Accolade Healthcare Danville
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, Illinois.
- Location
- 801 North Logan Avenue, Danville, Illinois 61832
- CMS Provider Number
- 145243
- Inspections on file
- 45
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Accolade Healthcare Danville during CMS and state inspections, most recent first.
A resident who required maximum assistance for mobility and transfers was left unsupported during a therapy session when a PTA proceeded without a second staff member, contrary to the care plan and facility policy. The resident fell forward off the bed, sustaining a head laceration that required emergency treatment and staples. Staff interviews confirmed the resident's dependency and the need for two-person assistance, which was not provided at the time of the incident.
Three residents had discrepancies between their documented and observed range of motion (ROM) abilities due to inaccurate MDS coding. In several cases, staff interviews and direct observation showed that residents had more or less impairment than what was recorded in their MDS assessments, with one staff member admitting to misunderstanding the criteria for impaired ROM.
Four dependent residents did not receive required assistance with activities of daily living, including nail care, shaving, and feeding. Two residents had long, dirty fingernails despite needing staff help, one was not shaved as required by facility policy, and another was left without feeding assistance for an extended period. These deficiencies were confirmed through observation, interviews, and record review.
Three residents with pressure ulcers did not receive required interventions such as specialized mattresses, regular repositioning, or pressure relieving boots, and initial wound assessments were not completed in a timely manner. Staff and family confirmed lapses in care, and documentation was missing or delayed, contrary to facility policy.
Three residents experienced medication administration errors when nurses failed to follow physician-ordered protocols, including administering insulin after a meal instead of before, giving Metoprolol Tartrate despite a low heart rate, and not checking vital signs before administering Carvedilol. These actions resulted in a medication error rate of 12%, surpassing the acceptable threshold.
Surveyors found that medications, including insulin and a controlled substance, were not consistently labeled with opened dates or properly documented in controlled medication records. A controlled medication brought from home lacked a required count sheet, and medications were not always stored in locked compartments as per policy. Additionally, a resident was found with medications left at the bedside for self-administration without a physician order or care plan documentation, and the LPN did not observe the resident taking the medications, contrary to facility policy.
Two residents with respiratory symptoms were not placed on contact or droplet precautions, and no signage or PPE was provided outside their rooms. Both were observed coughing, with one unable to maintain respiratory hygiene, and both participated in communal activities without precautions. Additionally, a nurse failed to disinfect a blood glucose meter after use, leaving it on the medication cart and potentially contaminating the area.
A resident with Down syndrome and limited ROM was observed with contracted hands and lacked documented interventions or goals for ROM or contracture management in the care plan. Although a restorative program was recommended and staff were educated, there was no evidence of a formal program or documentation that ROM interventions were being provided, with staff indicating these tasks were expected to occur during ADLs without supporting records.
A nurse did not check the gastric residual volume before administering medications and water flushes through a g-tube for a resident, despite facility policy and the care plan requiring this step. The nurse only checked tube placement and confirmed the omission, while the ADON verified that gastric residual should be checked at the time of medication administration.
A resident with severe cognitive impairment and total care needs was found with a new femur fracture of unknown origin. Despite facility policy requiring reporting of unexplained injuries, the incident was not reported to the state agency because staff believed the injury was pathological and not suspicious for abuse.
A resident with a care plan requiring a bed alarm for fall prevention was found with the alarm sensor pad unplugged and the alarm module placed across the room, rendering the intervention nonfunctional. The resident was nonverbal at the time, and a nurse confirmed the alarm was not set up as required by the care plan.
The facility failed to implement and document appropriate pressure ulcer prevention and care for three residents, leading to the development and deterioration of pressure ulcers. A resident developed a stage two pressure ulcer that worsened to an unstageable ulcer due to lack of a turning schedule and nutritional evaluation. Another resident had discrepancies in wound assessments, and a third resident did not receive a recommended low air loss mattress. These failures contributed to declining skin integrity and facility-acquired pressure ulcers.
A facility failed to reposition a dependent resident as required by their care plan. The resident was observed sitting in a reclining geriatric chair for several hours without repositioning. A CNA confirmed the resident was not laid down until the early afternoon, despite being up since late morning. The resident's spouse had previously raised concerns about the lack of repositioning. The care plan required repositioning every two hours and as needed.
A resident experienced significant weight loss over several months, but the facility failed to document and assess this adequately. The resident's care plan did not reflect the weight loss, and there was no timely evaluation by a dietitian or physician. Observations showed low meal intake, and the facility did not follow its policies for weight monitoring and nutritional assessment.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with pressure ulcers, as required by their policy. Observations revealed a lack of EBP signage and PPE carts near residents' rooms, and staff were not wearing gowns during high-contact care activities. The ADON confirmed the absence of EBP orders and signage for affected residents, and the DON acknowledged missing EBP documentation for a resident. This indicates a failure to follow infection prevention measures.
A resident with Peripheral Vascular Disease and Type 2 Diabetes Mellitus developed a bruise on the left foot after a mechanical lift transfer. The facility failed to monitor and document the bruise, leading to an infection and hospitalization. Initial assessments were incomplete, and the wound nurse was not informed due to being on vacation. The facility's policies for monitoring and physician notification were not followed, resulting in the resident's condition worsening.
