Wheaton Village Nrsg & Rhb Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheaton, Illinois.
- Location
- 1325 Manchester Road, Wheaton, Illinois 60187
- CMS Provider Number
- 145715
- Inspections on file
- 24
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Wheaton Village Nrsg & Rhb Ctr during CMS and state inspections, most recent first.
The facility failed to implement its grievance process for concerns about delayed call light response and missing or misdirected laundry and personal items. A resident and a representative reported call light response delays of 15–20 minutes or longer, sometimes up to an hour with no response, and the DON acknowledged receiving weekly concerns and Ombudsman complaints about call lights without corresponding grievance documentation or follow-up. Multiple residents and staff reported ongoing problems with missing clothing, items returned to the wrong rooms, and laundry staff turnover, while records lacked complete admission inventories or documentation of refusals. Resident council minutes and an Ombudsman grievance reflected repeated laundry concerns, yet there was no evidence that these grievances were consistently documented, investigated, or resolved in accordance with the facility’s grievance and resident rights policies.
Two cognitively intact residents with multiple chronic conditions, including diabetic polyneuropathy, osteoarthritis, hemiplegia, COPD, and respiratory failure, did not receive ordered doses of Gabapentin and Combivent Respimat as scheduled, even though an agency LPN had documented afternoon medications as administered. Video review showed the LPN at the nurses’ station, bathroom, medication room, and medication cart, but not moving the cart to resident rooms or preparing and giving medications in accordance with physician orders and facility policy.
The facility failed to maintain proper food safety and sanitation standards, affecting all residents receiving oral nutrition. Issues included using a dishwasher with a broken detergent line and low chlorine levels, improper food storage and labeling, and inadequate garbage disposal and sanitation practices. These deficiencies were observed during a kitchen tour, with expired and improperly stored food items, uncovered garbage cans, and low sanitizer levels noted.
The facility failed to ensure accessible call lights for five residents, impacting their ability to request assistance. Observations showed call lights were either missing, unreachable, or improperly placed, despite residents' ability to use them and needing assistance for ADLs. This was confirmed by staff and contradicted the facility's policy on call light accessibility.
The facility failed to properly store medications for five residents who were not assessed or had orders to self-medicate or store medications at the bedside. Medications were found unsecured in residents' rooms, and staff interviews confirmed that medications should be locked and residents supervised during administration. The facility's policy required a written order and assessment for self-administration, which was not followed.
The facility failed to provide written notification to two residents and their representatives about the reasons for discharge, and did not inform the Ombudsman. One resident with Alzheimer's and chronic kidney disease was transferred to a hospital for dehydration and a UTI without proper notification. Another resident with end-stage renal failure experienced multiple hospitalizations without receiving written notices. The facility's policy did not address these notification requirements.
The facility failed to provide written notification of its bed hold policy to two residents or their representatives upon hospital transfer, as required by its policy. One resident was transferred due to a sudden change in mental status, while another had multiple hospitalizations. The facility's leadership admitted to not following the practice of providing written notice, despite the policy requirements.
Two residents in the facility did not receive necessary nail care despite being dependent on staff for assistance due to conditions like arthritis. Their nails were excessively long, and staff interviews revealed that nail care was not provided as per facility guidelines, which emphasize regular trimming to prevent infections and maintain hygiene.
The facility failed to ensure proper respiratory care and infection control for three residents. One resident used a nasal cannula that had fallen on a dirty floor, while another had CPAP tubing on the floor, and a third stored her CPAP mask unbagged among clothing. The facility's policy lacked infection control guidelines.
The facility failed to provide the required square footage per resident in 12 rooms, affecting 35 residents. Rooms designed for three residents provide only 74 square feet each, while those for four residents offer 78 square feet. The administrator noted this issue is cited annually.
The facility was found to have resident rooms below ground level, affecting all residents reviewed. The administrator confirmed that the facility's structure has not changed since its inception, and this deficiency is cited annually.
Two residents experienced significant delays in receiving trust fund cash withdrawals due to procedural issues and missing signatures, with one resident waiting weeks for a requested amount. The facility's policy did not specify timely disbursement for larger withdrawals, contributing to the delay.
A CNA reported an allegation of abuse involving another CNA hitting a resident, but the facility failed to report this to the IDPH or police as required by their policy. The DON did not investigate the new allegation, as the initial investigation attributed the injury to the resident's combativeness. The facility's records show no investigation into the new allegation, despite policy requirements for immediate reporting.
