Accolade Healthcare Of Savoy
Inspection history, citations, penalties and survey trends for this long-term care facility in Savoy, Illinois.
- Location
- 302 West Burwash, Savoy, Illinois 61874
- CMS Provider Number
- 145439
- Inspections on file
- 74
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Accolade Healthcare Of Savoy during CMS and state inspections, most recent first.
The facility failed to reasonably accommodate residents’ needs by not keeping call lights within reach for multiple residents and not maintaining a functional electric bed for a resident’s toileting independence. Several residents with conditions such as dementia, weakness, deconditioning, incontinence, hemiplegia, and impaired mobility were observed in bed or in wheelchairs without accessible call lights, with call cords found on the floor, under beds, or draped out of reach while they requested help for needs such as toileting, warmth, and fluids. Another resident with paraplegia and significant mobility impairments relied on an electric bed and bedside commode for independent bowel and bladder toileting but reported that the bed remote had malfunctioned intermittently for months, leaving the bed at a height mismatch with the commode and requiring the resident to manipulate exposed wires to adjust the bed. Maintenance records documented repeated problems with the bed remote, and an LPN confirmed the resident is reliable in reporting care concerns.
The facility failed to prevent accidents by not providing adequate supervision and not controlling environmental hazards for three residents. A resident with dysphagia and documented choking risk, whose care plan required supervised meals, was observed eating lunch alone in bed on multiple occasions after reporting a choking episode, and speech therapy was not promptly engaged despite prior recommendations for supervised dining. Another cognitively impaired, fully dependent resident ingested shampoo/body wash that had been left within reach, later developing vomiting, diarrhea, and low oxygen saturation, necessitating ER transfer, even though the product was labeled for external use only. A third resident with dementia, severe cognitive impairment, a history of falls, and high fall risk experienced an unwitnessed fall after staff propped open a keypad-locked central bathroom door that was supposed to remain locked and only used with staff supervision.
A resident with severe cognitive impairment had multiple elevated blood glucose readings documented, but staff did not notify the physician as required by both physician orders and facility policy. The DON and NP confirmed that these elevated results should have been reported, and the facility's policy mandated notification for readings above 200 mg/dl.
A resident with glaucoma did not receive prescribed Latanoprost eye drops for the first ten days of admission because the medication was not available. The resident reported the missed doses to staff, who confirmed the medication was on order. The DON verified the delay in administration, which was documented in the MAR, despite facility policy requiring timely medication administration.
A resident who was severely cognitively impaired and dependent on staff received water flushes, nutritional feeding, and medications through a G-tube without the LPN first checking tube placement, as required by physician orders and facility policy. The DON confirmed that the necessary verification was not performed before administration.
A resident with a G-Tube and severe cognitive impairment, who was on Enhanced Barrier Precautions (EBP) due to MDRO risk, received medication, water flushes, and nutritional feeding from an LPN who did not wear a gown as required by facility policy. The LPN was aware of the EBP protocol, and PPE was available and signage posted, but the protocol was not followed during high-contact care activities.
Two residents with complex medical histories did not receive appropriate monitoring and reporting of blood pressures, daily weights, and urination as ordered, leading to delayed recognition and response to significant changes in their conditions. Staff failed to notify providers of abnormal findings and unsuccessful attempts to collect urine samples, and did not consistently document or resume required monitoring after hospital readmissions, resulting in delayed treatment and adverse outcomes.
Two residents were transported in wheelchairs without foot pedals, leading to one sustaining ankle fractures after her leg dropped while being pushed by a staff member. Another resident with cognitive impairment exited the memory care unit unnoticed and was found in a nearby parking lot, with staff failing to follow the facility's missing resident policy or update the care plan after the incident.
The facility did not ensure that provider progress notes and incident reports were consistently uploaded into residents' EMRs, resulting in incomplete records for several residents. In one case, a resident's injury and the related provider note were not documented in the EMR, and in another, a resident's elopement was not recorded, nor were required notifications and procedures followed by the LPN and administrator.
A resident eloped from the memory care unit and was found by a family member in a nearby church parking lot. The LPN on duty did not assess the resident, notify the physician or power of attorney, or follow the facility's missing resident policy, including required notifications and documentation. The administrator and nurse practitioner were not informed of the incident, and the DON was only notified after the resident was found.
A resident with severe osteopenia and recent right ankle fractures was evaluated by a podiatrist, who ordered Vitamin D3 2000 units daily. The order was documented in a progress note but was not transcribed or implemented, resulting in the resident continuing to receive less than the prescribed amount of Vitamin D3. The DON confirmed that new orders from specialty appointments were not communicated to the facility, leading to the deficiency.
A resident did not receive prescribed doses of Metoprolol, Midodrine, and Novolog insulin after a hospital discharge because an ADON mistakenly discontinued the medications, believing the resident was still hospitalized. The medications were not properly resumed, and there was no documentation explaining the missed doses or physician notification, resulting in significant medication errors.
A CNA took an unauthorized video of a resident with severe cognitive impairment and multiple diagnoses, using a personal cell phone and storing the video in personal cloud storage accessible to others. This action violated facility policy prohibiting the recording of residents and compromised the resident's right to privacy.
A resident experienced a fall that was not reported by a CNA to the licensed nurse, resulting in a lack of notification to the resident's physician and family. The incident was not documented in the medical record, and the family member only learned of the fall through informal means. Facility policy requiring prompt reporting of accidents and incidents was not followed.
A resident experienced a fall that was not reported to a licensed nurse, resulting in the resident being moved from the floor by CNAs without a nursing or neurological assessment. The incident was only discovered after a family member raised concerns, despite facility policy requiring nurse notification and assessment before moving a resident after a fall.
A resident with severe cognitive impairment and a history of potential for abuse was verbally abused with a racial slur and then physically struck on the head by another resident, despite care plan interventions and staff presence. The incident was witnessed by an LPN and occurred in the presence of the physically intact resident’s daughter. No injuries were noted after assessment.
A resident with severe cognitive impairment and a history of bruising was found with a large, unexplained bruise on the right upper extremity. Nursing staff documented and reported the injury internally, but the facility did not report the incident to the state agency as required, assuming it was related to the resident's medical history and anticoagulant use. This action was not in accordance with facility policy, which mandates reporting injuries of unknown origin to the state within 24 hours.
A resident with pressure ulcers did not receive proper Enhanced Barrier Precautions (EBP) during wound care, as two nurses performed the procedure without donning gowns, despite facility policy and orders requiring gown and glove use for high-contact care. The staff mistakenly believed EBP supplies were for the roommate, and the DON confirmed EBP should have been followed.
A resident who experienced a fall was initially assessed with no pain, but later developed significant left hip pain that was reported by therapy staff to nursing. There was a delay in notifying the provider and in obtaining a STAT x-ray, resulting in a delayed diagnosis and treatment of a hip fracture. Staff interviews and documentation revealed lapses in communication and failure to follow acute change protocols.
