Waterford Care Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 7445 North Sheridan Road, Chicago, Illinois 60626
- CMS Provider Number
- 145659
- Inspections on file
- 24
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Waterford Care Center, The during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple medical conditions was found by hospital staff to have bruising and bleeding in the vaginal and perineal area, in addition to other bruises. The ER nurse notified the facility nurse, but the information was not promptly reported to the abuse coordinator or state agency as required by facility policy. Facility staff interviews confirmed delays and lack of communication regarding the incident, resulting in a deficiency in abuse reporting procedures.
A resident with cognitive impairment and on anticoagulants was found by hospital staff to have unexplained bruising and bleeding in the vaginal and perineal areas, which was reported to a facility nurse. The facility failed to document, report, or investigate these findings as required by policy, and key leadership, including the DON and Administrator, were not notified. No investigation into the injury of unknown origin was initiated.
A resident with moderate cognitive impairment and multiple psychiatric diagnoses experienced a choking episode requiring the Heimlich maneuver and supplemental oxygen. Although the provider was notified, the state guardian was not informed of the incident or the change in condition, contrary to facility policy and guardianship requirements.
A resident in an LTC facility did not receive their prescribed Baclofen 10 mg due to a medication shortage. The nurse used a substitute Baclofen 5 mg card with a torn-off label, which is against professional standards. The DON was unaware of the shortage and confirmed that borrowing medications is not allowed. Facility policies require proper labeling and administration of medications.
A resident did not receive her prescribed Ambien medication for two days after returning from knee surgery due to unavailability in the facility. Despite a sufficient supply being dispensed, the medication was not administered as confirmed by the MAR. The DON and RN were aware of the issue, but the facility failed to adhere to its policy of administering medications as per prescriber orders.
The facility failed to follow proper sanitation and food storage practices, with uncovered and unlabeled food items found in the freezer and personal items on the clean dish rack. The Dietary Manager confirmed these practices were against facility policy, which requires food to be dated and personal items stored in designated areas.
The facility failed to conduct timely PASARR screenings for four residents, leading to a deficiency. These residents, with various mental health diagnoses, were not evaluated for Level I or Level II PASARR prior to or upon admission, as required. The Social Services Director acknowledged the oversight but could not provide a reason for the lapse.
The facility failed to set low air loss mattresses to the correct weight settings for four high-risk residents, compromising the effectiveness of these devices in preventing pressure ulcers. The Wound Care Nurse confirmed that the settings should match the residents' current weights, but observations showed discrepancies, such as a resident weighing 219 pounds with a mattress set to 290 pounds.
A survey found deficiencies in medication management at an LTC facility. An LPN left a medication cart unattended and unlocked on the first floor, while an RN found expired vitamin D tablets on the second floor. The DON confirmed the importance of securing medication carts and discarding expired medications, as per facility policy, to prevent unauthorized access and administration of expired drugs.
The facility failed to maintain proper infection control by not covering a linen cart, risking contamination, and a CNA did not wear a gown while caring for a resident on Enhanced Barrier Precautions. The resident had a history of MRSA and required specific precautions, which were not adhered to, as confirmed by the DON.
The facility failed to maintain the dignity of two residents. One resident, with a history of dementia, was repeatedly observed disrobed in bed with the privacy curtain open, exposing them to others. Despite the resident's preference to disrobe, staff acknowledged the need for privacy measures, which were not consistently applied. Another resident with a urinary catheter was seen with an uncovered drainage bag, despite expressing the need for a privacy bag with straps. These incidents highlight a failure to adhere to policies ensuring resident dignity and privacy.
A resident with respiratory failure and asthma was found with an incorrect oxygen flow rate of 2 LPM instead of the prescribed 3 LPM. The resident's oxygen cannula was also not in place, reportedly removed by a CNA. A nurse confirmed the error and corrected the flow rate. The DON highlighted the importance of following physician orders and ensuring proper oxygen administration.
