West Suburban Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomingdale, Illinois.
- Location
- 311 Edgewater Drive, Bloomingdale, Illinois 60108
- CMS Provider Number
- 145333
- Inspections on file
- 49
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at West Suburban Nursing & Rehab Center during CMS and state inspections, most recent first.
Two residents who were cognitively intact but dependent on staff for toileting and incontinence care did not receive timely assistance consistent with their care plans and facility policy. One resident with hemiplegia and multiple chronic conditions reported that staff typically changed her brief only twice daily and that she was told if she requested a change after early afternoon, she would be placed in bed and left there until the next shift, a practice confirmed by a CNA during observation. Another resident with neurologic and psychiatric diagnoses, bowel and bladder incontinence, and care-planned two-hour checks and regular toileting reported activating the call light for bathroom assistance but waiting about three hours without help, resulting in a wet bed.
Three residents were enrolled in a new Medicare Advantage plan without being fully informed in a language or terminology they understood, leading to emotional distress, confusion about medication coverage, and changes in healthcare providers. One resident with moderate cognitive impairment was unable to access cancer medication, another with limited English proficiency was not provided information in his primary language and his Power of Attorney was not contacted, and a third resident felt pressured to enroll and became emotionally upset. The facility lacked a policy for obtaining consent for such changes.
A resident experienced severe dental pain and required a tooth extraction after the facility failed to provide timely dental services, despite repeated requests and documented assessments indicating dental issues. The resident's dental concerns were not addressed for several months, and no dental visits were documented during this period, contrary to facility policy.
The facility failed to verify and document that individuals signing Medicare Advantage enrollment forms on behalf of residents with cognitive impairment had the legal authority to do so. Multiple residents with moderate to severe cognitive impairment were enrolled in a new Medicare Advantage I-SNP plan by family members or significant others without proper POA or surrogate documentation in the medical record, and the facility lacked a policy to ensure compliance with CMS requirements.
The facility allowed an outside insurance vendor to change the Medicare Advantage plans of three cognitively impaired residents without proper consent or notification of their legal representatives. The Social Service Director provided a list of residents to the insurance agent, but did not ensure that only those capable of informed consent were approached. Enrollment forms were signed with typed signatures, and there was no documentation that family members or POAs were notified or involved, despite facility policy requiring protection against exploitation.
A resident with multiple complex medical conditions did not have a neurology consult scheduled as ordered by a physician for a second opinion, due to the facility's failure to track and arrange the appointment. The staff member responsible for scheduling was unable to provide evidence of an appointment, and the resident remained without the required specialist evaluation.
A resident with multiple health conditions and moderate cognitive impairment repeatedly requested help to see an audiologist due to hearing difficulties. Despite a formal grievance and internal communications among staff, there was no documentation that the facility assisted the resident in making an appointment or ensured access to audiology services.
A resident who is cognitively intact requested transfer to a facility closer to family and provided a list of preferred locations. Despite repeated requests and involvement from the Ombudsman, the facility's Social Services staff made minimal documented efforts, with only one referral sent and no evidence of follow-up or communication with the suggested facilities. The resident's chart lacked documentation of referrals or follow-up, and emails from the Ombudsman requesting updates went unanswered.
Two residents with dementia were left unsupervised in the dining area when the only staff present left to answer a phone call. During this time, one resident attempted to move into a spot at the table, resulting in physical contact and a fall that caused bruising and required hospital evaluation.
The facility failed to protect residents from abuse, as evidenced by two incidents involving physical altercations. In the first incident, a resident with intact cognition confronted another resident with dementia, resulting in a physical altercation and injuries. In the second incident, a resident with severe cognitive impairment physically confronted another resident over a misunderstanding, leading to minor injuries. Both incidents highlight the facility's failure to prevent abuse and ensure resident safety.
