West Chicago Living And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Chicago, Illinois.
- Location
- 928 Joliet Road, West Chicago, Illinois 60185
- CMS Provider Number
- 14E392
- Inspections on file
- 37
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at West Chicago Living And Rehab Center during CMS and state inspections, most recent first.
A resident with schizophrenia, major depressive disorder, and generalized anxiety disorder, who was cognitively intact, was in the dining room with peers when another cognitively intact resident with schizoaffective disorder, bipolar type, began loudly singing, running, and was non-redirectable. After the disruptive resident placed a phone on the first resident’s table, the first resident moved the phone to another table and used a curse word, prompting the disruptive resident to grab him from behind and push him to the floor, causing elbow redness and later-reported bruising and pain. Staff and leadership acknowledged that this was physical abuse and that it was their responsibility to prevent such abuse, despite an existing abuse prevention policy stating the facility’s commitment to protect residents from abuse and to do all within its control to prevent it.
Two cognitively intact residents, both with mental health diagnoses, were involved in an incident where one resident purchased an object grabber for another resident experiencing difficulty bending. Facility leadership, including psych social services and the former administrator, confiscated the grabber, citing concern it could be used as a weapon and stating a physician order was required, but did not provide the purchasing resident with written policy justification or return of the item. Despite memos and verbal complaints from the resident describing arbitrary denial of rights, lack of professionalism, and discourtesy, documentation shows only that staff offered to help return the item and later obtained a physician order for a different grabber for the intended recipient. The original grabber’s location was unknown, and there was no evidence that a physician had deemed it medically inappropriate or that the restriction was documented as required by the facility’s resident rights policy.
A resident with schizoaffective disorder, intact cognition, and a documented history of physical and verbal aggression, including prior liquid-throwing behavior and felony convictions for aggravated battery, was able to obtain coffee during lunch and throw it on another cognitively intact resident with multiple serious medical conditions after becoming annoyed by her talking. An activity aide witnessed the incident, and the aggressive resident admitted he threw the coffee because he found the other resident annoying. Despite existing care plans identifying him as an offender requiring monitoring and supervision, the facility’s incident investigation inaccurately stated he had no history of verbal aggression toward peers and deemed the abuse allegation unfounded.
A resident reported that another resident approached her in the dining room, grabbed her walker, made explicit verbal threats to harm and kill her, and caused her to feel scared. Staff interviews and written statements corroborated that the aggressor resident grabbed and pushed the walker toward the victim while making these threats, and video review confirmed the physical interaction with the walker. Although the facility’s abuse policy requires immediate reporting of abuse allegations to the state health department, the incident was only investigated internally and there is no evidence that the allegation was reported to the Illinois Department of Public Health.
Multiple residents experienced uncomfortably high room temperatures and humidity due to repeated air conditioning failures. Despite maintenance efforts and offers to relocate residents, the cooling systems remained unreliable, leading to sustained periods of discomfort as confirmed by temperature readings and resident complaints.
A staff member disclosed a resident's personal information, including her name and housing situation, to another resident during a discussion about discharge planning. This action violated the facility's privacy policies and the resident's right to confidentiality, as confirmed by staff interviews and facility records.
Surveyors found that dishes were not properly sanitized due to a malfunctioning dish machine that failed to dispense chlorine sanitizer, and staff did not test the machine before use. Additionally, dented cans were stored with other canned goods instead of being separated. These failures affected all residents receiving food from the kitchen.
The facility did not fully implement or document its water management program for Legionella, as the plan lacked identification of building water systems needing control measures, risk assessments, and a complete water distribution diagram. The Maintenance Director performed some flushing and cleaning tasks, but these were not included as control measures in the official plan, and the plan was not updated to reflect current practices or facility needs. A resident had previously tested positive for Legionella pneumonia, but the water management program remained incomplete.
The facility did not use a standardized tool, such as McGeer's or Loeb's criteria, to identify infections before starting antibiotics, as required by its own antibiotic stewardship policy. Instead, staff relied on the EMR Infection Control Module, which does not indicate whether infection criteria are met, affecting all residents receiving antibiotics.
Six residents who selected a substitute meal at lunch received turkey sandwiches that did not provide the same protein content as the main entrée of baked chicken. The sandwiches were prepared with less turkey than required and did not include cheese as specified in the recipe, resulting in a lower protein portion than intended.
A resident with a history of endocarditis and a cardiac valve prosthesis was prescribed daily Doxycycline Hyclate with instructions for continued use until evaluated by an Infectious Disease (ID) specialist. The facility failed to ensure the resident was seen by an ID practitioner, resulting in ongoing antibiotic therapy without the required specialist assessment.
A resident with chronic kidney disease, hypertensive heart disease, and diabetes reported swelling in the hands, feet, and face and requested a diuretic. Lab tests were ordered, and an antibiotic was prescribed and administered before urine culture results were available. The culture later showed no infection, and the NP confirmed the antibiotic should not have been given, resulting in unnecessary drug administration.
Two residents on mechanical soft diets were served chopped baked chicken in varying sizes instead of the required ground consistency, contrary to dietary orders and facility policy. The cook manually chopped the chicken and added gravy, rather than following the recipe for ground deboned chicken, and the dietitian confirmed that proper recipe guidance was not followed.
A resident with mental health diagnoses and intact cognition was physically abused by another resident, who threw coffee and struck her in a common area. Multiple staff and video evidence confirmed the incident, and facility leadership acknowledged the failure to provide a safe environment as required by policy.
A facility failed to have policies in place to address the intimacy rights of mentally ill female residents, leading to a resident becoming pregnant and experiencing psycho-social harm. The facility did not adequately assess her ability to engage in safe sex practices, and there was no tracking of intimate relationships or distribution of contraceptives. The resident's care plan was not updated to address her desire to become pregnant and her engagement in unprotected sex.
A resident was physically abused by another resident who became aggressive after being told to stop being rude. The aggressor shoved and punched the victim, resulting in an injury. Staff intervened, and the aggressor was later discharged. Both residents had mental health diagnoses, and the facility's abuse policy was not effectively enforced.
The facility failed to provide adequate documentation for the involuntary discharge of two residents, one due to safety concerns after an altercation and another after leaving unsupervised. The facility did not document the specific needs they could not meet or follow up on the residents' conditions, violating state and federal regulations.
