Warren Park Health & Living Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 6700 North Damen Avenue, Chicago, Illinois 60645
- CMS Provider Number
- 145806
- Inspections on file
- 25
- Latest survey
- September 24, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Warren Park Health & Living Ctr during CMS and state inspections, most recent first.
Staff failed to prevent and address incidents of unwanted sexual contact between residents and between staff and residents. A resident with a history of mental illness was reported to have groped a female resident who had expressed her discomfort, and a staff member was observed patting the same resident on the rear. The care plan lacked updated interventions, and staff minimized or failed to recognize the seriousness of the behaviors, contrary to facility policy.
The facility's pest control program was ineffective, as evidenced by mouse droppings found in multiple rooms on the 2nd and 3rd floors. Residents confirmed the presence of mice, with one resident reporting having killed a mouse. The Maintenance Director was unaware of the issue, despite regular pest control services, and facility policy requires the environment to be pest-free.
The facility failed to discard expired food, label food items with use-by dates, and sanitize cooking equipment per manufacturer's directions. A container of tuna salad was found past its discard date, and sliced deli turkey lacked a use-by date. Additionally, the Quaternary solution used for sanitizing was below the recommended concentration, indicating improper disinfection of kitchen items. These deficiencies could affect the safety of food served to 123 residents.
The facility failed to ensure reusable cloth incontinence briefs were in good condition, as observed by a surveyor who found a stained brief on a linen cart. The Laundry Aide assumed it was acceptable for use since it was not torn, despite washing it twice. The Housekeeping Director confirmed the stains were from urine and feces, and stated the aide is responsible for discarding such linens. This failure potentially affects 40 incontinent residents.
The facility did not refer four residents with serious mental illness for a PASARR Level II evaluation, despite their diagnoses indicating a need for further assessment. The facility's policy requires such referrals when a Level I screen suggests potential mental disorders, but the Social Service Director stated that the facility only conducts PASARR screenings when instructed by an outside agency.
A medication cart was found unlocked and unattended in an LTC facility, with keys left inside the lock. An RN responsible for the cart admitted to forgetting to secure it due to being busy. The cart contained medications for residents on the 1st and 3rd floors, posing a risk of unauthorized access and potential adverse reactions. The DON confirmed the danger and the facility's policy requires medications to be locked when not in use.
A registered nurse in an LTC facility failed to sanitize a wrist blood pressure cuff device between uses on multiple residents during medication administration. The nurse admitted to forgetting to clean the device due to nervousness. The DON confirmed that all shared equipment must be sanitized to prevent infection spread, as per facility policy.
Two residents were found without appropriate clothing or incontinence briefs, compromising their dignity. One resident was left exposed due to a lack of properly sized briefs, while another was found completely naked under a blanket. Staff acknowledged the dignity issue, and facility policies emphasize treating residents with respect, yet these standards were not upheld.
A resident's air loss mattress was incorrectly set for a weight range of 240-320 pounds, despite the resident weighing between 100-110 pounds. This error resulted in a firm mattress, unsuitable for pressure distribution, potentially worsening the resident's stage IV pressure wound. The resident, with a high risk for pressure wounds due to multiple health conditions, requires proper mattress settings to prevent further skin breakdown.
Two high fall risk residents experienced falls due to inadequate supervision in a facility. One resident fell in the bathroom without assistance, while another fell in the dining room with no staff present. Both residents had high Morse Fall Scale scores and required supervision, but staff were unaware of the incidents, indicating a lapse in communication and adherence to care plans.
The facility failed to offer pneumonia vaccines to three residents upon admission, as required by its policy. Despite consent being obtained, the vaccines were not administered, and there was no documentation in the residents' electronic health records. The Infection Preventionist and Director of Nursing acknowledged the oversight, which affected residents with chronic health conditions, increasing their risk for pneumonia.
A resident with a history of falls and complex medical conditions was not properly assessed or monitored, leading to a significant injury. Despite being a high fall risk, the facility did not conduct necessary fall risk assessments or update the care plan after previous falls. The resident was eventually hospitalized with a cervical vertebrae fracture and subdural hematoma, highlighting a failure in implementing adequate fall prevention measures.
A resident with a complex medical history was found with a new hematoma on her head, which was not reported to the state agency as required by the facility's policy. Despite the facility's protocol for reporting injuries of unknown origin, the administrator was unaware of the injury, and it was not documented or reported within the mandated 24-hour period.