The facility failed to provide timely assistance with transfers to bed and showers for residents requiring staff assistance, affecting three residents. One resident, dependent on staff for bathing, reported not receiving scheduled showers due to insufficient staffing, with records showing only nine showers offered over ten weeks. Another resident experienced a four-hour delay in being transferred to bed due to staff shortages, highlighting the facility's failure to meet scheduled care needs.
The facility failed to provide adequate staffing, resulting in missed showers and delayed transfers for residents requiring assistance. A resident with multiple sclerosis and another with paraplegia did not receive scheduled showers due to insufficient CNAs. Another resident experienced a four-hour delay in being transferred to bed, causing dizziness. Staffing records showed frequent understaffing, with only four CNAs for 86 residents, impacting care delivery.
The facility failed to prevent cross-contamination in food service by not ensuring proper handling of pans, trays, and utensils. A dietary aide used the same gloves for cleaning and handling clean items, while another aide did not wash hands between handling dirty and clean dishes. These actions violated the facility's policies on handwashing and dishwashing, potentially affecting 183 residents receiving food from the kitchen.
The facility failed to dispose of expired medications and did not maintain the correct refrigeration temperature for medications, affecting nine residents. Expired medications were found on a medication cart, and the medication refrigerator was at 50°F, above the recommended range for certain medications. This indicates lapses in medication management and storage practices.
The facility failed to provide pureed broccoli and ham at the required smooth consistency for residents on a pureed diet. Observations revealed that the food contained small chunks, requiring chewing, which is inappropriate for such diets. The cook did not test the consistency before service, affecting four residents. Facility guidelines specify that pureed food should be the consistency of pudding or mashed potatoes.
A resident with Alzheimer's and dementia was injured after being pushed out of bed by her confused and aggressive roommate, resulting in a large hematoma. The facility failed to ensure the safety of the resident, who required extensive assistance and was non-ambulatory, despite the roommate's known history of agitation and aggression.
A resident with rheumatoid arthritis experienced a lapse in treatment due to the facility's failure to clarify medication orders after a missed appointment. The resident, who missed her September appointment due to transportation issues, did not have her steroid medication orders updated, resulting in continued pain and inadequate treatment. The oversight was partly due to a float nurse being unaware of the missed appointment and the lack of follow-up by the nursing staff.
A resident did not receive prescribed eyeglasses despite being alert and oriented to express her needs. She reported seeing an eye doctor and receiving a prescription, but the facility did not follow up to ensure she received the glasses. The Social Services representative acknowledged the prescription but noted the glasses might not have arrived, and no option to order them was provided to the resident.
A resident with multiple health conditions, including a right leg amputation and stage 3 sacral pressure ulcer, was found without a protective dressing on the ulcer. Despite physician orders for daily dressing changes, the wound nurse was not informed of the missing dressing, leading to non-compliance with the facility's guidelines for pressure injury prevention and treatment.
The facility failed to implement adequate smoking precautions for a resident who was observed smoking without the necessary safety measures, such as a smoking apron, despite her care plan requirements. Additionally, another resident at risk for falls was left without a functioning call light, preventing him from alerting staff for assistance. These deficiencies highlight lapses in safety protocols and supervision.