A resident with schizophrenia and other conditions was not notified of her involuntary discharge after leaving the facility AMA following an emotional crisis related to her pregnancy. The facility did not provide the required AMA form or IVD notice, violating its own policies and federal guidelines.
A pregnant resident with schizophrenia and a history of elopement was allowed to leave a facility unsupervised, despite known risks and previous incidents requiring emergency intervention. The facility failed to follow established protocols, such as contacting emergency personnel or having the resident sign an AMA form, leading to her unauthorized departure. The resident was later found by family members and police, highlighting a deficiency in supervision and safety measures.
A resident, assessed as cognitively intact, requested to manage her own Social Security payments, which were initially handled by the facility as her representative payee. Despite the resident's request and a psychiatrist's agreement to sign a letter confirming her capability, the facility delayed providing the necessary documentation, citing the need for a discharge plan. This delay violated the resident's right to manage her own financial affairs.
The facility failed to implement proper infection control practices for three COVID-19 positive residents, including inadequate PPE use and disposal, and improper hand hygiene. Additionally, the facility lacked a system to monitor and prevent the growth of Legionella and other waterborne pathogens, as they did not test the water. Soiled linen was also improperly stored, potentially affecting all residents.
The facility did not provide education on the benefits, risks, and side effects of the COVID-19 vaccine to staff, despite offering the vaccine. Interviews with staff, including an Activities Aide and a Psych Rehab Social Assistant, confirmed the lack of education. The Assistant Director of Nursing/Infection Control Nurse and the Director of Nursing admitted to not providing or documenting any educational efforts regarding the vaccine.
The facility failed to maintain a safe and comfortable environment for residents due to unresolved temperature control issues and maintenance deficiencies. Residents experienced discomfort from high room temperatures, and one resident faced inconvenience and distress due to a leaking bathroom that had not been repaired since May. The absence of a maintenance director contributed to these ongoing issues.
The facility failed to invite residents to quarterly care plan meetings and maintain active care plans for specific medical diagnoses. Several residents reported not attending or being invited to these meetings, and there was no documentation of invitations or attendance. Additionally, a resident with alcohol dependence did not have a care plan addressing this condition, despite the facility's policy requiring it.
The facility failed to properly label and manage medications, leading to potential safety risks for residents. An RN was unaware of the expiration date for an insulin pen, and a haloperidol pill was not discarded after a resident left. Additionally, tramadol and lorazepam medications were improperly stored, with compromised pills not being wasted as required. The facility's policies on medication control and storage were not followed, risking contamination and adverse effects.
A facility failed to document a resident's DNR status in the EMR, despite having a paper POLST. The resident, with multiple diagnoses, was considered a full code due to the absence of a physician's order in the EMR. Staff interviews revealed that the nurse is responsible for entering the code status, while the psychosocial team scans the POLST, and the DON updates the profile. The facility's policy presumes consent to CPR unless a DNR order is documented.
A resident with an enlarged prostate experienced a delay in receiving a urology appointment due to scheduling errors and insurance issues. Despite a physician's order and insurance approval, the appointment was not made, leading to worsening symptoms. The facility's policy to confirm and arrange outside appointments was not followed.
A resident was observed with long, jagged toenails and dirty feet, indicating a lack of appropriate foot care. The resident reported wearing socks due to a bunion and sore, and stated that the foot doctor was too busy to see her. A CNA confirmed that she is not allowed to cut toenails, and the scheduler could not provide documentation of the last podiatrist visit. The facility lacked a policy on foot care.
A resident with multiple health conditions did not receive timely visits from her primary care physician, as required by facility policy. Instead, she was only seen by a nurse practitioner and medical students. The facility's administrator confirmed the physician's absence and lack of documentation in the resident's medical record, highlighting a failure to comply with federal regulations and facility policy.
The facility failed to provide necessary behavioral health services for two residents. One resident with alcohol dependence did not receive promised AA meetings or substance abuse support, while another resident with mental health issues experienced frequent cancellations of scheduled therapy sessions. Staff confirmed the lack of services and documentation, highlighting a gap in the facility's behavioral health care provision.
The facility did not post the daily staffing information on time, affecting all 85 residents. The staffing sheet for a specific day was not posted at the reception desk, with the last update being from the previous day. The administrator and receptionist acknowledged the oversight, with the receptionist responsible for posting the sheet unable to explain the delay. The facility's policy requires staffing numbers to be posted within two hours of each shift's start, which was not followed.
A resident with multiple diagnoses did not receive her scheduled 9 PM medications due to the LPN's failure to bring the medications to her when she was unable to get out of bed due to pain. The LPN incorrectly documented the medications as refused, leading to a deficiency in medication administration services and quality of care.
The facility failed to maintain a safe, clean, and comfortable environment for its 90 residents. Observations revealed dirty and damaged walls, broken furniture, and hazardous flooring. Residents reported these issues, but they were not addressed promptly due to insufficient maintenance staff. The administrator acknowledged the ongoing hazards and delays in repairs.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident (R1) from physical abuse by another resident (R2). On the evening of 3/6/26, R2 was observed by staff to be singing loudly, running back and forth in the dining area, and was described as non-redirectable, with residents complaining about the noise. R1, who has diagnoses of schizophrenia, major depressive disorder (recurrent, moderate), and generalized anxiety disorder and was assessed as cognitively intact, was in the dining room with other residents attempting to talk and watch a movie. R2 placed his phone on the table where R1 was sitting; R1 moved the phone to another table and told R2 he did not want the phone on his table, and also called R2 a curse word. R2 then grabbed R1 from behind, pushed him to the floor, and stood over him until staff separated them. R1 initially reported feeling okay and not hurt, with staff documentation noting no injury other than slight redness to an elbow at the time of assessment. During the investigation, R1 later reported bruising and pain to his right elbow and lower back, stating that the elbow injury occurred when he landed on the floor. Staff accounts, including the RN assigned to both residents and the DON, confirmed that R2 had been running around, talking or singing loudly, and was not redirectable prior to the incident, and that R2 physically grabbed and pushed R1 to the ground after R1 moved his phone. R2’s face sheet shows a diagnosis of schizoaffective disorder, bipolar type, and his MDS indicated he was cognitively intact, with no prior history of aggression at the facility. The facility’s Abuse Prevention Policy states that physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that the facility is committed to protecting residents from abuse and doing all that is within its control to prevent occurrences of abuse. The final incident investigation concluded that physical abuse was founded, determining that R2’s act of grabbing and pushing R1 to the ground constituted physical abuse. Both the Administrator and the DON acknowledged in interviews that the event was physical abuse and that it is the facility’s job to prevent abuse, indicating that the facility did not keep R1 free from abuse as required by its policy and regulatory standards.