Failure to Timely Report Injury of Unknown Origin and Hospital Findings
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for a resident who was cognitively impaired and had multiple medical conditions, including long-term use of anticoagulants. The resident was re-admitted to the facility with documented bruising on her arms, legs, and thighs, but there was no documentation of bruising or bleeding in the vaginal or perineal area in the facility's records. During a subsequent hospitalization, an ER nurse identified bleeding and bruising in the resident's vaginal and perineal area, as well as additional bruising on the right thigh, and communicated these findings to the facility nurse. The facility nurse stated she was unaware of the bruising and bleeding in those areas and did not immediately report the information to the abuse coordinator or the state agency. Interviews with facility staff revealed that the wound care nurse had observed bruising on the resident's extremities and groin area upon re-admission and reported this at a morning meeting, but did not observe vaginal bleeding. The nurse in charge at the time of the resident's transfer to the hospital acknowledged being informed by the ER nurse about the bruising and bleeding but delayed notifying the Director of Nursing and did not report the incident to the abuse coordinator or state agency as required. The Director of Nursing and Administrator both confirmed they were not notified about the hospital's findings of vaginal bleeding and bruising, and facility policy requires immediate reporting of any suspected abuse, including injuries of unknown origin. Facility policies reviewed indicate that all incidents, allegations, or suspicions of abuse, neglect, or injuries of unknown source must be reported immediately to the administrator and appropriate authorities, with initial reporting to the state agency required within two hours if abuse or serious bodily injury is suspected. In this case, the failure to promptly report the injury of unknown origin and the findings communicated by the hospital staff constituted a deficiency in the facility's abuse reporting procedures.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an allegation of injury of unknown origin for one resident with significant medical history, including long-term anticoagulant use, cognitive impairment, and a colostomy. The resident was re-admitted to the facility with documented bruising on her arms and legs, but there was no documentation in the care plan or progress notes regarding bruising or bleeding in the vaginal, groin, or perineal areas. Hospital records and interviews with the emergency room nurse indicated that the resident was found with bleeding and bruising in these sensitive areas, which was communicated to the facility nurse at the time of hospitalization. Despite this notification, the facility staff did not document or report the new findings of vaginal and perineal bruising and bleeding. The nurse in charge at the time of the incident acknowledged being informed by the hospital but did not immediately notify the Director of Nursing or the Administrator, as required by facility policy. The Director of Nursing and Administrator both stated they were not made aware of the hospital's findings regarding the vaginal injuries, and no investigation was initiated into the injury of unknown origin. Facility policy requires immediate reporting and investigation of any alleged abuse or injury of unknown source, especially when the resident cannot explain the injury and the location is suspicious. In this case, the lack of timely reporting and investigation by staff resulted in a failure to respond appropriately to an allegation of potential abuse or injury of unknown origin, as required by both facility policy and regulatory standards.
Failure to Notify State Guardian After Resident Choking Incident
Penalty
Summary
The facility failed to notify a resident's state guardian following a significant change in the resident's condition. The resident, who has a history of dementia, schizoaffective disorder, and major depressive disorder, experienced a choking episode during dinner. The nurse on duty responded by performing the Heimlich maneuver, clearing the airway obstruction, and administering supplemental oxygen when the resident's oxygen saturation dropped to 89-90%. The resident's condition stabilized after intervention, and the provider was notified, but there was no documentation that the state guardian was informed of the incident or the change in oxygen saturation within 24 hours. Interview with the nurse involved revealed that he was unaware the resident had a state guardian and therefore did not notify the guardian after the incident. The Director of Nursing confirmed that facility policy requires notification of the resident's physician and representative or guardian in the event of a change in condition or incident. The resident's guardianship documentation also specifies that the public guardian must be notified immediately of incidents or changes in condition. Despite these requirements, the guardian was not informed as required.
