Whitehall Of Deerfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Deerfield, Illinois.
- Location
- 300 Waukegan Road, Deerfield, Illinois 60015
- CMS Provider Number
- 145706
- Inspections on file
- 23
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Whitehall Of Deerfield during CMS and state inspections, most recent first.
Staff failed to follow infection prevention and control practices for residents on contact/droplet isolation for COVID-19. A CNA and a PTA were observed placing N95 respirators over surgical masks instead of using a properly fitted N95 alone, and the PTA moved between COVID-19 isolation rooms without removing masks or performing hand hygiene. Facility leadership and policies specified that residents with COVID-19 require gown, gloves, eye protection, and a fit-tested N95, with all PPE changed and hand hygiene performed between residents, and posted signs instructed staff to clean hands before entering and when leaving rooms and to remove the N95 after exiting, but these requirements were not followed in the observed care.
Dietary staff did not follow facility recipes or portion sizes, resulting in residents receiving less than the required amount of three bean salad and mandarin oranges. Additionally, pureed soup was not prepared according to the recipe, with residents receiving strained broth instead of a pureed mixture, leading to complaints from a resident.
Surveyors observed dietary staff failing to follow safe food handling procedures, including using the same gloves for dirty and clean dishes, not washing hands properly, and leaving serving utensils uncovered or improperly stored. The Food Service Director confirmed these actions were not consistent with facility policy, potentially affecting all residents receiving food from the kitchen.
Surveyors found that insulin pens and Tuberculin PPD vials were not labeled with open or expiration dates and were not always stored securely. Insulin pens were left unsecured on top of a medication cart, and open, undated Tuberculin vials were found in the medication room refrigerator. Staff confirmed these medications were in use for residents, and facility policy requires proper labeling and secure storage, which was not followed.
Several residents with indwelling medical devices or wounds did not have required enhanced barrier precautions (EBP) signage or PPE carts outside their rooms, despite documentation indicating the need for EBP. Staff were observed not changing gloves or performing hand hygiene between dirty and clean care tasks. Documentation inconsistencies and lack of adherence to infection control protocols were noted for multiple residents.
A resident requiring assistance with personal care and feeding was observed being fed by an Activity Coordinator who stood over him rather than sitting at eye level, contrary to facility policy and expectations for maintaining resident dignity.
Two residents did not receive care as ordered: one with significant weight loss and multiple medical conditions was not weighed weekly as prescribed, and another with a history of blood clots did not have compression stockings applied according to physician orders. Staff were unaware of or did not follow the orders, and the DON confirmed that all physician orders are expected to be followed.
Three residents at high risk for pressure injuries did not consistently receive required pressure-relieving interventions, such as heel offloading devices or protective boots, as outlined in their care plans and physician orders. Staff observations and interviews confirmed that these interventions were not always in place, and documentation of refusals was lacking.
A resident with a history of hemiplegia and a contracted hand was repeatedly observed without the required rolled washcloth in place to prevent further injury, despite facility policy and staff acknowledgment that this intervention was necessary.
A resident was found with prescribed mycophenolate tablets left at their bedside to take later, despite not having orders to self-administer medications. Facility policy and the DON confirmed that medications should not be left with residents unless self-administration is authorized.
A resident who had previously received a PCV13 vaccine did not receive the required follow-up PPSV23 dose, and there was no documentation of refusal in the medical record. The facility's policy, consistent with CDC guidelines, required this second dose, but it was missed and confirmed by the ADON.
A resident with severe cognitive impairment and dependency on staff was found with a bruised and swollen left big toe, later diagnosed as a fracture. The injury was first noticed by a weekend caregiver but was not reported to facility staff until the next day by another caregiver. The facility's policy requires immediate reporting of such injuries, which was not adhered to by the caregiver.
A resident, who was nonverbal and severely cognitively impaired, sustained a fracture to the left great toe due to improper mechanical lift transfer. The CNA admitted to transferring the resident alone, contrary to the facility's policy requiring two staff members. The resident's physician noted a history of osteomyelitis, suggesting increased fracture susceptibility, but attributed the injury to blunt force trauma.