A resident with moderate cognitive impairment and physical limitations did not receive adequate fingernail care, as their nails were observed to be long and dirty. Despite the resident's request for nail care, a CNA did not provide it during routine hygiene assistance. The facility's policy requires regular nail care to maintain cleanliness and prevent infection, but this was not followed.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in the development and improper management of pressure ulcers. One resident, who was incontinent and required assistance, was not repositioned as per the care plan, leading to a stage two pressure ulcer. Another resident with a stage three pressure ulcer on the heel was not positioned correctly to offload pressure, despite care plan instructions. The facility did not follow its skin and wound management guidelines, failing to document and report the wounds to the physician.
The facility failed to implement effective fall interventions for three residents, resulting in significant injuries. One resident sustained a head laceration and arterial bleed, another had bilateral wrist fractures, and a third experienced multiple falls with skin tears. The interventions in place were insufficient to prevent these incidents.
The facility failed to timely notify the physician of newly developed, draining wounds for a resident. The resident had no wounds documented upon readmission from the hospital, but later developed three open areas with green pus. The physician was not notified until the following day when antibiotics were ordered, contrary to the facility's policy and guidelines.
The facility failed to culture a resident's draining wound before administering antibiotics, did not assess a surgical incision upon admission, and inaccurately transcribed wound treatment orders for three residents. Additionally, the facility did not monitor and record fluid intake for a resident, contrary to their care plan and facility policies.
The facility failed to assess and measure a pressure ulcer upon admission for a resident. The resident's unstageable coccyx wound was not documented with measurements or descriptions until the following day. The wound nurse confirmed that wounds should be assessed and measured upon admission, as per the facility's guidelines, which were not followed in this case.
The facility failed to employ a qualified Director of Food and Nutrition Services, with the current Dietary Manager lacking necessary education and qualifications. Observations revealed unsanitary conditions in the kitchen, including rust, grease, and food debris on equipment. The Administrator confirmed the DM's lack of qualifications.
The facility failed to maintain kitchen equipment in a clean and sanitary condition, potentially affecting all 96 residents. The Dietary Manager confirmed that the commercial mixer had rust, grease, and food debris buildup, while the can opener had grease, metal fragments, rust, and a peeling silver laminate coating, along with a sticky substance in the shaft holder sleeve.
The facility failed to have required members, including the Infection Preventionist and Medical Director, attend QAA meetings, potentially affecting all 96 residents. The Medical Director provided only verbal reviews, and the Infection Preventionist was absent on specific dates, contrary to the facility's QAA Committee requirements.
The facility failed to ensure residents' dignity and timely care, as evidenced by prolonged periods of incontinence without timely assistance and delayed responses to call lights. Residents and their family members reported multiple instances of inadequate care, with staff often being unresponsive or preoccupied with personal activities. This compromised the residents' well-being and dignity.
The facility failed to accurately encode a resident's health status on the MDS regarding dialysis. A resident, who goes to an outside facility for dialysis treatment three times per week, had their dialysis treatments omitted from their MDS. The Administrator/Registered Nurse acknowledged the inaccuracy.
A resident with multiple medical conditions did not receive PRN dressing changes for a left knee wound as per physician's orders. Observations on two consecutive days showed the dressing was saturated, and RNs confirmed it should have been changed more frequently.
A resident with multiple diagnoses and high fall risk experienced several unwitnessed falls due to inadequate implementation of fall interventions. Despite requiring supervision and assistance, the resident's care plan was not consistently followed, leading to injuries and hospital evaluation. The facility's staff often failed to respond promptly to call lights, and essential safety measures like bed alarms were found non-functional.
A resident with multiple medical conditions, including MRSA, did not receive physician-ordered IV antibiotics on two consecutive days due to issues with their PICC line. Despite attempts to replace the PICC line, delays occurred, leading to missed doses and a delay in treatment.
The facility failed to maintain accurate medical records for a dialysis resident, as required assessments for the dialysis port were not documented due to an error in the electronic medical record entry by the physician.
A facility failed to follow infection control protocols during high-contact wound care activities for a resident with multiple diagnoses, including recent amputation and pressure ulcers. Staff did not wear gowns as required by the facility's enhanced barrier precautions policy, leading to a noted deficiency.
Failure to Provide Adequate Staff Assistance During Therapy Session Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact but required maximum assistance with mobility and transfers due to overweight status and functional decline, was left without adequate staff support during a therapy session. The resident's care plan specified that two staff members were needed to assist during therapy sessions. Despite this, a physical therapist assistant (PTA) proceeded with the session alone, attempting to have the resident sit on the side of the bed and then stand, even though the resident was dependent for bed mobility and did not stand independently. During the session, the PTA let go of the resident and walked to the other side of the bed to reposition the resident, leaving the resident unsupported. The resident subsequently fell forward off the bed, hitting the bedside table and sustaining a head laceration that required emergency treatment and 15 staples. Witnesses, including another resident and staff, confirmed that the PTA did not attempt to assist or prevent the fall and that the resident typically required two staff members for all transfers and mobility tasks. Interviews with staff, including a CNA, LPN, DON, and the resident's nurse practitioner, consistently indicated that the resident was dependent on staff for mobility and that the PTA should have waited for additional assistance before proceeding. The facility's safety policy also required two or more persons to assist when necessary for resident safety. The failure to follow the care plan and facility policy directly resulted in the resident's fall and injury.