Two residents in the facility had improperly positioned urinary catheter collection bags and tubing, leading to potential infection risks. One resident's catheter bag was hung at bladder level, causing urine stagnation, while another resident's tubing was dragging on the floor. Both residents have medical conditions that increase their risk for urinary tract infections.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting and incontinence care to residents who were dependent on staff for these activities of daily living. One resident with hemiplegia, anoxic brain damage, neuralgia, depression, anxiety, low back pain, weakness, cognitive communication deficit, and muscle wasting required a mechanical lift with two staff for transfers and was care planned to be toileted at regular intervals, including before and after meals, activities, naps, and at bedtime. The MDS documented that this resident was cognitively intact, dependent on staff for toileting, and frequently incontinent of bladder and bowel. The resident reported that staff typically changed her brief only when getting her up around late morning and again when putting her to bed in the evening, and that staff told her if she requested a change after early afternoon, she would be transferred to bed and have her brief changed but would have to remain in bed until the next shift began. During observation, when the resident requested a brief change early in the afternoon, a CNA confirmed she would transfer the resident to bed and change her but stated the resident would need to remain in bed until the next shift because the CNA had not yet had a break and needed to complete rounds before the end of her shift. This practice conflicted with the expectations stated by the DON and Administrator, as well as with the facility’s written incontinence care guidelines requiring assistance after incontinent episodes and at least every two hours based on care planning. Another resident, with diagnoses including cerebral infarction, cirrhosis, depression, anxiety, seizures, encephalopathy, schizoaffective disorder, dementia, hemiplegia, abnormal gait/mobility, weakness, and a history of falls, was care planned as incontinent of bowel and bladder, to be checked every two hours, toileted at regular intervals, and assisted with toileting as needed. The care plan also noted that this resident’s ADL needs, including transfers and toileting, could fluctuate with acute changes or exacerbations of chronic conditions. The MDS showed the resident had intact cognition, required substantial/maximal assistance for toileting, and supervision/touching assistance for transfers. The resident reported that on one evening she activated her call light because she needed to use the bathroom but was not assisted for approximately three hours, during which time she wet the bed. These findings demonstrate that staff did not provide toileting assistance and incontinence care in accordance with the residents’ assessed needs, care plans, and facility policy.
Failure to Ensure Residents Understood Health Insurance Changes
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood changes to their health insurance coverage, specifically regarding enrollment in a new Medicare Advantage plan by a third-party vendor. Several residents reported not understanding the implications of signing up for the new plan, with some indicating they were pressured or inadequately informed by facility staff and the insurance agent. One resident, who has moderate cognitive impairment and multiple complex medical diagnoses including cancer, dementia, and anxiety, stated he did not understand the new insurance would affect his medication coverage and experienced significant distress when he was unable to access his cancer medication. The Director of Nursing confirmed there was a period during which the resident's medication access was uncertain due to the insurance change. Another resident, whose primary language is Polish and who is cognitively intact but has a significant medical history including heart disease and depression, reported not understanding the insurance documents he signed and felt misled about the services he would receive. His son, who holds Power of Attorney, was not contacted about the insurance change, and the facility lacked documentation of the Power of Attorney or any communication with the son regarding the change. The enrollment form for this resident was completed with a typed signature and indicated assistance from an insurance agent, but there was no evidence the information was provided in a language the resident could understand. A third resident, also cognitively intact and with a history of Parkinson's disease and depression, described being approached by the Social Service Director to hear a presentation about the new insurance. Despite initially declining, the resident felt pressured to enroll and later became emotionally distressed upon learning the change meant a new doctor and nurse practitioner. The facility administrator acknowledged there was no policy regarding obtaining consents for such changes, and the only documentation provided to residents was a brochure outlining general rights, including the right to information in a language they understand.
Failure to Provide Timely Dental Services Resulting in Resident Pain and Tooth Extraction
Penalty
Summary
The facility failed to follow its policy to ensure a resident received timely routine and emergency dental services. Despite multiple requests from the resident, staff, and the Ombudsman beginning in May, there was no documented follow-up or dental evaluation until late August. The resident had lost a dental filling in May and repeatedly reported severe pain to various staff members, including the Social Service Director and the Ombudsman, who submitted a grievance on the resident's behalf. Nursing documentation indicated that a request for a dental referral was made in June, and a nursing assessment in July noted broken or carious teeth, but there was no evidence that these concerns were addressed or that the resident was seen by a dentist during this period. The resident's medical record showed a history of multiple chronic conditions, including COPD, dementia, anxiety, hypertension, anemia, and other significant diagnoses. The Minimum Data Set assessment indicated moderate cognitive impairment and a need for assistance with activities of daily living. Despite these vulnerabilities, the facility did not document any dental visits for the resident from April of the previous year until late August, even though a dental exam in April had already recommended urgent extractions of two teeth. There was also no documentation that the resident refused the recommended extractions at that time. When the dentist finally saw the resident in late August, the resident was found to have significant pain, swelling, and infection due to the lost filling. The dentist was unable to perform an extraction immediately because of the infection and prescribed antibiotics, returning a few days later to extract the affected tooth. The dentist confirmed that if the resident had received prompt dental care when the initial concerns were raised, the pain and infection could have been prevented. The facility's own policy required prompt assessment and coordination of dental care, but there was no evidence that these procedures were followed.