A facility failed to inform a resident's representative, who is also the Power of Attorney, about a care plan meeting. The resident, diagnosed with developmental and autistic disorders, had no documentation indicating that their representative was informed of the care plan meeting. The facility's staff stated that notifications are given verbally, but no policy was provided to support this practice.
The facility was cited for deficiencies in food handling, including improper glove use and inadequate sanitization of food thermometers. A dietary aide used the same gloves for handling both dirty and clean dishes, while a cook failed to properly sanitize a thermometer between food items, contrary to facility policies.
The facility failed to enforce smoking safety protocols for two residents, leading to non-compliance with smoking contracts. One resident was observed smoking without a protective apron, and another smoked unsupervised without a designated schedule. Despite the facility's policy requiring protective measures, staff did not enforce these rules, compromising resident safety.
A resident with an indwelling urinary catheter was observed with the catheter tubing dragging on the floor, compromising infection control practices. The DON confirmed the tubing should not be on the floor due to infection risks. The resident had multiple medical conditions, and the care plan lacked specific catheter-related interventions. The facility's catheter policy did not address preventing tubing from dragging on the floor.
A resident with moderate cognitive impairment and multiple health conditions was found with an unconsumed Telmisartan pill, indicating a failure in medication administration. The RN confirmed the pill was left from a previous shift, contrary to the facility's policy requiring supervision during medication pass.
A resident with dysphagia was served thin soup instead of the prescribed nectar thick consistency, due to staff's lack of awareness and failure to update the care plan. The resident's medical history includes neurocognitive disorder and Parkinson's disease, necessitating a specific diet to prevent aspiration.
A resident with a left hip prosthetic experienced a dislocation due to the facility's failure to consistently apply hip precautions. Despite orders for a knee immobilizer and abduction pillow, the resident's leg was found shortened and internally rotated, indicating a dislocation. The abduction pillow was missing, and the resident was sent to the hospital for further evaluation.
Improper Hand Hygiene and PPE Use for COVID-19 Isolation Residents
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to hand hygiene and proper use of PPE for residents with COVID-19. The facility census was 151 residents, and at least three residents were documented as COVID-19 positive and on contact/droplet isolation with N95 precautions. Isolation tracking records showed that these residents had tested positive for COVID-19 on specific dates and were placed on isolation the same day. Their room doors were posted with signs requiring N95 plus eye protection and contact precautions. Despite these requirements, a CNA was observed going to COVID-19 isolation rooms wearing a surgical mask, then placing an N95 mask over the surgical mask along with other PPE before entering, contrary to the facility’s stated requirement that a fit-tested N95 be worn appropriately without a surgical mask underneath. A PTA was observed exiting a COVID-19 positive resident’s room wearing a surgical mask over an N95 mask, not removing either mask or performing hand hygiene upon leaving the room, and then proceeding directly to another COVID-19 positive resident’s room wearing the same masks. The PTA stated he performs in-room therapy with COVID-19 positive residents and relies on door signs to identify isolation status, and also stated he believed he could go to multiple COVID-19 rooms wearing the same N95 mask. The Infection Prevention Nurse and Director of Rehab both stated that residents with COVID-19 are on contact/droplet isolation requiring gown, gloves, eye protection, and an N95 mask, and that all PPE, including the N95, must be changed and hand hygiene performed between residents. The Regional Nurse reported that staff are educated on donning and doffing PPE using the isolation poster. Facility policies and posted signage required hand hygiene before entering and after leaving rooms and removal of the N95 after exiting, which was not followed in the observed instances.
Failure to Follow Dietary Recipes and Portion Sizes
Penalty
Summary
The facility failed to ensure that dietary staff followed facility recipes and portion sizes as required. On the observed date, dietary staff were seen using a 4oz slotted spoodle to serve three bean salad and mandarin oranges, but the actual portions provided were less than 4oz, with the mandarin oranges being approximately 2oz and the three bean salad approximately 3oz. The posted kitchen menu did not indicate portion sizes, and staff would need to consult the recipe binder for correct measurements. The facility's diet spreadsheet specified that a #8 scoop, which provides 4oz, should be used for both items, but this was not followed. Additionally, the process for preparing pureed beef barley soup did not follow the facility's recipe. Instead of pureeing the entire soup (including solids and liquid) to a smooth consistency, kitchen staff strained the solids and served only the liquid portion to residents requiring pureed diets. This resulted in at least one resident receiving a thin, broth-like liquid instead of pureed soup, leading to dissatisfaction and complaints. The recipe for pureed beef barley soup was found to have been altered with white-out to indicate straining for broth, but the unaltered recipe required blending the entire soup to a smooth consistency.