The facility failed to provide adequate care for residents dependent on staff for activities of daily living. A resident was admitted to the hospital with poor oral hygiene and had not been bathed or received oral care since returning. Another resident lacked oral care supplies and assistance, while a third was found saturated in urine and with old feces, indicating neglect in toileting care. The DON confirmed these deficiencies, stating the care provided was unacceptable.
A facility failed to identify and manage pressure ulcers for a resident returning from the hospital. The resident had stage two pressure wounds and a deep tissue injury, which were not assessed or treated by staff. The LPN did not perform a full skin check, and the wound nurse was not informed. The facility did not notify the treatment nurse, physician, or family, and there were no treatment orders or interventions in place.
The facility failed to accurately encode MDS for three residents, leading to incorrect documentation of falls and injury severity. One resident had multiple falls, including a major injury, but the MDS recorded only minor injuries. Another resident had a major injury from a fall, but the MDS documented only one fall with injury. A third resident's fall with a skin tear was recorded as a fall with no injury. The DON and RN Manager confirmed these inaccuracies.
The facility failed to obtain weights per physician orders for two residents and did not adequately monitor an at-risk resident for weight loss. One resident experienced severe weight loss without a proper care plan or notification to their representative. Another resident with congestive heart failure was not weighed daily as required, missing 53 daily weights. A third resident, nutritionally at risk due to renal dialysis, was also not weighed according to orders, with several weights missed. The facility acknowledged these deficiencies.
A resident with End Stage Renal Disease was hospitalized due to a central venous catheter infection after the facility failed to monitor the dialysis access site and maintain communication with the dialysis center. The facility's protocol required nursing staff to assess the site and communicate any changes, but these actions were not documented, leading to the resident's infection and hospitalization.
The facility failed to implement fall interventions for three residents, including ensuring a resident wore a required back brace, completing quarterly fall risk assessments, and maintaining functional call light systems. These deficiencies were confirmed by staff and observed during a survey.
A resident with severe cognitive impairment tested positive for COVID-19, but the facility failed to notify the family representative and healthcare providers of this diagnosis and subsequent changes in the resident's condition, including lethargy and abnormal lung sounds. The facility's policies require such notifications, but documentation was lacking.
A facility failed to document the application of a physician-ordered TLSO back brace for a resident with dementia and vertebral fractures. The Electronic Medication/Treatment Administration Records lacked nurse initials to confirm the brace was applied, due to an error by the admissions nurse in setting up the administration record option.
A resident admitted after joint replacement surgery did not receive prescribed Oxycodone for pain due to unavailability at the facility. The nurse on duty failed to contact medical staff for an alternative, resulting in the resident experiencing severe pain until the next day when the Nurse Practitioner intervened.
A facility failed to manage a resident's PICC line, which was necessary for administering IV antibiotics for osteomyelitis. The facility's policy required regular dressing changes to prevent infections, but no changes were documented until after the PICC line fell out, necessitating a peripheral IV. The oversight was confirmed by the ADON, who acknowledged that no dressing changes were performed since the resident's admission.
The facility failed to maintain residents' dignity by not responding to call lights in a timely manner, affecting several residents. Reports indicated wait times of up to 45 minutes, with staff sometimes turning off call lights without returning. Resident Council Meeting Minutes documented ongoing concerns, and a printout showed over 650 instances of delayed responses. Staffing levels appeared inadequate, contributing to prolonged response times.
The facility failed to maintain clean and safe bathroom flooring, affecting 15 residents. Observations revealed ground-in dirt, stains, and trip hazards due to cracks and loose edges in the vinyl floors. The Maintenance Director and Administrator acknowledged the issues, with the former expressing a desire to replace the vinyl with epoxy floors.
A resident's family member reported that a CNA startled the resident awake and was rude during care. The facility failed to report this allegation of mental abuse to the state agency within the required 2-hour timeframe, as mandated by their policy. The incident was only reported after a surveyor's intervention.
Two residents were affected by misappropriation of property by facility staff, with one resident experiencing unauthorized transactions totaling $1,515.96. The facility's investigation revealed that a CNA took photographs of residents' personal information, violating facility policy. The implicated CNA was suspended following the discovery.
A CNA at a facility was found to have taken unauthorized photographs of two residents' personal items, including debit cards and a Social Security card, and shared them with another individual. This breach of the facility's Abuse Prevention Program led to fraudulent transactions on one resident's account, causing financial distress. The CNA denied the allegations and was terminated.
The facility failed to ensure fall interventions and safety measures were in place, affecting three residents. One resident fell from a low air loss mattress due to improper positioning, another fell while trying to reach for a drink with no fall mat or call light within reach, and a third fell attempting to sit in a rolling chair left unattended in a dementia unit.
A resident with no cognitive impairment and frequent incontinence reported feeling humiliated by a CNA who questioned her about wearing a diaper and needing to use the bathroom. The facility's policy on resident dignity was not followed, leading to a dignity issue for the resident.
The facility failed to protect a resident from verbal and mental abuse by another resident with severe cognitive impairment. The abusive resident accused the other of theft, used racial slurs, and caused fear and distress. Despite staff intervention, the abusive behavior continued, highlighting a deficiency in the facility's abuse prevention measures.
The facility failed to ensure an allegation of physical and verbal abuse by one resident towards another was reported to the Administrator/Abuse Prevention Coordinator. This resulted in both residents continuing to reside in the same bedroom, potentially subjecting one resident to further abuse. The incident was documented by an LPN but not properly escalated, leading to a delay in addressing the abuse allegations.
A resident with multiple medical conditions fell during a mechanical lift transfer when a CNA attempted the transfer alone, contrary to the facility's policy requiring two staff members. The resident fell out of the sling, hitting her buttocks and head, and was sent to the Emergency Department but returned with no injuries.
