis and severe malnutrition, had both Biofreeze and Vitamin C gummies on her dresser, which she stated she brought from home and kept in her room. There were no physician orders for these items. A third resident was found with a tube of diclofenac sodium gel, prescribed for sciatic nerve pain, on her overbed table and later in her wash basin. The LPN assigned to this resident confirmed that no residents were assessed or permitted to keep medications at bedside, and that the diclofenac was not scheduled for administration during his shift. Facility policy requires all medications to be secured in a locked storage area.
Failure to Timely Collect Urinalysis as Ordered
Penalty
Summary
The facility failed to follow the physician's orders for obtaining a urinalysis in a timely manner for a resident diagnosed with metabolic encephalopathy, unspecified fracture of the right pubis, muscle weakness, dementia, depression, scoliosis, and altered mental status. The resident was cognitively impaired and dependent on staff for toileting. On 06/16/24, a physician's order was written to collect urine for a urinalysis and culture & sensitivity, but the urine was not collected until 06/18/24. There was no documentation explaining the delay in the progress notes. The Director of Nursing acknowledged that the urinalysis should have been collected as ordered and admitted to not documenting a conversation with the resident's daughter, who had requested the test due to the resident's symptoms of tiredness and headache. The Medical Doctor confirmed that the order was expected to be followed promptly. The facility's Infection Prevention and Control Policy required notification of the Director of Nursing or designee if a resident developed signs or symptoms of infection, but this protocol was not followed in this case.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate ADL care to four residents, as observed and documented by surveyors. Resident 8, who has intact cognition and requires partial to moderate assistance with hygiene, was found with a beard he did not like and stated that staff had not assisted him with shaving. Resident 9, with moderately impaired cognition and needing partial to moderate assistance with personal hygiene, had several white hairs on her chin that she wanted removed, but staff had not recently attended to this. The next day, the facial hair was still present. Resident 14, with severely impaired cognition and requiring substantial to maximal assistance with personal hygiene, was observed with dirty fingernails on two consecutive days. Resident 19, who has intact cognition and needs partial to moderate assistance with personal hygiene, had several white hairs on her upper lip and chin that she did not like, and staff had not assisted in removing them. Certified Nurse Aide V16 confirmed that CNAs are responsible for shaving and nail care, which is typically done on residents' shower days. The facility's policies on Nail Care and Shower and Hygiene, both revised in 2023, state that nursing staff should regularly check and maintain residents' nail care and provide necessary hygienic care. However, the observations and resident statements indicate that these policies were not being adequately followed, leading to the deficiencies noted in the report.
Failure to Maintain Nutritional Status and Monitor Weights
Penalty
Summary
The facility failed to maintain a resident's nutritional status and monitor weights as ordered, resulting in significant weight loss for one resident. The resident, who was dependent on enteral feeding due to malnutrition and weight loss, experienced a 10% weight loss over several months. The facility's records showed multiple dates where the resident's weight was not obtained as ordered. Additionally, the resident's tube feeding orders were not consistently followed, with observations noting that the tube feeding pump often did not have formula hanging and the feeding was not administered for the full prescribed duration. The dietitian and Director of Nursing were unaware of the missing weights and the incomplete feedings, which contributed to the resident's weight loss. The resident's medical history included severe cognitive impairment and dependency on staff for most activities of daily living. The resident's progress notes indicated an episode of vomiting that led to a hospital admission, but no other vomiting episodes were documented. Despite the dietitian's adjustments to the tube feeding regimen to address weight loss, the resident continued to lose weight due to the inconsistent administration of the feedings. Interviews with staff revealed a lack of awareness and adherence to the prescribed feeding schedule and weight monitoring orders, further exacerbating the resident's nutritional decline.