Allure Of Galesburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Galesburg, Illinois.
- Location
- 1145 Frank Street, Galesburg, Illinois 61401
- CMS Provider Number
- 145987
- Inspections on file
- 40
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 16 (4 serious)
Citation history
Health deficiencies cited at Allure Of Galesburg during CMS and state inspections, most recent first.
A resident with significant psychiatric diagnoses and a plenary guardian, documented as having impaired social interaction and poor decision-making with men, engaged in ongoing romantic and sexually explicit electronic communication with a dietary aide who had been trained on abuse prevention and was later allowed to resign due to "growing feelings" for the resident. Despite policies prohibiting staff–resident sexual relationships and abuse via technology, the resident’s care plan was not updated to include recommended supervision of phone use, restrictions on contacts, or any assessment of capacity to consent to sexual activity, and did not reflect increased supervision measures discussed in internal meetings. The aide continued to communicate with the resident, meet her at church without staff supervision, and, according to the facility’s investigation and a police report, engaged in multiple non-consensual sexual encounters with her in his vehicle during church services, while also verbally abusing her roommate during sexually explicit calls. Sign-in/out records for community outings lacked documentation of who accompanied the resident, and staff knowledge of the resident “sneaking around” with the aide at church did not result in timely protective interventions, leading to staff-to-resident sexual and verbal abuse and failure to safeguard the resident’s rights and safety.
A facility failed to immediately report multiple abuse, neglect, and exploitation allegations to the State Agency and local police as required by its abuse policy. An administrator learned that a dietary aide was pursuing a romantic relationship with a resident under plenary guardianship, including boyfriend/girlfriend-type texts and sexually explicit electronic communications, but did not notify authorities when this was discovered. The same resident later reported non-consensual sexual encounters with the former staff member off-site, while another resident reported repeatedly witnessing sexually explicit video calls between them and being cursed at and threatened by the former staff member when she asked them to stop. Additionally, a resident’s report of being physically assaulted by other residents, documented in ED records, was not reported to authorities after the facility became aware. Staff interviews showed that several employees knew of the inappropriate relationship and sexually explicit video interactions, yet there was no timely reporting or documented assessment of the resident’s capacity to consent to sexual activity.
A cognitively impaired resident with a plenary guardian, lacking any documented assessment of capacity to consent to sex, became involved with a dietary aide who, while employed, engaged in boyfriend/girlfriend-type texting, sexually explicit video chats, and attempts to form an intimate relationship, and later allegedly sexually assaulted the resident on multiple occasions off-site. Facility staff, including the administrator, DON designee, psychosocial staff, and a CNA, became aware over time of the aide’s inappropriate communications and excessive time with the resident, but the aide was allowed to resign without an abuse investigation, no report was made to the State Agency, and no care plan interventions or enhanced supervision were implemented. The resident’s roommate reported repeatedly witnessing sexual acts and conversations via phone video and being subjected to profane verbal abuse and threats by the former aide, yet there was no documented investigation, no State report, and no care plan updates for her safety. Additionally, when the resident reported in an ED visit that she had been physically assaulted by other residents, the facility did not immediately investigate or report this allegation, contributing to an Immediate Jeopardy finding.
A cognitively intact resident with multiple behavioral health and pain-related diagnoses had an active PRN order for Norco 10/325 mg. Pharmacy records and video evidence confirmed that an agency RN received a 30-tablet card of this controlled substance and placed it in the med cart, with no discrepancies noted at the end of her shift. Two days later, staff discovered the Norco card was missing when a refill request was denied because the prescription had already been filled. Review by the DON found that multiple nurses were not performing required beginning- and end-of-shift controlled-substance counts, and video surveillance did not consistently capture the med cart, preventing clear identification of who removed the medication.
The facility failed to follow its own controlled-substance storage and accountability policies, resulting in a missing card of 30 tablets of Hydrocodone-APAP (Norco) for a resident. Pharmacy records and video showed that an agency RN received the controlled medication and placed it in the med cart, but the medication was later found to be missing. Review of controlled-substance inventory sheets revealed that multiple nurses did not perform required shift-to-shift controlled-drug counts or verify controlled-substance cards, leading to unaccounted-for loss of the resident’s controlled medication.