Failure to Maintain Accessible Call Lights and Functional Electric Bed for Toileting Independence
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not maintaining call lights within reach for multiple residents and not ensuring a consistently functional electric bed for toileting independence. The facility’s own Call Lights policy required staff to keep call lights within easy reach when a resident is in bed or in a chair. Surveyors observed five residents in their rooms without accessible call lights: one resident in a wheelchair in a room smelling of bowel movement, who stated she was soiled and waiting for staff but had her call light coiled on the floor out of reach; another resident in a wheelchair who wanted fresh ice water but could not reach a call light hanging over a folded fall mat; a resident sitting on the side of a bed that was soiled with urine, with the call light coiled on the floor by the wall; a resident sitting on her bed asking for help who did not know where her call light was, later found on the floor under the bed; and another resident sitting on her bed, asking for help because she was cold and needed a blanket, whose call light was coiled on the floor out of reach. Care plans for these residents documented risks such as falls, dementia, weakness, deconditioning, incontinence, vision and hearing problems, hemiplegia, confusion, and the need for staff assistance with ADLs, and directed staff to keep call lights within reach and encourage their use. The deficiency also includes the facility’s failure to ensure an electric bed remained consistently functional for a resident who relied on it to maintain toileting independence. This resident, with diagnoses including paraplegia, muscle wasting and atrophy, abnormality of gait and mobility, and lack of coordination, was unable to walk and used a wheelchair. The resident reported independent use of a bedside commode for bowel and bladder toileting, facilitated by raising and lowering the electric bed with a remote to match the commode height for transfers. The resident stated the bed remote had been intermittently malfunctioning for months, causing the bed to become stuck at a higher position than the commode and making transfers back into bed difficult, with the commode sliding on the floor during attempts to transfer. The resident reported informing staff numerous times about the malfunctioning remote without timely resolution and described having to manipulate the wires to operate the bed. When the surveyor observed the resident attempting to use the remote, the buttons did not work, and the facility maintenance log documented issues with wires hanging from the remote and the remote not working on multiple prior dates. An LPN familiar with the resident reported that the resident does not make false statements about staff and nursing care.
Failure to Prevent Accidents Through Adequate Supervision and Hazard Control
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement interventions to prevent accidents for multiple residents. One resident with dysphagia, hemiplegia, vascular dementia, and a care plan identifying a swallowing problem and risk for choking and aspiration was ordered a mechanical soft diet and required supervision while eating. The resident’s MDS documented that she coughed or choked during meals and had complaints of difficulty or pain with swallowing. A nurse’s progress note recorded that the resident reported a choking episode during a noon meal, with a short instance of labored breathing, and that her diet was downgraded and a referral to speech therapy was entered. Despite this, surveyors observed the resident eating lunch in bed in her room on two separate dates without staff supervision. The Director of Therapy confirmed that therapy had not been promptly notified of the choking episode and that prior speech therapy discharge recommendations included supervised dining and upright posture. Another deficiency involved a resident with cognitive impairment, dependence for all ADLs, inattention, disorganized thinking, and bowel and bladder incontinence who ingested an unknown amount of shampoo and body wash. An incident report documented that a CNA entered the room and observed the resident holding the bottle with the lid off, stating it tasted good and offering a drink. The CNA removed and discarded the bottle and notified an LPN. The incident report and staff interviews indicated that the resident subsequently vomited, developed diarrhea, and had decreased oxygen saturation with abnormal lung sounds, leading to transfer to the ER. The manufacturer’s safety data sheet for the product specified it was for external use only and to consult a physician if ingested. The DON acknowledged that the shampoo/body wash should not have been left where the resident could reach and drink it. A third deficiency concerned a resident with dementia, osteoporosis, osteoarthritis, severely impaired cognition, a history of falls, and a high fall risk score who resided on the memory care unit. A fall investigation documented that the resident had an unwitnessed fall and was found on the ground at the doorway to a central bathroom. The investigation and subsequent interview with the Dementia Unit Director indicated that staff had propped the central bathroom door open, allowing the resident to access the bathroom independently. The central bathroom was observed with a keypad lock, and the Dementia Unit Director stated the door was supposed to remain shut and locked at all times, with residents only accessing the bathroom under staff supervision. This sequence of events showed that the door was not maintained in the required locked state, contributing to the resident’s unwitnessed fall.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of multiple elevated blood glucose levels, as required by both physician orders and facility policy. The resident in question was documented as severely cognitively impaired and had a physician order for blood glucose monitoring twice daily. Despite repeated blood glucose readings above 200 mg/dl, there was no evidence in the electronic medical record that the physician was notified of these elevated results. The medication administration record showed numerous instances where the resident's blood glucose exceeded the reporting threshold, with values ranging from 206 mg/dl to 350 mg/dl over several days. Interviews with facility staff, including the Director of Nursing and a Nurse Practitioner, confirmed that the facility's policy required staff to report any blood glucose readings above 200 mg/dl. Both staff members acknowledged that the elevated readings should have been reported to the physician, but this did not occur. The facility's policy on blood glucose monitoring, revised in June 2023, also specified that such results must be communicated to the physician or according to physician-ordered parameters.
Failure to Administer Prescribed Eye Drops Due to Medication Unavailability
Penalty
Summary
The facility failed to administer Latanoprost 0.005% ophthalmic solution as prescribed to one resident diagnosed with glaucoma. The resident's physician order and care plan both directed staff to administer the eye drops in each eye at bedtime, starting from the date of admission. However, the medication was not available and was not administered on multiple days during the resident's initial stay, as documented in the Medication Administration Record. The resident reported not receiving the medication for the first ten days and stated that nursing staff informed him it was on order. The Director of Nursing confirmed that the medication was not available for the first ten days of the resident's admission. Facility policy requires that medications be administered timely and in accordance with orders.
Failure to Verify G-Tube Placement Prior to Medication and Feeding Administration
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to check the placement of a resident's gastrostomy tube (G-tube) prior to administering scheduled water flushes, a liquid nutritional bolus feeding, and morning medications. The resident was documented as severely cognitively impaired and fully dependent on staff for daily care. Physician orders and the resident's care plan required that the G-tube placement and gastric residual be checked and recorded before administering any feedings or medications. The LPN did not follow these orders or the facility's policy, which specifically instructed staff to verify G-tube placement before administering medications. Interviews with the LPN and the Director of Nursing (DON) confirmed that the required checks were not performed prior to the administration of substances through the G-tube. Both staff members acknowledged that there was no way to confirm whether the administered substances entered the resident's stomach as intended, since the placement was not verified. The facility's policy, revised in February 2024, also required checking G-tube placement before medication administration, which was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During G-Tube Medication Administration
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow the facility's Enhanced Barrier Precautions (EBP) protocol during medication administration for a resident with a gastrostomy tube (G-Tube) who was on EBP due to the presence of an indwelling medical device and risk for multi-drug resistant organisms (MDROs). The resident was documented as severely cognitively impaired and dependent on staff for all activities of daily living, including oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility, and transfers. The resident's care plan and physician orders required staff to use gown and gloves during high-contact care activities, such as G-Tube care, to prevent the transmission of MDROs. On the observed date, the LPN administered water flushes, medications, and nutritional bolus feeding through the resident's G-Tube without wearing a gown, despite signage and available personal protective equipment (PPE) outside the resident's room indicating EBP requirements. The LPN acknowledged awareness of the EBP protocol and the need to wear a gown during these activities. Additionally, the Director of Nursing (DON) confirmed that the LPN should have checked the placement of the G-Tube prior to administering any substances, as failure to do so could result in improper administration. The facility's policy, reviewed prior to the incident, clearly outlined the necessity of gown and glove use during high-contact care for residents on EBP.