Deficient Food Handling and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure safe food handling procedures were practiced in the kitchen, as observed during multiple instances involving dietary staff. One dietary aide was seen wearing the same gloves while handling both dirty and clean dishes, including moving between the dirty and sanitized sides of the dish machine and rinsing gloved hands without soap. The Food Service Director confirmed that staff should remove gloves and wash hands after handling soiled items and before handling clean items, in accordance with facility policy. Additionally, there were no soap dispensers available at the sink where the aide rinsed their gloved hands. Further observations revealed that kitchen staff did not properly cover or clean serving utensils between uses. A cook's helper repeatedly placed uncovered scoops back onto the warmer or into clean pans after use, and a cook stored portion cups inside soup base containers, returning them after use. The Food Service Director acknowledged that these practices were not in line with facility food handling policies, which require food to be stored, prepared, handled, and served to minimize the risk of foodborne illness. These deficiencies had the potential to affect all residents receiving food from the kitchen.
Failure to Label and Secure Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and secure storage of medications, specifically insulin pens and Tuberculin PPD solution vials, for several residents. During inspection of medication carts, two open insulin pens were found without open or expiration dates, and one insulin pen was found to be expired. These pens belonged to two residents and were not immediately removed from the cart as required. Additionally, a nurse was seen leaving insulin pens unsecured on top of a medication cart while attending to other tasks. Medication Administration Records confirmed that the insulin pens were actively being used for residents with orders for insulin administration. Further inspection of the medication room refrigerator revealed two open Tuberculin PPD vials that were not labeled with open dates. Staff acknowledged that these vials should be dated and that they are used for new admissions requiring TB skin tests. Records showed that three recently admitted residents received doses from these vials. Facility policies require all opened medication vials to be labeled with the date opened and expiration date, and all medications to be stored securely, but these procedures were not followed as observed during the survey.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control practices, specifically regarding enhanced barrier precautions (EBP) and hand hygiene, for several residents with indwelling medical devices or wounds. Multiple residents who required EBP due to the presence of devices such as indwelling catheters, gastrostomy tubes, or interventional radiology drains did not have appropriate EBP signage or personal protective equipment (PPE) carts outside their rooms as required by facility policy. In several cases, the residents' care plans or risk evaluation forms indicated the need for EBP, but there were no corresponding physician orders or visible precautions in place at the time of observation. Direct observations revealed that staff did not consistently follow proper glove use and hand hygiene protocols during resident care. For example, a CNA was observed providing incontinence care to a resident without changing gloves or performing hand hygiene between handling soiled and clean items, which is contrary to infection control standards. The Director of Nursing confirmed that hand hygiene and glove changes should occur after contact with dirty items and before touching clean items, but this was not observed in practice. Documentation reviews further showed inconsistencies between residents' medical records, care plans, and the actual implementation of EBP. Some residents with documented indwelling devices did not have EBP orders or visible precautions, while others had discrepancies between risk evaluation forms and progress notes regarding the presence of such devices. These lapses in infection control practices and documentation were observed for multiple residents, indicating a systemic failure to ensure adherence to established infection prevention protocols.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, pneumonitis, difficulty walking, need for assistance with personal care, dysphagia, depression, and anxiety disorder was observed during a lunch meal sitting in a high back recliner. The Activity Coordinator was standing in front of the resident while spooning thickened liquids and pureed food into his mouth, rather than sitting at eye level. The facility's policy requires staff to respect residents' privacy and dignity at all times, and the Administrator confirmed that staff are expected to sit while feeding residents to facilitate engagement.