A nurse pre-prepared and stacked multiple residents' medications, resulting in a resident with complex medical conditions receiving another resident's medications. The error was not immediately reported, and the resident required emergency hospitalization and intubation due to overdose. Ongoing pre-popping and stacking of medications by staff was observed, in violation of facility policy.
Nursing staff were observed pre-preparing and stacking medication cups, including those containing controlled substances, on and inside medication carts rather than keeping them secured and under direct observation as required by facility policy. Both a registered nurse and an LPN confirmed this practice, which involved multiple residents and included controlled drugs such as Clonazepam, Ativan, and Tylenol with Codeine.
Surveyors observed that multiple servings of mixed fruit, applesauce, and cooked chicken breasts were stored in refrigeration units without proper covering or dating, contrary to facility policy. The Dietary Manager confirmed these items should have been labeled and covered.
The facility did not notify the state mental health authority for reevaluation when PASRR short-term approvals ended for six residents. Medical records lacked documentation of required referrals or reevaluations after the expiration of PASRR Level II approvals, as confirmed by the Social Services Director.
Surveyors found that the facility did not implement or maintain required fall prevention interventions for several residents who had experienced falls, as documented interventions such as non-skid strips and perimeter mattresses were not in place during inspection. Additionally, a resident with psychiatric diagnoses repeatedly possessed and used prohibited smoking materials, and the facility failed to update assessments or enforce its smoking safety policy.
Surveyors found that four residents receiving oxygen therapy did not have their oxygen humidification bottles and tubing changed or dated according to facility policy, despite staff confirming the requirement for weekly changes. This failure to follow established procedures affected residents with orders for oxygen therapy, including those with chronic respiratory conditions.
The facility did not ensure that flu and pneumonia vaccines were offered or properly documented for several residents, as required by policy. Immunization records lacked evidence that these vaccines were administered, declined, or even offered, and this lapse was confirmed by the facility's regional nurse consultant.
Two residents with psychiatric diagnoses were not timely assessed for walking pass privileges after requesting participation in the program, resulting in significant delays. One resident's assessment was not initiated for months, while another experienced a prolonged gap between request and reinstatement of privileges, contrary to facility policy.
A resident was subjected to verbal abuse when a CNA yelled and cursed at him, as confirmed by both staff witnesses and the resident. The incident was documented, and the resident reported feeling that the staff member's conduct was unprofessional and inappropriate.
Staff did not follow enhanced barrier precautions during wound care for a resident with open wounds, as gowns and gloves were not available and not used, and no signage was present. Infection surveillance records were incomplete, with missing monthly logs and insufficient documentation in antimicrobial therapy reports. Additionally, an LPN failed to properly disinfect a blood glucose meter between residents, using an alcohol wipe instead of the required disinfectant, potentially affecting several residents.
Nurse staffing information was not posted daily or made accessible, as the displayed sheet was outdated and hidden behind another document. The administrator confirmed the required posting was not done at the start of each shift, potentially affecting all residents.
A resident with severe mental illness physically assaulted another resident by throwing a canister and punching the individual in the chest near the drink station. The incident was witnessed by another resident, partially captured on video, and promptly reported to the administrator and physician. The victim was assessed and found to have no injuries, and staff responded immediately after being notified.
A resident with a history of serious mental illness was subjected to sexual and mental abuse by a CNA over six months. The CNA bribed the resident with alcohol and drugs in exchange for sexual favors, leading to fear, depression, and the need for STD prophylaxis. The facility failed to prevent this abuse, resulting in Immediate Jeopardy.
The facility failed to provide mandatory annual QAPI in-service training to its staff, as revealed by a review of training logs and confirmed by the Corporate Nurse. This oversight, which was not listed as a required yearly training, has the potential to affect all 93 residents in the facility.
A facility failed to report an allegation of staff-to-resident sexual abuse to the State Agency within the required timeframe. A resident reported inappropriate sexual encounters with a CNA, who had resigned. The Administrator was informed by an LPN but delayed reporting to the State Agency until the resident stated the encounters were non-consensual, violating the facility's Abuse Policy.