Failure to Monitor and Report Changes in Condition for Two Residents
Penalty
Summary
The facility failed to monitor and report significant changes in condition for two residents, including not consistently tracking and reporting blood pressures, daily weights, and urination as required by physician orders and facility policy. For one resident, who had a history of heart failure, kidney disease, and recent hospitalization, there was a lack of routine documentation and provider notification regarding low urine output, low blood pressures, and weight gain. Despite orders to notify the provider for specific changes, such as no urinary output for eight hours or significant weight gain, these were not reported in a timely manner. Attempts to collect urine samples were unsuccessful over several days, and there was no documentation that the provider was notified of these failed attempts or of the resident's ongoing symptoms and abnormal findings until the resident's condition had significantly deteriorated. The resident subsequently experienced a series of acute medical events, including hyponatremia, acute kidney injury, renal failure, urinary tract infection, and required hospitalization and dialysis. Documentation shows that the resident and family had expressed concerns about urine output and fluids to staff, but these concerns were not adequately addressed or communicated to the provider. Staff interviews revealed confusion about when to escalate care, how to document and report changes, and how to follow up on orders, particularly over weekends when laboratory services were limited and there was no nurse manager present to ensure continuity of care. A second resident, also with a history of heart failure and recent hospitalizations, did not have daily weights or vital signs resumed or documented after readmission from the hospital, despite clear orders to do so. The lack of monitoring and documentation was confirmed by facility leadership, who cited issues with order entry and access to provider notes in the electronic medical record. These failures resulted in delays in recognizing and responding to changes in condition for both residents, as evidenced by the lack of timely provider notification and incomplete monitoring as required by policy and physician orders.
Failure to Prevent Accidents and Inadequate Supervision Resulting in Resident Injury and Elopement
Penalty
Summary
The facility failed to ensure the use of wheelchair foot pedals during transportation for two residents, resulting in one resident sustaining significant injury. One resident, who had recently undergone right knee replacement surgery and was admitted for rehabilitation, was transported by a physical therapy assistant in a wheelchair without foot pedals. The resident, unable to hold her leg up due to weakness and fatigue, dropped her right leg as the wheelchair crossed a threshold, causing her ankle to twist and resulting in acute nondisplaced fractures of the medial and lateral malleoli. The resident's medical records confirmed the absence of prior ankle pain or injury, and both the staff involved and the director of nursing acknowledged that the lack of foot pedals contributed to the injury. Another resident, who had a recent clavicle fracture and was receiving therapy, was also observed being transported in a wheelchair without foot pedals, requiring her to hold her feet up during transport. Staff confirmed that foot pedals were not in use and should have been applied. Additionally, the facility failed to provide adequate supervision for a cognitively impaired resident at risk for elopement. The resident, who had a documented history of dementia and was assessed as low risk for elopement, was able to exit the memory care unit through an alarmed door and was found in a nearby church parking lot by a visitor. The incident was not reported to the administrator or medical director, and the facility's missing resident policy was not followed. There was no immediate reassessment of the resident's elopement risk or update to the care plan following the incident, and required notifications and documentation were not completed as outlined in facility policy. These deficiencies were identified through observation, interviews, and record review, highlighting failures in both accident prevention during wheelchair transport and supervision of residents at risk for elopement. The lack of adherence to established safety protocols and failure to follow facility policy directly contributed to resident injury and unauthorized exit from the facility.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as required by its own policies and professional standards. For several residents, provider progress notes were not uploaded into the electronic medical record (EMR), making them inaccessible to floor nurses and not part of the official resident record. Specifically, provider notes for four residents were only available through a separate electronic health record system accessible by nurse managers, not by floor staff. Additionally, an incident involving a resident's right leg injury was documented in an incident report but not in the resident's EMR, and the related provider note was also missing from the EMR. In another case, a resident eloped from the facility, but the incident was not documented in the resident's medical record, and required notifications and procedures outlined in the facility's missing resident policy were not followed. The LPN involved did not document the elopement or the steps taken after the resident's return, and the administrator was unaware of the incident until after it occurred. The facility's policy requires thorough documentation and specific actions in the event of a missing resident, but these were not completed or recorded in the medical record.
Failure to Notify Physician and Power of Attorney After Resident Elopement
Penalty
Summary
The facility failed to notify the physician and power of attorney following an incident in which a resident eloped from the memory care unit. The resident exited the facility through an alarmed door and was found by a family member in a nearby church parking lot, approximately a football field away from the facility. The LPN on duty did not complete an assessment, notify the resident's physician or family, or follow the facility's Missing Resident Policy, which requires immediate notifications and specific actions when a resident is discovered missing. The administrator was unaware of the incident until after it occurred, and the nurse practitioner confirmed that no communication was received regarding the elopement. The Director of Nursing was informed by the LPN after the resident was found but only instructed the LPN to document the resident's exit-seeking behavior. The facility's policy mandates prompt notification of the attending physician and legal representative, as well as thorough documentation and incident reporting, none of which were completed in this case.
Failure to Transcribe and Implement Physician's Order for Vitamin D3
Penalty
Summary
A deficiency occurred when the facility failed to transcribe and implement a physician's order for Vitamin D3 2000 units daily for a resident who had sustained right ankle fractures. The resident, who had severe osteopenia and was already receiving Os-Cal Calcium plus D3 and a multivitamin, was evaluated by a podiatrist who documented the new order in a progress note. However, this order was not transcribed or implemented as of several days after the evaluation. The failure was identified during a review of the resident's records, which showed that the resident continued to receive less than the prescribed amount of Vitamin D3. The DON confirmed that new orders or progress notes from orthopedic or podiatry appointments were not communicated to the facility and had to be obtained from the electronic health records system. This lack of communication led to the omission of the physician's order for increased Vitamin D3 supplementation.
Significant Medication Errors Due to Improper Discontinuation and Lack of Documentation
Penalty
Summary
A resident was discharged from the hospital with orders for Metoprolol Succinate, Midodrine, and Novolog insulin, which were to be administered according to specific schedules. The resident's Medication Administration Record showed that these medications were discontinued after the morning dose on 7/23/25 and were not given again prior to the resident's subsequent hospitalization on the evening of 7/24/25. There was no documentation in the medical record explaining why the medications were stopped or indicating that the physician was notified about the missed doses. The Assistant Director of Nursing stated that they mistakenly believed the resident was still hospitalized and used a batch order to discontinue the medications, later attempting to resume them, but not all orders were restored due to the timing of the batch process. This resulted in missed doses of significant medications, which were acknowledged as medication errors.