Failure to Honor Residents’ Rights to Personal Property and Explanation of Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to retain personal property and to receive explanations and justification when such property is restricted. One resident (R4), with intact cognition and a diagnosis including major depressive disorder, purchased an object grabber for another cognitively intact resident (R5), who had multiple mental health diagnoses. When the grabber arrived, the receptionist directed R4 to take it to psychiatric social services and then to the administrator. The Psychiatric Rehabilitation Services Director (V3) and the former Administrator (V5) determined the grabber could potentially be used as a weapon and confiscated it, telling R4 that R5 would need a physician order to use such a device. Despite R4’s request, the facility did not provide a policy or written justification supporting the confiscation or the requirement for a physician order for the grabber. R4 reported feeling disrespected, dismissed, and that his rights and R5’s rights were being arbitrarily denied. He wrote at least two memos documenting his displeasure with what he described as lack of professionalism, arbitrary denial of resident rights, and discourtesy toward himself and R5. These memos stated that he followed procedures, that his item was confiscated, that he was told the administrator would not allow the object in the facility, and that he requested but did not receive a policy explaining why the grabber was not allowed. Social services notes show staff told R4 the shape of the grabber could render it usable as a weapon and offered to help him return it for a refund, and later documented that his concerns did not rise to the level of abuse, that he was allowed to vent, and that he remained dissatisfied and felt he was not being listened to. R5 separately approached psych social services stating he wanted to use the grabber purchased for him by another resident, and was informed, per the administrator, that he was not allowed to have it due to facility regulations. Subsequently, R5 obtained a physician order for a grabber and the facility provided a different grabber, but the original grabber purchased by R4 was not returned to him and its whereabouts were unknown to the Assistant Administrator (V2), the Director of Nursing (V7), or V3. The facility’s Resident Rights Policy states that residents have the right to retain and use personal property in their immediate living quarters unless deemed medically inappropriate by a physician and documented in the clinical record, and the facility’s dignity document states staff will not speak in a manner that could be interpreted as condescending, critical, or argumentative. The record and interviews do not show that a physician deemed the original grabber medically inappropriate or that the decision to confiscate and withhold it from R4 and R5 was documented in the clinical record, nor that R4 received the requested written policy justification or the return of his personal item.
Failure to Prevent Resident-on-Resident Abuse by Known Aggressive Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident threw hot coffee on another resident. The resident who committed the act had intact cognition, a diagnosis of schizoaffective disorder, and a documented history of physical and verbal aggression, including throwing liquid at a peer and calling a roommate an “idiot.” His background check and an identified offender care plan showed felony convictions for aggravated battery and battery with bodily harm, and he was to be monitored and supervised. Despite this known history and care plan directives, he was able to obtain coffee during lunch service and throw it on another cognitively intact resident during an interaction in which he reported being annoyed by her talking. The resident who was the target of the coffee-throwing incident had diagnoses including malignant neoplasm of the colon, liver, and intrahepatic bile duct, schizophrenia, epilepsy, and low back pain, with intact cognition. An activity aide witnessed the incident, reporting that the aggressive resident threw coffee at the other resident after they had been speaking and she got up. Progress notes documented that the aggressive resident admitted throwing coffee because he found the other resident annoying. The facility’s Final Incident Investigation Report inaccurately stated that the aggressive resident had no history of verbal aggression with peers and concluded the allegation of abuse was unfounded, despite documentation of prior verbal abuse and the resident’s own admission to throwing the beverage.
Failure to Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the Illinois Department of Public Health (IDPH) as required by its Abuse Prevention Policy. A resident (R1) reported that another resident (R2) threatened her, including threats to hit her with a walker, shove the walker up her anus, and kill her. Staff interviews and written witness statements confirm that R1 told the Psychiatric Rehabilitation Services Counselor and the Assistant Administrator that R2 approached her in the dining room, grabbed her walker, made explicit verbal threats of physical harm and death, and that R1 stated she was scared and did not know what R2 was going to do. An investigation assessment and investigation document completed by the former Administrator describe the incident, including review of video footage showing R2 walking up to R1, speaking toward her, placing both hands on R1’s walker, lifting it slightly off the ground, and pushing it toward R1. The facility’s Abuse Prevention Policy requires employees to report any incident, allegation, or suspicion of abuse to the Administrator immediately and requires the Administrator or designee to notify the Department of Public Health’s regional office immediately by telephone or fax when an allegation of abuse has been made. While the Assistant Administrator reported the allegation internally to the former Administrator and an internal investigation was conducted, the investigation documentation does not show that the allegation was reported to IDPH. The current Administrator reviewed the investigation report and stated that, based on the threats made toward R1, the incident should have been reported to IDPH and that she had no evidence that such a report was made by the facility.
Failure to Maintain Comfortable Room Temperatures Due to Air Conditioning Malfunctions
Penalty
Summary
The facility failed to maintain cool and comfortable room environments for residents, as evidenced by multiple reports of excessive heat and humidity in resident rooms over several days. Several residents, all cognitively intact except for one with moderate cognitive impairment, reported their rooms being uncomfortably hot, with some describing the conditions as unbearable. Temperature and humidity readings taken in various rooms confirmed elevated levels, with temperatures frequently reaching 78-82 degrees Fahrenheit and humidity levels between 54-64%. Residents attempted to alleviate discomfort by opening windows, but this was discouraged by staff due to high outside temperatures. Facility staff, including the Administrator and Maintenance personnel, acknowledged ongoing issues with the air conditioning units across multiple resident halls. Maintenance staff described repeated breakdowns, intermittent functioning, and difficulties in sourcing necessary repair materials such as freon. Despite efforts to monitor and repair the units, some air conditioners remained nonfunctional for extended periods, and staff were not always aware of the elevated temperatures in resident rooms at the time they occurred. Documentation, including grievances and progress notes, showed that residents had formally complained about the heat, and while alternative rooms were offered, residents declined due to the perception that all rooms were affected. The facility's Emergency Operations Plan required maintenance checks of all AC units, but the persistent failures and delayed repairs resulted in sustained periods where residents were exposed to uncomfortable and potentially unsafe room temperatures.