Two residents were involved in separate incidents of physical abuse by another resident, who smacked them during altercations. The resident responsible for the abuse was cognitively intact and admitted to the actions, which were influenced by misunderstandings and personal perceptions. The facility failed to prevent these incidents, despite being aware of the resident's history of conflicts with roommates.
The facility failed to document significant incidents in resident records, including a physical altercation and an allegation of inappropriate behavior during a home visit. Despite investigations and interventions, such as police involvement and 1:1 supervision, these events were not recorded in the residents' medical records.
A facility failed to identify, monitor, and treat pressure wounds on a resident's feet, resulting in unstageable wounds. Despite having a pressure reduction boot and instructions for offloading, the resident's feet were observed in contact with the mattress multiple times. The care plan did not document the wounds or interventions, and staff were unaware of the wounds, indicating a breakdown in communication and care planning.
The facility failed to properly dispose of kitchen waste by leaving the lids open on the outside trash receptacle, contrary to its policy requiring tightly fitting lids. This was confirmed by the Head Cook and has the potential to affect all 90 residents.
The facility failed to ensure a pest-free environment in the kitchen, as gnats were observed on and around the juice dispenser spigot/handle. This was confirmed by the Head Cook during a kitchen tour, despite the facility's policy requiring food service areas to be free from pests.
The facility failed to maintain a clean and functional women's shower room, affecting all female residents on the E Wing. Observations revealed broken shower heads, minimal water pressure, non-functional toilets, and a lack of privacy. Residents reported long-standing issues, with one stating the problems have persisted for three years. The maintenance director noted plans for a remodel, but the current state includes missing faucets, broken fixtures, and no soap in dispensers.
A disposable razor was found on the counter in the women's shower room, accessible to residents on the E-Wing. An LPN confirmed that razors should be locked up and only given to residents by staff, highlighting a failure in maintaining a hazard-free environment.
The facility failed to develop comprehensive care plans for two residents, resulting in unaddressed medical needs. One resident had skin discoloration and lesions not included in their care plan, despite a physician's assessment. Another resident had skin conditions and foot wounds that were not addressed in their care plan, with necessary interventions like offloading boots not being utilized. The facility's ADON and DON acknowledged these oversights.
A facility failed to address skin care concerns for a resident with discoloration and lesions on both upper extremities. Despite policies requiring regular skin assessments, the resident's records lacked documentation of treatments or physician orders. Staff confirmed the absence of treatment orders and protective measures. A subsequent evaluation diagnosed the resident with Actinic Keratosis, highlighting the facility's failure to provide necessary care.
A facility failed to provide physician orders for oxygen administration and did not change oxygen tubing and humidifier bottles per policy for a resident. The resident was observed receiving oxygen at 3.5L over three days without a physician order, and the equipment was not changed weekly as required. An LPN confirmed the policy, and the ADON was unaware of the continuous oxygen use.
A resident on hospice care with multiple diagnoses was prescribed Seroquel, an antipsychotic, without documented indication or target behaviors. Despite no signs of psychosis or identified behaviors over three months, the medication was administered. The DON could not provide a reason for its use, highlighting a deficiency in medication management.
The facility failed to provide rooms with at least 80 square feet per resident, affecting multiple residents. The Maintenance Director confirmed the deficiency, and a previous waiver was submitted to the State Agency. However, the current administrator was unaware of any recent waivers. A letter from the State Agency confirmed that certain rooms were waivered for not meeting the requirement.
The facility failed to protect two residents from verbal abuse by an RN, who was overheard cussing and yelling at one resident and blaming another. The incident was substantiated through an investigation, and the RN was terminated.
The facility failed to revise care plans for three residents who had their smoking privileges revoked due to non-compliance with smoking rules. Despite the revocations being in place for several months, the care plans were not updated to reflect these changes, as confirmed by the DON. The Social Service Director was responsible for the revisions, but they were not completed.
