Winston Manor Cnv & Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2155 West Pierce, Chicago, Illinois 60622
- CMS Provider Number
- 14E169
- Inspections on file
- 25
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Winston Manor Cnv & Nursing during CMS and state inspections, most recent first.
Two cognitively intact residents with psychiatric and medical conditions reported that another resident repeatedly entered or roamed their units, followed them, entered a room at night, and directed sexually explicit, demeaning, and threatening language toward them, including threats of physical harm and sexually violent acts. Multiple agency RNs confirmed that this resident frequently came onto a different floor, harassed female residents, made sexually inappropriate remarks, yelled, used derogatory names, and made threats despite redirection attempts. Nursing notes documented the resident’s agitation, aggressive behavior, and harassment of a female resident, while leadership and facility policy acknowledged residents’ rights to be free from verbal and sexual abuse and harassment by anyone in the facility.
A resident with multiple comorbidities and intact cognition slipped and fell in a hallway bathroom after entering a dark room with a very wet floor and no wet floor signage, resulting in a left ankle trimalleolar fracture. The DON reported being told by the agency RN that the bathroom floor was wet, and stated she expected staff to remove the water and post a wet floor sign. A NP confirmed that liquid on the floor is a fall risk, and the unwitnessed fall report documented the RN finding the resident on the bathroom floor after hearing calls for help. Facility housekeeping duties included cleaning and wet mopping floors with proper safety precautions, but the bathroom floor remained wet at the time of the incident.
The facility failed to maintain resident bathrooms and shower rooms in a safe, clean, and homelike condition. A resident reported that bathrooms and shower rooms were dirty, sometimes lacked shower curtains, and had peeling drywall. Surveyors observed black and brown buildup on shower walls on multiple floors, peeling paint and drywall, a hole in a shower room ceiling, a third-floor restroom with a hole in the wall and a roll of paper towels placed on a garbage can instead of in a dispenser, a missing toilet seat in a second-floor shower room stall, and a torn, stained shower curtain and dirty light fixture in a fourth-floor shower room. Staff interviews confirmed that housekeeping was supposed to scrub showers daily, that these conditions were uncomfortable and unsanitary, and that maintenance and housekeeping were responsible under facility policies for keeping the building in good repair and providing thorough housekeeping services to support a homelike environment.
A resident with multiple psychiatric diagnoses was physically and verbally attacked by her roommate, who also has a history of psychiatric disorders. The aggressor hit the resident, threw items, and attempted to use her cane as a weapon, causing physical pain and emotional distress. Staff responses were inconsistent, with some not recognizing or reporting the abuse, and facility leadership did not fully investigate or document the incident until days later, contrary to facility policy requiring immediate reporting and investigation.
A resident was physically attacked by her roommate, involving hitting and objects being thrown, and staff intervened to separate them. Despite witnessing the incident, staff did not report the abuse within the required two-hour timeframe, and facility leadership was not fully aware of the severity until days later, resulting in delayed notification to authorities.
Two residents were found living in rooms with significant maintenance issues, including water leaks, holes in walls and ceilings, musty odors, and exposed rusty metal. Despite being reported to maintenance staff, these problems remained unaddressed for over a month, resulting in unsafe and non-homelike living conditions.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
Three residents left the facility without authorization, including one who eloped during a smoke break and two who did not return after leaving, despite one having no pass privileges. Staff communicated internally and contacted police, but failed to report these incidents to the State Agency or complete required incident reports, in violation of facility policy.
A resident with schizoaffective disorder, depression, and mild intellectual disabilities exhibited repeated maladaptive and aggressive behaviors, including anger and physical outbursts. Despite these ongoing issues, staff did not develop a person-centered behavior care plan until prompted by a surveyor, rather than at the time the behaviors were first observed, contrary to facility policy.
The facility did not document COVID-19 vaccination status, consent, or education for several residents with complex medical conditions, despite policy requirements. Leadership and staff interviews revealed inconsistent processes for tracking and auditing immunization records, with missing documentation and unclear procedures following leadership changes and a transition to electronic records.