Inaccurate MDS Coding for Range of Motion Impairments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, resulting in discrepancies between the documented range of motion (ROM) impairments and the residents' actual physical abilities. For one resident, the MDS indicated limited ROM in the lower extremities and no impairment in the upper extremities, while observation revealed a contracture in the left hand and inability to flex the fingers. Another resident's MDS inconsistently documented one-sided impaired ROM across multiple assessments, despite staff interviews confirming that the resident had upper and lower extremity impaired ROM and was totally dependent on staff for activities of daily living since admission. A third resident's MDS documented one-sided impairment for ROM to upper and lower extremities, but both staff interviews and direct observation showed that the resident could move both arms and legs, assist with feeding, and hold a coffee cup unassisted. The MDS Coordinator acknowledged misunderstanding the definition of impaired ROM when coding previous MDS assessments. The facility's policy requires accurate and thorough assessments per MDS guidelines, but these requirements were not met for the residents involved.
Failure to Assist Dependent Residents with ADLs: Nail Care, Shaving, and Feeding
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for four residents who were dependent on staff for personal hygiene, eating, and grooming. Observations revealed that two residents had long, jagged, and dirty fingernails, with no documentation of refusal of nail care in their care plans. Both residents were noted to have cognitive impairments and required staff assistance for personal hygiene, yet their fingernails remained untrimmed and unclean over consecutive days. The Assistant Director of Nursing confirmed the condition of the residents' fingernails and acknowledged that CNAs are responsible for providing this care. Another resident, who required extensive assistance for bathing and showering, was observed with facial hair stubble and reported not being offered shaving services since admission, despite expressing a preference to be clean-shaven. The resident's care plan indicated a need for staff assistance, and facility policy required shaving on shower days, but records showed the resident was not shaved during a recent shower. Additionally, a resident who was dependent on staff for eating was left unattended with an untouched meal tray for an extended period, with staff confirming that assistance had not been provided until much later. Facility policies for nail care, shaving, and feeding dependent residents were not followed as observed in these cases.
Failure to Prevent and Treat Pressure Ulcers and Complete Timely Wound Assessments
Penalty
Summary
The facility failed to implement necessary interventions to prevent and treat pressure ulcers and did not complete initial wound assessments for three residents with pressure ulcers. For one resident with multiple comorbidities, including diabetes, morbid obesity, and chronic kidney disease, the care plan required a specialized air mattress and repositioning every two hours. However, the resident was observed without the required air mattress on multiple occasions and remained in a wheelchair for extended periods. The resident and a family member confirmed the absence of the air mattress and prolonged time spent in the wheelchair. The Assistant Director of Nursing verified that the resident should have had a special mattress and regular repositioning, which was not provided. Another resident, who was dependent on staff for mobility and incontinent of bowel and bladder, had a history of a stage four coccyx pressure ulcer that had healed but subsequently reopened as a stage three ulcer. The care plan required turning and repositioning every two hours, but the resident was observed sitting in a wheelchair for several hours without being offered to lie down. Staff confirmed the resident was not repositioned as required. Additionally, there was no documented assessment of the reopened wound at the time it was first identified, with the initial assessment only completed two days later. The nurse responsible for the resident's care acknowledged the lack of timely documentation, and the Assistant Director of Nursing confirmed the absence of an initial wound assessment prior to the documented date. A third resident, who was dependent on staff for lower body dressing and turning in bed, had a right heel pressure ulcer and was supposed to use pressure relieving boots while in bed. The resident was observed in bed without the boots, with heels directly on the mattress, and the boots were found in the wheelchair. The CNA assigned to the resident was unaware of the need for pressure relieving boots and only applied them after being prompted. The care plan required the use of these boots, and the Assistant Director of Nursing confirmed this intervention was not followed. Additionally, there was no documented assessment of the resident's right heel pressure ulcer upon readmission, with the first assessment completed several days later. The facility's policies required timely notification and documentation of wounds, which was not adhered to in these cases.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to properly administer medications as ordered for three residents, resulting in a medication error rate of 12%, which exceeds the acceptable threshold. In one instance, a registered nurse administered Novolin Regular Insulin to a resident after the resident had already eaten lunch, rather than prior to the meal as required by the physician's sliding scale order. The nurse confirmed that the blood glucose was checked and insulin was given after the meal, contrary to the prescribed protocol. In another case, a nurse administered Metoprolol Tartrate to a resident despite the resident's heart rate being below the physician-ordered parameter of 90 beats per minute. The nurse acknowledged that the medication should not have been given under these circumstances. Additionally, a third resident received Carvedilol without the nurse checking the required blood pressure and heart rate prior to administration, as specified in the physician's order. The nurse admitted to not obtaining these vital signs before giving the medication. The facility's policy requires checking the MAR, verifying orders, and obtaining any necessary monitoring parameters before administering medications.
Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to medication labeling, storage, and documentation. During a review of the medication cart, it was observed that an insulin pen for one resident was not labeled with an opened date, and two insulin vials for other residents were labeled with both opened and discard dates. Additionally, a bottle of Clonazepam, a controlled medication, was found without an accompanying controlled count sheet, despite facility policy requiring such documentation for all controlled substances, including those brought from home. The Assistant Director of Nursing confirmed that controlled medications from outside sources should be counted and documented upon arrival. The facility's policies also require that all medications be stored in locked compartments and that multi-dose containers be labeled with opened dates, which was not consistently followed. In a separate incident, a resident was found asleep in bed holding a medication cup containing several pills. The LPN stated that the medications had been given earlier and that the resident typically self-administers them, but there was no physician order or care plan documentation permitting self-administration or bedside storage of medications. The ADON confirmed that nurses are required to observe residents taking their medications and that no residents were currently approved for self-administration. These findings demonstrate failures to adhere to facility policies and accepted professional standards regarding medication labeling, storage, and administration.
Failure to Implement Infection Control Precautions and Equipment Disinfection
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents exhibiting symptoms of respiratory infection and during blood glucose monitoring. Two residents with respiratory symptoms, including one diagnosed with pneumonia and another with a non-productive cough and fever, were not placed on contact or droplet precautions as required by facility policy and CDC guidelines. Observations revealed that neither resident had transmission-based precaution signage on their doors, nor was personal protective equipment available outside their rooms. Both residents were observed coughing frequently, with one unable to practice respiratory hygiene and seen contaminating bed linens, and both were allowed to interact with other residents in communal areas without precautions in place. Additionally, a registered nurse failed to disinfect a blood glucose meter after use on a resident, contrary to the facility's policy requiring cleaning and disinfection after each use with an EPA-approved cleaner. The blood glucose meter was placed on the medication cart without being sanitized, potentially contaminating the cart. The nurse was unsure of the required disinfection frequency and confirmed the lapse in protocol. The Assistant Director of Nursing later verified that bleach wipes should be used to disinfect blood glucose meters after each use.
Failure to Maintain or Improve Range of Motion and Address Contractures
Penalty
Summary
A deficiency was identified when the facility failed to maintain or improve range of motion (ROM) and address contractures for a resident with Down syndrome and adult failure to thrive, as recommended by the restorative program. Observations showed the resident had contracted hands and limited finger movement, yet the care plan did not document any interventions or goals related to ROM, contractures, or a restorative program. The resident's Minimum Data Set (MDS) indicated limited ROM in the lower extremities, but no impairment in the upper extremities, and the care plan only referenced deficits in activities of daily living (ADLs) without addressing ROM needs. Physical therapy records documented that a restorative program for ROM, transfers, and bed mobility was established and staff were educated on these interventions. However, interviews with facility staff revealed that there was no formal restorative or functional maintenance program in place for the resident, and no documentation existed to show that such interventions were being provided. Staff stated that ROM and related interventions were expected to be completed by CNAs during ADLs, but there was no evidence in the electronic health record or care plan to confirm that these tasks were being performed.
Failure to Check Gastric Residual Volume During G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse failed to check the gastric residual volume prior to administering medications and water flushes through a gastrostomy tube for a resident with a g-tube. The facility's policy and the resident's care plan both required monitoring of gastric residual volume before administering nutrition and medications. During observation, the nurse stopped the feeding, disconnected the tubing, and checked tube placement using the air rush technique, but did not check the gastric residual volume at the time of medication administration. The nurse confirmed this omission, stating that the gastric residual had only been checked earlier in the shift. The assistant director of nursing also confirmed that gastric residual volume should be checked at the time of g-tube medication administration.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state agency within the required two-hour timeframe for one resident. The resident, who had severe cognitive impairment and was dependent on staff for all mobility and care needs, was found with a shortened and rotated right leg. Nursing staff notified the resident's Power of Attorney and a Nurse Practitioner, who assessed the resident and ordered x-rays. The x-ray revealed a new comminuted fracture of the distal femur, and the resident was subsequently hospitalized for surgical repair. There was no evidence or report of a fall or trauma, and the resident was unable to explain the cause of the injury. Despite the facility's policy requiring injuries of unknown source to be reported if the cause is unobserved or unexplained, the injury was not reported to the Illinois Department of Public Health. The Administrator stated that the injury was not reported because the Nurse Practitioner did not suspect abuse due to the absence of bruising and because the physician later determined the fracture was pathological. The timeline from the initial observation to the physician's assessment and diagnosis was immediate, but the required state notification was not made.
Failure to Implement Bed Alarm as Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a fall prevention intervention as outlined in a resident's care plan. During observation, a resident was found lying in bed with a bed alarm sensor pad in place, but the sensor's cord was not plugged into the alarm module. The alarm module itself was located across the room, approximately eight feet away from the bed, making it nonfunctional. The resident did not respond verbally to greetings or questions at the time of observation. A registered nurse confirmed that the alarm was not connected as required by the care plan, which specified the use of a bed alarm for safety and increased supervision in the resident's room. The care plan interventions had been initiated prior to the observation, but the required equipment was not properly set up, resulting in the failure to provide the intended fall prevention measures.