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to provide food services in a manner that prevents foodborne illness, affecting all 166 residents receiving food services. During a kitchen tour, several deficiencies were observed, including improperly labeled and dated food items, open and exposed food products, and expired food items. For instance, a storage bin containing oatmeal was not labeled with contents or expiration dates, and an open box of instant food thickener was exposed to air. Additionally, various food items in the walk-in freezer and cooler were found to be open to air, covered in frost, or freezer burned, such as unbaked chocolate chip cookies, mostaccioli, barbeque ribs, and hamburger patties. The walk-in cooler contained improperly stored and expired food items, including shredded mozzarella cheese with a red substance, hot dogs with white specks, and pureed mandarin oranges past their expiration date. Furthermore, personal food items were found in the facility kitchen, which could lead to cross-contamination and foodborne illness. The facility also demonstrated poor sanitization practices. The microwave was found with food splatters and grease smears, and the sanitization buckets were not properly measured, with one bucket testing at 500 ppm instead of the required 200 ppm. The disinfectant dispenser on the wall was not operational, leading staff to pour disinfectant without measuring it. Additionally, a dietary aide was observed entering the kitchen and food preparation line without washing hands, and another dietary aide touched her hair without wearing a hair net while preparing food trays. The sanitization level for the three-compartment sink was found to be 0 ppm, and an oven mitt that fell on the floor was used to remove a pan from the oven without being washed. The 2nd floor pantry and servery refrigerator also had several issues. There was no thermometer or temperature log, and the freezer section was filled with ice buildup. Various food items were found undated, expired, or improperly stored, including a bag labeled chicken soup with a dried yellow substance, a container with apple pie, and a takeout container with multiple food items. The servery refrigerator contained moldy and undated food items, such as broccoli, green beans, bacon, and partially eaten chicken parts. The facility did not provide temperature logs for the 2nd floor unit refrigerators or product concentration information for their quat sanitizer or directions for their testing strips.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for self-administration of medications and did not obtain physician orders for residents to self-administer medications or to store medications in their rooms. This deficiency was observed in five residents who had various medications at their bedside without proper authorization or assessment. For instance, one resident had Tums Calcium Carbonate on their bedside dresser without a physician's order or care plan for self-administration. Another resident had multiple antifungal medications and Clotrimazole cream at their bedside, also without the necessary orders or assessments. Additionally, a resident had Nystatin Powder, lubricant eye drops, and Chloraseptic sore throat spray in their room without proper documentation or orders for self-administration. The facility's policy requires an interdisciplinary team to evaluate a resident's ability to self-administer medications and obtain a physician's order for storing medications at the bedside, which was not followed in these cases. In another instance, a resident with major depressive disorder and generalized anxiety disorder had Fluticasone Propionate Nasal Spray at their bedside, which was brought by a family member. The resident's medical records did not contain a physician's order for the medication to be stored at the bedside or an assessment for self-administration. The Director of Nursing confirmed that the facility only had one resident authorized to self-administer medications, and it was not this resident. The facility's policy mandates that medications brought from home should be shown to the nurse and stored in the medication cart unless there is a physician's order and a completed self-administration assessment form. Another resident with a wedge compression fracture and other chronic conditions had an inhaler on their bedside table. The resident stated that the staff did not bring the medication to them, so they kept it at their bedside. The Director of Nursing later confirmed that the assessment and physician's order for self-administration were obtained only after the issue was brought to their attention. The facility's policy requires an assessment and physician's order before allowing residents to self-administer medications and store them at the bedside, which was not adhered to in this case as well.
Failure to Ensure Call Lights Were Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to dependent residents, affecting four residents (R8, R21, R77, and R147). For instance, R21, who has diagnoses including respiratory failure and moderate cognitive impairment, did not have her call light within reach while receiving care. This resulted in her being unable to call for assistance when she experienced shortness of breath. Similarly, R8, who has moderate cognitive impairment and requires assistance for various activities of daily living, was observed multiple times without the call light within reach, despite his care plan indicating it should be accessible. R8 expressed that staff often did not provide him with the call light, and he was unable to locate it himself. R77, who has severe cognitive impairment and is dependent on staff for all activities of daily living, also did not have her call light within reach during care. She mentioned that if the call light was out of reach, she was unable to call for help. Additionally, R147, who has moderate cognitive impairment and requires substantial assistance for personal care, was found with the call light on the ground and out of reach. The facility's Call Light Policy states that call lights should be within reach of residents at all times, but this was not adhered to in these cases, leading to the deficiency.