Unauthorized Video Recording of Resident by CNA
Penalty
Summary
A facility failed to protect a resident's right to privacy when a Certified Nurse Aide (CNA) took an unauthorized video of a resident using a personal cell phone. The resident involved had diagnoses including dementia, hemiplegia, cerebral infarction, and major depressive disorder, and was documented as having severe cognitive impairment, being immobile, and dependent on staff for all activities of daily living. The video, which was approximately 10-12 seconds long, showed the resident fully clothed and in bed, with bedding covering the lower extremities and torso, while the resident was speaking to the CNA. The audio in the video was indecipherable. The CNA stored the video in personal digital cloud storage, which was accessible to others, including the CNA's boyfriend and his mother. The facility's employee handbook explicitly prohibits photographing or recording residents due to privacy rights, and the CNA had previously acknowledged understanding and agreeing to these policies. The incident was discovered when the video was accessed and reported by a third party, leading to facility leadership being notified.
Failure to Report Resident Fall and Notify Physician and Family
Penalty
Summary
The facility failed to report a resident's fall to the licensed nurse, which resulted in the resident's physician and family member not being notified of the incident. A Certified Nursing Assistant (CNA) found the resident on the floor by the bed, but did not immediately report the fall to the nurse on duty, as the nurse was not readily available and the CNA became occupied with other duties. The fall was not documented in the resident's medical record, and the only reference to the incident was found in the risk management section, which was not accessible to survey staff. The resident's family member and legal Power of Attorney was not informed of the fall and only learned about it through a third party. The resident's medical record did not contain documentation of the actual fall event, though it did show a post-fall neurological check and subsequent monitoring. The nurse manager confirmed that the fall was not reported by staff at the time it occurred, and that the incident was only discovered after questioning staff members. Facility policy requires that all accidents and incidents be reported to the department manager and the charge nurse so that appropriate medical attention can be provided, but this protocol was not followed in this case.
Failure to Report and Assess Resident Fall
Penalty
Summary
Facility staff failed to report a resident fall to a licensed nurse, resulting in the absence of a nursing and neurological assessment before the resident was moved from the floor. A certified nursing assistant (CNA) discovered the resident on the floor by the bed while delivering a meal tray. Unable to locate the licensed nurse, the CNA, with the help of another CNA, picked up the resident and returned them to bed without notifying the nurse on duty. The incident was only discovered when a family member inquired about the fall during a care plan conference the following day. At the time of the incident, there were at least two licensed nurses and a nurse manager present on the unit. Facility policy requires that all accidents and incidents be reported to the charge nurse, and that residents not be moved until examined by a licensed nurse. The failure to follow this policy led to the resident not being assessed for injuries or neurological changes prior to being moved after the fall.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of potential for abuse and neglect was subjected to both verbal and physical abuse by another resident. The incident involved one resident, who is dependent on staff for activities of daily living and has multiple medical diagnoses including spastic quadriplegic cerebral palsy and schizophrenia, being verbally abused with a racial slur and then physically struck on the head by another resident. The care plan for the cognitively impaired resident included interventions such as monitoring whereabouts and behaviors, and staff were instructed to intervene in potential or actual acts of abuse or neglect. The event was witnessed by an LPN, who observed the physically intact resident wheel up to the cognitively impaired resident and strike them on the head with an open palm after the latter was heard yelling a racial slur. The incident occurred in the presence of the physically intact resident’s daughter, who confirmed the verbal abuse. Both residents were assessed after the altercation, with no injuries noted. The facility’s abuse prevention policy affirms the right of residents to be free from abuse by anyone, including other residents, and requires staff to monitor and intervene as necessary. Despite these policies and care plan interventions, the facility failed to prevent the verbal and physical abuse between residents.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the state survey agency as required by its own policy and state regulations. A resident with severe cognitive impairment and multiple medical diagnoses, including atrial fibrillation and a history of bruising, was observed with significant discoloration (11 cm x 7 cm) on the right upper extremity. The injury was documented by nursing staff and reported internally to the Administrator and Director of Nursing, but no external report was made to the Illinois Department of Public Health. The facility's policy mandates that all accidents and incidents, including those of unknown origin, be reported to the department supervisor and that major injuries be reported to the state agency within 24 hours. Despite the resident's inability to explain the cause of the injury and the absence of any clear source, facility staff assumed the bruise was related to the resident's medical history and anticoagulant use. The Assistant Director of Nursing confirmed that the injury was not considered to be of unknown origin and therefore was not reported to the state agency. This omission occurred even though the facility's policy specifically requires reporting such incidents when the origin is unknown.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers, as required by facility policy and physician orders. The policy specifies that gloves and gowns must be worn during high-contact care activities for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms (MDROs). The resident in question had a stage three pressure injury on the left Achilles area and a stage four pressure injury on the left ischial area, and the care plan and physician orders both indicated that EBP should be maintained during high-contact care, including wound care and urinary catheter care. During an observation, a registered nurse and an LPN entered the resident's room and performed wound care without donning gowns, despite an EBP sign on the door instructing staff to wear gowns and gloves for such activities. Both staff members stated that they believed the EBP sign and supplies were intended for the resident's roommate, not for the resident receiving wound care. The Director of Nursing later confirmed that the resident was on EBP and that the staff should have worn gowns and gloves during the wound treatment.
Delay in Reporting and Treatment of Post-Fall Hip Fracture
Penalty
Summary
The facility failed to timely report and address post-fall pain and did not implement radiology orders promptly for a resident who experienced a fall. After the resident was found on the floor in the early morning hours, initial assessments documented bruising and abrasions but no pain, and the on-call physician was notified. However, later therapy notes indicated the resident began complaining of significant left hip pain, refused to participate in therapy, and requested an x-ray. Despite these complaints, there was a delay in notifying the physician about the pain and in obtaining the necessary diagnostic imaging. Therapy staff reported the resident's pain to nursing staff, but there was no immediate follow-up with the physician regarding the new onset of pain. An x-ray was eventually ordered as STAT, but the imaging was not performed until the following day. The nurse practitioner was not notified of the resident's pain until the day after the x-ray order was placed, at which point a STAT x-ray was again ordered and the resident was placed on nonweight bearing status. The x-ray ultimately revealed an acute nondisplaced left femoral intertrochanteric fracture, requiring surgical intervention. Interviews with staff confirmed that the resident's complaints of pain were communicated between therapy and nursing, but not escalated to the provider in a timely manner. The delay in reporting and acting on the resident's post-fall pain, as well as the delay in obtaining the ordered x-ray, resulted in a delay in diagnosis and treatment of the hip fracture. Documentation also showed that the provider was not aware of the fall or the pain until well after the incident, and the facility's protocol for acute condition changes was not followed.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate care for residents who were dependent on staff for activities of daily living, including bathing, oral care, and toileting. One resident, who was severely cognitively impaired and totally dependent on staff, was admitted to the hospital with poor oral hygiene, including thick hardened oral secretions. Observations revealed that this resident had not been bathed or had oral care since returning from the hospital, as evidenced by disheveled appearance, urine odor, and a white film on teeth and tongue. The Director of Nursing confirmed that the resident had not received a bath since readmission, and the hospital reported that it took 45 minutes to clean the resident's mouth upon arrival. Another resident, who was cognitively intact and required partial assistance with oral care, was observed with food in their teeth and reported not having a toothbrush or toothpaste. The medical record did not document any oral care assistance. Additionally, a third resident, dependent on staff for toileting, was found saturated in urine and with old feces, indicating they had not been changed for many hours. The CNAs confirmed the lack of care, and the Director of Nursing stated that the care provided was not acceptable, as residents should be checked and changed every two hours.