Failure to Protect Resident Privacy During Discharge Planning Discussion
Penalty
Summary
A deficiency occurred when a staff member, specifically a Psychiatric Rehabilitation Services Coordinator (PRSC), disclosed a resident's personal information to another resident during a discussion about discharge planning and housing. The PRSC used the resident's name and specific details about her housing situation as an example while speaking to another resident, rather than using a generalized or anonymous example. This disclosure was confirmed by interviews with the resident involved, the PRSC, the Director of Nursing (DON), and other staff, all of whom acknowledged that the resident's name and situation were inappropriately shared. The resident whose information was disclosed was cognitively intact and had a diagnosis of schizophrenia. She reported the incident to the facility administrator, expressing that her privacy rights had been violated. Facility records and progress notes corroborated that the resident did not want her name mentioned in conversations with other residents. The facility's policies on resident rights and privacy require the protection of personal and medical information, which was not upheld in this instance.
Failure to Sanitize Dishes and Store Food Safely
Penalty
Summary
The facility failed to ensure proper food safety practices in two key areas: dish sanitization and canned food storage. During an initial kitchen tour, three dented cans of Salsa Para Enchiladas were found stored alongside other canned goods in the dry storage area. The dents were located at the seams, and the Dietary Manager acknowledged that staff had missed these defects during storage. Additionally, the dishwashing process was observed to be deficient. The dish machine, which uses chlorine as a chemical sanitizer, was not dispensing sanitizer as required. When tested with a chlorine test strip, no sanitizer was detected, and dietary staff admitted they had not tested the machine prior to washing dishes after breakfast. The dish machine log confirmed that required checks for wash temperature and chlorine concentration were not completed for that meal service. The posted requirements on the dish machine specified a minimum chlorine concentration of 50 parts per million (ppm), but this standard was not met during the observed cycle. The operation manual for the dish machine also emphasized the importance of proper sanitizer concentration and regular testing. The facility census at the time was 88 residents, all of whom received food prepared in the kitchen. No residents were on NPO status. The failure to properly sanitize dishes and to separate dented cans from usable stock directly affected all residents receiving meals from the facility kitchen.
Failure to Implement Comprehensive Water Management Program for Legionella
Penalty
Summary
The facility failed to follow its water management program for Legionella, affecting all 88 residents. The Maintenance Director reported that he flushes water in empty resident rooms and soiled utility rooms, documenting these tasks in an electronic system. However, the Administrator confirmed that the facility's water management plan does not include flushing as a control measure, nor does it identify specific building water systems requiring control measures or assess the level of risk in those areas. The plan also lacks a diagram showing how water is distributed throughout the facility, only including a diagram of water flow out of the building. Additionally, the plan was already in place before the current Maintenance Director started and he did not participate in its development. A resident previously tested positive for Legionella pneumonia, prompting water testing that returned negative results. The facility has an eyewash station in the laundry room, which the Maintenance Director checks for functionality, and another station is planned for the kitchen. The Water Management Program document does not identify building water systems needing Legionella control measures or assess the risk of hazardous conditions in those systems, and it lacks a comprehensive diagram of the facility's water system. These omissions indicate the facility did not fully implement or document required elements of its infection prevention and control program related to water management.
Failure to Use Standardized Tool for Infection Identification in Antibiotic Stewardship
Penalty
Summary
The facility failed to follow its policy for antibiotic stewardship by not utilizing a standardized tool to identify infections in residents when antibiotics were prescribed. Interviews with the Infection Preventionist Nurse revealed that while information about antibiotic use was logged into the EMR Infection Control Module, McGeer's criteria or any other standardized tool was not used to determine if a resident had an infection. The Director of Nursing confirmed that the facility does not use McGeer's criteria, citing a copyright issue, and relies solely on the EMR infection module, which does not indicate whether infection criteria are met before starting antibiotics. The Regional Nurse Consultant also acknowledged the absence of a standardized tool for infection identification in the EMR. A review of infection tracking records from November 2024 to the present showed no evidence that a standardized tool was used when residents were started on antibiotics. The facility's own Antimicrobial/Antibiotic Stewardship Program policy requires the use of McGeer Criteria or the EMR Infection Control Module for infection information collection, but the EMR module does not provide a standardized method to determine infection status. This deficiency applied to all 88 residents in the facility, as the process for monitoring and identifying infections prior to antibiotic use was not standardized as required by policy.
Failure to Provide Nutritionally Equivalent Substitute Meal Options
Penalty
Summary
The facility failed to provide a substitute meal option with nutritional content equivalent to the main entrée for six residents who chose the substitute meal during lunch. The main entrée, baked chicken, was specified to provide 3 oz of protein per portion. However, the substitute turkey sandwich was prepared with approximately 3.5 slices of deli turkey, which, when weighed, amounted to only 2.7 oz, and did not include cheese as specified in the recipe. The cook did not weigh the turkey slices or include cheese, and the dietary manager confirmed the protein portion was less than required. The dietitian stated that substitute menu items should match the protein serving portions of the main entrée and follow recipe specifications.
Failure to Follow Physician Order for Infectious Disease Consultation
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for an Infectious Disease (ID) consultation for a resident with a history of unspecified valve endocarditis and infection related to a cardiac valve prosthesis. The resident, who was cognitively intact, had an active order for Doxycycline Hyclate to be administered daily until evaluated by an ID practitioner. Despite this order, there was no evidence in the electronic medical record or progress notes that the resident was ever seen by an ID specialist to assess the continued need for the antibiotic. Staff interviews confirmed that the facility was unaware that the ID consultation had not been scheduled since the initial order was made. The MDS Coordinator and the Assistant Director of Nursing/Infection Preventionist both acknowledged that the required follow-up for the ID evaluation was not completed, and the facility's own guidelines require that verbal orders be followed through as required. This lapse resulted in the resident continuing antibiotic therapy without the intended specialist evaluation.