Failure to Implement and Document Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement and document appropriate pressure ulcer prevention and care for three residents, leading to the development and deterioration of pressure ulcers. Resident R4, who had moderate cognitive impairment and was dependent on staff for mobility, developed a stage two pressure ulcer that worsened to an unstageable ulcer. The facility did not implement a turning and repositioning schedule until after the ulcer had deteriorated, and there was no documentation of pressure relieving interventions prior to the ulcer's development. Additionally, R4's nutritional status was not evaluated by a Registered Dietitian after the ulcer was identified, despite significant weight loss and a low albumin level. Resident R3 had discrepancies in wound assessments, with the facility's electronic software system preventing corrections to staging errors. R3's coccyx wound was initially staged incorrectly, and the left buttock pressure ulcer was documented as being on the right buttock. These documentation errors contributed to inadequate wound management and care planning. Resident R1 was recommended to have a low air loss mattress for wound prevention, but there was no documentation that this intervention was implemented. CNAs who cared for R1 did not recall the presence of an air mattress, and the Director of Nursing confirmed the lack of documentation. These failures in implementing and documenting pressure ulcer prevention measures contributed to the residents' declining skin integrity and the development of facility-acquired pressure ulcers.
Failure to Reposition Dependent Resident
Penalty
Summary
The facility failed to ensure that a dependent resident received necessary repositioning, as required by their care plan. On multiple observations throughout the morning and early afternoon, the resident was seen sitting upright in a reclining geriatric chair without being repositioned. A Certified Nursing Assistant confirmed that the resident was not laid down until the early afternoon, despite being up since late morning. This lack of repositioning was a concern previously raised by the resident's spouse in a grievance, indicating that the resident was not being repositioned throughout the day as needed. The resident's care plan specifically required total assistance with transfers and repositioning every two hours and as needed, which was not adhered to during the observed period.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately identify and assess significant weight loss in a resident, referred to as R3, and did not ensure that the resident's nutrition and weight loss were evaluated by a physician and dietitian in a timely manner. R3 experienced a total weight loss of 20.61% from May 2024 to February 2025, with significant losses noted over three and six-month periods. Despite this, R3's care plan did not document the significant weight loss, and there was no evidence of evaluation by a dietitian prior to February 4, 2025, or by a physician after November 26, 2024. Observations revealed that R3 consumed only a small portion of meals, with many instances of meal refusals and low intake percentages recorded. The resident's meal intake records showed numerous entries of 0-25% consumption and several refusals, indicating a persistent issue with food intake. Additionally, R3 had pressure ulcers, which were not adequately addressed in relation to the resident's nutritional needs. The facility's policy required weekly weights and dietary recommendations for residents with significant weight loss, but these were not consistently followed. Interviews with facility staff, including the Director of Nursing and the Registered Dietitian, confirmed the lack of timely evaluation and documentation of R3's weight loss. The dietitian noted that significant weight loss should trigger a nutritional evaluation and physician notification, which did not occur until February 2025. The facility's failure to adhere to its own policies and procedures regarding weight monitoring and nutritional assessment contributed to the deficiency in care for R3.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with pressure ulcers, as observed during a survey. The facility's policy requires the use of gloves and gowns during high-contact care activities for residents with wounds or indwelling medical devices to prevent the transfer of Multidrug Resistant Organisms (MDROs). However, the survey found that there was no EBP signage or personal protective equipment (PPE) carts near the rooms of the affected residents, and staff were not wearing the required gowns during care activities. For one resident, R3, who had pressure ulcers on the left buttock and coccyx, there was no EBP signage on the room door, and staff were observed not wearing gowns during repositioning. The Assistant Director of Nursing (ADON) confirmed the absence of signage and stated that the EBP order was not reinstated after the resident's contact isolation ended. Similarly, for another resident, R4, with a coccyx pressure ulcer, there was no EBP signage or PPE cart, and staff were observed not wearing gowns during care activities. The ADON confirmed the lack of signage and EBP orders for R4 prior to the survey. Additionally, for resident R1, there was no documentation of EBP in the electronic medical record, and staff were unsure if EBP was required. Staff members reported using gloves and masks but could not recall wearing gowns or seeing EBP signage. The Director of Nursing confirmed the absence of EBP documentation for R1. These findings indicate a failure to adhere to the facility's EBP policy, resulting in inadequate infection prevention measures for residents with pressure ulcers.
