Accolade Hc Of Paxton On Pells
Inspection history, citations, penalties and survey trends for this long-term care facility in Paxton, Illinois.
- Location
- 1001 East Pells Street, Paxton, Illinois 60957
- CMS Provider Number
- 145603
- Inspections on file
- 38
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Accolade Hc Of Paxton On Pells during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions expired under hospice care, but due to unclear communication and lack of documentation among LPNs and other staff, the funeral home was not notified in a timely manner to remove the body. The remains were discovered by a housekeeper the following day, highlighting a breakdown in shift-to-shift reporting and responsibility for postmortem procedures.
A resident with dementia and multiple mobility issues eloped after an LPN and CNA exited through an employee service door that was not properly secured. The staff did not confirm the door was locked, and the resident followed them outside, becoming locked out and later found knocking on their room window. The facility's policy requiring staff to monitor resident whereabouts and ensure safety was not followed.
A resident with a diagnosis of PTSD was admitted without proper assessment or identification of trauma triggers, and the care plan did not include interventions for PTSD. After a discussion about possible alternative placements, the resident became distressed, experienced a manic episode with PTSD symptoms, and attempted to leave the facility, leading to police and EMS involvement and transfer to a hospital.
A resident with severe cognitive impairment developed multiple pressure ulcers due to the facility's failure to implement and document appropriate pressure relieving interventions. The resident was left in a wheelchair for extended periods without adequate pressure relief, and staff failed to update the care plan or coordinate pain management effectively. The facility's documentation and communication regarding the resident's wounds were inadequate, leading to a lack of timely treatment and intervention.
The facility failed to track culture results and organisms in infection control logs, and staff did not consistently implement Enhanced Barrier Precautions (EBP) or use personal protective equipment as required. This included not wearing gowns during high-contact care and failing to report changes in residents' conditions, such as cloudy urine in a resident with a history of UTIs, leading to hospitalization.
The facility failed to employ sufficient staff with the necessary competencies in food and nutrition services, affecting all 92 residents. The dietary manager lacks certification, and the RD only visits weekly. Concerns about menu nutritional values were raised, and a formal complaint was filed without response. The consulting company has not been onsite, leaving the facility responsible for compliance.
The facility failed to ensure menus and substitutions met residents' therapeutic diets and nutritional needs. During a lunch service, residents on specific diets received inappropriate items, and no fruit was served. The RD raised concerns about the menu not meeting state requirements and filed a complaint. Additionally, a resident with cognitive impairment was given ice cream instead of the prescribed pureed pears, contrary to facility policy.
The facility failed to maintain food safety and storage standards, affecting all 92 residents. Observations revealed food debris, improper storage, and unlabeled items in the kitchen. During meal service, food temperatures were not checked, and cold coleslaw was served above safe temperatures. The in-house dietician expressed concerns about the dietary services, noting the absence of the consulting company managing food services. Facility policies on food storage and safety were not followed, leading to potential health risks.
The facility failed to appoint a qualified Infection Preventionist with the necessary training, affecting 92 residents. The Administrator and nurse managers, who lacked the required training, collectively managed the role before hiring a new Wound Nurse/Infection Preventionist, who also had not completed the necessary training.
The facility failed to notify residents and their representatives in writing about hospital transfers and did not provide bed hold notices for four residents reviewed for hospitalizations. The Director of Nursing and other staff confirmed that bed hold forms were not being completed or sent to families, despite the facility's policy requiring such communication. This issue was consistent across multiple hospitalizations, indicating a systemic problem in the facility's process.
A facility failed to perform proper hand hygiene during catheter care for a resident, as CNAs did not wash hands before donning gloves or after completing care. Additionally, the resident's urinary catheter drainage bag was not consistently covered with a dignity bag, violating the facility's policy.
A resident with severe malnutrition and other health issues experienced a significant weight loss after being readmitted to the facility. The facility failed to obtain a re-admission weight, notify the physician and family, and develop a care plan to address the weight loss, contrary to their Weight Management policy.
A resident with severe cognitive impairment did not have their privacy maintained during wound care. On two occasions, staff, including a wound nurse, a wound nurse practitioner, a CNA, and the DON, failed to pull the privacy curtain, exposing the resident's buttocks and perineal area to the hallway and doorway. This was against the facility's policy requiring privacy during ADLs.