Unnecessary Antibiotic Administration Due to Incomplete Assessment
Penalty
Summary
A resident with multiple diagnoses, including chronic kidney disease, hypertensive heart disease, and type 2 diabetes mellitus, was admitted to the facility and later complained of swelling in the hands, feet, and face. The resident requested a diuretic, and laboratory tests were ordered. Despite the absence of infection indicated by the urine culture results, an antibiotic (nitrofurantoin) was prescribed and administered for five days based on the initial symptoms and urinalysis results. The electronic medical record and progress notes confirm that the antibiotic was given before the urine culture results were available, which later showed only mixed urogenital flora not indicative of infection. The nurse practitioner acknowledged that, based on the resident's symptoms and the laboratory findings, the antibiotic should not have been administered. This sequence of actions resulted in the resident receiving an unnecessary medication.
Failure to Provide Properly Prepared Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food in the appropriate form for residents on mechanical soft diets, as required by their dietary orders and facility policy. During tray line service, the cook prepared mechanical soft diet meals by manually chopping baked chicken and adding gravy, resulting in pieces of varying sizes rather than the required ground consistency. Two residents on mechanical soft diets were served this improperly prepared chicken, despite the menu and recipe specifying ground deboned chicken with gravy. The dietitian confirmed that the recipe guidance for mechanically altered diets should be followed, and facility policy requires adherence to prescribed texture modifications for therapeutic diets.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of mental illness and intact cognition was subjected to physical abuse by another resident while waiting in line. The incident involved one resident throwing coffee on and striking the other, as confirmed by video evidence, multiple staff witness statements, and the aggressor's own admission. The abused resident reported being hit in the mouth and having coffee thrown on her, and her care plan identified her as being at risk for abuse due to her mental health diagnosis. The facility's incident report and risk management documentation corroborated the occurrence of physical abuse. Despite the facility's policy to maintain a safe and secure environment free from abuse, the event occurred in a common area with staff present. Staff and administrative interviews acknowledged that the actions were willful and deliberate, and that the facility failed to provide a safe environment for the resident. The facility's abuse policy defines abuse as the willful infliction of injury or harm, and the incident met this definition according to both the administrator and the assistant director of nursing.
Failure to Address Intimacy Rights and Safe Sex Practices
Penalty
Summary
The facility failed to have a system or policies in place to address the intimacy rights of mentally ill female residents of child-bearing age, leading to a significant deficiency. This deficiency resulted in a female resident becoming pregnant by another resident, which caused her psycho-social harm and led to her hospitalization. The resident, who has schizophrenia, anxiety disorder, epilepsy, and asthma, was unable to care for a child due to her need for 24-hour custodial care. The facility did not adequately assess her ability to engage in safe sex practices, and she refused condoms and other forms of birth control. The facility's lack of policies and processes to monitor menstruation cycles, perform pregnancy testing, distribute contraceptives, and complete intimacy assessments and consents contributed to the deficiency. Staff interviews revealed that there was no tracking of residents engaging in intimate relationships or the distribution of condoms. The facility did not have a process to monitor residents in intimate relationships, and there was no policy regarding contraceptives. The resident's care plan was not updated to address her desire to become pregnant and her engagement in unprotected sex. The facility's failure to address these issues resulted in an Immediate Jeopardy situation, as the resident's pregnancy placed her in a catastrophic situation. The facility was aware of the resident's intimate activity and her refusal of contraceptives but did not take appropriate actions to prevent the pregnancy. The facility's policies did not address how to care for residents who become pregnant while residing at the facility, and there was no process to track intimate relationships or the distribution of condoms.
Removal Plan
- Policies have been developed for Contraception Policy, Menstrual Cycle Monitoring Policy, Intimate Relationship Assessment and Education Form Policy.
- Nursing and PRSD/PRSC staff have been training regarding Contraception Policy, Menstrual Cycle Monitoring Policy, Intimate Relationship Assessment and Education Form Policy and responsibilities regarding all policies.
- Residents of childbearing age and who engage in sex are offered contraceptives by PRSC/PRSD staff. If resident chooses medicine-based contraceptive, they will be referred to nursing who will contact MD for orders.
- New admissions will have admission assessment completed and placed on menstrual cycle tracking as indicated.
- New admissions will have Intimacy assessment and Education Form completed upon admission assessment and will have contraceptives offered. If resident chooses medicine based contraception, MD will be contacted per nursing.
- The facility has developed new policies on Contraception use, Intimate Relationship assessment and education form, and Menstrual Cycle Monitoring. Policies reviewed with Medical Director.
- The facility will ensure that Nursing Staff and psych social staff are educated on responsibilities regarding the following policies: Contraception policy, Menstrual Cycle Monitoring Policy, and Intimate Relationship Assessment and Education Form Policy. Employees that are on vacation will be educated prior to returning to the facility.
- The facility will audit residents medical record to identify female residents of childbearing age, these residents will have menstrual cycle tracking by nursing staff and will be offered contraception and education regarding contraception. If resident chooses medicine-based contraception, MD will be contacted for orders per nursing. Facility audit initiated by the PRSD.
- The facility PRSD and the PRSCs educated on intimacy assessment and education form policy, including review of intimacy assessment and education form, review of need to educate residents regarding contraception and safe sex practices, review of educating residents regarding risks of pregnancy which include an understanding that they will not be able to continue to reside in facility. Education provided by Regional Director of Behavioral Health.
- A QA tool developed to monitor menstrual tracking. During facility rounds, the DON or designee will ensure that menstrual tracking is completed. New admissions will be added to the QA tool.
- A QA tool developed to review status of contraceptive use for biological female residents of childbearing age. DON or designee will review orders to ensure that biological female residents of childbearing age have orders for medicine-based contraceptives or have documented refusal of medicine-based contraceptives. New admissions will be added to the QA tool.
- A QA tool has been developed to review status of intimate relationship assessments and education form. PRSD or designee will review completed intimate relationship assessments and education form for completion and intimacy care plan. New admissions will be added to the QA tool.