Failure to Monitor and Document Resident's Wound
Penalty
Summary
The facility failed to routinely assess and monitor a bruise/hematoma on a resident's left foot, update the physician, and assess and measure post-surgical wounds upon readmission. The resident, who had diagnoses of Peripheral Vascular Disease and Type 2 Diabetes Mellitus, developed a bruise on the left foot after a mechanical lift transfer. Initial documentation noted the bruise, but subsequent weekly skin assessments failed to document the bruise or any changes, and there was no physician notification or assessment until the resident was hospitalized. Upon hospitalization, the resident was diagnosed with septic shock and a left foot abscess, requiring intravenous antibiotics and surgical intervention to drain the hematoma. The facility's records lacked documentation of assessments or monitoring of the bruise after the initial identification, and the wound nurse was not informed of the bruise due to being on vacation. The facility's policies required significant bruises to be monitored weekly and physician notification for changes in condition, which were not followed in this case. After readmission, the resident had multiple wounds on the left foot, but the initial readmission assessment incorrectly documented these as being on the right foot, and no measurements were taken. The wound nurse later assessed the wounds, but the initial lack of documentation and monitoring contributed to the deficiency. The facility's policies outlined procedures for documenting and monitoring wounds, which were not adhered to, leading to the resident's condition worsening and requiring hospitalization.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident with moderate cognitive impairment and significant physical limitations, including right-sided hemiplegia/hemiparesis following a cerebral infarction and Type 2 Diabetes Mellitus. The resident required substantial assistance for personal hygiene, as documented in their care plan. During an observation, a Certified Nursing Assistant (CNA) provided incontinence care and washed the resident's face and underarms but did not offer or provide nail care, despite the resident's fingernails being long and dirty with a black substance underneath. The resident expressed a desire for their nails to be cleaned and trimmed, stating that staff typically perform this task every three days, but it had not been done for two days. Later, the CNA acknowledged the condition of the resident's nails and stated that nail care is usually performed twice a week during bathing or showers. The CNA confirmed that the resident's nails were long and dirty and mentioned that nurses are responsible for trimming the nails of diabetic residents. The facility's policy on nail care emphasizes maintaining cleanliness, preventing infection, and ensuring comfort, but this was not adhered to in the resident's case.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement appropriate pressure ulcer care and prevention measures for two residents, leading to the development and lack of proper assessment of pressure ulcers. For the first resident, the facility did not adhere to the care plan that required repositioning every two hours and the use of pillows to offload pressure. The resident, who was incontinent and required substantial assistance, was found with a wet brief and two open wounds, one of which was a stage two pressure ulcer. The wounds were not documented or reported to the physician until the surveyor's observation, indicating a lapse in communication and documentation by the nursing staff. The second resident, who had a stage three pressure ulcer on the right heel, was not positioned correctly to offload pressure from the heels. The resident's care plan included interventions to float the heels using a wedge cushion, but the cushion was improperly placed, causing the heels to rest on the mattress. This improper positioning was observed multiple times, and the staff failed to ensure the heels were floated as required by the care plan. The resident's medical history included conditions such as diabetes and peripheral vascular disease, which increased the risk for skin integrity issues. The facility's guidelines and policies for skin and wound management were not followed, as evidenced by the lack of immediate implementation of pressure-relieving interventions and inadequate monitoring of wounds. The wound nurse was not informed of the new wounds, and there was no documentation of physician notification or updated care plans to address the residents' pressure ulcers. This indicates a systemic issue in communication and adherence to established protocols for wound care management.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement effective fall interventions for three residents, resulting in significant injuries. Resident 1, who had a history of falls and was identified as a high fall risk, fell multiple times despite being placed near the nurse's station for supervision. The interventions, such as redirecting and checking metabolic panels, were ineffective. This resident sustained a head laceration requiring nine sutures and an arterial bleed after falling twice within a short period. The Director of Nursing acknowledged that more effective interventions could have prevented the second fall. Resident 2, also identified as a high fall risk, fell while trying to move her walker and sustained bilateral wrist fractures. The intervention to move her bed was insufficient, and the facility delayed obtaining stat X-rays, which were eventually performed days later. This delay in diagnosis and treatment resulted in the resident requiring bilateral splints and increased assistance with daily activities. Resident 3, with severe cognitive impairment and a high fall risk, fell twice within a week. The first fall occurred due to a broken toilet grab bar, and the second fall resulted in a large skin tear. The intervention to obtain a urine culture was ineffective as it returned negative. Staff members noted that this resident required close supervision and frequent reminders to sit down, indicating that the interventions in place were not adequate to prevent falls.
Failure to Timely Notify Physician of Resident's Wounds
Penalty
Summary
The facility failed to timely notify the physician of newly developed, draining wounds for one resident. The resident was readmitted from the hospital and initially had bruising to the groin and abdomen, but no wounds were documented at that time. On a subsequent date, a CNA discovered three new open areas with green pus above the resident's penis. The wounds were cleaned, and a dressing was placed, but there was no documentation that the physician was notified of these wounds on the day they were found. The physician was only notified the following day when antibiotics were ordered. The facility's Registered Nurse/Wound Nurse confirmed that the physician should have been notified immediately and that green pus is a sign of infection. The facility's policy requires the physician to be notified of changes in the resident's condition, including symptoms of infection and pressure sores. The facility's guidelines also state that if the wound nurse is not available, the nurse on duty is responsible for notifying the physician to obtain treatment orders. The failure to notify the physician promptly led to a delay in treatment for the resident's wounds.
Deficiencies in Wound Care and Hydration Monitoring
Penalty
Summary
The facility failed to culture a resident's draining wound prior to initiating antibiotics, assess a resident's surgical incision upon admission, and accurately transcribe wound treatment orders for three residents. One resident was readmitted from the hospital with no documentation of abdominal wounds, but later developed open areas with green pus. Antibiotics were administered without a wound culture, and the wound was not evaluated by the wound physician until much later. Another resident with a surgical above-knee amputation had no initial wound measurements or descriptions documented upon readmission. The wound nurse confirmed that wounds should be assessed and measured upon admission, but this was not done in this case. A third resident had a right heel wound that was not transcribed correctly in the electronic medical record, leading to incorrect administration of wound treatments. The facility also failed to monitor and record fluid intake for one resident. The resident's care plan documented specific fluid needs, but there was no routine recording of fluid intake besides the evening snack intake. The Director of Nursing confirmed that meal intakes documented only the percentage consumed and not the fluid intake amounts. The facility's policy on hydration and prevention of dehydration was not followed, as fluid intake was not monitored and documented as required. These deficiencies highlight significant lapses in wound care management and hydration monitoring. The facility's policies on antibiotic stewardship, skin and wound management, and hydration were not adhered to, leading to inadequate care for the residents involved. The lack of proper documentation, assessment, and follow-up contributed to the deficiencies observed during the survey.