A resident with moderate cognitive impairment and impaired range of motion did not receive necessary therapy or restorative nursing services after transferring to the facility. The resident's care plan lacked documentation for addressing these needs, and the facility's Functional Maintenance Program was not applied. The resident was on antibiotics for pneumonia, delaying therapy screening, but the lack of restorative services was a significant oversight.
A resident slipped from a wheelchair during transport due to improper positioning of a mechanical lift sling, requiring emergency assistance. The facility failed to investigate the incident, document it as a fall, or update the resident's care plan. Additionally, no fall risk assessments were completed in 2024, contrary to facility policy.
The facility failed to maintain proper hygiene and storage for respiratory equipment for two residents. One resident's CPAP mask was left uncovered on the nightstand, and another resident's oxygen tubing was found on the floor without a storage bag. The care plan for the second resident did not address their COPD or oxygen use, despite having a physician's order. Staff confirmed the improper storage and care of the equipment.
A facility failed to limit a PRN order for Lorazepam, an antianxiety medication, to 14 days as per its protocol. A resident was prescribed the medication on a PRN basis for agitation/restlessness, but the order remained active beyond the 14-day limit without reassessment, despite the resident not using the medication since shortly after it was prescribed. This was confirmed by the DON during an interview.
The facility failed to implement effective fall interventions for two residents, resulting in multiple falls and injuries. One resident, with moderate cognitive impairment, experienced several falls, including two with head lacerations. Despite being identified as restless, the facility did not promptly implement new safety measures. Investigations into the falls were inadequate, lacking thorough assessment of contributing factors. Another resident with severe cognitive impairment also fell while attempting to self-transfer, with care plan interventions not consistently followed.
A facility failed to report a potential abuse incident involving two residents. A CNA observed a resident with schizophrenia in the bed of another resident with severe cognitive impairment, kissing them on the cheek. The CNA and an LPN removed the resident but did not report the incident to the Administrator. The Administrator learned of the incident the next day, confirming the failure to report it immediately.
A resident with dementia fell from bed and sustained severe injuries after CNAs failed to explain care procedures and ensure safety during bed repositioning. The resident was startled by the bed's noise and fell before staff could intervene. The care plan required clear communication, which was not followed.
A facility failed to re-evaluate and coordinate discharge plans for a resident with stage three pressure ulcers, resulting in the resident being discharged home without necessary home health services or a wound clinic appointment. The post-acute care coordinator did not document the denial of home health services or notify the nurse practitioner, leading to the resident's subsequent hospitalization.
The facility failed to conduct and document weekly skin assessments, identify a reopened pressure ulcer, notify the physician, and obtain treatment orders for a resident. Significant gaps in documentation and miscommunication among staff led to inadequate pressure ulcer management.
Failure to Communicate and Document Funeral Home Notification After Resident Death
Penalty
Summary
The facility failed to establish clear communication and documentation regarding the notification to a funeral home for the removal of a deceased resident's remains. The resident, who had multiple medical diagnoses including traumatic subdural hemorrhage, dementia, COPD, heart disease, chronic kidney disease stage 4, anxiety disorder, scoliosis, GERD, and a history of repeated falls, expired at 11:52 AM under hospice care. Although the hospice nurse and family were present at the time of death, and the Director of Nursing was notified, there was no confirmation or documentation that the funeral home had been contacted to remove the resident's remains. Multiple LPNs on different shifts assumed that either the hospice nurse or another staff member had made the necessary notification, but none confirmed or documented this action. As a result, the resident's body remained in the facility until the following day, when a housekeeper discovered the remains and notified nursing staff, prompting the eventual call to the funeral home. The lack of clear communication and documentation among staff members led to a significant delay in the removal of the deceased resident's body. Shift-to-shift handoffs did not include confirmation of funeral home notification, and there was no entry in the resident's chart indicating when the remains were removed. The hospice nurse had informed staff that the facility was responsible for contacting the funeral home after the family had spent time with the resident, but this responsibility was not clearly assigned or followed up on by facility staff. This breakdown in communication and documentation resulted in the resident's remains remaining in the facility for an extended period after death.