- The results of the monitoring completed under this plan are submitted to the QA/QAPI Committee for review and follow-up and reviewed with Medical Director.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. One resident, identified as R9, reported that another resident, R7, became upset and physically aggressive after being told to stop being rude to others. R7 shoved R9 against a bookcase and later punched her in the face while she was in line for her medications. This altercation resulted in R9 sustaining a linear abrasion on her forearm and a punch to her left eye, although no bruise was reported. Staff members, including an LPN and a Psychiatric Rehab Social Counselor, witnessed the incident and intervened by calling a Code Orange due to the combative situation. The facility's records show that R9 is cognitively intact and has a history of mental health issues, including bipolar disorder and anxiety disorder. R7, who was involuntarily discharged from the facility following the incident, also had multiple mental health diagnoses and exhibited verbal and physical behaviors towards others. The facility's policy on abuse, effective since March 2022, prohibits any form of abuse, including physical abuse, which is defined as the infliction of injury that requires medical attention. Despite this policy, the incident occurred, highlighting a failure in protecting residents from abuse.
Inadequate Documentation for Involuntary Discharges
Penalty
Summary
The facility failed to provide adequate physician documentation for the involuntary discharge of two residents, R1 and R7, which is a violation of state and federal regulations. R7 was discharged to a behavioral hospital due to safety concerns after an altercation with another resident. However, the facility did not document the specific needs they could not meet, the efforts made to meet those needs, or the services the receiving facility would provide. This lack of documentation is a critical oversight in the discharge process. R1, a long-term resident with a history of mental health issues, left the facility unsupervised and was later found by her family and police. The facility considered her departure as leaving Against Medical Advice (AMA) but did not provide her with an AMA form or an Involuntary Discharge (IVD) notice. Despite completing a petition for R1's involuntary transfer to a hospital due to a mental health crisis, the facility did not follow up on her condition or consider her for readmission, citing her as permanently discharged. The facility's policies on AMA and involuntary discharge require specific documentation and communication, which were not adhered to in these cases. The lack of proper documentation and follow-up for both residents highlights significant deficiencies in the facility's discharge procedures, potentially impacting the residents' care and safety.
Failure to Notify Resident of Involuntary Discharge
Penalty
Summary
The facility failed to provide a resident with a notification of involuntary discharge, which is a violation of regulatory requirements. The resident, who had been diagnosed with schizophrenia, epilepsy, anxiety, myopia, astigmatism, and hyperlipidemia, was confirmed to be pregnant while residing at the facility. On the day following the pregnancy confirmation, the resident left the facility against medical advice (AMA) after experiencing an emotional crisis. The facility staff, including the Psychiatric Rehab Social Director and the Director of Nursing, acknowledged that the resident was not given an AMA form or an involuntary discharge (IVD) notice before leaving the facility. The facility's administrator confirmed that the resident was permanently discharged without being notified or given an IVD notice, despite the facility's awareness of the resident's mental health condition and pregnancy. The facility's policy requires that residents be informed and provided with documentation when leaving AMA or being involuntarily discharged. However, in this case, the facility did not adhere to its own policies or federal guidelines, which mandate that notice of involuntary transfer or discharge and the opportunity for a hearing must be provided at least 30 days prior to discharge, or as soon as practicable. The facility completed a petition for the resident's involuntary transfer to an emergency inpatient facility due to acute mental illness symptoms, but failed to provide the necessary documentation and notification to the resident, her representative, or the ombudsman, as required by law.
Failure to Supervise Resident with Elopement Risk
Penalty
Summary
The facility failed to adequately supervise a pregnant resident with schizophrenia, who had a known history of elopement, leading to her unauthorized departure from the facility. The resident, who had been residing at the facility for mental health care, was confirmed to be pregnant and was not administered her antipsychotic medications as instructed. On the morning of the incident, the resident was observed to be calm in the dining room before a code green was called, indicating a resident elopement. Despite the presence of the Administrator, Director of Nursing, and other staff, the resident was allowed to leave the facility without signing an Against Medical Advice (AMA) form or contacting emergency personnel. The resident's history included multiple instances of elopement attempts and behaviors indicating a risk for self-harm, including suicidal and homicidal ideations without a plan. Previous incidents had resulted in the facility contacting emergency services and petitioning for the resident's hospitalization. However, on this occasion, the facility did not follow the same protocol, and it was the resident's family who contacted the police after finding her approximately half a mile from the facility. The facility's response to the resident's elopement was inconsistent with their previous actions, and no clear explanation was provided for this deviation. The resident's care plan included interventions for her history of unauthorized departures and paranoid delusional statements. Despite these measures, the facility did not effectively prevent the resident's elopement or ensure her safety. The facility's elopement policy defined elopement as the unplanned, unauthorized leaving of the facility by a resident unable to understand the risks, which was applicable in this case. The lack of supervision and failure to adhere to established protocols contributed to the deficiency in providing a safe environment for the resident.
Failure to Relinquish Financial Control to Resident
Penalty
Summary
The facility failed to honor a resident's right to manage her own financial affairs, as required by federal and state laws. The resident, who was assessed as cognitively intact, had initially authorized the facility to act as her representative payee for her Social Security payments upon admission. However, she later requested to manage her own finances and sought a letter from the facility to provide to the Social Security office, which was necessary for her to receive her payments directly. Despite the resident's request and the psychiatrist's agreement to sign such a letter, the facility's social services representative delayed writing the letter, citing the need for a discharge plan before proceeding. The resident expressed her desire to manage her finances to facilitate her discharge and search for an apartment. The facility's administrator and medical records staff confirmed the resident's cognitive ability to make such decisions. However, the social services representative had not yet provided the necessary documentation to the resident, resulting in a failure to comply with the resident's rights. The facility's own documents affirm the resident's right to manage personal funds, yet the delay in providing the letter impeded the resident's ability to exercise this right.