Failure to Protect Resident From Staff Sexual and Verbal Abuse and to Assess Capacity for Sexual Consent
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident with a plenary guardian from staff-to-resident sexual abuse, failure to assess the resident’s capacity to consent to sexual activity, and failure to protect residents from staff-to-resident verbal abuse. The facility had an Abuse, Neglect, and Exploitation policy prohibiting all forms of abuse, including sexual and verbal abuse and abuse facilitated through technology, and an employee union agreement that specified discharge for any employee maintaining or attempting to maintain a sexual or romantic relationship with a resident. Despite these policies, a dietary aide (V7) developed and pursued a personal, romantic, and sexual relationship with a resident (R3) who had a court-appointed plenary guardian due to inability to manage her person or property and lack of capacity to make and communicate responsible decisions. The facility did not complete or document any evaluation of R3’s ability to consent to sexual activity in her electronic health record and did not incorporate her guardianship status or consent capacity into her care plan. R3’s medical and psychosocial history included Borderline Personality Disorder, ADHD, Major Depressive Disorder (including with severe psychotic symptoms), Anxiety Disorder, suicidal ideation, and impaired social interaction. Her care plan documented that she frequently spoke with, texted, or called men, became easily emotionally involved, made poor decisions related to the opposite sex, manipulated situations and staff to leave the building unsafely, used her cell phone to manipulate men online to pick her up, and made false accusations. However, the care plan was not updated after the facility became aware of sexually inappropriate conversations and video nudity via electronic communication between R3 and V7, nor after the guardian restricted R3’s contacts to specific family and staff. The IDT noted that R3 required assistance to think logically about safety and was at risk of exploitation or abuse related to smartphone and social media use, and recommended supervised phone use with the smartphone secured at the nurses’ station, but these interventions were not added to the care plan. The facility also failed to protect R3 and her roommate (R6) from ongoing inappropriate and abusive interactions involving V7. Progress notes documented that R6 complained about R3 getting completely naked in the room with the door and curtain open while talking or videoing on social media, and a behavior note recorded that R6 reported R3 engaging in sexual conversation with a male on a call, during which the male (identified as V7) cursed at R6 and called her names when R6 asked them to stop. Text messages later obtained from R3’s phone showed ongoing personal, romantic, and sexually explicit communication between R3 and V7, including expressions of love, plans for a future together, and explicit sexual content. The facility’s own abuse investigation and a police report documented that R3 reported at least three non-consensual sexual encounters with V7 in his vehicle in a church parking lot during church services, involving forced intercourse, episodes of feeling woozy or blacking out after consuming food or a pill provided by V7, and threats of harm if she disclosed the events. Although the facility’s QAPI/QAA documentation referenced immediate protection measures and increased supervision for R3, these measures were not incorporated into her care plan, and sign-in/sign-out sheets for community outings did not consistently document who accompanied her, allowing continued unsupervised contact with V7 in the community and ongoing verbal abuse toward R6. The facility’s handling of V7’s employment further contributed to the deficiency. V7 had received multiple in-services on abuse prevention, sexual abuse, personal boundaries, and the facility’s abuse policy, yet he was allowed to resign due to “growing feelings for a resident” without the incident being treated and reported as abuse or exploitation at that time. The guardian reported being told by the Administrator that V7 left on his own and that the facility did not have to complete paperwork or report to the state agency, despite the guardian’s assertion that V7’s conduct constituted exploitation and that R3 could not consent to a relationship. After V7’s resignation, R3 continued to attend church services in the community without staff supervision, and the van driver and a nurse reportedly knew R3 had been “sneaking around” with V7 at church. The facility’s root cause analysis acknowledged that R3 attended church with no staff supervision, met V7 there, and left services to go to the parking lot with him, where sexual relations were reported, yet the care plan and supervision practices were not adjusted in a timely or effective manner to prevent further abuse or protect R3 and R6 from staff-to-resident sexual and verbal abuse.