Failure to Address Resident Grievances on Call Light Response and Laundry/Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances without reprisal and to establish and implement an effective grievance process, specifically regarding call light response times and laundry/personal belongings. A resident representative reported that one resident’s call light responses often took 15–20 minutes, leading the resident to attempt to toilet independently to avoid accidents; the resident confirmed this account. Another resident reported that staff sometimes took an hour to respond to his call light, with occasions of no response, and stated he used his call light or cell phone to request assistance and wore pullups due to bed sores. The DON acknowledged receiving call light concerns approximately once per week, including complaints from the Ombudsman, and stated such concerns should be documented on grievance forms and followed up on, but could not provide evidence of follow-up or documentation. Review of grievances from December 2025 through March 2026 showed no reports, findings, or resolutions related to poor call light response times. The facility also failed to address and document grievances related to laundry and missing personal items. A resident representative stated that one resident’s family had been doing her laundry due to missing items, including comforters in winter, and both the representative and resident reported that clothing sometimes went missing; the resident’s clothes at bedside were not labeled, and no inventory beyond admission was found in the record. The same representative reported that other residents’ clothes were routinely returned to another resident’s room, that something of that resident’s was missing every week, and that this was a common issue; the resident confirmed missing items from laundry, and the facility had only attempted to inventory her belongings about six months after admission with no subsequent updates. Another resident reported missing clothes, seeing other residents wearing his shirts, and missing about five pairs of shoes; his record contained no admission inventory or documentation that he declined an inventory. A fourth resident reported issues with clothes being returned from laundry and stated he had reported this to nurses. Staff interviews and facility documents further demonstrated unaddressed grievances and inadequate protection of personal property. A CNA reported recent issues with missing items from laundry related to laundry staff turnover, and another CNA stated she had received resident complaints about not receiving their clothes, noting that the former permanent laundry aide had left and new staff were unfamiliar with residents’ clothing, although she stated that residents’ clothes were labeled. Resident council minutes from December 2025 documented concerns about clothes not being returned correctly due to laundry staff not reading labels, and minutes from January and February 2026 documented concerns about clothes going to the wrong rooms and missing from laundry. A grievance form dated 02/21/2026 included Ombudsman-reported concerns about a resident’s missing items. The DON and ADON stated that the facility had an inventory form to be completed on admission and uploaded to the chart, that refusals should be documented, and that families were educated to label belongings or the facility would do so, and the DON acknowledged prior staffing issues in laundry and ongoing clothing return problems over several months. The facility’s Resident Rights Policy required reasonable care to protect personal property from loss, and the Grievance Policy required investigation and written findings to the administrator within five working days of receiving a written grievance, but the surveyors found no documentation showing that reported concerns about call lights or laundry were consistently documented, investigated, or resolved.
Failure to Administer and Accurately Document Scheduled Medications
Penalty
Summary
Surveyors identified a failure to ensure residents were free from significant medication errors when an agency LPN did not administer ordered medications as scheduled, despite documenting them as given. On the survey date around midday, the LPN reported she had already completed afternoon medications, and the manual medication administration record showed medications signed off. However, review of video footage between 10:45 AM and 11:40 AM showed the LPN at the nursing station, bathroom, medication room, and medication cart, but did not show her moving the cart to resident rooms, preparing medications, or entering resident rooms to administer medications, contrary to the facility’s medication administration policy requiring the cart to be moved close to residents before preparing and administering medications. One resident with diagnoses including diabetic polyneuropathy, osteoarthritis, and hemiplegia, and with intact cognition per MDS, reported in the afternoon that she had not received her scheduled dose of Gabapentin 800 mg ordered three times daily at 8:00 AM, 1:00 PM, and 5:00 PM. Another resident with diagnoses of COPD and acute and chronic respiratory failure, also cognitively intact per MDS, had an order for Combivent Respimat 20-100 mcg, one puff every six hours at 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. The evidence from resident report, EMR review, and video review showed that ordered medications for these residents were not administered as prescribed, despite being documented as given.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation standards, impacting all residents receiving oral nutrition from the facility kitchen. During a kitchen tour, it was observed that the low-temperature dishwasher was used despite having a broken detergent line and low chlorine levels, which are essential for proper dish sanitation. The Dietary Manager acknowledged that the dishwasher should not have been used under these conditions, yet the Dietary Aide continued to use it until instructed otherwise. Additionally, the facility did not maintain appropriate storage and labeling practices for food items. The milk cooler was found to be operating at temperatures above the recommended 40 degrees Fahrenheit, with milk cartons inside also measuring above this threshold. Several food items, including thawed frozen egg products, tomatoes, cottage cheese, raisins, and sweetened coconut, were either not dated, expired, or improperly stored, violating the facility's policy on labeling and dating foods. The facility's failure to use the first-in, first-out method for food storage further contributed to the risk of serving expired or spoiled food to residents. The facility also neglected proper garbage disposal and sanitation practices. Uncovered garbage cans with visible food debris were observed near the dishwasher, and small black flies were seen in the hallway outside the kitchen. Clean plates were improperly stored near a handwashing sink, risking contamination. The sanitizer bucket used by the cook showed low quaternary levels, indicating inadequate sanitization. These observations highlight the facility's failure to maintain a clean and safe kitchen environment, as outlined in their policies.