Infection Control Deficiencies in COVID-19 Precautions and Water Management
Penalty
Summary
The facility failed to adhere to appropriate infection control practices for three COVID-19 positive residents, identified as R15, R54, and R60. Observations revealed that outside R15's room, there was a sign indicating the need for droplet precautions, including eye protection, but no eye protection was available. Additionally, a housekeeping staff member, V9, entered R15's room without wearing eye protection. Similarly, outside R60's room, there was a sign for droplet precautions, but no PPE supplies were available, leading V9 to retrieve PPE from another room. V9 entered R60's room without eye protection and improperly disposed of PPE in an open box in the hallway. After visiting R54's room, V9 failed to remove her N95 mask before leaving the room and did not perform hand hygiene afterward. The facility also lacked a system to monitor measures to prevent the growth of Legionella and other waterborne pathogens in the building's water systems. The Assistant Director of Nursing/Infection Preventionist (ADON/IP), V10, acknowledged the absence of closed containers for disposing of contaminated PPE and the lack of water testing. The facility's water management plan was not effectively implemented, as it did not include testing the water for pathogens. Additionally, soiled linen was improperly stored in open bins, which could contribute to the transmission of infections. The facility's infection control hand hygiene policy required hand hygiene before and after entering isolation settings, which was not consistently followed by staff.
Failure to Educate on COVID-19 Vaccination
Penalty
Summary
The facility failed to provide education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine, which has the potential to affect all residents. Observations and interviews revealed that staff members, including an Activities Aide and a Psych Rehab Social Assistant, were offered the COVID-19 vaccine but did not receive any education about it. The Assistant Director of Nursing/Infection Control Nurse admitted to not offering any education or having documentation to show that information about COVID-19 vaccinations was provided to staff. The Director of Nursing acknowledged the need for staff education on the current COVID-19 vaccination, as some staff might not be aware, and education could potentially change their minds. However, there was no documentation to show that such education had been provided.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for three residents due to issues with room temperature and maintenance. On July 9, 2024, it was observed that the shared room of two residents was very warm, with temperatures recorded at 82°F, exceeding the facility's standard range of 70-81°F. The residents reported that the air conditioning was not functioning properly, causing discomfort, especially in the afternoons. The Housekeeping Director confirmed the temperature issues and noted the absence of a maintenance director since spring, which contributed to the unresolved problem. Additionally, another resident reported similar temperature issues in her room, which had persisted for about a month. Further observations revealed maintenance deficiencies in one resident's bathroom, where a blanket was used to collect water leaking from behind the wall. The bathroom had missing tiles, exposed plaster, and a leaking faucet, which forced the resident to shower in another room, causing inconvenience and distress. The facility's maintenance records showed an open work order for these issues dating back to May 15, 2024, which had not been addressed. The Sister Facility's Maintenance Director, who was not informed of the need for repairs, confirmed the severity of the bathroom's condition and the necessity for repairs. The facility administrator acknowledged the potential safety hazards and the impact on residents' mental health due to these unresolved issues.
Failure to Invite Residents to Care Plan Meetings and Maintain Active Care Plans
Penalty
Summary
The facility failed to invite residents to their quarterly care plan meetings and maintain active care plans for specific medical diagnoses. This deficiency was observed in six residents who were reviewed for care plans. One resident expressed that he had not attended any care plan meetings this year and was not invited to the meetings scheduled earlier in the year. The facility's policy requires that residents be notified and invited to these meetings, but there was no documentation to show that this resident was invited or refused to attend. The resident, who is cognitively intact, has multiple diagnoses including schizoaffective disorder and hypertensive heart disease, and his care plans were updated without his participation. Additionally, other residents who were alert and oriented reported not attending or being invited to care plan meetings. The facility lacked documentation of invitations or attendance for these residents. Furthermore, a resident with a diagnosis of alcohol dependence did not have a care plan addressing this condition, despite the facility's acknowledgment that such a care plan should have been established upon admission. This resident also has a history of residential instability due to alcohol and depression, highlighting the importance of addressing this diagnosis in their care plan.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly label and manage medications for four residents, leading to potential safety risks. During an inspection, it was observed that a Basaglar insulin Kwik Pen for one resident did not have an 'opened on' or 'use by' date, despite the label indicating it expires 28 days after opening. The RN responsible was unaware of the expiration date, acknowledging that using expired insulin could have adverse effects, including the risk of the resident going into shock. Additionally, a green pill identified as haloperidol was left in a medicine cup for a resident who had already left for an outside program, with the RN admitting it should have been discarded to prevent potential administration errors. Further issues were identified with medication storage and handling. A medication card for another resident containing tramadol had pills taped and others open, which the RN acknowledged should have been wasted with two nurses present due to it being a controlled substance. Similarly, a lorazepam medication card for another resident had an open blister, which the LPN stated should be wasted as it could be contaminated. The facility's administrator confirmed that compromised blister packs should be discarded to prevent contamination and potential risks to residents, including allergic reactions or negative interactions with other medications. The facility's policies on medication control and storage were not adhered to, as medications were not routinely checked for expiration dates, and compromised medications were not properly destroyed.
Failure to Document Resident's DNR Status in EMR
Penalty
Summary
The facility failed to enter a physician's order reflecting a resident's chosen code status of Do Not Resuscitate (DNR). This deficiency was identified for one resident, who was part of a sample size of 21 residents reviewed for advanced directives. The resident, who has multiple diagnoses including schizophrenia, asthma, bipolar disorder, major depressive disorder, osteoarthritis, fibromyalgia, and osteoporosis, did not have a physician's order for code status in their Electronic Medical Record (EMR). Although a paper copy of the resident's POLST (Physicians Order for Life Sustaining Treatment) was available in the facility binder, it was not reflected in the EMR. Interviews with facility staff revealed that the administrator acknowledged the absence of a physician's order for the resident's code status in the EMR, and stated that the nurse is responsible for obtaining and entering this information. The psychosocial team is tasked with scanning the POLST into the EMR, and the Director of Nursing (DON) is responsible for updating the resident's profile. Without a physician's order, the resident is considered a full code. Both a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) indicated they would look for the code status in the EMR or the resident's profile during an emergency. The facility's policy on Advanced Directives states that all residents are presumed to have consented to CPR unless there is documentation specifying a DNR order, which should be supported by a physician's order obtained by nursing personnel.