A resident with multiple mental health diagnoses was physically assaulted by another resident, resulting in a bleeding lip, head injury, and emotional trauma. The incident occurred in the dining area, where staff were present but did not intervene. The assaulted resident's roommate stopped the attack, and the resident reported the incident to the DON. Nursing staff provided immediate care, and the physician was notified. The facility's abuse prevention policy was not upheld in this case.
A resident with a history of schizophrenia, depression, and nicotine dependence eloped from an unenclosed smoking area during a monitored break. The staff member present did not immediately notify management or initiate the required emergency response, instead informing the receptionist after the fact. The resident was later returned by police and was physically and verbally aggressive upon return, indicating a failure to follow facility elopement procedures and placing the resident's safety at risk.
Two residents with histories of mental health disorders and aggressive behavior engaged in two separate physical altercations in the facility's lobby, resulting in injuries including a bloody nose and back pain. Despite staff intervention after the first fight, both individuals were kept in proximity, leading to a second altercation. Staff interviews revealed a lack of specific training and procedures for handling abuse situations, and facility policies requiring prevention of abuse were not effectively implemented.
The facility did not follow its abuse prevention policy by failing to review a resident's criminal background check within the required timeframe and not ensuring that an agency LPN and the Maintenance Director were educated on abuse prevention procedures. This lack of compliance contributed to two physical altercations between residents with mental health diagnoses, as staff were unprepared to prevent or manage the incidents.
A resident with schizophrenia and ADHD, who was cognitively intact and required supervision, was not protected from staff-to-resident abuse when a Social Services Director allegedly pulled a chair from under the resident, causing a fall. Witnesses reported the incident as abuse, but it was not promptly reported to the DON or Administrator, resulting in a failure to follow abuse prevention and reporting policies.
The facility failed to follow its infection control policy by not providing gowns for laundry staff handling soiled linen, and by not storing clean linen in a protected area. A staff member only wore gloves, and a large fan blew air across both dirty and clean areas, which were not physically separated, risking cross-contamination.
A facility failed to provide a safe environment by not installing covers on fluorescent tube lights in residents' rooms, affecting seven residents. The exposed lights posed a risk of injury, as residents had to touch the bulbs to turn them on, and the tubes were covered in dust. The Maintenance Director acknowledged the safety concerns, confirming that the lights should have protective covers to prevent hazards.
A resident with intact cognition and multiple medical conditions, including diabetes, was found to have excessively long toenails due to the facility's failure to provide regular podiatry care as per policy. Despite the resident's requests and the facility's policy that only a podiatrist should cut toenails, the resident was only seen once by the podiatrist since admission. Staff interviews and record reviews revealed inconsistencies in documenting podiatry service refusals.
A facility failed to communicate a neurologist's recommendation for speech therapy to a resident's primary physician, resulting in the resident not receiving the recommended therapy. The resident, diagnosed with Schizoaffective Disorders and Tardive Dyskinesia, was on Clozapine. The facility's protocol requires such recommendations to be communicated and documented, but this was not done.
A resident was prescribed antibiotics without proper documentation or indication, violating the facility's antibiotic stewardship program. Staff were unclear about the rationale for the prescription, and vital signs were not monitored as required. The resident was unaware of the reason for the antibiotic treatment.
The facility did not meet the required 80 square feet per bed for five rooms. The Administrator confirmed the deficiency, and a surveyor inspection revealed that four rooms were unoccupied, while one was occupied by three residents who had no concerns. The facility had a waiver from the Illinois Department of Public Health for these rooms.