Failure to Verify Legal Authority for Medicare Advantage Enrollment
Penalty
Summary
The facility failed to ensure that there was proper documentation verifying that residents' representatives had the legal authority to make decisions regarding enrollment in a Medicare Advantage plan. This deficiency was identified for eight residents who were enrolled in a new Medicare Advantage Institutional Special Needs Plan (I-SNP) through an outside insurance vendor. The process involved the Social Service Director (SSD) introducing the insurance agent to residents and contacting representatives for those deemed non-decisional based on their Brief Interview for Mental Status (BIMS) scores. However, the SSD was not present during the enrollment discussions or when consent forms were signed, and the facility did not verify or maintain documentation confirming the legal authority of those signing on behalf of cognitively impaired residents. For several residents with moderate to severe cognitive impairment, as indicated by low BIMS scores, enrollment forms were signed by family members or significant others whose legal authority to act as Power of Attorney (POA) or health care surrogate was not established in the residents' medical records. In some cases, POA paperwork was either missing, incomplete, or executed after the enrollment forms were signed. For example, one resident's enrollment form was signed by a significant other, but the POA paperwork did not include the resident's name, and another resident's daughter signed the enrollment form before POA documentation was completed. Other cases involved siblings or children signing without any supporting legal documentation in the records. The facility did not have a policy regarding the obtaining of consents for such enrollments, and staff relied on the insurance vendor's process without ensuring compliance with CMS requirements. CMS guidance specifies that an authorized representative must have legal authority under state law and that documentation of this authority must be available upon request. The lack of verification and documentation of legal authority for those enrolling residents with cognitive impairment in the Medicare Advantage plan constituted the deficiency identified during the survey.
Failure to Protect Residents from Exploitation During Medicare Advantage Plan Changes
Penalty
Summary
The facility failed to protect residents from exploitation by allowing an outside insurance vendor to make unauthorized changes to the Medicare Advantage plans of cognitively impaired residents. The process involved the facility's Social Service Director (SSD) introducing the insurance agent to residents and providing a list of residents deemed 'conversational' or cognitively intact, based on BIMS scores. However, the SSD was not present during the insurance presentations or when enrollment forms were signed, and could not explain why residents with BIMS scores below 12 were included. The insurance agent relied solely on the facility's assessment of residents' decisional capacity and did not verify cognitive status or legal authority to consent. Three residents were specifically identified as having their Medicare Advantage plans changed without proper consent. One resident, with severe cognitive impairment and no documented POA or family notification, was unable to recall or understand the insurance change and had a history of mental illness and behavioral symptoms. Another resident, also with moderate cognitive impairment and no POA or family notification, did not understand the insurance discussion or why they signed the paperwork. The third resident, with severe cognitive impairment and a documented POA, was not able to understand or recall the insurance change, and the POA was not contacted or present for the consent process. In all cases, the enrollment forms were signed with a typed signature, and there was no evidence that the residents or their legal representatives were properly informed or consented to the changes. The facility's own policies require the prevention of exploitation and the identification of residents at increased risk for abuse or neglect, including those with cognitive impairment. Despite this, the facility did not ensure that only residents capable of informed consent were approached by the insurance agent, nor did they notify or involve family members or legal representatives as required. The process lacked oversight, documentation, and verification, resulting in unauthorized changes to vulnerable residents' insurance coverage.