Medication Mismanagement and Labeling Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of medication management, affecting a resident who was prescribed Baclofen 10 mg for musculoskeletal therapy. The issue arose when the resident's Baclofen medication was not available in the facility, and the nurse discovered that the medication had been lost. The pharmacy confirmed that a 30-day supply had been dispensed and signed for by a facility staff member, indicating that the medication should still have been available. In response to the shortage, a nurse used a substitute bingo card containing Baclofen 5 mg tablets, which had a torn-off label with another resident's name and the current resident's name handwritten on it. The Director of Nursing (DON) was unaware of the medication shortage until the day of the survey and confirmed that the practice of borrowing medications from one resident to administer to another is against professional standards. The facility's policy clearly states that medications ordered for a particular resident may not be administered to another resident, and any drug containers with missing or incorrect labels should be returned to the pharmacy for proper labeling. The DON also mentioned that she collects discontinued medication bingo cards in her office until the pharmacy picks them up, but she did not supply the Baclofen 5 mg card to the nurses. This incident highlights a breach in medication management protocols, as the facility failed to ensure proper labeling and administration of medications according to professional standards.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the resident's physician, resulting in a significant medication error for one resident. The resident, who had returned to the facility after knee surgery, did not receive her prescribed Ambien medication for two days. The Director of Nursing (DON) and a Registered Nurse (RN) were aware of the issue, as the medication was not available in the facility. Despite a 30-day supply of Ambien being dispensed to the facility and signed for by a staff member, the medication was not administered on the specified dates, as confirmed by the medication administration record (MAR). The General Manager of Pharmacy confirmed that there was a sufficient supply of Ambien, and there should not have been any lapses in administration. However, the DON was unsure if the medications were properly managed when the resident was readmitted, and did not verify if the medication was available in the emergency box. The facility's policy requires medications to be administered in accordance with prescriber orders, which was not adhered to in this case, leading to the deficiency.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food storage practices, as observed during a kitchen tour. Several food items, including turkey hot dogs, chicken patties, and chicken leg quarters, were found in the walk-in freezer uncovered and without open or discard dates. This lack of labeling and proper storage could potentially lead to foodborne illnesses, as dietary staff may not be aware of how long the food has been open. The Dietary Manager acknowledged that all food items should be dated once removed from their original packaging, in accordance with the facility's policy. Additionally, personal items such as cell phones and eyeglasses were found on the clean dish rack, which is against the facility's policy that prohibits storing personal belongings in the kitchen to prevent cross-contamination. The Dietary Manager confirmed that these items belonged to dietary employees and reiterated that personal items should be stored in designated areas like the locker room. The facility's policy on food storage and employee personal items, dated 2017, outlines these requirements to ensure safe food handling and storage practices.
Failure to Conduct Timely PASARR Screenings
Penalty
Summary
The facility failed to initiate a new Level I PASARR screening for four residents, which is a requirement for assessing mental disorders or intellectual disabilities. The deficiency was identified during a survey where it was found that residents R6, R7, R11, and R32 did not have the necessary PASARR screenings completed prior to or upon their admission to the facility. This oversight was discovered when the surveyor requested the PASARR screenings and found that they were only completed on 12/18/2024, despite the residents having been admitted earlier. Resident R11 was admitted with diagnoses including schizoaffective disorder and bipolar disorder, yet there was no documentation of a PASARR Level I or Level II evaluation prior to the survey date. Similarly, Resident R6, who has a history of schizoaffective disorder and other mental health conditions, was found to require a Level II evaluation, but this had not been conducted. Resident R7, with a history of bipolar disorder and self-harmful ideation, also required a Level II evaluation, which was not completed in a timely manner. Resident R32, who has a history of major depressive disorder and dementia, was similarly found to need a Level II evaluation. The Social Services Director acknowledged the responsibility for completing and submitting PASARR screenings but could not provide a reason for the failure to conduct these screenings. The facility's policy mandates that all new admissions undergo a Level I PASARR screening to determine the need for a Level II evaluation, which was not adhered to in these cases.