Failure to Protect Residents From Verbal and Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively intact residents from verbal and sexual abuse by another resident, identified as R4. R3, with schizophrenia, generalized anxiety disorder, neuralgia and neuritis, and a BIMS score of 14, reported that R4 followed him in the hallway, asked to use his laptop and headphones, and later entered his room around 2:00 a.m., calling him a “b****” and telling him to perform a sexual act when R3 told him to leave. R3 stated that R4 told him he could come into his room if he wanted to and that, after being sent to the hospital and returning, R4 again came into his room around 2:00 a.m. R4’s nursing progress notes documented agitation, aggressive behavior, and that he went to another floor to harass a female resident. R14, with major depressive disorder, schizoaffective disorder, essential hypertension, hidradenitis suppurativa, and a BIMS score of 15, reported that R4, newly admitted, came onto her unit where he did not belong and made sexual remarks about his penis size and wanting someone to perform oral sex at the nurses’ station. She stated that when staff told R4 he could not take snacks from that unit, he became aggressive, called them “bitches,” made threats to kill them, and repeatedly left and returned to the unit. R14 further reported that during a meal in the dining room, R4 got in her face, motioned toward her with a balled fist, called her a “fat bitch,” threatened to shove a cane into her buttocks, and stated proudly that he was a pedophile when she told him he was acting like one. She also reported that he continued roaming her floor after bedtime and attempted to follow her to see which room she was going to until a nurse intervened. Staff interviews corroborated that R4 repeatedly came to the second floor, where female residents including R3 and R14 were located, and made inappropriate and threatening remarks. An agency RN (V13) stated that R4 was pacing, unable to be redirected, and was reported to be harassing female residents on another floor, becoming loud and aggressive. Another agency RN (V6) reported that R4 came to the second floor several times, made inappropriate remarks to R3 and R14, refused multiple redirection attempts to return to his own unit, and then began yelling, calling them “bitches,” and threatening to punch them in the face before eventually returning to his floor. The DON acknowledged that residents have a right not to be harassed or verbally assaulted and that all residents should feel safe. Facility policy states that residents have the right to be free from abuse, including verbal and sexual abuse, and that administration is responsible for protecting residents from abuse by anyone, including other residents.
Failure to Maintain Dry Bathroom Floor Leads to Resident Fall and Ankle Fracture
Penalty
Summary
The facility failed to ensure that a resident bathroom floor was dry and free of liquid, resulting in a fall with injury. A cognitively intact, morbidly obese resident with epilepsy, vitamin D deficiency, type 2 diabetes mellitus, and hypertension reported that she was walking from her bedroom to a hallway bathroom in the early morning hours when she entered a dark bathroom with no light on and no wet floor sign present. She stated the bathroom floor was very wet with water, and she slipped, fell, and called for help. Staff responded, and CNAs called 911; EMTs transferred her to the hospital, where imaging showed a left ankle trimalleolar fracture with mild posterior displacement of distal fibula fracture fragments, along with deformity, ecchymosis, tenderness, and decreased range of motion. The DON stated she was informed that the resident slipped and fell on water on the bathroom floor and that the agency RN assigned to the resident that night had reported the bathroom floor was wet. The DON also stated she would expect nursing staff to remove the water from the floor and place a wet floor sign to prevent a patient from falling. A nurse practitioner stated that fall prevention should be in place for all residents, that floors should be free of waste, rugs, or carpets, and that liquid on the floor is a fall risk because residents can slip and fall on it. The unwitnessed fall report documented that the RN heard someone calling for help from the bathroom and found the resident on the floor, reporting pain and exhibiting a limp left foot. The facility’s housekeeper job description included cleaning floors, including damp/wet mopping and disinfecting, in accordance with proper safety precautions, but the report documents that the bathroom floor remained wet at the time of the resident’s fall.