Failure to Maintain Proper Temperature Logs and Cleanliness for Residents' Personal Refrigerators
Penalty
Summary
The facility failed to maintain proper temperature logs, thermometers, and cleanliness for residents' personal refrigerators. During the initial tour, it was observed that several residents' refrigerators lacked thermometers and contained expired or unlabeled food items. For instance, R62's fridge had no thermometer and contained undated sandwiches and stained surfaces. Similarly, R53's fridge had moldy bread and no thermometer, and R94's fridge contained unlabeled food items and no temperature log. Interviews with staff, including the Director of Nursing (DON), Administrator, and Housekeeping Director, revealed inconsistencies in the responsibility for maintaining these refrigerators, with each department assuming the other was responsible for temperature logs and cleanliness. The Housekeeping Director admitted to not having completed the March temperature logs for some residents' refrigerators, further highlighting the lapse in protocol adherence. The facility's policies on refrigerator maintenance and food brought from outside were not followed. The policies require that refrigerators in residents' rooms be kept clean, have thermometers, and maintain temperatures between 32 and 41 degrees Fahrenheit. Additionally, food items should be properly labeled and dated, with expired items removed. However, these procedures were not adhered to, as evidenced by the presence of expired and unlabeled food items in multiple residents' refrigerators. The lack of proper monitoring and maintenance of these refrigerators poses a risk to the residents' health and safety.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from physical restraints. Resident R77, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed with full-length side rails up on multiple occasions. The CNA and LPN confirmed that the side rails were kept up to prevent falls, but the Director of Nursing acknowledged that having both full-length side rails up constituted a restraint, which could pose a risk of the resident trying to climb over and falling from a greater height. No proper assessment or care plan was documented for the use of these side rails as restraints. Resident R386, who was cognitively intact and independent with ambulation and transfers, was observed with a position change alarm on her bed and chair. Despite the resident expressing that the alarm was aggravating and unnecessary, staff insisted it was mandatory. The resident had no documented assessment, care plan, or physician's order for the use of the mobility alarms. The Director of Nursing confirmed that the alarms were put in place without proper assessment and acknowledged that such alarms could be considered restraints if they prevented the resident from moving. The facility's policies on side rails and restraints were reviewed, showing that any device that restricts freedom of movement should be assessed and evaluated to determine if it is a restraint. The policies also required a physician's order and a detailed care plan for the use of any restraint. The facility failed to comply with these policies, resulting in the inappropriate use of physical restraints for both residents without proper assessments or documentation.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to administer medications timely as per the physician's orders for one resident. The resident, who had intact cognition, was on strict contact isolation precautions due to an active infection (ESBL urine) and required antibiotic therapy. On one occasion, the resident did not receive her evening medications, including antibiotics, blood thinners, and other critical medications, until nearly midnight, despite multiple requests to the staff. The medications were scheduled for 5 PM and 9 PM but were administered six and two hours late, respectively. The resident's doctor was not notified about the delay in medication administration. The Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time and that giving medications late can cause significant issues. The facility's policy on medication pass, last reviewed in July 2023, states that the facility adheres to all federal and state regulations regarding medication pass procedures. However, the resident's Medication Administration Audit Report and Progress Notes indicated a clear deviation from this policy, as the medications were administered significantly late without notifying the physician.