Failure to Identify and Manage Pressure Ulcers
Penalty
Summary
The facility failed to properly identify, assess, and manage pressure wounds for a resident, leading to a deficiency in pressure ulcer care. Upon the resident's return from the hospital, where they were documented to have multiple pressure injuries, the facility did not conduct a complete skin assessment as required by their Skin and Wound Management Guidelines. The resident had stage two pressure wounds on the coccyx and buttocks, and a deep tissue injury on the right heel, which were not identified or treated by the facility staff. The Licensed Practical Nurse who readmitted the resident did not perform a full skin check, and the wound nurse was not informed of the existing wounds. The facility's failure to notify the treatment nurse, physician, or family about the resident's wounds, and the lack of treatment orders or interventions for the pressure injuries, further contributed to the deficiency. Observations revealed that the staff, including CNAs and the Nurse Manager, were unaware of the resident's pressure wounds, and the dressings on the wounds appeared old and undated. This lack of communication and adherence to protocol resulted in inadequate care for the resident's pressure ulcers.
Inaccurate MDS Encoding for Falls and Injuries
Penalty
Summary
The facility failed to accurately encode the Minimum Data Sets (MDS) to reflect the true status of residents regarding falls and the severity of injuries incurred. This deficiency affected three residents. One resident, who was observed wearing a padded helmet, had experienced multiple falls, including a significant fall resulting in a subdural hematoma, a scalp laceration, and a wrist fracture. However, the MDS inaccurately documented only two falls with no injuries since the prior assessment. Another resident had a fresh scar on the forehead and had previously sustained bilateral nasal fractures and a scalp laceration requiring sutures. The MDS inaccurately recorded only one fall with injury, omitting another fall with a major injury. A third resident, observed with a gauze dressing on the forearm, had a documented fall resulting in a skin tear, yet the MDS recorded this as a fall with no injury. The Minimum Data Set Manual 3.0 specifies that injuries such as skin tears, abrasions, lacerations, bruises, hematomas, or sprains are considered injuries, while fractures, joint dislocations, closed head injuries, and subdural hematomas are considered major injuries. The Director of Nursing and a Registered Nurse Manager confirmed the inaccuracies in the MDS coding for these residents, acknowledging that the number of falls and the severity of injuries were not correctly documented. This failure to accurately encode the MDS could lead to inadequate care planning and interventions for the residents involved.
Failure to Monitor Resident Weights and Address Severe Weight Loss
Penalty
Summary
The facility failed to obtain weights per physician orders for two residents and did not adequately monitor an at-risk resident for weight loss. Specifically, one resident experienced severe weight loss without a proper care plan or notification to the resident's representative. The facility's weight policy required weekly weights in cases of significant weight changes, but this was not followed for the resident who lost a significant amount of weight over several months. The resident's care plan did not address the severe weight loss, and there was no order for nutritional supplements or increased weight monitoring until after the issue was identified. Another resident with a history of congestive heart failure was not weighed daily as required by their care plan and physician orders. The resident's care plan specified daily weights and notification of the provider if there was a significant weight gain, but the facility missed 53 daily weights over a period of time. This oversight could have impacted the resident's health management related to their heart condition. A third resident, who was nutritionally at risk due to renal dialysis and other medical conditions, was also not weighed according to physician orders. The resident's care plan required weights to be taken on specific days, but several weights were missed. The facility acknowledged that residents were not being weighed per physician orders, which contributed to the deficiencies identified in the report.
Failure to Monitor Dialysis Access Site and Communicate with Dialysis Center
Penalty
Summary
The facility failed to provide adequate dialysis care and coordination for a resident, resulting in the resident's hospitalization due to a central venous catheter infection. The facility did not maintain regular communication with the dialysis center and failed to monitor the resident's dialysis access site for signs of infection. The facility's Dialysis Protocol required nursing staff to monitor the access site and communicate with the dialysis center regarding any changes in the resident's condition. However, the resident's medical records lacked orders to monitor the dialysis site for several months, and there was no documentation of routine communication with the dialysis center. The resident, who had diagnoses including End Stage Renal Disease and Chronic Kidney Disease, was hospitalized with a suspected central line-associated bloodstream infection. The resident reported increased drainage and itching at the dialysis site, which was confirmed by the emergency department to have erythema and purulent drainage. Despite the facility's protocol and transfer agreement with the dialysis center, the nursing staff did not document assessments of the catheter site or maintain communication with the dialysis center, contributing to the resident's infection and subsequent hospitalization.
Failure to Implement Fall Interventions and Assessments
Penalty
Summary
The facility failed to implement necessary fall interventions for three residents, R1, R2, and R3, which were identified during observations, interviews, and record reviews. R1, who has a history of repeated falls and multiple fractures, was observed without the required TLSO back brace while out of bed, despite physician orders and family instructions. The Director of Nursing confirmed the absence of the brace, and R1's family member expressed concerns about the staff's failure to ensure the brace was worn, which is critical for R1's spinal support. R2, diagnosed with dementia and a history of falls, did not have quarterly fall risk assessments documented for March and June 2024. The Director of Nursing acknowledged the missing assessments, indicating they were likely not completed. Additionally, R2's care plan interventions were not followed, as observed by the absence of non-skid material in R2's wheelchair, the wheelchair being unlocked and out of reach, and the lack of visual cues to remind R2 to use the call light for assistance. These oversights were confirmed by the Director of Nursing and a Licensed Practical Nurse. R3, who has a history of falls and requires assistance with daily activities, was found transferring herself unsteadily in a shared bathroom due to a malfunctioning call light system. R3 communicated that she had to use a different bathroom because the call light in her room did not alert staff for assistance. The Social Service Director confirmed the call light issue and acknowledged R3's tendency to transfer herself without waiting for staff, leading to previous falls. Staff members, including a CNA and an LPN, confirmed that R3 should not be transferring herself and noted the lack of staff intervention during a shift change.