Failure to Monitor Weights and Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to monitor weights as ordered for a resident with significant weight loss and multiple complex medical conditions. The resident, an eighty-three-year-old female with diagnoses including Parkinson's disease, acute post hemorrhagic anemia, stage 3 sacral pressure ulcer, dysphagia, mild protein-calorie malnutrition, and pancreatic cancer, was readmitted from the hospital with a physician's order for weekly weights. Despite this order, only two weights were documented in the medical record over a period of more than a month, and the clinical nutrition manager confirmed that regular weight monitoring is necessary to identify and address weight loss. Additionally, the facility failed to apply compression stockings as ordered for a resident with a history of blood clots. The resident, who had a right lower extremity deep vein thrombosis and an inferior vena cava filter, had a physician's order for bilateral knee-high stockings to be applied in the morning and removed at bedtime. Observations on multiple occasions showed the resident was not wearing the stockings, and an LPN was unsure if the resident was supposed to wear them. The director of nursing confirmed that the expectation is to follow all physician orders, including those for compression stockings.
Failure to Implement Pressure-Relieving Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain appropriate pressure-relieving interventions for residents identified as being at high risk for pressure injuries. For one resident with a history of diabetes, peripheral vascular disease, and an unstageable sacral pressure ulcer, staff did not consistently offload the resident's heels as required by the care plan, despite the resident being at high risk for pressure injuries. Observations showed the resident's legs and heels were directly on the mattress without protective devices, and the resident reported that staff had not recently offered to place anything under his legs. The resident's family was not informed of any refusals, and staff interviews confirmed that offloading should be reattempted if initially refused. Another resident, who had an order for heel suspension boots to be worn in bed or in a wheelchair every shift, was observed with only one boot in place and no documentation of refusal. Staff confirmed the boots were necessary to prevent new wounds, especially given the resident's tendency to cross her legs, which impairs circulation. A third resident, at high risk for pressure injuries due to Parkinson's disease and decreased mobility, was observed multiple times with his heels and feet directly on the footrest of a recliner without any protective devices, contrary to the care plan and facility policy. The facility's own wound care guidelines require offloading of heels, but this was not consistently implemented for these residents.
Failure to Implement Contracture Prevention Measures
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, dysphagia, and a sacral pressure injury was observed multiple times with a contracted left hand bent up on his chest, without any device in place to address the contracture. The resident's record and a facility-obtained picture indicated that a rolled washcloth should be used in the contracted hand to prevent further injury. However, during several observations, no such device was present. The DON confirmed that the rolled washcloth was intended to be in place as an intervention for the contracture. The facility's Restorative Nursing Program policy requires appropriate nursing and restorative services, including contracture prevention and management, but these were not consistently implemented for this resident.
Medication Administration Not in Accordance with Professional Standards
Penalty
Summary
A deficiency occurred when a resident was found with a cup containing two pills, identified as mycophenolate, on their bedside table. The resident stated that they were holding the medication to take later on an empty stomach, as they had not yet eaten breakfast. Review of the resident's medical orders confirmed a prescription for mycophenolate but did not include authorization for self-administration of medications. The Director of Nursing confirmed that facility procedure requires nurses to remove medications if a resident chooses not to take them at the time of administration and that no residents were currently authorized to self-administer medications. Facility policy also mandates adherence to all federal and state regulations regarding medication pass procedures.