Failure to Adjust Bed Frame, Creating Hazard
Penalty
Summary
The facility failed to adjust the mattress and bed frame, resulting in an exposed metal frame that posed a hazard. This deficiency was observed in a resident who was cognitively impaired and dependent on staff for transfers and repositioning. The resident's care plan included interventions to keep the environment uncluttered and free of potentially harmful items. However, on multiple occasions, the metal bed frame was observed to be exposed and not covered by the mattress, creating a potential risk for injury. Despite the facility's policy to ensure safety and remove hazardous items, the exposed metal frame was not addressed until a surveyor pointed it out. The Director of Maintenance confirmed that the bed frame could be adjusted by anyone and that maintenance could be contacted for assistance if needed. The Director of Nursing acknowledged that the exposed metal parts were a potential hazard that could cause skin tears. The facility's failure to promptly address this issue led to the deficiency being cited.
Failure to Evaluate Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to evaluate for gradual dose reductions (GDR) for a resident receiving psychotropic medications. The resident, who was admitted with diagnoses including dementia and depression, was not being followed by a psychiatrist. Despite being prescribed Prozac and trazadone hydrochloride, no GDR had been conducted since the resident's admission. The Director of Nursing (DON) acknowledged that the resident was overdue for a GDR and that there were no specific notes written by a psychiatrist. The Nurse Practitioner confirmed that the primary care physician was responsible for the GDR, which should be completed every six months. Additionally, the nursing staff had not been documenting the resident's behaviors, which is essential for evaluating the effectiveness of the medication and determining the need for dosage adjustments or additional medications. The facility's policy requires GDR within the first year of initiating the medication and annually thereafter, unless contraindicated with documented rationale from a psychiatrist. The report highlights that the facility did not adhere to its own policy regarding GDR for psychotropic medications. The lack of documentation and evaluation for GDR, as well as the absence of psychiatric oversight, contributed to the deficiency. The facility's failure to monitor and document the resident's behaviors further compounded the issue, making it difficult for medical staff to assess the necessity and effectiveness of the prescribed medications. This oversight could potentially impact the resident's overall well-being and treatment outcomes.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 10.34%. One incident involved an LPN administering Norco 5/325 mg to a resident at 9:15 AM without verifying the doctor's order or the last administration time. The resident's Medication Administration Record (MAR) indicated scheduled doses at 6 AM, 2 PM, and 10 PM, with no dose scheduled for 9:15 AM. Additionally, the PRN order for Norco was specifically for administration prior to wound care, which was not performed on the day in question. The LPN did not document the administration of the 9:15 AM dose on the MAR, and the wound care coordinator confirmed that no wound care was done that day for the resident, whose wound had already healed by 3/18/24. Another incident involved an LPN crushing extended-release medications, Metoprolol 50 mg ER and Potassium Chloride 20 meq ER, and mixing them with applesauce before administering them to a resident. The facility's policy and the ISMP Do Not Crush List explicitly state that extended-release medications should not be crushed. The Director of Nursing (DON) and other nursing staff confirmed that crushing extended-release medications can interfere with their absorption and effectiveness. The facility's policy on medication pass procedures also emphasizes the importance of checking before crushing medications to ensure they are appropriate for crushing.
Failure to Apply PPE and Perform Hand Hygiene for Residents on Contact Isolation
Penalty
Summary
The facility failed to apply PPE and perform proper hand hygiene for a resident on contact isolation for C. Diff. A CNA was observed exiting the resident's room without performing hand hygiene and provided incontinence care without changing gloves or washing hands. The Director of Housekeeping, two Wound Care Technicians, and a Wound Care LPN were also observed in the resident's room without wearing the required PPE and failed to perform proper hand hygiene. The Director of Nursing confirmed that staff should wear a gown, gloves, and mask in the resident's room and perform hand hygiene before and after resident care. Another resident with respiratory failure and continuous oxygen orders was left without oxygen during a bed bath. The CNA left the room to get water, leaving the resident's nasal cannula on the floor and the call light out of reach. The resident appeared short of breath and requested help from the surveyor. A Restorative Aide later placed the nasal cannula back on the resident without ensuring it was clean. The Administrator confirmed that the nasal cannula should be kept in a bag to prevent infection.
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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