Failure to Schedule Neurology Consult per Physician Order
Penalty
Summary
The facility failed to follow physician orders to obtain a neurology consult for a resident who required a second opinion for spine consultation at a tertiary care center. Despite a physician's order dated June 18, 2025, there was no evidence that an appointment had been scheduled for the resident. The resident, who was admitted with multiple diagnoses including mononeuropathy of the left lower limb, PVD, hypertension, heart disease, and other significant conditions, reported ongoing leg weakness and expressed frustration about the delay, stating that staff indicated it could be several more months before an appointment could be arranged. The resident was cognitively intact and dependent on staff for most activities of daily living. During the investigation, the staff member responsible for scheduling appointments was unable to locate any documentation or confirmation of a scheduled neurology appointment for the resident, either in the facility's appointment calendar or among her personal and office papers. The facility's policy requires that upon receiving a physician's order for an outside appointment, the nurse must notify the staff member coordinating transport and ensure the appointment is scheduled and tracked. However, there was no system in place to reliably track or confirm appointments, resulting in the resident's continued wait for necessary medical evaluation.
Failure to Assist Resident in Accessing Audiology Services
Penalty
Summary
A resident with multiple medical diagnoses, including COPD, dementia, generalized anxiety disorder, and hearing difficulties, repeatedly requested assistance from facility staff to see an audiologist. Despite these requests, and a formal grievance submitted by the ombudsman in May, there was no documentation that the facility assisted the resident in making an appointment with an audiologist or that the resident had seen one as of early September. The resident's electronic medical record and Minimum Data Set indicated moderate cognitive impairment and a need for supervision with most activities of daily living. Facility records show that the ombudsman submitted the resident's grievance to the administrator, and a registered nurse communicated the need for an audiology referral to the social services director in June. The nurse also contacted the insurance case manager to obtain a list of providers, including an audiologist. However, there was no evidence that staff followed up on the provider list or facilitated an appointment. The lack of follow-through resulted in the resident not receiving the requested audiology services over several months.
Failure to Assist Resident with Discharge Planning and Transfer Requests
Penalty
Summary
The facility failed to adequately assist a resident in discharge planning, specifically in facilitating a transfer to another facility closer to the resident's family. The resident, who is cognitively intact, expressed a clear desire to move and provided a list of preferred facilities. Despite repeated requests and involvement from the Ombudsman, there was minimal documented action by the facility's Social Services staff. Only one referral was documented as sent, with no evidence of follow-up or confirmation of receipt, and no further documented efforts or communication with the suggested facilities. The resident's chart lacked documentation of referrals or follow-up actions from December 2024 to the present. Interviews with facility staff and the Ombudsman confirmed that the resident's requests were not actively pursued, and the administrator of a local facility reported never receiving a referral. Email correspondence showed ongoing requests from the Ombudsman for updates and additional facility options, but these were not responded to by the facility. The facility's own discharge planning policy emphasizes preparation and coordination, but these steps were not followed in this case, resulting in a lack of progress toward meeting the resident's expressed needs and preferences for transfer.