Failure to Secure Exit Door Results in Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to ensure that an exit door was properly secured after use, resulting in the elopement of a resident. On the day of the incident, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) exited the facility through an employee service door with a keypad lock to smoke. Both staff members acknowledged that the door sometimes does not latch unless it is pulled closed, and neither could confirm if the door was properly locked when they left. Shortly after, the CNA observed the resident, who has diagnoses including dementia, Alzheimer's disease, cognitive decline, and repeated falls, in the hallway prior to their exit. Upon returning, the CNA heard knocking and found the resident outside, knocking on their room window. The resident was then brought back inside by staff. The resident later confirmed that they had followed the staff out the door and were unable to re-enter the facility after the door locked behind them. The facility's policy requires staff to be aware of residents' locations at all times and to ensure their safety, but this was not followed, as staff did not verify the door was secured and did not maintain awareness of the resident's whereabouts. The incident was reported to the facility administrator, and interviews with involved staff confirmed the sequence of events and the failure to ensure the door was locked.
Failure to Identify PTSD Triggers and Provide Resident-Centered Interventions
Penalty
Summary
The facility failed to identify potential triggers for Post-Traumatic Stress Disorder (PTSD) and did not implement resident-centered interventions for a resident admitted with a diagnosis of PTSD. Upon admission, the resident's Brief Trauma Questionnaire did not address the PTSD diagnosis or identify possible behavioral triggers, and the care plan was not updated to include interventions or triggers related to PTSD. The resident had a complex medical history, including Parkinson's Disease, COPD, Lupus, Generalized Anxiety Disorder, Major Depression, and substance dependence. Despite these diagnoses, the facility did not adequately assess or plan for the resident's PTSD-related needs. Following a conversation with the Social Service Director about possible alternative placements, the resident became suspicious and believed she was being involuntarily discharged, which was not the case. The resident subsequently experienced severe emotional distress, including a manic episode and PTSD symptoms, and was unable to be redirected or emotionally regulated by staff interventions. The situation escalated to the point where the resident attempted to leave the facility, resulting in police and emergency medical services involvement and eventual transfer to a hospital for evaluation and treatment. The lack of trauma-informed and culturally competent care contributed to the exacerbation of the resident's behavioral symptoms.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement appropriate pressure ulcer care and prevention strategies for a resident, resulting in the development of two stage two and one stage three pressure ulcers. The resident, who has severe cognitive impairment and is dependent on staff for various activities, was observed sitting in a wheelchair for extended periods without adequate pressure relief. Certified Nursing Assistants (CNAs) reported that the resident was not laid down between meals as required, and pressure relieving boots were only introduced after the development of a heel wound. The facility's documentation and communication regarding the resident's pressure ulcers were inadequate. The Wound Nurse and Wound Nurse Practitioner discovered undated dressings and were unaware of the resident's right ischium wound until the day of the assessment. The resident's care plan had not been updated to reflect the presence of pressure ulcers or new pressure relieving interventions since 2022. Additionally, the facility's electronic medical record (EMR) lacked documentation of pressure relieving interventions, and there were missing skin assessments for December 2024 and January 2025. The facility's staff failed to coordinate pain management effectively, as evidenced by the resident's expressions of pain during wound care without prior administration of pain medication. The Director of Nursing (DON) acknowledged the missing skin assessments and the lack of updates to the resident's care plan. The facility's policies on wound treatments and skin management were not followed, as pressure relieving interventions were not consistently implemented, and there was a lack of timely notification to the physician regarding new wounds.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to adequately track culture results and organisms in their infection control logs, which are essential for identifying trends and preventing outbreaks. The logs from August 2024 to January 2025 did not document culture results for wound or urinary tract infections, nor did they track bacterial organisms. This oversight was confirmed by the facility's administrator, who acknowledged that while the tracking was being done, it was not properly logged. The facility's policy requires the Infection Control Nurse or Designee to monitor infections and complete incidence reports monthly, quarterly, and annually, using laboratory records and infection control rounds. In several instances, staff failed to implement Enhanced Barrier Precautions (EBP) as required. For example, staff did not wear gowns when entering rooms with EBP signs, which indicated the need for gowns and gloves during high-contact care. In one case, a wound nurse did not perform hand hygiene or change gloves consistently during wound care, and failed to disinfect equipment used during the procedure. The Director of Nursing confirmed that EBP should be implemented for residents with pressure ulcers and urinary catheters, and that gowns and gloves should be worn for all high-contact care. Additionally, there were failures in monitoring and reporting changes in residents' conditions. One resident with a history of urinary tract infections had cloudy urine, which was noted by a nurse but not communicated effectively to the nurse practitioner, resulting in the resident being hospitalized for a UTI. The facility's policy requires that changes in a resident's condition be reported to the attending physician by licensed personnel. Despite the presence of EBP signs, staff did not consistently use personal protective equipment, such as gowns, when providing care to residents with indwelling catheters.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, potentially affecting all 92 residents. The dietary manager, identified as V3, admitted to not being a certified dietary manager and lacking any certifications. The Director of Nursing, V2, confirmed that the Registered Dietician (RD), V7, only visits the facility once a week and is not present full-time. V7 expressed concerns about the nutritional values of the menus and stated that she had offered educational services and menu writing, but these offers were not accepted by the facility. V7 also mentioned filing a formal complaint with the facility administration and the contracted dietary company, but received no response. The consulting dietary services company, represented by V24, revealed that the RD responsible for writing the menus is no longer employed with them, and there has been no collaboration with the local RD. V24 stated that their company is a software company and has not been onsite recently, leaving the facility responsible for alternative menus and compliance. The facility's policy requires the director of food and nutrition services to hold an active certified dietary manager or food service manager certification, which V3 does not possess. Additionally, V3 was unable to provide her food safety certification, further highlighting the deficiency in staffing qualifications.