Failure to Maintain Clean, Homelike Resident Bathrooms and Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment in resident bathrooms and shower rooms, affecting all 139 residents. A resident reported that bathrooms and shower rooms were terrible, did not seem up to code, were not cleaned, sometimes lacked shower curtains, and had peeling drywall. During a tour of the second, third, and fourth floor shower rooms, the surveyor observed black and brown substances on shower walls on all three floors and a hole in a shower room ceiling with drywall and paint peeling from the ceiling and walls. Further observations showed additional environmental deficiencies. In a third-floor unisex restroom, the surveyor observed a hole in the wall behind the restroom door and a roll of paper towels used for hand drying sitting on top of a garbage can instead of in a paper towel holder. In the second-floor shower room, the first toilet stall was missing a toilet seat, although the toilet itself was functional. In the fourth-floor shower room, the surveyor observed a torn white shower curtain with black spots and a ceiling light fixture with a black stringy substance adhering to the fixture and ceiling. Interviews with staff confirmed awareness of these conditions and their inconsistency with a homelike environment. The Maintenance Director stated that the black substance on the shower walls was likely soap, grime, or rust buildup and acknowledged that residents may not feel comfortable showering in rooms with peeling paint and dark spots. A housekeeper stated that housekeeping staff are supposed to scrub showers daily to prevent the black substance and acknowledged that it looks uncomfortable. The Maintenance Technician and Maintenance Director both recognized that the hole in the restroom wall and the paper towel roll on the garbage can did not represent a homelike or sanitary environment. The Maintenance Director also acknowledged the missing toilet seat and stated that they would not want a toilet at home without a seat. Facility policies and job descriptions reviewed by the surveyor documented that maintenance and housekeeping are responsible for maintaining the building in good repair, free from hazards, and providing routine and thorough housekeeping services to promote resident comfort and a homelike environment.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident verbal and physical abuse involving one resident with a history of post-traumatic stress disorder, anxiety, schizoaffective disorder, and other medical conditions. The incident involved another resident with schizoaffective and major depressive disorders, who became verbally and physically aggressive during the night, pulling back privacy curtains, playing loud music, turning on bright lights, and ultimately physically attacking her roommate. The aggressor hit the roommate multiple times, threw personal items at her, and attempted to take her walking cane to use as a weapon. The victim reported experiencing significant physical pain, mental anguish, and fear following the attack, stating she was sore for a week and afraid to sleep. Staff responses to the incident were inconsistent and inadequate. One CNA witnessed the argument but did not report it, believing it was not abuse. Another CNA and an LPN intervened during the physical altercation, separating the residents and removing the victim from the room. However, there was confusion and inaccuracy in the documentation of witness statements, with one CNA denying authorship of a written statement attributed to her and stating she was never asked for her account of the incident. The facility's Director of Nursing and Administrator were notified of the incident but did not fully investigate or ascertain the extent of the physical abuse until several days later. Neither asked the victim if she had been physically struck or injured during their initial follow-up. The facility's abuse policy requires immediate reporting and thorough investigation of suspected abuse, but these procedures were not followed. The incident was not promptly or accurately reported to the appropriate authorities, and the severity of the abuse was not recognized or documented in a timely manner. The lack of immediate and thorough investigation, as well as the failure to recognize and report the abuse, resulted in the resident experiencing ongoing pain and emotional distress.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Reporting Policy by not reporting an allegation of resident-to-resident physical abuse within the required two-hour timeframe. On the night in question, one resident was physically attacked by her roommate, who hit her multiple times, threw objects at her, and attempted to strike her with a cane. The incident was witnessed by multiple staff members, including a Certified Nurse Assistant and an Agency-Certified Nurse Assistant, who intervened to separate the residents. Despite the severity of the incident, including the involvement of law enforcement and the removal of the aggressor to a hospital for psychiatric evaluation, the event was not reported to the appropriate authorities within the mandated period. Interviews with staff revealed a lack of immediate recognition and reporting of the abuse. The Certified Nurse Assistant present did not report the altercation, perceiving it as minor arguing, while the Agency-Certified Nurse Assistant confirmed witnessing physical violence. The Director of Nursing and Administrator were not fully informed of the extent of the incident until several days later, and the required report to the state agency was delayed. The facility's policy clearly defines immediate reporting as within two hours, but this protocol was not followed, resulting in a delay in notifying authorities about the abuse allegation.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents. In one instance, a resident's room had a hole in the ceiling, chipped paint, a musty odor, and a blue blanket placed on the floor to collect water from a leak that occurred when it rained. The resident reported having informed the Maintenance Director about the issue, but no repairs had been made. The Maintenance Director confirmed being aware of the water leak for approximately one and a half months and had notified the Regional Maintenance Director, but no vendors had come to address the problem. The Maintenance Director also stated that no residents should be living in the room under these conditions and that a room change was necessary. In another case, a different resident's room had a large hole in the wall with exposed rusty metal and chipped paint throughout the ceiling. The resident stated that someone had started repairs but did not return to complete the work. The Maintenance Director explained that the painter responsible for the repairs was let go and no one else had been assigned to finish the job. The Regional Maintenance Director was aware of the ongoing issues and had attempted to patch the roof without success. Both maintenance staff confirmed that the rooms were not safe for occupancy until repairs were completed. The facility's policy requires a safe, clean, and homelike environment, which was not maintained in these instances.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report Unauthorized Departures and Elopement