Inadequate Supervision in Dining Area Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision in the dining area, resulting in a resident-to-resident incident that led to a fall. Two residents with dementia and cognitive deficits, both residing in the memory care unit, were involved. During a noon meal, one resident attempted to move into a spot at the table occupied by another resident. In the process, there was physical contact, and the first resident lost her balance and fell to the floor. There were no staff witnesses to the incident, and another resident present could not recall staff being in the area at the time. On the day of the incident, only one staff member was monitoring the dining room, as other staff were either on break or passing meal trays. The sole staff member left the area to answer a phone call, leaving the dining room unsupervised. This absence of supervision allowed the incident to occur without immediate intervention. Following the fall, the resident was found to have bruising on her buttock and was sent to the emergency room for evaluation, as per facility protocol for unwitnessed falls.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving residents R6, R7, R4, and R5. In the first incident, R6 entered R7's room and initiated a physical altercation. R7, who has a history of dementia and other mental health issues, was accused by R6 of rummaging through other residents' belongings. R6, whose cognition was intact, confronted R7 and used a jiu-jitsu move to throw R7 to the ground, resulting in R7 sustaining a head injury and other minor injuries. The police were involved, and video surveillance contradicted R6's claims, showing that R7 had not left his room prior to the altercation. In the second incident, R4, who has a history of misinterpreting situations and responding with aggression, physically confronted R5 in the dining room over a box of pizza. R4, whose cognition was severely impaired, believed R5 was taking someone else's pizza and attempted to pull R5 away by his sweatshirt, resulting in a scratch on R5's cheek. Witnesses, including a psychologist and an LPN, observed the altercation and intervened to separate the residents. The police were notified, and R4 was sent to the hospital following the incident. Both incidents highlight the facility's failure to prevent resident-to-resident abuse and ensure a safe environment. The facility's abuse prevention policy was not effectively implemented, as evidenced by the lack of staff intervention before the altercations escalated. The facility's inability to protect residents from physical harm and intimidation resulted in injuries and distress among the involved residents.
Failure to Provide Timely Assistance with Transfers and Showers
Penalty
Summary
The facility failed to provide timely assistance with transfers to bed and showers for residents who require staff assistance, affecting three residents in the sample. Resident R2, diagnosed with multiple sclerosis and other conditions, was dependent on staff for bathing. Despite being scheduled for two showers a week, R2 reported not receiving showers due to insufficient staffing, with records showing only nine showers offered over ten weeks. Similarly, R3, also dependent on staff for bathing, reported not receiving scheduled showers due to a lack of CNAs, with records indicating only nine showers offered in the same period. Resident R8, who required substantial assistance for transfers and bathing, experienced a significant delay in being transferred to bed, waiting four hours due to staff shortages. R8 reported feeling dizzy from sitting too long and had to call a nurse to be transferred. The Resident Council Meeting minutes also highlighted concerns about call lights not being answered promptly, especially during the second shift. R8's shower records showed only seven showers offered over ten weeks, further indicating the facility's failure to meet scheduled care needs.
Inadequate Staffing Leads to Missed Showers and Delayed Transfers
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of residents requiring assistance with transfers and bathing. Three residents, identified as R2, R3, and R8, were affected by this deficiency. R2, diagnosed with multiple sclerosis and other conditions, expressed dissatisfaction with not receiving scheduled showers due to insufficient staff. Records indicated R2 was only offered nine showers over a ten-week period, despite the facility's policy of offering two showers per week. Similarly, R3, who also required staff assistance for bathing, reported not receiving scheduled showers due to a lack of CNAs. Records showed R3 was offered only nine showers in the same period. R8, who required substantial assistance for transfers, experienced a significant delay in being transferred to bed, waiting four hours due to staff shortages. This delay caused R8 to experience dizziness from sitting too long. The facility's staffing records revealed that the first floor was often understaffed, with only four CNAs available for approximately 86 residents, leading to inadequate care. The Director of Nursing acknowledged the staffing issues, citing restrictions on using agency staff and increased call-offs due to illnesses as contributing factors.