Failure to Meet Therapeutic Diets and Nutritional Needs
Penalty
Summary
The facility failed to ensure that menus and menu substitutions were developed, prepared, and followed to meet residents' therapeutic diets and nutritional needs according to established national guidelines. During a lunch meal service observation, it was noted that the facility did not provide variations of items served based on therapeutic diets, and there were no smaller or larger portions served. Specifically, residents on Low Concentrated Sweets (LCS) and No Added Salt (NAS) diets received regular coleslaw and full dessert bars, contrary to their dietary requirements. Additionally, there were no fruit items served during the meal, which was inconsistent with the facility's documented menu. The Registered Dietician (RD) expressed concerns that the facility's current menu did not meet state requirements for fruit and vegetable servings, including necessary vitamins. The RD had attempted to communicate these concerns to the facility administrator and the consulting dietary company but received no response. The RD also noted that the facility's menu did not meet the required minimum national dietary standards and had filed a formal complaint. The facility's dietary staff were unaware of the necessary variations for therapeutic diets, and the recipe book used did not include recipes for low salt or low concentrated sugars. Furthermore, the facility failed to provide appropriate substitutes for menu items. For instance, a resident with severe cognitive impairment and significant weight loss was not served the pureed pears listed on their meal ticket but was instead given ice cream. The RD confirmed that ice cream was not an appropriate substitute for pears and that applesauce would have been a suitable alternative. The facility's policy on menu substitutions required that substitutes be of similar nutritive value and planned with the dietitian, which was not adhered to in this case.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which has the potential to affect all 92 residents. During a kitchen and storage area tour, food debris was found inside the toaster, on the countertop, and on the floor. Boxes of food were improperly stacked in the food prep area, and bulk bin containers were placed in a high-traffic area. In the walk-in freezer, a bin labeled 'Meatballs' contained an unidentifiable substance with freezer burn, and the standing cooler had unlabeled and undated sliced ham and cheese. The dietary aide cooler contained uncovered and undated pudding bowls, and the dry storage had bins of oatmeal and brown sugar without expiration dates, with scoops improperly stored. During lunch meal service, food temperatures were not checked before serving, and the cold coleslaw was served at 54 degrees Fahrenheit, above the safe temperature range. The cook did not perform hand hygiene or change gloves after touching surfaces, and the dietary manager admitted that food temperatures are usually not checked during service. The facility's production sheet documented incorrect starting temperatures for food, with BBQ pork shoulder below the safe benchmark. The in-house dietician expressed serious concerns about the dietary services, noting that the consulting company managing food services had not been present recently. Further observations revealed ongoing issues with food storage and labeling. The walk-in freezer still contained the improperly stored 'Meatballs,' and the dietary aides' cooler had uncovered and undated yogurt cups. Employee drinks and unlabeled thickened lemon water were stored in the cooler, and raw meat was improperly stored in the cold storage. The facility's policies on food storage and safety were not followed, as evidenced by the lack of proper labeling, dating, and storage practices, as well as the failure to maintain food temperatures within safe ranges.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a qualified Infection Preventionist with the required training in infection prevention and control, which has the potential to affect all 92 residents. The facility's assessment indicated that an Infection Control Preventionist should be part of the staffing plan. However, the Administrator stated that the recently hired Wound Nurse/Infection Preventionist had not completed the necessary training. Prior to this hire, the Administrator and nurse managers collectively oversaw the infection prevention role, despite lacking the required training. The newly hired Infection Preventionist confirmed not having officially taken over the role and had not completed the training course, leaving the Administrator to handle infection prevention and control duties.