Penalty
Summary
The facility failed to timely report incidents involving three residents who left the facility without authorization. One newly admitted resident eloped during a smoke break, while two other residents left the facility—one on a pass and did not return, and another left alone despite having an active physician order prohibiting unsupervised passes. The administrator confirmed that the police were contacted regarding the missing residents, but also stated unawareness of the requirement to report missing residents to the State Agency. Documentation revealed that the facility did not complete or submit incident reports for these events as required by their own policy, and the reportable binder contained no records of these incidents. Interviews and record reviews indicated that staff were aware of the residents' absences and communicated internally, but failed to follow through with external reporting obligations. Nursing notes and sign-out sheets documented the residents' departures and lack of return, but there was no evidence of timely notification to the State Agency. Additionally, the medical chart for the resident who eloped lacked an elopement assessment or care plan. The facility's policy requires all accidents or incidents to be investigated and reported to the administrator, with incident reports to be completed and submitted to the DON within 24 hours, which was not done in these cases.
Failure to Timely Develop Person-Centered Behavior Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered behavior care plan to address a resident's mental and psychosocial needs, specifically for a resident with schizoaffective disorder, depression, and mild intellectual disabilities. The resident exhibited a history of dysfunctional behavior, including anger, agitated depression, and restless or agitated actions such as rocking, picking, and banging. Despite these behaviors and a specific incident where the resident kicked a door after becoming upset, the facility did not initiate a behavior care plan until prompted by a surveyor. The care plan addressing inappropriate and maladaptive behaviors was only created on the day it was requested by the surveyor, rather than at the time the behaviors were first observed. Staff interviews confirmed that the resident was known to become angry quickly and had demonstrated both verbally and physically abusive behaviors, such as raising his voice, using profanity, and making demeaning statements. The psychiatric rehabilitation services coordinator acknowledged that the resident's quickness to anger and other behavioral issues were not care planned as required. Facility policy states that any observed behavior should be care planned immediately to ensure appropriate interventions can be implemented, but this was not followed in the resident's case.
Failure to Document COVID-19 Vaccination Status, Consent, and Education
Penalty
Summary
The facility failed to ensure proper documentation of COVID-19 vaccination status, consents, and education for four residents, despite having a policy requiring such documentation. Record reviews revealed that the immunization records for these residents contained no data regarding their COVID-19 vaccination status, consent, or education. Interviews with facility leadership and staff indicated a lack of consistent processes for tracking and auditing vaccination status, with leadership changes and a transition from paper to electronic records contributing to the deficiency. Staff reported that while the vaccine was offered and refusals were sometimes obtained verbally, there was no consistent documentation of consent or declination, and signatures were not always collected as required by policy. The residents involved had multiple complex medical diagnoses, including schizophrenia, bipolar disorder, asthma, hypertension, and depression. The facility's own policies required that all residents be offered the COVID-19 vaccine, that education be provided, and that documentation of acceptance, refusal, or exemption be maintained in the medical record. However, the investigation found that for the residents reviewed, there was no documentation of education, consent, or vaccination status, and staff were unclear on the current process for tracking and auditing this information.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place in the dining area, where a male resident with a history of Schizophrenia, Seizures, Depression, Scoliosis, and PTSD, and a BIMS score of 15/15, was physically assaulted by another male resident diagnosed with Schizoaffective Disorder, Bipolar Type, Diabetes 2, Anxiety, and Epilepsy, also with a BIMS score of 15/15. The altercation resulted in the first resident sustaining a bleeding lip, a bump to the right temporal area, and complaints of pain in his leg and arm. The assaulted resident reported feeling traumatized and fearing for his life during the incident. The report details that the altercation occurred when the first resident walked past the other resident's table, leading to the second resident knocking him to the floor and punching him multiple times in the face. Staff, including kitchen personnel, were present in the area but did not intervene during the incident. The assaulted resident's roommate intervened to stop the attack. The resident reported the incident to the DON, and nursing staff provided immediate care for his injuries, including treating his lip and applying ice to his head. The police were called but did not take action, and the resident was sent to the hospital but left before being evaluated due to a long wait. Documentation and interviews confirm that the facility was aware of the altercation and the injuries sustained. The resident was assessed by nursing staff, and the physician was notified. X-rays were ordered and returned negative for fractures. The incident was reported in facility documentation, and it was noted that the resident had no prior history of physical altercations. The facility's abuse prevention policy states that residents have the right to be free from abuse, neglect, and exploitation, but this right was not upheld in this instance.