Failure to Notify Family and Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's family representative and healthcare providers of significant changes in the resident's condition, including a positive COVID-19 test result and a decline in consciousness, abnormal lung assessment, and a productive cough. The resident, who had severe cognitive impairment due to Alzheimer's Disease and Unspecified Dementia, tested positive for COVID-19, but there was no documentation that the family representative or the attending physician was informed of this diagnosis. Additionally, the resident exhibited symptoms such as lethargy, diminished lung sounds, and a productive cough, yet there was no record of these changes being communicated to the family or healthcare providers. The Director of Nursing acknowledged the lack of documentation regarding the notification of the resident's condition changes. The facility's policies require that both the attending physician and the resident's responsible party be notified of any significant changes in the resident's condition, including symptoms of an infectious process and changes in the level of consciousness. Despite these policies, the Licensed Practical Nurse involved did not notify the family or the nurse practitioner, assuming that the previous shift had already done so, which was not documented.
Incomplete Documentation of Physician-Ordered Back Brace
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident diagnosed with dementia and vertebral fractures. The deficiency involved the lack of documentation for the application of a physician-ordered TLSO back brace, which was to be worn by the resident when out of bed. The Physician Order Summary Report indicated that the brace was active and required, but the Electronic Medication/Treatment Administration Records did not have the necessary nurse initials to confirm the brace was applied over a period of 24 days. This oversight was attributed to an error by the admissions nurse, who failed to set up the administration record option for nurses to document the application of the brace.
Failure to Provide Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R1, upon their admission. R1, who had recently undergone joint replacement surgery and was diagnosed with Chronic Lymphocytic Leukemia, was admitted to the facility with a physician's order for Oxycodone 5 mg to be administered every six hours as needed for severe pain. However, upon admission, the facility did not have the prescribed pain medication available, resulting in R1 experiencing severe pain. On the night of R1's admission, the nurse on duty, V5, was informed by R1 that they would need pain medication to sleep. Despite this, V5 did not contact the Nurse Practitioner or R1's doctor to obtain an alternative pain medication order. The facility's emergency box did not contain the specific Oxycodone prescribed, only Oxycodone with Tylenol, which was not administered. Consequently, R1 did not receive any pain medication until the following day, leading to significant discomfort. The Nurse Practitioner, V7, discovered R1 in excruciating pain during a visit the next morning and took immediate action to address the situation. V7 ordered an emergency prescription for Percocet, which was available in the emergency box, and ensured R1 received the necessary medication. The facility's failure to have the correct medication available and the lack of communication with medical staff to obtain an alternative contributed to the deficiency in pain management for R1.
Failure to Maintain PICC Line Leads to Complications
Penalty
Summary
The facility failed to properly manage the peripherally inserted central catheter (PICC) line for a resident diagnosed with osteomyelitis, who required intravenous antibiotics. The facility's policy required PICC line dressings to be changed every seven days or as needed to prevent infections. However, upon review, it was found that the resident's August Medication Administration Report (MAR) did not document any dressing changes for the PICC line, and the order for dressing changes was only placed on September 9, 2024. The resident reported that the PICC line fell out on September 7, 2024, due to the lack of dressing changes, necessitating the use of a peripheral IV until a new PICC line was placed on September 9, 2024. Interviews with the Assistant Director of Nurses (ADON) confirmed that the resident was admitted with a PICC line for intravenous antibiotics and that no dressing change orders were placed or documented until after the PICC line fell out. The ADON acknowledged that the facility realized the oversight on September 7, 2024, and confirmed that no dressing changes had been performed since the resident's admission on August 29, 2024. This oversight led to the resident's PICC line falling out, requiring additional medical intervention to continue the necessary antibiotic treatment.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain residents' dignity by not responding to call lights and requests for assistance in a timely manner. This issue affected eight residents out of 17 reviewed in a sample of 35. Residents reported waiting times of up to 45 minutes for call lights to be answered, particularly during meal times and overnight shifts. Some residents mentioned that staff would turn off the call lights and promise to return but failed to do so unless the call light was pressed again. The facility's Resident Council Meeting Minutes from the past three months documented ongoing concerns about call light response times, especially during the night shift. The administrator provided a printout showing call light response times over the last 30 days, with over 650 instances exceeding 20 minutes. Despite this documentation, it did not address the residents' claims that staff would turn off call lights without returning. The report highlights that the facility's staffing levels may be inadequate, as residents noted that there were not enough CNAs to cover all halls effectively, leading to prolonged response times. This deficiency in timely response to call lights compromises the residents' dignity and their ability to exercise self-determination and communication rights.
Deficiency in Bathroom Flooring Maintenance
Penalty
Summary
The facility failed to maintain the flooring in resident bathrooms in a clean, safe, and homelike manner, affecting 15 residents out of 23 reviewed for environmental concerns. During an environmental tour, it was observed that the bathroom vinyl floors in several rooms had ground-in dirt and stains that could be rubbed off with a dry piece of bathroom tissue. Some stains were embedded in the vinyl, and there were cracks and loose edges at the bathroom thresholds, presenting a trip hazard. Residents confirmed that the floors were cleaned recently, yet the dirt and stains persisted. The Maintenance Director acknowledged the issues with the vinyl floors, expressing a desire to replace them with poured epoxy floors, as the current flooring could not be adequately cleaned, especially in the cracks. The Administrator confirmed the presence of stained and dirty floors in the bathrooms. Additionally, some rooms had missing thresholds at the entry doors, which was noted as a common issue. The facility's Resident Roster documented the residents residing in the affected rooms.
Failure to Timely Report Allegation of Mental Abuse
Penalty
Summary
The facility failed to report an allegation of mental abuse to the state agency within the required 2-hour timeframe. This deficiency involved a resident who was reportedly startled awake by a CNA during the night. The resident's family member initially reported the incident to the facility, describing the staff member as rude. The facility's representative, V1, investigated by speaking with the resident, who confirmed that a CNA had startled her awake and had not properly cleaned her after using a bedpan. The resident also reported that the CNA was rude and yelled at her from the hallway. Despite these allegations, the facility did not report the incident to the Illinois Department of Public Health until prompted by a surveyor. The facility's policy mandates that any allegation of abuse be reported immediately, but not more than 2 hours after the allegation. V1 initially did not consider the family member's complaint as an allegation of abuse, which led to the delay in reporting. The facility's failure to adhere to its own abuse prevention policy resulted in a deficiency being cited by the surveyors.
Misappropriation of Resident Property by Facility Staff
Penalty
Summary
The facility failed to protect two residents from misappropriation of property by facility staff, resulting in financial exploitation. One resident, who is cognitively intact and requires total assistance with daily activities, reported her debit card missing. An investigation revealed that 11 fraudulent transactions totaling $1,515.96 were made from her account, involving mobile payment services and online sports betting. The names associated with the transactions were unknown to the resident. A CNA was implicated in taking photographs of the resident's personal information, including her debit card and Social Security card, and sharing them with an external individual. The facility's investigation, prompted by a tip-off from an external individual, led to the suspension of the implicated CNA. The investigation also uncovered that another resident's debit card information was compromised, although no unauthorized transactions were made. The facility's policy prohibits staff from photographing or recording residents or their private spaces for non-medical purposes, yet this policy was violated, leading to the misappropriation of the resident's property.