Improper Handling of Food Service Items Leads to Cross-Contamination Risk
Penalty
Summary
The facility failed to ensure proper handling of food service pans, trays, and utensils, leading to potential cross-contamination affecting all 183 residents receiving food from the kitchen. Observations revealed that a dietary aide, V4, wore the same gloves while performing multiple tasks, including cleaning food debris from a three-compartment sink and handling clean, sanitized pans. V4 did not change gloves between these tasks, which included stacking wet pans on top of clean, dry ones, contrary to the facility's policy that prohibits stacking until items are completely dry. Another dietary aide, V6, was observed handling both dirty and clean dishes without washing hands in between tasks. V6 moved between the dirty and clean sides of the dish machine without adhering to handwashing protocols, as outlined by the facility's handwashing policy. The facility's dietitian, V8, confirmed the standard practice of washing hands before serving food, after touching garbage, and between handling dirty and clean dishes. The facility's policies on handwashing and machine dishwashing, both dated 4/2017, emphasize the importance of preventing cross-contamination through proper handwashing and ensuring that pots and pans are dried before stacking.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to properly dispose of expired medications and did not maintain the correct refrigeration temperature for medications, affecting nine residents. During an inspection, a Licensed Practical Nurse found expired medications, including a glucagon injection and various eye drops, on a medication cart. The nurse confirmed that eye drops are marked with the date they are opened and are considered usable for 30 days thereafter. However, several medications were found to be past their expiration dates, indicating a lapse in the facility's medication management practices. Additionally, the medication refrigerator on the second floor was found to be at 50 degrees Fahrenheit, which is above the recommended storage temperature for certain medications. This refrigerator contained insulin, eye drops, and a multidose vial of Tuberculin, all of which require refrigeration at temperatures between 36 and 46 degrees Fahrenheit. The facility's policy and the pharmacy guidelines specify these temperature requirements, but the facility failed to adhere to them, compromising the proper storage of medications.
Inadequate Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that pureed broccoli and pureed ham were prepared to a smooth consistency, as required for residents on a pureed diet. This deficiency was observed during a survey where the cook, identified as V7, was seen preparing pureed broccoli that contained small chunks, which were not tested for consistency before being placed in a steam table pan for service. Similarly, the pureed ham also contained small chunks, requiring chewing, which is inappropriate for a pureed diet. This issue affected four residents who were on a pureed diet. The facility's guidelines for pureed food preparation, dated 10/25/23, specify that pureed food should be the consistency of pudding or mashed potatoes, which was not adhered to in this instance.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident, identified as R146, from abuse, resulting in a traumatic incident. R146, who was admitted with Alzheimer's disease, dementia, and other conditions, was found with a large bump on her forehead and bruising on her face. The incident occurred when R146's roommate, R72, who has a history of aggressive behavior and confusion, pushed R146 out of bed, believing it was her own. This resulted in R146 falling to the floor and sustaining a significant hematoma. The facility's records indicate that R146 required extensive assistance for bed mobility and was non-ambulatory, highlighting her vulnerability. R72, who was admitted with alcohol-induced dementia and other psychiatric conditions, had a documented history of agitation and aggression. Despite this, R72 was placed in a shared room with R146. The facility's Memory Care policy emphasizes providing a safe environment, yet the incident suggests a failure in ensuring the safety and proper placement of residents with known behavioral issues. The report details the observations and statements from staff members who witnessed the aftermath of the incident, confirming the aggressive behavior of R72 and the resulting injury to R146.
Failure to Clarify Medication Orders After Missed Appointment
Penalty
Summary
The facility failed to clarify medication orders for a resident with rheumatoid arthritis after a missed medical appointment. The resident, who suffers from rheumatoid arthritis, COPD, anxiety, major depressive disorder, and low back pain, was observed experiencing pain in her hands, shoulder, and arms. She reported not receiving treatment for her rheumatoid arthritis, despite being on a regimen of injections and steroids. The resident missed a scheduled appointment in September due to transportation issues, and her follow-up appointment was set for November. However, her steroid medication orders were not clarified after the missed appointment, leading to a gap in her treatment. The resident's nurse on the day of the new orders, a float nurse, was unaware of the missed appointment and did not follow up on the steroid medication orders. The Director of Nursing confirmed that the resident's appointment was missed and rescheduled, but the necessary follow-up to clarify the prednisone order was not conducted. The resident's physician orders for October did not include prednisone until the end of the month, indicating a lapse in the continuity of care for her rheumatoid arthritis treatment.