Failure to Provide Accessible Call Lights
Penalty
Summary
The facility failed to provide access to the resident call system for five residents, which is essential for obtaining needed assistance. Observations revealed that one resident's call light was on the floor entangled among personal items, making it unreachable. Another resident was found without a call light on multiple occasions, confirmed by both a CNA and an RN. This resident was cognitively intact and required extensive assistance for activities of daily living (ADLs), yet was unable to communicate needs due to the absence of a call light. Additional observations showed a resident verbally calling for help without a call light, and another resident's call light was found behind a dresser, inaccessible. A fifth resident's call light was under the bed, out of reach, despite being able to communicate needs and use the call light for assistance. The facility's policy requires call lights to be accessible from various positions, yet this was not adhered to, as confirmed by the Director of Nursing.
Improper Medication Storage and Lack of Assessment for Self-Administration
Penalty
Summary
The facility failed to properly store medications for residents who were not assessed or had orders to self-medicate or store medications at the bedside. This deficiency was observed in five residents, each with different medications left unsecured in their rooms. For instance, one resident had a medication cup with a pill on her dresser without an order to keep medications at the bedside, and the facility could not provide an assessment form to show she was evaluated to self-administer medications. Another resident had three bottles of Flonase on her bedside table, and although she was cognitively intact, there was no assessment form to show she was evaluated to self-administer medications. The resident's care plan was updated during the survey to allow her to self-administer Flonase, but prior to this, there was no documentation supporting her ability to do so. Similarly, another resident had an inhaler on his bedside table without a physician's order to self-administer or store medications at the bedside, and his care plan did not indicate he could self-administer medications. Additional observations included a tube of prescription cream and Nystatin powder left on bedside tables without proper orders or assessments for self-administration. Staff interviews revealed that medications should be locked in the medication cart and that residents should be supervised when administering their medications. The facility's policy required a written order and an assessment for residents to self-administer medications and store them at the bedside, which was not followed in these cases.
Failure to Notify Residents and Ombudsman of Discharge
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding the reasons for discharge, as well as failing to notify the Ombudsman. This deficiency was identified in two residents, R73 and R51, who were reviewed for discharge. R73 was admitted to the facility with multiple diagnoses, including Alzheimer's Disease and chronic kidney disease. On a specific date, R73 experienced a sudden change in mental status and was transferred to a hospital for dehydration and a urinary tract infection. The facility administrator admitted that they do not notify residents or their representatives in writing about the reasons for hospital transfers, nor do they inform the Ombudsman. No documentation of such notifications was found in R73's medical records. Similarly, R51, who has diagnoses including end-stage renal failure and chronic anemia, reported multiple hospitalizations without receiving written notices of transfer. The facility's progress notes confirmed these hospitalizations, but there was no evidence of written notifications to R51 or the Ombudsman. The facility's existing policy on discharge did not address the requirement for written notification to residents, their representatives, or the Ombudsman, as confirmed by the facility's administrator and director of nursing.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives upon transfer to a hospital, as required by its own policy. This deficiency was identified in the cases of two residents. The first resident, admitted with multiple diagnoses including Alzheimer's Disease and chronic kidney disease, was transferred to a hospital due to a sudden change in mental status and was diagnosed with dehydration and a urinary tract infection. The Director of Nursing acknowledged that the facility forgot to provide the bed hold notice to the resident's representative at the time of transfer, and no documentation of such notice was found in the resident's medical records. The second resident, who had diagnoses including end-stage renal failure and chronic anemia, reported multiple hospitalizations without recalling receiving a bed hold notice. The clinical records for this resident also lacked documentation of providing the required notice to the resident and the Ombudsman. The facility's Administrator and Director of Nursing admitted that the practice of providing written notice to residents, families, and the Ombudsman was not followed, despite the facility's policy stating that such notification should be given at the time of transfer.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, both of whom were dependent on staff for assistance with activities of daily living. Resident R71 had nails that were a quarter of an inch long and jagged, and despite repeatedly asking staff for help due to his arthritis, his nails had not been cut since his admission. His care plan indicated a need for substantial assistance with personal hygiene due to decreased mobility and endurance. Similarly, Resident R107 had fingernails that were one inch long and expressed a preference for shorter nails, but was unable to cut them herself due to arthritis. She could not recall the last time staff had assisted with her nail care. Interviews with facility staff, including CNAs and the Director of Nursing, revealed that nail care was typically performed on shower days or as needed. However, the CNAs responsible for these residents admitted they had not provided nail care. The facility's policies emphasized the importance of regular nail trimming to prevent infections and maintain hygiene, yet these guidelines were not followed for the residents in question. The lack of nail care was a clear deficiency in meeting the residents' needs for personal hygiene assistance.