Failure to Assess and Measure Pressure Ulcer Upon Admission
Penalty
Summary
The facility failed to assess and measure a pressure ulcer upon admission for one resident (R2). R2 was readmitted from the hospital and had an unstageable coccyx wound documented in the Nurses Weekly Skin assessment. However, there were no measurements or descriptions of the wound in R2's medical record until the following day. The Wound Summary later documented the wound's characteristics and measurements. During an observation, the wound nurse and wound physician assessed the wound, noting its size and condition. The wound nurse confirmed that wounds should be assessed and measured upon admission, as per the facility's Skin and Wound Management Guidelines, which were not followed in this case.
Unqualified Dietary Manager and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, potentially affecting all 96 residents. The Dietary Manager (DM), who was actively supervising dietary operations, admitted to not having completed the required DM education due to high staff turnover. Observations revealed significant cleanliness issues, including rust, grease, and food debris on a commercial table top mixer, and a buildup of grease, metal fragments, and rust on a commercial can opener. The Administrator confirmed that the DM lacks the necessary qualifications and has been enrolled in an online Dietary Manager course since the previous year.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illness affecting all 96 residents. During an initial tour of the kitchen, the cook identified the commercial-sized table-top mixer and can opener as clean. However, upon further inspection by the Dietary Manager, it was confirmed that the mixer had a buildup of rust, grease, and food debris on the underplate directly over the mixing bowl. Additionally, the can opener had a buildup of grease, metal fragments, rust, and a peeling silver laminate coating, with a brown and black sticky substance present in the can opener shaft holder sleeve. These unsanitary conditions were acknowledged by the Dietary Manager, who stated that they needed to be addressed.
Failure to Ensure Required QAA Meeting Attendance
Penalty
Summary
The facility failed to have the required members attend Quarterly Quality Assurance (QAA) meetings, potentially affecting all 96 residents. The facility's QAA meeting attendance forms from 6/6/23 through 4/20/24 showed that the Infection Preventionist was not present on 6/26/23, and the Medical Director only provided a verbal review on 11/21/23 and 4/20/24. The Administrator confirmed that the Medical Director's verbal review was not sufficient and that the Infection Preventionist's absence was not compliant with the required attendance. The QAA Committee list indicated that specific members, including the Administrator, Director of Nursing, and Medical Director, among others, needed to be present for the meetings, but this requirement was not met during the specified dates.
Failure to Ensure Residents' Dignity and Timely Care
Penalty
Summary
The facility failed to ensure residents' rights to dignified activities of daily living, affecting six residents. Residents reported that call lights were often left unanswered for hours, leading to prolonged periods of incontinence without timely care. One resident mentioned being left in a soiled bed for hours, causing embarrassment and frustration, while another resident's family member confirmed finding their relative in a similar state multiple times. The facility's policy requires staff to provide incontinence care every two hours, but this was not consistently followed, as evidenced by the residents' and family members' testimonies. A registered nurse acknowledged that residents were not changed in a timely manner, attributing it to the residents' refusal, which was contradicted by the residents' statements. The facility's Resident Council Group Meeting Notes also documented complaints about delayed responses to call lights. Additionally, a family member of another resident reported that the facility was often short-staffed, particularly on nights and weekends, leading to inadequate care. This family member observed staff hiding and using their phones instead of attending to residents' needs. Several residents expressed their dissatisfaction with the care provided, noting that they often waited for extended periods before receiving assistance. One resident mentioned feeling weak and at risk of passing out due to being left in a wheelchair for hours. The facility's failure to respond promptly to call lights and provide timely incontinence care compromised the residents' dignity and well-being, as documented by the surveyors' observations and interviews with residents and their family members.
Inaccurate MDS Encoding for Dialysis Treatment
Penalty
Summary
The facility failed to accurately encode a resident's health status on the Resident Assessment Instrument (Minimum Data Set) regarding dialysis. This deficiency was identified during an observation, interview, and record review. A resident, who had a dressing on their left upper arm covering a dialysis port, stated they go to an outside facility for dialysis treatment three times per week. The resident's Physician Order Sheet confirmed the dialysis schedule. However, the resident's MDS, which indicated no cognitive impairment, failed to document the dialysis treatments. The Administrator/Registered Nurse acknowledged the inaccuracy in the MDS encoding.