Failure to Schedule Timely Urology Appointment for Resident
Penalty
Summary
The facility failed to make a timely appointment for a resident experiencing urinary urgency symptoms, despite having a physician's order for a urology referral. The resident, who was cognitively intact and had a history of an enlarged prostate, had been waiting for three months to see a specialist. The initial referral was sent on April 1, 2024, but the first urology office did not accept new patients. A subsequent appointment was scheduled for June 20, 2024, but was canceled because the office did not accept the resident's insurance. Although the insurance had approved a second urologist, the appointment was not made, and the resident's symptoms worsened. The Director of Nursing (DON) indicated that once insurance approval is obtained, appointments should be scheduled promptly. However, the Medical Records/Scheduler admitted that the urology appointment fell through the cracks due to the resident having several other appointments. The facility's policy requires confirmation and arrangement of all outside appointments, but this was not adhered to in this case. The resident expressed frustration over the delay, as his urinary symptoms were worsening, and he had already been tested and ruled out for bladder and urinary tract infections.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as R51, in a sample of 21 residents. On July 9, 2024, a staff member informed R51 that she could not go out to smoke without shoes, prompting R51 to remove her sock and reveal her right foot. Her toenails were observed to be very long and jagged, with a black spot on her right toe. Later that day, R51 showed the surveyor her long, claw-like toenails on both feet, and the bottoms of her feet were filthy and black. R51 mentioned wearing socks due to a bunion and sore on her foot and stated that the foot doctor was too busy to see her. On July 11, 2024, a CNA, identified as V17, stated that she is not allowed to cut residents' toenails as they are seen by a foot doctor. However, the scheduler, identified as V4, could not provide documentation of when the podiatrist last saw R51. The facility did not provide a policy on Activities of Daily Living or foot care.
Failure to Provide Timely Physician Visits
Penalty
Summary
The facility failed to provide timely physician visits for a resident, identified as R6, who was part of a sample of 21 residents. R6, who was admitted to the facility with multiple diagnoses including major depressive disorder, diabetes, and chronic kidney disease, reported not having seen her primary care physician, V20, in over four months. Instead, she was only seen by a nurse practitioner and medical students. This lack of direct physician visits was confirmed by the facility's administrator, who acknowledged that the physician should be rounding in person monthly but had not done so for R6. The facility's policy requires residents to be seen by a physician or extender at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. The policy allows for alternating visits between the physician and a nurse practitioner after the initial visit. However, there was no documentation of V20, who is also the facility's Medical Director, having conducted any personal visits for R6. The administrator admitted to the absence of such documentation in R6's electronic medical record, indicating a failure to adhere to the facility's policy and federal regulations regarding physician visits.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for two residents with specific needs. One resident, identified as R83, who has a history of alcohol dependence, reported that the facility did not offer Alcoholics Anonymous (AA) meetings or any substance abuse support groups, despite being informed that such services would be available. The resident expressed difficulty in managing alcoholism without support and noted that the facility had purchased AA books but had not initiated any group sessions. Interviews with staff confirmed the absence of AA meetings and a lack of documentation for any substance abuse groups being held. The Director of Nursing acknowledged that if AA meetings were needed, the facility should either provide them on-site or arrange for residents to attend external meetings. Another resident, R52, who has multiple mental health diagnoses, including schizoaffective disorder and PTSD, was scheduled for weekly video therapy sessions with a contracted therapist. However, these sessions were frequently canceled, with the last documented session occurring nearly a month prior. The Psych Rehabilitation Services Coordinator and the Administrator confirmed the cancellations and the lack of alternative one-on-one sessions by the assigned PRSC, as required when the therapist was unavailable. The importance of these sessions for R52 was emphasized, given her preference for individual therapy over group sessions.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post the daily staffing information, affecting all 85 residents. On July 9, 2024, at 9:38 AM, the daily staffing sheet was not posted at the reception desk for the current date, with the last posting dated July 8, 2024. The administrator, identified as V1, acknowledged on July 11, 2024, that the daily census sheet for July 9, 2024, was not completed by the expected time of 9:30 AM. The receptionist, identified as V12, who was responsible for posting the daily staffing sheet, admitted to not having it posted on time and was unsure why it was not done. The facility's policy, effective since April 2020, requires the posting of staffing numbers within two hours of each shift's start, indicating a lapse in adherence to this guideline.
Failure to Administer Scheduled Medications as Ordered
Penalty
Summary
The facility failed to administer scheduled medications as ordered for one resident, leading to a deficiency in medication administration services and quality of care. The resident, who had multiple diagnoses including schizoaffective disorder, multiple sclerosis, and chronic pain, did not receive her scheduled 9 PM medications on the specified date. Despite the resident's inability to get out of bed due to nerve pain, the LPN on duty did not bring the medications to her and incorrectly documented the medications as refused in the Medication Administration Record (MAR). The Assistant Director of Nursing confirmed that the LPN should have returned to the resident to assess the situation and administer the medications as ordered. The resident's Electronic Medical Record (EMR) and Minimum Data Set (MDS) indicated that she was cognitively intact and had a complex medical history. On the night in question, the LPN made multiple attempts to have the resident come to the nurses' station for her medications but did not take appropriate action when the resident reported being in pain and unable to get up. The facility's Medication Administration policy requires that medications be administered within a specific time frame and that nurses return to the resident if they are not available initially. The LPN's failure to follow these guidelines resulted in the resident missing her scheduled medications for anxiety, depression, multiple sclerosis, and pain management.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure maintenance and housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment for all 90 residents. During an environmental tour, it was observed that a resident's room had dirty and scraped walls with a red-stained mark, a broken nightstand, and a broken floor area. Another resident's overhead light fixture was broken, and the bulb was dirty. The main dining room had broken walkway tiles and an uneven floor. Interviews with the residents revealed that these issues had been reported but not addressed in a timely manner. The housekeeping manager was unaware of some of the issues, and the maintenance manager indicated that the facility lacked sufficient maintenance staff to address the concerns promptly. The administrator acknowledged the ongoing issues and the tripping hazard posed by the broken tiles. The facility's work order log showed ongoing painting and plumbing issues, and the facility policy emphasized maintaining the building in good repair and free from hazards. Despite these policies, the facility failed to address the maintenance concerns effectively. The housekeeping manager stated that she rounds the facility daily and reports concerns, but some issues remained unresolved. The maintenance manager confirmed that he was covering for the lack of maintenance staff and was unable to complete all work orders. The administrator mentioned efforts to hire maintenance staff but acknowledged the existing hazards and delays in addressing them.
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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