Incorrect Low Air Loss Mattress Settings for High-Risk Residents
Penalty
Summary
The facility failed to ensure that low air loss mattress devices were set to the correct weight settings for four residents who were at high risk of developing pressure ulcers. These residents were observed to have their mattress settings either too high or too low compared to their current weights, which could compromise the effectiveness of the mattresses in preventing pressure ulcers. For instance, one resident with a weight of 219 pounds had their mattress set to 290 pounds, while another resident weighing 86 pounds had their mattress set to 120 pounds. The facility's Wound Care Nurse confirmed that the low air loss mattresses should be set according to the current weight of the residents to effectively decrease pressure on bony areas and prevent pressure ulcers. The facility uses the BRADEN score to assess the risk of skin breakdown, and all four residents had scores indicating a high risk for developing pressure ulcers. The facility's policy requires that individuals at risk for pressure ulcers be placed on appropriate support surfaces, but the incorrect settings observed indicate a failure to adhere to this policy.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage and disposal, as observed during a survey. On the first floor, a medication cart was found unattended and unlocked, which was the responsibility of an LPN. This cart contained medications for residents on that floor, posing a risk of unauthorized access. Additionally, on the second floor, a medication cart inspection revealed a bottle of vitamin D tablets with an expiration date of the previous month. The RN acknowledged that expired medications should be discarded promptly to prevent administration to residents. The Director of Nursing confirmed the importance of securing medication carts when unattended to prevent access by residents or visitors. The facility's policy mandates that all drugs and biologicals be stored in locked compartments and that expired medications be returned to the pharmacy or destroyed. The survey findings indicated that these policies were not followed, potentially affecting the 86 residents residing in the facility.
Infection Control Deficiencies in Linen Storage and PPE Usage
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, specifically regarding the storage of facility linen and the use of Personal Protective Equipment (PPE) by staff. A linen cart was observed in the hallway without a side covering, containing towels, sheets, pillowcases, and gowns, which could lead to contamination. The Director of Nursing and the Maintenance Supervisor acknowledged that uncovered linen could become contaminated, and the linen cart with the missing flap needed replacement. Additionally, a Certified Nurse Assistant (CNA) was observed providing care to a resident on Enhanced Barrier Precautions without wearing a disposable gown, as required. The resident, who had a history of MRSA and was on long-term enteral feeding, required Enhanced Barrier Precautions. The Director of Nursing confirmed that staff should wear a mask, gloves, and a disposable gown when caring for such residents, but this protocol was not followed in this instance.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R6, by not ensuring their body was covered to prevent exposure to others. R6, who has a history of dementia and schizoaffective disorder, was observed multiple times lying in bed with only a diaper and socks on, with the privacy curtain open, allowing them to be viewed from the doorway. Despite R6's preference to disrobe, the facility staff, including the Director of Nursing and Social Services Director, acknowledged that the privacy curtain should be drawn to maintain dignity. However, the care plan addressing R6's behavior of disrobing was only updated after the surveyor's observation, indicating a lack of proactive measures to address the issue. Another deficiency was noted with a resident identified as R117, who was observed with a urinary catheter drainage bag hanging underneath their wheelchair without a privacy bag. R117, who has a neurogenic bladder and uses a suprapubic catheter, expressed the need for a privacy bag with straps, as the one provided by the facility was deemed useless. The Registered Nurse confirmed that the urinary drainage bag should be covered for dignity reasons, and the Director of Nursing reiterated that covers are supposed to be used. However, the lack of a proper privacy bag at the time of observation indicates a failure to uphold the resident's dignity. The facility's policies on Activities of Daily Living and Quality of Life-Dignity emphasize the importance of maintaining residents' dignity and privacy. These policies require that residents be treated with respect and that their privacy be protected, including covering urinary catheter bags. The observed deficiencies in maintaining resident dignity and privacy suggest a failure to adhere to these policies, as evidenced by the exposure of R6 and the uncovered urinary drainage bag of R117.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to a resident's care plan by not following the physician's order for the correct oxygen flow rate. The resident, who has acute and chronic respiratory failure with hypoxia and unspecified asthma, was observed with an oxygen flow rate set to 2 liters per minute (LPM) instead of the prescribed 3 LPM. This discrepancy was noted during an observation when the resident was found with the oxygen cannula tubing not in place, and the resident reported that a CNA might have removed it during care. The resident expressed the need for continuous oxygen use due to shortness of breath related to asthma and COPD. A registered nurse confirmed the incorrect oxygen flow rate and adjusted it after checking the physician's orders. The Director of Nursing emphasized the importance of following doctor's orders for oxygen administration to meet the individual needs of residents and stated that CNAs should not remove oxygen tubing but should inform nurses to ensure proper administration. The facility's policy on oxygen administration requires verification of physician orders and adherence to the care plan, which was not followed in this instance.
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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