Failure to Provide Prescribed Eyeglasses
Penalty
Summary
The facility failed to ensure that a resident received a pair of corrective eyeglasses as prescribed. The resident, identified as R118, reported on multiple occasions that she had seen an eye doctor and was prescribed glasses, but had not received them. On 10/28/24, R118 stated she needed glasses but had not gotten them. On 10/29/24, the Social Services representative, V20, confirmed that R118 had a prescription from an eye exam conducted on 6/17/24 but had not received the glasses, suggesting they might not have arrived yet. On 10/30/24, R118 reiterated her need for glasses and expressed that she was not given the option to order them, nor was there any follow-up from the facility. The resident's care plan indicated she was alert, oriented, and able to express her needs, yet the facility did not ensure she received her prescribed eyeglasses.
Failure to Maintain Protective Dressing for Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to ensure a protective dressing was in place for a resident with a stage 3 sacral pressure ulcer. The resident, a male with multiple diagnoses including orthopedic aftercare following surgical amputation, type 2 diabetes, peripheral vascular disease, end-stage renal disease, and hypertensive heart disease, was observed without a dressing on his sacral pressure ulcer. This observation was made when a Certified Nursing Assistant (CNA) was providing assistance, revealing an open area on the resident's sacrum without the required dressing. The resident's physician had documented a stage 3 sacral pressure ulcer with specific treatment orders to cleanse with normal saline, apply triad cream, oil emulsion, and foam dressing daily. However, the wound nurse was not informed that the dressing was missing, and thus it was not re-applied as per the facility's guidelines. The facility's guidelines emphasize the importance of evidence-based recommendations for the prevention and treatment of pressure injuries, which were not adhered to in this instance.
Failure to Implement Smoking and Fall Prevention Precautions
Penalty
Summary
The facility failed to implement adequate smoking precautions for a resident, identified as R30, who was observed smoking without the necessary safety measures in place. R30, who uses an electric wheelchair and has limited use of her left arm, was seen smoking with cigarette ashes on her lap and clothing, and without the required smoking apron on multiple occasions. Despite the facility's policy and care plan indicating that R30 requires a smoking apron due to her inability to independently handle smoking products and dispose of ashes safely, staff did not consistently ensure she wore the apron. The activity aid acknowledged the oversight, noting that there is a list of residents who need aprons for safety, but it was not always followed. Additionally, the facility failed to ensure proper fall prevention interventions for another resident, R152, who is at risk for falls due to general weakness and is dependent on staff for assistance. R152's call light was not functioning, preventing him from alerting staff when needed. Despite pressing the call light multiple times, it did not alarm, and the issue was not recorded in the maintenance book for repair. This oversight left R152 without a reliable means to request assistance, as confirmed by the Director of Nursing, who found no record of the malfunction in the maintenance log.
Improper Positioning of Urinary Catheter Collection Bags
Penalty
Summary
The facility failed to ensure proper positioning of urinary catheter collection bags and tubing for two residents, leading to potential infection risks. One resident, who was observed in an electric wheelchair, had a urinary catheter collection bag hung at the same level as the bladder, causing urine to remain stagnant in the tubing. This resident has a history of a perpetual urinary tract infection and a care plan that requires monitoring the position of the drainage bag to ensure it is below the waist for proper drainage. Another resident was seen propelling himself in a wheelchair with urinary catheter tubing dragging on the floor, which was observed multiple times. The tubing contained bloody urine and was not properly positioned, posing a risk for bacterial contamination. This resident has a diagnosis of neuromuscular dysfunction of the bladder and is at risk for urinary tract infections due to catheter use. The facility's guidelines emphasize the importance of keeping the drainage bag below the bladder level to prevent catheter-associated urinary tract infections.
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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