Failure to Provide PRN Dressing Changes
Penalty
Summary
The facility failed to provide PRN dressing changes for a resident (R7) as per the physician's orders. R7, who has multiple medical diagnoses including pyogenic arthritis, type 2 diabetes mellitus, and a methicillin-susceptible Staphylococcus aureus infection, had orders for daily and PRN dressing changes for a left knee wound. On two consecutive days, observations revealed that R7's left knee dressing was saturated with a light red and brown substance, indicating it had not been changed as needed. Both times, registered nurses acknowledged that the dressing should have been changed earlier due to its saturated state. The facility's Dressing Change Policy, revised in February 2024, states that the purpose of a dressing change is to protect the wound from contamination, absorb drainage, prevent infection, and promote healing. Despite this policy, the facility did not adhere to the PRN dressing change orders, resulting in R7's dressing remaining saturated and potentially compromising the wound's condition. The failure to change the dressing as needed was confirmed by two registered nurses who stated that the dressing should have been changed more frequently than once a day given its saturated state.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to provide and implement fall interventions to prevent falls for a resident (R29). R29 had multiple diagnoses, including malignant neoplasm of the pancreas, secondary malignant neoplasm of the liver, spinal stenosis, and abnormalities of gait and mobility. Despite being at high risk for falls and requiring supervision and assistance with toileting and transfers, R29 experienced several unwitnessed falls. The care plan included interventions such as a bed alarm, non-skid socks, and prompt response to call lights, but these were not consistently implemented or effective in preventing falls. R29's fall investigations revealed multiple incidents where the resident fell due to ambulating without a walker, improper footwear, and attempting to use the bathroom without assistance. The falls resulted in injuries, including a forehead hematoma and dizziness, requiring hospital evaluation. The facility's Director of Nursing (DON) acknowledged that the interventions were not adequately addressed or updated to prevent further falls. Additionally, the resident's call lights were often out of reach, and the bed alarm was found unplugged and non-functional. Interviews with staff and the resident confirmed that R29 frequently waited for long periods for assistance, leading to attempts to ambulate independently. The Occupational Therapist and Physical Therapy Assistant noted that R29's condition worsened due to chemotherapy, requiring more assistance. Despite these needs, the facility did not ensure close supervision or timely response to call lights, contributing to the resident's repeated falls and injuries.
Failure to Administer IV Antibiotics Due to PICC Line Issues
Penalty
Summary
The facility failed to administer two physician-ordered intravenous antibiotic medications on two consecutive days, resulting in a delay in treatment for a resident diagnosed with Pyogenic Arthritis, Type 2 Diabetes Mellitus, Morbid Obesity, and a Methicillin-resistant Staphylococcus Aureus (MRSA) infection. The resident's Medication Administration Record (MAR) indicated that the intravenous antibiotics Vancomycin and Ertapenem were not administered due to issues with the resident's peripherally inserted central catheter (PICC) line, which had infiltrated and caused swelling in the resident's arm. Despite the facility's attempts to contact the entity responsible for PICC line placement, there was a delay in replacing the PICC line, leading to missed doses of the antibiotics on two consecutive days. The resident's nursing notes and interviews with staff confirmed that the PICC line was removed due to infiltration, and there were delays in coordinating the replacement of the PICC line. The Director of Nursing acknowledged that the resident did not receive the required doses of Vancomycin and Ertapenem on the specified dates and stated that the resident should have been sent to the hospital for a new PICC line to ensure the continuation of the ordered IV antibiotics. The failure to administer the antibiotics as prescribed resulted in a significant medication error and a delay in the resident's treatment for the MRSA infection.
Failure to Maintain Accurate Medical Records for Dialysis Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident undergoing dialysis. The resident, who has no cognitive impairment, had an undated gauze wound dressing on their left upper arm covering a dialysis fistula port. The resident reported that the facility nurses did not assess the dialysis port fistula patency by thrill and bruit. The Physician Order Sheet (POS) documented the need for dialysis three times per week and required checks for signs of infection and patency of the AV shunt. However, the POS had an incomplete order for how often the thrill and bruit checks should be completed. The Treatment Administration Record (TAR) for the month showed no nurse initials indicating that the required assessments were completed, with an X symbol populating the entire record. The Director of Nursing (DON) confirmed that the nurses were supposed to sign off the TAR but did not, due to an error in the electronic medical record entry by the physician. The facility's dialysis protocol policy, revised in August 2022, states that nursing is responsible for providing care for dialysis residents, but this was not adhered to in this case.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during high-contact resident wound care activities. Specifically, a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) did not wear gowns while performing wound care on a resident with multiple diagnoses, including Type II Diabetes Mellitus, gangrene, and recent left above-knee amputation. The resident had enhanced barrier precautions in place, which required the use of gowns and gloves during high-contact care activities to prevent the transfer of multi-drug resistant organisms (MDROs). During the observation, the RN and CNA entered the resident's room, donned gloves, but did not put on gowns as required by the facility's infection control policy. The RN proceeded to remove and replace the resident's soiled and bloody dressings on both the left above-knee amputation and a coccyx pressure ulcer without wearing a gown. The RN acknowledged the mistake, attributing it to nervousness due to being observed by a surveyor. The facility's infection control policy mandates the use of gowns and gloves during high-contact care activities, such as wound care, to prevent the spread of MDROs. The RN admitted awareness of the policy and recognized the failure to comply as a significant infection control issue. The policy specifically lists wound care as an activity requiring enhanced barrier precautions, which were not followed in this instance, leading to the deficiency noted in the report.
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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