Failure to Follow Elopement Policy During Resident Smoking Break
Penalty
Summary
The facility failed to consistently follow its elopement policy and procedure, resulting in a resident leaving the premises unsupervised during a scheduled smoking break. The resident, who was alert and oriented but forgetful, ambulatory with a steady gait, and had diagnoses including schizophrenia, major depressive disorder, and nicotine dependence, was able to elope despite staff being present to monitor the smoking area. The area was not enclosed, and staff were required to have a walkie talkie and immediately notify management if a resident attempted to leave. However, the staff member monitoring the smoking break did not immediately inform management or initiate the required emergency response when the resident eloped, instead relaying the information in passing to the receptionist after the fact. The delay in notification resulted in a lack of immediate response to the resident's elopement. The resident was eventually returned to the facility by police and was noted to be physically and verbally aggressive and non-directable upon return. Facility policy required staff to attempt to prevent residents from leaving, seek help from other staff, and immediately inform the charge nurse or DON if a resident left or attempted to leave. These steps were not followed, placing the resident's health and safety at risk.
Failure to Prevent and Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to prevent and protect residents from physical abuse, as evidenced by two separate physical altercations between two residents with intact cognition and histories of mental health disorders. Both residents had documented histories of aggressive and inappropriate behavior, including prior incidents of agitation and aggression. On the day of the incident, the first altercation occurred in the lobby, where one resident verbally provoked the other, leading to a physical fight in which punches were exchanged, resulting in a bloody nose for one resident. Multiple staff members, including an escort, activity aide, and maintenance director, were present and intervened to separate the residents. Despite the initial altercation, both residents were kept in proximity to each other on the same floor. Approximately an hour later, a second physical fight occurred in the same area, with both residents again exchanging blows, resulting in one being pinned to the ground and complaining of back pain. Staff had difficulty separating the residents during the second incident, and police and paramedics were called to the facility. Both residents were subsequently transferred to the hospital for evaluation and treatment. Interviews with staff revealed that there was a lack of specific training and procedures on how to handle abuse situations, and several staff members, including the maintenance director and DON, acknowledged that the second fight could have been prevented if the residents had been separated after the first incident. The facility's policies required the prevention of abuse, but staff actions did not prevent repeated physical altercations between the residents, resulting in physical harm.
Failure to Follow Abuse Prevention Policy and Staff Training Requirements
Penalty
Summary
The facility failed to follow its abuse prevention program policy and procedure in two key areas: timely review of criminal history background checks for new admissions and ensuring staff were educated and understood the abuse prevention program. Specifically, the facility did not check and review the criminal history background check within 24 hours of admission for one resident, despite the policy requiring this step. The resident's criminal history record was dated two days after admission, indicating the process was not completed as required. Additionally, two staff members, including an agency LPN and the Maintenance Director, were not educated or fully aware of the facility's abuse prevention program policy and procedure. The agency LPN, on her first day, was unaware of the abuse coordinator and had not received any abuse-related in-service or education. The Maintenance Director also reported not receiving specific training on how to handle abuse situations, which he believed contributed to the recurrence of a physical altercation between two residents. The deficiency was further evidenced by two physical altercations between residents with histories of mental health diagnoses, including schizophrenia and bipolar disorder. After the first altercation, both residents were kept in the same location, leading to a second fight. Multiple staff and residents confirmed that the second incident could have been prevented if the residents had been separated. The lack of staff training and failure to follow abuse prevention protocols contributed to the escalation and recurrence of resident-to-resident physical abuse.
