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F0658
D

Failure to Maintain Undisturbed Environment Prior to Coroner Arrival

Decatur, Illinois Survey Completed on 11-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an undisturbed environment following the death of a resident prior to the arrival of the coroner. After the resident passed away, video footage showed that four CNAs entered the resident's room and provided post-mortem care, including transferring the resident's body from the floor back to the bed using a mechanical lift. The CNAs reported that they were not instructed not to touch the body or the environment, and stated that they acted at the request of the resident's family to clean up the resident. The LPN on duty contacted EMS and the coroner's office, but did not recall being instructed not to disturb the body or the environment. The LPN acknowledged that staff should not touch the body or environment until cleared by the coroner. When the coroner arrived, the resident's body had already been moved and the room had been cleaned, with no medical supplies present. The coroner stated that in such cases, the body and environment should be left untouched as it is considered a possible crime scene, and that the facility should not have tampered with the body after death. The facility administrator confirmed that there was no policy in place regarding post-mortem care for coroner cases, and that staff were expected to follow the standard of care.

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