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives in writing about hospital transfers and did not provide a bed hold notice for four residents reviewed for hospitalizations. Specifically, the facility did not have documentation of a bed hold policy in the medical records of residents who were hospitalized, including R39, R17, R25, and R52. Interviews with the Director of Nursing (DON) revealed that the nurses were no longer completing bed hold forms at the time of hospitalization, and nothing was being sent to families. This lack of communication and documentation was confirmed by the facility's Administrator and Licensed Practical Nurse (LPN), who acknowledged that the bed hold policy was not being provided to residents' representatives. The facility's Discharge/Transfer Policy, dated August 2023, requires that written information about the bed hold policy be provided to residents and their representatives before a transfer to a hospital or therapeutic leave. However, the facility did not adhere to this policy, as evidenced by the absence of bed hold notices in the medical records and the lack of written communication with residents' representatives. The failure to provide this information was consistent across multiple instances of hospitalization for the residents reviewed, indicating a systemic issue in the facility's process for handling hospital transfers.
Failure in Hand Hygiene and Catheter Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during catheter care for a resident, which could lead to potential contamination. Certified Nursing Assistants (CNAs) V33 and V34 did not wash their hands before donning gloves to provide catheter care for the resident. After completing the catheter care, they continued to handle the resident's incontinence brief, sheets, blankets, and call light with the same gloved hands, and subsequently exited the room without performing hand hygiene. Both CNAs confirmed their failure to perform hand hygiene before and after the catheter care. Additionally, the facility did not ensure that the resident's urinary catheter drainage bag was consistently covered with a dignity bag, as required by the facility's Catheter Care and Maintenance Policy. On multiple occasions, the drainage bag was observed hanging uncovered on the bed frame, visible from the hallway. This was only corrected on the third day of observation. The facility's Hand Washing Policy emphasizes the importance of hand hygiene as the primary means to prevent the spread of infections, requiring staff to wash hands before and after direct contact with residents and after removing gloves.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adhere to its Weight Management policy, resulting in a deficiency related to the care of a resident with significant weight loss. The policy mandates that all residents be weighed upon re-admission and weekly for the first four weeks, with any significant weight loss requiring physician notification and a care plan update. However, the facility did not obtain a re-admission weight for the resident within 24 hours, nor did they notify the physician or the resident's family about the significant weight loss. Additionally, there was no documented care plan addressing the resident's risk for or actual weight loss. The resident in question was diagnosed with severe protein-calorie malnutrition, muscle wasting and atrophy, dysphagia, and a low body mass index. After being discharged to the hospital and readmitted to the facility, the resident experienced a 14.5% weight loss over one month. Despite these conditions and the significant weight loss, the facility did not take the necessary steps to address the resident's nutritional needs, as confirmed by the Director of Nurses.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain privacy during wound care for a resident with severe cognitive impairment. On two separate occasions, wound care was performed without pulling the privacy curtain to block the view from the doorway and hallway, exposing the resident's buttocks and perineal area. The first incident involved a wound nurse, a wound nurse practitioner, and a CNA, who entered and exited the room without ensuring privacy. The second incident involved the Director of Nursing and a CNA, who also failed to pull the privacy curtain during the observation of the resident's wounds. The facility's policy on resident privacy and dignity requires that privacy be maintained during activities of daily living, including wound care, by closing the door and drawing the curtain.
Failure to Provide Range of Motion Services
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion for a resident, identified as R34, who was reviewed for range of motion issues. R34, who has moderate cognitive impairment and impaired range of motion in one upper and one lower extremity, was observed sitting in a wheelchair with a brace on the right leg and reported not receiving any therapy services or exercise programs since admission. The facility's MDS Coordinator confirmed that R34 had not been evaluated by therapy since transferring from another facility, and the Director of Nursing acknowledged the lack of restorative nursing services for R34. R34's care plan did not document any problems, goals, or interventions to address the impaired range of motion, and there was no record of therapy or restorative nursing services being provided. The facility's Functional Maintenance Program outlines the need for a Contracture Risk Evaluation upon admission and the implementation of custom interventions to prevent decline, but these were not applied to R34. The resident had been on antibiotics for pneumonia, which delayed the therapy screening, but the lack of restorative services was a significant oversight.