Failure to Protect Resident from Staff-to-Resident Abuse and Timely Reporting
Penalty
Summary
A deficiency occurred when a resident with diagnoses including schizophrenia, insomnia, and ADHD, who was cognitively intact and required supervision with activities of daily living, was not protected from staff-to-resident abuse. The incident involved the Social Services Director (SSD) and was witnessed by another resident and an activity aide. According to witness statements, the SSD attempted to remove the resident from her office by shoving and pulling the chair out from under the resident, causing the resident to fall to the floor. The activity aide reported this action as abuse and stated that the situation escalated as a result of the SSD's actions. The resident became upset, broke the chair, and subsequently left the facility, leading to police involvement and a hospital transfer. The incident was not immediately reported to the Director of Nursing (DON) or the Administrator, both of whom stated they were unaware of the abuse allegation until informed by surveyors. The activity aide claimed to have reported the incident to the DON on the day it occurred, but the DON denied receiving any such report. The Administrator, who also serves as the abuse coordinator, was only made aware of the resident's behavioral outburst and not the alleged abuse by the SSD. Facility policy defines abuse as the willful infliction of injury or unreasonable confinement, and both the DON and Administrator acknowledged that pulling a chair from under a resident, causing a fall, constitutes abuse. The facility failed to ensure that the resident was protected from abuse and that allegations were promptly reported and investigated according to policy. The care plan for the resident specified that the resident should remain safe and free from mistreatment, and the facility's abuse prevention policy requires protection from abuse by anyone. The lack of timely reporting and investigation of the incident contributed to the deficiency identified by surveyors.
Inadequate Use of PPE and Linen Storage in Laundry Room
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy regarding the use of personal protective equipment (PPE) during the handling of soiled and clean linen. During an observation in the laundry room, it was noted that the staff member responsible for laundry, identified as V18, did not wear a gown while sorting and handling soiled laundry, only gloves. Additionally, there were no gowns available in the laundry area for use. The clean linen was stored uncovered under a metal table, and a large industrial fan was blowing air across both the dirty and clean areas, which were not physically separated, potentially leading to cross-contamination. The Housekeeping Director, identified as V19, confirmed that the staff should wear gowns and gloves when handling soiled laundry to prevent contamination. V19 acknowledged the absence of gowns in the laundry room and the lack of a physical barrier between the dirty and clean areas. The facility's policy on laundry services emphasizes the importance of using PPE, including gowns, gloves, and masks, during manual rinsing and sorting of soiled linen, and storing clean linen in a protected area. The failure to follow these procedures has the potential to affect all 77 residents in the facility.
Exposed Fluorescent Lights Pose Safety Risk
Penalty
Summary
The facility failed to provide a safe environment by not installing covers or guards on fluorescent tube lights located in over-the-head wall lights behind residents' beds. This deficiency was observed in the rooms of seven residents, affecting their safety and comfort. The exposed fluorescent tubes posed a risk of injury, as residents had to touch the bulbs to turn them on, and the tubes were covered in dust, indicating a lack of maintenance. Several residents, including those with intact cognition and those with cognitive impairments, reported using the over-the-head wall lights at night for reading or navigating their rooms without disturbing their roommates. The absence of covers or guards on these lights increased the risk of the tubes falling, breaking, or causing burns if touched when hot. The Maintenance Director acknowledged the safety concerns and confirmed that the lights should have protective covers or shields to prevent potential hazards. The facility's policy on maintenance and resident rights emphasizes the importance of maintaining a safe and operational environment, free from hazards. However, the lack of protective covers on the fluorescent lights in residents' rooms indicates a failure to adhere to these policies, compromising the safety and quality of life for the affected residents.