Failure to Protect Residents from Sexual Abuse and Inappropriate Contact
Penalty
Summary
The facility failed to follow its policy to ensure residents are free from sexual abuse, as evidenced by multiple observations and interviews involving inappropriate sexual contact between residents and between staff and residents. One resident, a man with schizoaffective and bipolar disorder who is moderately cognitively intact, was reported by another resident to have groped a female resident, who is cognitively intact, despite her expressing that she did not like the behavior and had told him to stop. Another resident and a staff member confirmed witnessing or hearing about these inappropriate interactions, with the staff member indicating that such behavior was sometimes consensual and sometimes not. The staff member also minimized the seriousness of the behavior, attributing it to typical male conduct rather than recognizing it as potentially abusive. Additionally, the surveyor observed a staff member, an activity aide, patting the same female resident on the rear in a playful manner, which the Director of Nursing acknowledged as inappropriate and unprofessional. The care plan for the male resident included counseling on appropriate sexual behavior and the need for consent, but interventions such as redirection were not documented in the care plan. The facility's abuse policy affirms residents' rights to be free from abuse, including sexual abuse, but the policy was not effectively implemented in these cases, resulting in residents being subjected to unwanted physical contact.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice on the 2nd and 3rd floors. Mouse droppings were observed in multiple rooms, including the toilet room floor of one resident's room on the 2nd floor and near the wardrobe dresser of another resident's room on the same floor. On the 3rd floor, over 100 mouse droppings were found next to a wardrobe cabinet in a resident's room. Interviews with residents confirmed the presence of mice, with one resident stating they had killed a mouse in their room. The Maintenance Director acknowledged the issue, despite pest control reports indicating no mouse activity, and stated that a pest control company regularly services the facility. The facility's policy mandates that it should be free of pests and rodents.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety protocols, which included not discarding expired food, not labeling food items with use-by dates, and not sanitizing cooking equipment according to the manufacturer's directions. During a kitchen inspection, a container of tuna salad was found with a preparation date indicating it should have been discarded, yet it remained in the refrigerator. Additionally, sliced deli turkey was observed without a use-by date, which is against the facility's policy. These oversights in food labeling and discarding practices have the potential to compromise the safety of food served to the 123 residents receiving meals from the facility's kitchen. Furthermore, the facility did not ensure proper sanitization of kitchen equipment. The concentration of the Quaternary solution used for sanitizing was found to be below the manufacturer's recommended level, indicating that the items were not being disinfected properly. The dietary manager acknowledged that the concentration should be checked before cleaning items, but it was revealed that the dishwasher did not check the concentration that morning. This lapse in following sanitization procedures could lead to cross-contamination and foodborne illnesses among residents.
Facility Fails to Maintain Clean Incontinence Briefs
Penalty
Summary
The facility failed to ensure that reusable cloth incontinence briefs intended for resident use were in good condition. During a tour of the laundry room, a surveyor observed a cloth incontinence brief with multiple, permanent dark colored stains on a linen cart intended for resident use. The Laundry Aide, identified as V13, acknowledged awareness that stained incontinence briefs should be discarded when new ones are received. However, V13 assumed it was acceptable for residents to continue using the brief since it was not ripped or torn, despite washing it twice. The Housekeeping Director, identified as V14, confirmed the presence of permanent stains on the incontinence brief, attributing them to urine and feces. V14 stated that V13 is responsible for notifying him when incontinence briefs and other linens need to be reordered and for discarding old, stained, and worn linens. The facility's policies emphasize the importance of providing a safe, clean, comfortable, and homelike environment, with linens in good condition. The failure to adhere to these policies potentially affects 40 incontinent residents residing in the facility.
Failure to Refer Residents for PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer four residents with serious mental illness to the appropriate state-designated authority for a PASARR Level II evaluation and determination. The residents involved had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, schizoaffective disorder, panic disorder, and major depressive disorder. Despite the PASARR screenings indicating a reasonable basis to suspect mental illness, there was no documentation showing that these residents were referred for the necessary Level II evaluations. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders as part of the PASARR process. If a Level I screen indicates potential criteria for these conditions, a referral to the state PASARR representative for a Level II evaluation is mandated. However, interviews with the Social Service Director revealed that the facility does not conduct or repeat PASARR screenings unless instructed by the outside agency responsible for PASARR screenings, leading to the oversight in referring the residents for further evaluation.