Misappropriation of Resident Property by CNA
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of property, as outlined in their Abuse Prevention Program. The deficiency involved a Certified Nursing Assistant (CNA) who allegedly took photographs of personal items belonging to two residents, including debit cards and a Social Security card, and shared these images with another individual. This breach of policy was discovered when a third party, not associated with the facility, provided evidence of the CNA's actions to the facility administrator. The facility's policy explicitly prohibits staff from photographing or recording residents or their private spaces for non-medical or non-facility purposes. The incident resulted in one resident experiencing fraudulent transactions totaling $1,515.96 after their debit card information was compromised. The resident expressed distress over the situation, as the fraudulent activity affected their financial stability, with most of their Social Security check going towards room and board at the facility. The other resident's debit card was also photographed, but no unauthorized transactions were reported. The CNA involved denied the allegations, attributing the situation to personal conflicts, and was subsequently terminated from the facility.
Failure to Ensure Fall Interventions and Safety Measures
Penalty
Summary
The facility failed to ensure fall interventions were in place, safely position a resident on a low air loss mattress, keep necessary items within reach for a resident, and store a rolling chair away from resident areas. Specifically, the facility did not complete post-fall assessments, transfer a resident post-fall according to facility policy, and thoroughly investigate falls. These failures affected three residents reviewed for falls. One resident (R1) with severe cognitive impairment and multiple medical conditions, including Chronic Obstructive Pulmonary Disease (COPD) and Vascular Dementia, fell from a low air loss mattress. The resident was found face down on the floor with his right arm pinned under his body. The investigation revealed that the resident was positioned in a high Fowler's position on the air mattress, which likely caused the fall. Staff admitted that the resident should not have been left unattended in that position. Another resident (R4) with moderate cognitive impairment and multiple medical conditions, including Chronic Osteomyelitis and Alzheimer's Disease, fell while trying to reach for a drink. The resident's fall mat was not in place, and the call light was out of reach. The resident was assisted back to bed without using a mechanical lift, and no physical or neurological assessments were completed before moving the resident. Additionally, a third resident (R5) with severe cognitive impairment and Alzheimer's Disease fell while attempting to sit in a rolling chair left unattended in a dementia unit. The resident was known to wander and required supervision due to poor safety awareness.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure a resident's right to dignified care and treatment, affecting one of three residents reviewed for dignity/abuse. The resident (R3) has no cognitive impairment and is frequently incontinent of bowel and bladder. During an interview, an Auxiliary Assistant (V10) reported overhearing a Certified Nursing Assistant (V13) question R3 about wearing a diaper and needing to go to the bathroom, which R3 found humiliating. R3 confirmed the incident, stating that V13's behavior made her feel disrespected and humiliated, although she did not feel it was abuse. The facility's Grievance/Complaint Form and interviews with the Administrator (V1) corroborated R3's account, identifying the issue as a dignity concern. The facility's policy on resident privacy and dignity emphasizes the importance of treating residents with respect and addressing them by their preferred names. However, the incident with V13, CNA, demonstrated a failure to adhere to this policy, resulting in a dignity issue for R3.
Failure to Protect Resident from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and mental abuse by another resident. This deficiency involved two residents, one with severe cognitive impairment and another with moderate cognitive impairment. The incident began when the resident with severe cognitive impairment accused the other resident of stealing her belongings, leading to a verbal altercation. The resident with severe cognitive impairment used racial slurs and got physically close to the other resident, causing fear and distress. Despite staff intervention, the abusive behavior continued, and the resident with severe cognitive impairment was not immediately removed from the room, leading to further incidents of verbal abuse. The resident with moderate cognitive impairment, who is bedridden and uses a wheelchair for mobility, reported feeling scared and threatened by the other resident's actions. The staff documented multiple instances where the abusive resident accused the other of theft and used racial slurs. The staff attempted to redirect the abusive resident and reassure her about her belongings, but the abusive behavior persisted. The facility's initial report to the State Agency and subsequent interviews with staff and residents confirmed the ongoing verbal abuse and the failure to protect the resident from such mistreatment. The facility's abuse prevention program aims to create a resident-sensitive and secure environment, but in this case, it failed to prevent the verbal and mental abuse. The staff's actions to separate the residents and address the abusive behavior were insufficient, as the abusive resident continued to harass the other resident. The facility acknowledged the incident and stated that the investigation was ongoing, but the deficiency in protecting the resident from abuse was evident in the documented events and staff statements.
Failure to Report Abuse Allegation
Penalty
Summary
The facility failed to ensure an allegation of physical and verbal abuse by one resident towards another was reported to the Administrator/Abuse Prevention Coordinator. This failure resulted in both residents continuing to reside in the same bedroom, potentially subjecting one resident to further abuse. The incident involved a resident becoming physically violent and verbally abusive towards her bedridden roommate, including pulling her hair and using racial slurs. The incident was initially reported by a housekeeper and documented by an LPN, but the report was not properly escalated to the on-call manager or the Administrator as required by the facility's policy. The LPN notified the Administrator via text message that a resident was combative but did not specify that the combative behavior involved physical and verbal abuse towards another resident. The Director of Nursing and the on-call RN Manager were not informed of the abuse allegations until the following day when a note was found in the resident's medical record. The LPN who initially documented the incident was terminated for failing to follow the protocol related to abuse prevention and reporting. The facility's policy on abuse prevention requires employees to report any incident, allegation, or suspicion of abuse immediately to the Administrator or an immediate supervisor. In this case, the failure to follow this policy resulted in a delay in addressing the abuse allegations and ensuring the safety of the residents involved. The facility's internal reporting requirements were not met, leading to a deficiency in handling the abuse incident appropriately.
Failure to Ensure Two Staff Members During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that two staff members were present during a mechanical lift transfer for a resident with Chronic Obstructive Pulmonary Disease, heart failure, and morbid obesity. The resident's care plan required two staff members for all transfers, including those using a mechanical lift. On April 20, 2024, a CNA attempted to transfer the resident from a wheelchair to a bed using a mechanical lift without the assistance of a second staff member. During the transfer, the resident fell out of the mechanical sling and hit the floor, resulting in a fall on her buttocks and head. The resident was sent to the Emergency Department and returned to the facility with no injuries. The incident report and interviews confirmed that the CNA proceeded with the transfer alone after the second staff member left the room due to an emergency phone call. The facility's policy on transfers, dated August 2017, clearly states that a minimum of two staff members is required for mechanical lift transfers. The administrator confirmed that the CNA did not follow this policy, leading to the resident's fall. The incident highlights a failure to adhere to established safety protocols, which are designed to prevent such accidents. The resident involved was independent in decision-making skills but required staff assistance for activities of daily living due to her medical conditions.
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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