Failure to Investigate and Document Fall Incident
Penalty
Summary
The facility failed to investigate and document a fall incident involving a resident, identified as R39, who was being transported in a van. During the transport, R39 slipped out of the wheelchair due to the mechanical lift sling being improperly positioned, causing R39 to slide down in the chair. Although R39 did not hit the floor, the incident was serious enough to require assistance from the fire department and an ambulance to transport R39 to the hospital. Despite this, the Director of Nursing (DON) did not consider it a fall, did not conduct an investigation, and did not implement any new interventions at that time. Additionally, the facility failed to complete fall risk assessments for R39, as required by their policy. The last documented fall risk assessment was in 2023, and no assessments were completed in 2024, despite the occurrence of falls. The facility's policy mandates that fall risk assessments be conducted quarterly and as needed following a fall or change in condition. The lack of timely assessments and updates to R39's care plan after the incidents indicates a failure to adhere to the facility's Accidents & Incidents Policy, which requires thorough investigation and documentation of all accidents and incidents involving residents.
Improper Storage and Care of Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper hygiene and storage for respiratory equipment for two residents. For one resident, the CPAP mask was observed uncovered and improperly stored on the nightstand, contrary to the facility's guidelines which require the mask to be cleaned daily, air-dried, and stored in a plastic bag when not in use. The Licensed Practical Nurse (LPN) confirmed the improper storage and acknowledged the need to store the mask in a bag. The Director of Nursing reiterated the facility's protocol for CPAP mask care, which was not followed in this instance. Another resident's oxygen equipment was also improperly managed. The oxygen concentrator was off, and the nasal cannula was found on the floor without a storage bag. The resident's care plan did not address their COPD or the use of oxygen and nebulizer treatments, despite having a physician's order for oxygen use as needed. The LPN confirmed the absence of a storage bag and the improper placement of the nasal cannula. The Director of Nursing stated that the tubing should be stored in a bag when not in use, which was not done in this case. Additionally, the care plan coordinator confirmed the care plan's omission of the resident's respiratory needs.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to adhere to its protocol regarding the limitation of PRN psychotropic medication orders to 14 days. Specifically, a resident was prescribed Lorazepam, an antianxiety medication, on November 14, 2024, with instructions to administer 0.25 ml every 4 hours as needed for agitation or restlessness. Despite the facility's protocol requiring a reassessment by a physician after 14 days, the medication order remained active beyond this period without reassessment, as the resident had not used the medication since November 18, 2024. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the 14-day limitation for PRN psychotropic medications as per the facility's protocol.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to develop and implement effective fall interventions and safety measures for two residents, resulting in multiple falls and injuries. One resident, who had moderate cognitive impairment and was a high fall risk, experienced several falls, including two that resulted in head lacerations requiring medical attention. Despite being identified as restless and anxious, the facility did not implement new safety interventions promptly, such as fall mats or bolsters, until after the falls occurred. The resident's care plan included interventions like keeping items within reach and bringing the resident to the common area when anxious, but these measures were not effectively executed or updated in response to the resident's changing condition. The facility's investigation into the falls was inadequate, as it did not thoroughly assess potential contributing factors such as the timing of toileting or incontinence care. The resident was often found attempting to get out of bed or a chair without assistance, indicating a need for more direct supervision or alternative interventions. Staff reported the resident's restlessness and attempts to self-transfer, but there was a lack of consistent implementation of interventions to address these behaviors. Additionally, there was no documentation of pain management being considered as a factor for the resident's restlessness, despite the potential for pain to contribute to such behavior. Another resident with severe cognitive impairment and a history of falls also experienced an unwitnessed fall while attempting to self-transfer. The care plan included an intervention to offer to lay the resident down after lunch, but this was not consistently followed by staff. The facility's policy required immediate investigation and implementation of appropriate interventions following accidents, but the investigations did not adequately address the root causes or ensure that staff were re-educated on necessary fall prevention measures. These deficiencies highlight a failure to provide adequate supervision and timely interventions to prevent falls and ensure resident safety.