Missed Pneumococcal Vaccination Dose
Penalty
Summary
The facility failed to administer a pneumococcal vaccine as required to one of five residents reviewed for immunizations. The resident was admitted to the facility and had documentation of receiving a Pneumococcal Conjugate Vaccine 13 (PCV13) on 10/20/18, but there was no record of a subsequent Pneumococcal Polysaccharide Vaccine 23 (PPSV23) or any documented refusal in the resident's electronic medical record. According to the facility's policy, which aligns with CDC recommendations, a PPSV23 should have been administered one year after the PCV13 for individuals over age 65. The Assistant Director of Nursing confirmed that the second dose was missed and not documented.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that a resident's caregiver immediately reported a new injury of unknown origin. The resident, who was nonverbal, severely cognitively impaired, and completely dependent on staff for all care, was found to have a bruise and swelling on her left big toe. The injury was first noticed by a weekend caregiver but was not reported to the facility staff until the following day by another caregiver. An X-ray later revealed an acute intra-articular corner fracture at the lateral margin of the left great toe. The facility's policy requires that all injuries of unknown origin be reported immediately to a nurse. However, the weekend caregiver did not report the injury to the facility staff or her staffing agency on the day it was discovered. The facility's administrator and director of nursing confirmed that caregivers hired by families are expected to follow the same reporting guidelines as facility staff. The failure to report the injury promptly was acknowledged by the caregiver and her agency supervisor.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide care to a resident in a manner that prevented injury, specifically during a mechanical lift transfer. The resident, who was nonverbal, severely cognitively impaired, and completely dependent on staff for all care, sustained an acute intra-articular corner fracture at the lateral margin of the left great toe. The injury was discovered by an agency caregiver who noticed the resident's left great toe was bruised and swollen. The resident's care plan indicated that all mechanical lift transfers should be conducted with two staff members present to ensure safety. However, a Certified Nursing Assistant (CNA) admitted to using the mechanical lift alone to transfer the resident, citing a lack of available assistance. The CNA stated that the resident's feet did not hit anything during the transfer, and no injuries were observed during incontinence care. The Director of Nursing confirmed that the facility's policy required two staff members for mechanical lift transfers. The resident's physician noted a history of osteomyelitis, which could make the foot more susceptible to fractures, but indicated the injury was likely caused by blunt force trauma.
Failure to Inform Resident's Representative of Care Plan Meeting
Penalty
Summary
The facility failed to inform or invite a resident's representative to a care plan meeting, which is a requirement for comprehensive care planning. The resident in question, identified as R1, was admitted to the facility with diagnoses of lack of expected normal physiological development in childhood and autistic disorder. R1's mother, who is also his guardian and Power of Attorney, reported that she was not informed of any care plan meetings or the care planning process. This was confirmed during an interview on December 2, 2024. Further investigation revealed that the Director of Social Services and the Director of Nursing both stated that residents and their representatives are verbally informed of care plan meetings. However, there was no documentation in R1's electronic medical record to indicate that his mother was informed of such meetings. A progress note from November 7, 2024, indicated that the initial plan of care was reviewed with R1 and his mother, but the Baseline Care Plan Conference/Care Plan Summary document dated November 25, 2024, did not have her signature. The facility was unable to provide a policy regarding care plan meetings.
Deficiencies in Food Handling and Sanitization Practices
Penalty
Summary
The facility was found to have deficiencies in food handling practices, specifically related to the use of gloves and the sanitization of food thermometers. During an observation, a dietary aide was seen wearing the same gloves while loading dirty dishes into the dishwasher and then using those same gloves to handle clean items, such as dipping a test strip into the 3-compartment sink. This practice was contrary to the facility's policy, which requires staff to change gloves or wash hands when moving from handling dirty to clean dishes to prevent contamination. Additionally, the facility failed to properly sanitize food thermometers between uses. A cook was observed using a metal-type thermometer to check the temperature of various food items without adequately sanitizing it between uses. The thermometer was only wiped with a brown paper towel or rinsed with water, which does not meet the facility's policy that requires thermometers to be sanitized according to the manufacturer's instructions, such as using an alcohol swab or the three-sink method. These practices were not in line with professional standards for food safety and could lead to cross-contamination.
Failure to Enforce Smoking Safety Protocols
Penalty
Summary
The facility failed to ensure that residents adhered to smoking contracts, compromising safety and supervision protocols. Resident R27 was observed smoking without a protective apron, despite the facility's policy requiring it. The Life Enrichment Director, V4, was present but did not enforce the use of the apron. R27's smoking schedule was noted on her wheelchair, and she confirmed that her cigarettes were kept in her room while the nurse held her lighter. The facility's smoking policy mandates that residents who require supervision must have their smoking materials held by nursing staff and wear a protective apron. However, there was no documentation of non-compliance in R27's progress notes, despite the observed breach of the smoking contract. Resident R24, who has a history of dementia and recent hospitalization for a shoulder fracture, was also found to be non-compliant with the smoking contract. R24 reported smoking alone without a designated schedule and without wearing a smoking apron, contrary to the facility's requirements. The Registered Nurse, V9, confirmed that smoking aprons were not provided to R24, although the facility administrator stated that aprons were available. R24's care plan indicated a need for fall precautions and frequent reorientation, yet the smoking assessment deemed her a safe smoker without the need for staff supervision. This inconsistency highlights a failure to enforce the smoking policy and ensure resident safety.