Failure to Provide Regular Podiatry Care for Resident
Penalty
Summary
The facility failed to adhere to its policy for nail care by not providing necessary toenail care for a resident, identified as R39, who was unable to perform this activity independently. Observations revealed that R39 had excessively long and curling toenails, with the large toenail appearing thick and scaly. Despite the resident's request for toenail trimming and the facility's policy that only a podiatrist should cut toenails, especially for diabetic residents, R39 had only been seen by the podiatrist once since admission. The resident expressed a desire for toenail care and denied ever refusing such services. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that the podiatrist visits the facility monthly but alternates between floors, which may have contributed to the oversight. The facility's records did not document any refusals by R39 for podiatry services, contradicting the paper documents provided later, which indicated refusals on specific dates. R39's medical history includes conditions such as schizophrenia, type 2 diabetes, hypertension, and Alzheimer's disease, with a cognitive assessment indicating intact cognition. The facility's failure to provide regular podiatry care as per policy resulted in the deficiency noted in the report.
Failure to Communicate Specialist's Recommendation
Penalty
Summary
The facility failed to communicate a specialist's recommendation to the primary physician and follow through with the recommended treatment for a resident diagnosed with Schizoaffective Disorders, Schizophrenia, and Drug Induced Subacute Dyskinesia. The resident was receiving the antipsychotic medication Clozapine and was examined by a neurologist for Tardive Dyskinesia. The neurologist recommended speech therapy, but this recommendation was not communicated to the resident's primary physician, nor was a referral for speech therapy ordered as per the resident's physician orders from April 2024. The Director of Nursing stated that the facility's protocol requires nurses to communicate any specialist recommendations to the primary physician and document this communication in the resident's chart. However, there was no documentation indicating that the neurologist's recommendation for speech therapy was relayed to the primary physician. Consequently, the resident did not receive the recommended speech therapy, highlighting a lapse in the facility's communication and documentation processes.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, as evidenced by the case of a resident who was prescribed antibiotics without proper documentation or indication. The resident, identified as R71, was observed to be on Bactrim DS, an antibiotic, without any documented clinical rationale or prescriber notes to justify its use. The order for the antibiotic was handwritten by a pulmonologist, but there was no corresponding documentation in the electronic health record to support the prescription. Additionally, vital signs such as temperature and respiratory rate were not monitored after the antibiotic was prescribed, which is a requirement under the facility's antibiotic stewardship program. Interviews with various staff members, including registered nurses and the Director of Nursing, revealed a lack of clarity and understanding regarding the reason for the antibiotic prescription. The Director of Nursing mentioned that the resident had lung nodules and lung disease, and the antibiotic might have been ordered prophylactically, but there was no concrete documentation to support this. The Infection Verification Form indicated that the criteria for pneumonia were not met, yet the resident was still on antibiotics. The staff acknowledged that vital signs should have been monitored and documented, but this was not done. Further investigation into the pulmonologist's notes revealed a suspicion of active rheumatoid lung and a plan to rule out methotrexate toxicity, but it was still unclear why the antibiotic was prescribed. The resident himself was unaware of the reason for the antibiotic treatment. The facility's antibiotic stewardship program requires prescribers to document the dose, duration, and indication for all antibiotic prescriptions, and to monitor clinical assessments and vital signs, which were not followed in this case.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet per bed for five resident rooms out of a total of 68 rooms. During an observation and interview on June 24, 2024, the Administrator acknowledged that five rooms did not meet the required square footage. On June 25, 2024, a surveyor, accompanied by the Maintenance Director, inspected these rooms and found that four were unoccupied, while one room was occupied by three residents who reported no concerns about the room size. The facility presented documentation indicating that these rooms had been granted a waiver by the Illinois Department of Public Health, allowing them to operate with less than the required square footage, as long as it did not affect resident health, safety, or welfare.
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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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