Medication Security Lapse in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were locked and secured while unattended, as observed by a surveyor. On the first floor, a medication cart was found unlocked and unattended with the keys left inside the lock. A registered nurse (RN) acknowledged responsibility for the cart, which contained medications for residents on both the 1st and 3rd floors. The RN admitted to forgetting to lock the cart and retrieve the keys due to being busy with other tasks. This oversight left the medications accessible to residents, posing a risk of overdose, adverse reactions, or other life-threatening complications. The Director of Nursing (DON) confirmed the danger of leaving medication carts unlocked and unattended, acknowledging the potential for residents to self-administer the wrong medications and suffer adverse reactions. The facility's policy, dated April 2021, mandates that compartments containing drugs and biologicals must be locked when not in use and that unlocked medication carts should not be left unattended unless under visible supervision. The facility census indicated that 68 residents resided on the 1st and 3rd floors, all potentially affected by this deficiency.
Failure to Sanitize Shared Medical Equipment
Penalty
Summary
The facility failed to ensure that shared medical equipment, specifically a wrist blood pressure cuff device, was cleaned and decontaminated between uses for four residents during medication administration observation. On multiple occasions, a registered nurse used the same blood pressure device on different residents without sanitizing it before or after each use. This occurred during a medication pass observation where the nurse measured the blood pressure and heart rate of several residents consecutively without cleaning the device, which was then stored in the medication cart or placed on top of it without disinfection. The registered nurse acknowledged the oversight, attributing it to nervousness and forgetting to clean the device. The Director of Nursing confirmed that all shared medical equipment must be sanitized before and after each use to prevent the spread of infection. The facility's policy mandates that reusable resident care equipment be decontaminated between residents according to CDC recommendations and the manufacturer's instructions. The failure to adhere to these protocols was observed and documented by the surveyors.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide dignity for two residents, R226 and R41, as observed during a survey. R226 was found lying in bed with his buttocks exposed, wearing only a shirt and a blanket partially covering him. He reported that a staff member removed his incontinence briefs because they were too small, and the facility did not have any briefs in his size. R226, who is cognitively intact with a BIMS score of 13/15, has multiple diagnoses including unspecified dementia and chronic kidney disease. The CNA, V4, confirmed the lack of appropriate incontinence briefs and mentioned that the facility uses reusable briefs for mostly bed-bound residents, while some residents have disposable briefs purchased by their families. R41 was observed completely naked under a blanket, without a gown or incontinence briefs, and was not alert to make his needs known. R41 has a BIMS score of 09/15, indicating cognitive impairment, and requires moderate assistance with ADLs. The CNA, V7, acknowledged the dignity issue and stated she was instructed to use reusable briefs for R41. The Director of Nursing confirmed that leaving residents without clothing or briefs is a dignity issue. Facility policies emphasize treating residents with dignity and respect, yet these incidents demonstrate a failure to uphold these standards.
Improper Air Loss Mattress Setting for Resident
Penalty
Summary
The facility failed to correctly set the air loss mattress for a resident, identified as R75, based on their weight, which is crucial for pressure wound treatment services. During an observation, the air loss mattress was set for a weight range of 240-320 pounds, while R75 actually weighed between 100-110 pounds. This incorrect setting made the mattress hard and firm, which is not suitable for pressure distribution and could potentially worsen the resident's stage IV pressure wound on the sacrum. The Director of Nursing initially assumed the setting was correct based on the displayed weight range, but it was later confirmed by the Restorative Nurse that the setting was inappropriate for R75's actual weight. R75 has a medical history that includes dementia, adult failure to thrive, muscle weakness, and other conditions that contribute to a high risk for pressure wounds, as indicated by a Braden Score of 10. The resident is dependent on staff for most self-care activities and has a facility-acquired pressure ulcer on the coccyx. The facility's policy and the mattress owner's manual both emphasize the importance of setting the mattress according to the resident's weight to prevent skin breakdown and promote comfort, which was not adhered to in this case.