Deficiency in Catheter Management and Infection Control
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter for a resident, leading to a deficiency in infection control practices. On May 28, 2024, a resident with an indwelling urinary catheter was observed sitting in a high back wheelchair in the dining room area, with the catheter tubing dragging on the floor as the resident propelled the wheelchair back and forth. A registered nurse was also observed pushing the resident to the dining room table while the catheter tubing continued to drag on the floor. This observation was confirmed by the Director of Nursing, who acknowledged that the catheter tubing should not be on the floor due to infection control concerns and the risk of the tubing being pulled out. The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease, atherosclerosis, and dementia with behavioral disturbances, among others. The resident's care plan indicated the use of enhanced barrier precautions due to the presence of the indwelling urinary catheter, but it did not address specific concerns or interventions related to the catheter. Additionally, the facility's indwelling catheter policy did not include procedures to prevent catheter tubing from dragging or laying on the floor, contributing to the deficiency observed.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident, identified as R79, took her prescribed medications as required. R79, who has moderate cognitive impairment and multiple diagnoses including hypertension and dementia, was observed with a medication cup containing a white pill and powdery fragments. She expressed confusion about whether she had taken the correct medication and requested assistance from a nurse. The Registered Nurse, V10, confirmed that the remaining pill was Telmisartan 40 mg, a medication scheduled to be taken twice daily for hypertension. The Director of Nursing, V2, stated that it is expected for nurses to supervise residents during medication administration to ensure all medications are taken. However, V10 indicated that the pill might have been left by the night shift nurse, as she personally ensures residents take their medications one by one. The facility's policy, revised in July 2023, mandates adherence to federal and state regulations during medication pass procedures, which was not followed in this instance, leading to the deficiency.
Failure to Provide Nectar Thick Liquids as Prescribed
Penalty
Summary
The facility failed to ensure that a resident's soup was prepared in a nectar thick consistency as required for their dietary needs. During an observation, a CNA served the resident a garden vegetable soup that appeared to be a thin liquid, contrary to the nectar thick requirement. Upon checking, it was found that the thickener was not properly mixed into the soup, and even after stirring, it did not achieve the necessary consistency. The CNA was unaware of the reason for the resident's nectar thick liquid requirement, and the resident himself was not aware of any swallowing issues. The resident in question has a medical history that includes neurocognitive disorder with Lewy bodies, Parkinson's disease, and dysphagia, among other conditions. The resident's care plan and physician orders indicated a need for a mechanical soft diet with nectar thick liquids to prevent aspiration due to swallowing difficulties. However, the care plan was not updated to reflect the current dietary requirements, and the staff failed to adhere to the facility's policy on managing dysphagia and aspiration risks, which requires proper documentation and communication regarding dietary changes.
Failure to Maintain Hip Precautions for Resident with Hip Prosthetic
Penalty
Summary
The facility failed to ensure that hip precautions and interventions were consistently applied for a resident with a left hip prosthetic, leading to a dislocation. The resident, who had a history of hip dislocation and was diagnosed with conditions including Periprosthetic Fracture around Internal Prosthetic Left Hip Joint, Difficulty in Walking, Chronic Obstructive Pulmonary Disease, Parkinson's Disease, and Dementia, was admitted to the facility. On a particular day, the resident complained of severe pain in the left hip, and an X-ray confirmed a dislocation. The resident was sent to the ER for further evaluation and returned to the facility with orders for a knee immobilizer and strict posterior hip precautions, including the use of an abduction pillow at all times. Despite these orders, the resident experienced another hip dislocation. On the morning of the incident, the physical therapist found the resident's left leg shortened and internally rotated, indicating a dislocation. The therapist noted that the abduction pillow, which was supposed to be in place, was missing. The CNA also reported that the resident was restless and often threw the pillow out of bed. The resident was subsequently sent to the hospital for surgery, but the procedure was put on hold as the family considered other options, including hospice care.
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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