Deficiency in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents, as observed during a survey. One resident, who had a diagnosis of Chronic Obstructive Pulmonary Disease and Schizoaffective Disorder, was seen using a nasal cannula that had fallen on the dirty floor, which was not in accordance with professional standards of practice. The resident's oxygen order was for 2-5 liters per minute as needed, but the resident was using it continuously. The RN acknowledged that the nasal cannula should have been bagged when not in use and replaced if it fell on the floor, but this was not done. Another resident with Dementia, Obstructive Sleep Apnea, and Diabetes Mellitus had a CPAP machine with tubing on the floor, and the room was noted to be dirty. A third resident, diagnosed with Asthma, Heart Failure, Depression, and Obstructive Sleep Apnea, stored her CPAP machine and mask unbagged among her clothing, which was also against infection control practices. The Director of Nursing confirmed that respiratory equipment should be bagged when not in use to prevent contamination, but the facility's policy on oxygen administration did not address infection control aspects.
Inadequate Room Size for Residents
Penalty
Summary
The facility failed to provide adequate square footage per resident in 12 of 48 rooms, as required by regulations. Specifically, rooms A22, A24, A26, A28, A30, A31, A33, and A34, which are designed to accommodate three residents each, only provide 74 square feet per resident. Additionally, rooms A18, A19, B7, and B8, intended for four residents each, offer only 78 square feet per resident. This deficiency affects 35 out of 110 residents, as indicated by the facility's daily roster. The administrator acknowledged that the facility has maintained the same room sizes since its inception and receives this deficiency annually during surveys.
Resident Rooms Below Ground Level
Penalty
Summary
The facility failed to ensure that resident rooms were at or above ground level, affecting all 36 residents reviewed for physical environment. Observations and interviews revealed that rooms B1 through B14 were located below the garden or ground level. The facility administrator acknowledged that the structure has remained unchanged since the facility's inception, and this deficiency has been cited annually during surveys.
Delayed Trust Fund Cash Disbursement
Penalty
Summary
The facility failed to provide resident trust fund cash to residents within three business days, affecting two of the three residents reviewed for trust funds. Resident R6 reported waiting weeks for her requested trust fund cash, with delays ongoing for several months. On June 6, 2024, R6 requested $450.00 from her trust fund, but the check was not issued until June 24, 2024, due to missing resident signatures. The check arrived at the facility on June 25, 2024, but was not cashed immediately, causing further delays. Staff interviews confirmed the delay in processing and disbursing the funds. Resident R7 also experienced significant delays in receiving trust fund cash withdrawals, stating that the checks were not arriving and that he had waited a month for a withdrawal when the facility changed banks. The facility's policy and procedures for resident personal trust funds did not specify that withdrawals of $100.00 or greater should be honored within three banking days, contributing to the delay. The facility's admission packet outlined residents' rights to manage their money and access their financial records, which were not upheld in these instances.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse according to its policy. A Certified Nursing Assistant (CNA) reported to the Administrator that another CNA allegedly hit a resident in the face, causing the resident to fall back and hit the bed. The reporting CNA attempted to contact the Illinois Department of Public Health (IDPH) using a number from a poster at the facility entrance but later realized it was a corporate number. The Administrator was unaware of any abuse allegations, and the Director of Nursing (DON) stated that the incident had been investigated and attributed the resident's facial injury to the resident becoming combative during care. Despite the new allegation of abuse, the DON did not report it to IDPH or the police, as the initial investigation concluded that the injury was due to the resident's combativeness. The facility's abuse prevention policy requires immediate reporting of any abuse allegations to the administrator and IDPH within two hours. However, the facility's records from April to July show no investigation into the new allegation. The policy also mandates contacting local law enforcement in cases of physical injury inflicted by staff, which was not done in this instance.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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