Failure to Report Potential Abuse Incident
Penalty
Summary
The facility failed to immediately report an allegation of potential sexual abuse involving two residents to the Abuse Coordinator and the State Surveying Agency. The incident occurred when a Certified Nursing Assistant (CNA) observed one resident, who is moderately cognitively impaired and diagnosed with schizophrenia, in the bed of another resident, who is severely cognitively impaired and dependent on staff for mobility. The CNA witnessed the resident on top of the covers, kissing the other resident on the cheek. Despite the CNA's awareness of the situation, the incident was not reported to the Administrator/Abuse Coordinator at the time it occurred. The CNA called for assistance from a Licensed Practical Nurse (LPN), who helped remove the resident from the bed. However, neither the CNA nor the LPN reported the incident to the Administrator. The Administrator only became aware of the situation the following morning during a meeting. The failure to report the incident immediately was confirmed by the Administrator, who acknowledged that staff should have reported the potential abuse incident to the Abuse Coordinator and the Department of Public Health.
Failure to Prevent Resident Fall During Bed Repositioning
Penalty
Summary
The facility failed to prevent a fall incident involving a resident, identified as R1, who sustained severe injuries including a skull fracture and brain bleed. The incident occurred when two CNAs, V3 and V4, were attending to R1 for repositioning. R1 was found lying close to the edge of the bed, and as V3 began to raise the bed, R1 became startled, pulled back the blanket, and fell to the floor. The CNAs were unable to catch R1 in time, resulting in the fall. The incident note and interviews with the CNAs revealed that R1 was not informed about the care procedure, which contributed to the resident's startled reaction and subsequent fall. R1's care plan indicated that the resident required assistance with bed mobility and could be uncooperative due to dementia and Alzheimer's disease. The care plan also emphasized the need for clear explanations of care activities to R1. The facility's policy on bed positioning required staff to explain procedures to residents before performing them. However, this protocol was not followed, as V4 admitted that R1 was not awakened or informed about the care, which likely led to the resident's startled response. The Director of Nursing confirmed that the bed's noise during elevation could have startled R1, and staff should have been positioned at the bedside to prevent falls.
Failure to Coordinate Discharge Plans and Notify Physician
Penalty
Summary
The facility failed to re-evaluate and coordinate discharge plans for a resident being discharged home, and did not notify the physician of changes in the discharge plan. The resident had stage three pressure ulcers on both heels, requiring specific wound care and pressure-relieving boots. The discharge plan did not specify if wound care would be provided by home health services or list any follow-up appointments with a wound clinic. Despite the resident's family being informed of the discharge and the setup of home health services, the resident was not accepted by any of the home health agencies contacted due to insurance issues and capacity constraints. This information was not communicated to the nurse practitioner or documented properly by the post-acute care coordinator. The resident was discharged home without the necessary home health services or a scheduled wound clinic appointment. The resident later required hospitalization and a wound clinic appointment due to the lack of proper wound care. Interviews with the staff revealed that the post-acute care coordinator failed to document the denial of home health services and did not notify the nurse practitioner, who would have recommended the resident stay in the facility longer. The director of nursing was also unaware of the denial of home health services and confirmed that proper follow-up should have been conducted and documented. The facility's discharge policy requires comprehensive discharge planning, which was not adhered to in this case.
Failure to Document and Manage Pressure Ulcer Care
Penalty
Summary
The facility failed to conduct and thoroughly document weekly skin assessments, identify a newly reopened pressure ulcer, notify the physician, and obtain pressure ulcer treatment orders for one resident. The resident, who is cognitively intact and at risk for pressure ulcers, had a history of stage two and stage three pressure ulcers that were facility-acquired. There were significant gaps in the documentation of weekly skin assessments, with no records from 2/25/24 to 3/22/24 and then again until 4/5/24. Additionally, the wound that had healed by 4/17/24 was not documented as reopened until 4/24/24, and there was no evidence of physician notification or treatment orders during this period. On 4/30/24, the wound nurse confirmed that the resident's left buttock wound had reopened and required treatment. The Licensed Practical Nurse who conducted the skin assessment on 4/19/24 did not notify the physician or measure the wound, mistakenly believing it was not a new wound. The Director of Nursing confirmed the lack of documentation for weekly skin assessments and wound assessments/measurements. The facility's Skin Condition Monitoring policy mandates weekly skin assessments and physician notification for new wounds, which was not adhered to in this case.
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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