Inadequate Supervision Leads to Falls for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate assistance and supervision to two high fall risk residents, leading to incidents where both residents experienced falls. One resident, identified as R50, reported slipping and hitting their head on the sink while in the bathroom alone, despite being at high risk for falls and requiring staff assistance for toileting and transfers. The incident was not immediately reported to the nursing staff, and the resident was able to return to bed without assistance. The staff, including a registered nurse and a certified nursing assistant, were unaware of the incident until informed by the surveyor, indicating a lapse in communication and supervision. Another resident, R84, also at high risk for falls due to impulsive behaviors and impaired cognitive function, fell in the dining room without any staff present to supervise. The fall was unwitnessed by staff, although other residents were present and called for help. The facility's fall coordinator confirmed that R84 requires supervision and touch assistance for mobility and that staff should be within eye distance to monitor and intervene as needed. The absence of staff in the dining room at the time of the fall suggests a failure to adhere to the facility's policy of providing adequate supervision for high-risk residents. Both residents had documented high fall risk scores on the Morse Fall Scale, and their care plans indicated the need for supervision and assistance to prevent falls. The facility's policies emphasize the importance of resident safety and supervision, yet the incidents involving R50 and R84 highlight deficiencies in implementing these policies effectively. The lack of staff presence and communication regarding the incidents contributed to the failure to prevent these falls, which could have been avoided with proper supervision and adherence to care plans.
Failure to Administer Pneumonia Vaccines Upon Admission
Penalty
Summary
The facility failed to adhere to its policy of offering pneumonia vaccines to residents prior to or upon admission. This deficiency was identified during a review of records and interviews, affecting three residents out of a sample of 25. The residents involved were an elderly male with chronic obstructive pulmonary disease, anemia, and other conditions; an elderly female with stage 4 chronic kidney disease, diabetes, and other health issues; and another elderly male with adult failure to thrive, muscle wasting, and dementia. None of these residents had documentation in their electronic health records indicating that they had been offered or administered the pneumonia vaccine upon admission. Interviews with facility staff revealed that the Infection Preventionist acknowledged the residents had consented to the vaccine but had not yet received it. The Director of Nursing stated that the facility's procedure is to offer the vaccine upon admission, obtain consent, and then order the vaccine from a contracted pharmacy, which should arrive within three days. However, the vaccines had not been administered as expected. The facility's policy, dated October 2022, mandates that all residents be assessed for eligibility and offered the pneumococcal vaccine series upon admission unless contraindicated or previously vaccinated, with detailed documentation required for those who receive the vaccine.
Failure to Assess and Prevent Falls in High-Risk Resident
Penalty
Summary
The facility failed to appropriately assess and evaluate a resident who was at high risk for falls, leading to a significant injury. The resident, a female with a complex medical history including schizophrenia, bipolar disorder, and seizures, had previously fallen on two occasions. Despite these incidents, the facility did not conduct fall risk assessments after the falls on February 19th and April 18th, 2024, nor did they update the resident's care plan with new interventions to prevent further falls. On May 21st, 2024, the resident was sent to the hospital with a diagnosis of a fracture of the cervical vertebrae and an acute subdural hematoma. Prior to this, the resident had refused to go to the hospital after a fall in April, despite sustaining a head injury. The facility's nurse practitioner noted a new hematoma on the resident's head on the day she was sent to the hospital, but no one knew how the injury occurred. The resident was described as impulsive and not adhering to fall precautions, yet no additional measures were implemented to address these behaviors. Interviews with facility staff revealed that the resident was considered a high fall risk upon admission, but the necessary assessments and interventions were not completed following her falls. The Director of Nursing acknowledged that more specific interventions could have been added after the resident's fall in April. The facility's policy on falls and fall risk management requires re-evaluation and potential changes to interventions if a resident continues to fall, which was not adhered to in this case.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy for reporting injuries of unknown origin, as evidenced by the case of a resident who sustained a new hematoma on her head. The resident, who has a complex medical history including schizophrenia, bipolar disorder, and seizures, was found with a new hematoma on her forehead by a nurse practitioner and a licensed practical nurse during an assessment. Despite the facility's policy requiring immediate reporting of suspicious bruises or injuries of unknown origin, the administrator was not informed of the new injury, and it was not reported to the state agency within the required 24-hour timeframe. The resident had a history of falls, with documented incidents occurring earlier in the year. On the day the new hematoma was discovered, the resident was sent to the hospital due to altered mental status and low oxygen saturation, where she was diagnosed with a fracture of the cervical vertebrae. The facility's abuse prevention program mandates that any injury of unknown source be reported and documented, but this protocol was not followed in this instance, leading to a deficiency in the facility's compliance with its own policies and state regulations.
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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