Failure to Timely Report Staff-to-Resident Sexual Exploitation and Other Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to immediately report multiple allegations of abuse, neglect, and exploitation to the State Agency, local police, and the Administrator as required by policy. The facility’s Abuse, Neglect, and Exploitation policy required all alleged violations to be reported immediately, but not later than two hours, when the events involve abuse or result in serious bodily injury, and within 24 hours for other events. Despite this, when the Administrator became aware in June that a dietary aide was attempting to initiate a personal or romantic relationship with a resident who had a plenary guardian due to disability and lack of capacity to make responsible decisions, the Administrator did not notify the State Agency or local law enforcement. The aide resigned after the Administrator reviewed text messages showing boyfriend/girlfriend-type communications and the aide’s desire for a relationship and to get the resident pregnant, but no report was made at that time. The resident involved in this staff-to-resident situation had been adjudicated a disabled person in need of a plenary guardian of person and estate, with the guardian authorized to make residential decisions and protect the resident’s best interests. The guardian reported being told by the Administrator that the aide had resigned and that the facility did not have to report the matter to the state health department. The guardian stated that she informed the Administrator that the aide’s conduct constituted exploitation and that the state needed to know an employee was trying to have a sexual and boyfriend-girlfriend relationship with her disabled daughter. Staff interviews and documentation showed that the psychosocial rehabilitation coordinator and the prior dietary manager both observed or were informed that the aide was spending excessive time with the resident, expressing romantic feelings, and sending messages such as “I love you” and wanting to get the resident pregnant. A CNA also reported seeing the resident video chatting with the aide at night, and another CNA reported several evenings of sexually explicit video chatting between the aide and the resident, which she said she reported to nurses. The facility also failed to immediately report other abuse allegations involving the same resident and her roommate. On one date, progress notes documented that staff spoke with the resident after the roommate complained that the resident was completely naked in the room with the door and curtain open while talking or videoing on social media with a male. On another date, a behavior note documented that the roommate reported the resident was engaging in sexual conversation via video with a male, identified as the former dietary aide, and that when the roommate asked them to stop, the aide cursed at and called the roommate names. The psychosocial rehabilitation coordinator stated she reported this to the Administrator, but there was no evidence these allegations of sexual exploitation by video or the verbal abuse and threats toward the roommate were reported to the State Agency or local police. The roommate later stated she had watched the resident and the aide having sex on the phone several times and that the aide repeatedly yelled at and threatened her when she asked them to stop, and she reported feeling abused and worried. In addition, the facility did not timely report an allegation of resident-to-resident physical abuse involving the same resident. Emergency department notes documented that the resident presented with suicidal ideation and reported being physically assaulted by two other residents the previous day. The Administrator acknowledged learning of this allegation only after receiving the hospital records months later and confirmed that, as of the survey, he had not notified the local police or State Agency regarding this allegation. The police report and the facility’s own abuse investigation later documented that the resident reported multiple instances of non-consensual sexual contact by the former dietary aide in a church parking lot on Sundays, including episodes where she described feeling woozy and blacking out after eating food provided by the aide. The Administrator did not notify the State Agency or local police about the aide’s initial attempts to initiate a personal relationship with the resident while employed, and the police and State Agency were not notified about the sexual relations at church until several days after the guardian reported the situation to facility staff. The Immediate Jeopardy was determined to have started when the Administrator first became aware that the aide was engaging in behavior indicating an attempt to initiate a personal or romantic relationship with the resident and failed to report this to the police or State Agency. This failure coincided with ongoing sexually inappropriate conversations and video nudity by electronic communication between the aide and the resident, which were not reported. The facility’s records and staff interviews showed that, during this period, there was no documented evaluation of the resident’s capacity to consent to sexual activity in the electronic health record, and staff reported they were never informed whether the resident could consent to sexual relationships or that she required supervision. The combination of unreported staff-to-resident sexual exploitation, unreported staff-to-resident verbal abuse toward the roommate, and unreported resident-to-resident physical abuse formed the basis of the cited deficiency for failure to timely report suspected abuse, neglect, and exploitation.
Removal Plan
- V7 resigned from the facility.
- V1 initiated an abuse investigation into R3's abuse allegation and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation into R3's abuse allegation and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation into R3 and R6's abuse allegations and notified IDPH; a final report will follow.
- V1 initiated an abuse investigation, notified IDPH, and notified the local police regarding R3's abuse allegation.
- V5 completed assessments on R3's capacity to consent to sexual relations with the involvement of V3, V35, and V36.
- The facility is evaluating R3's capacity to consent to sexual relations and implemented precautions to keep R3 safe.
- The facility developed a plan to ensure R3 has staff supervision while using the facility phones to ensure safe communication with others.
- V3 removed R3's phone and restricted R3's church visits.
- R3's care plan was updated with interventions to increase R3's safety.
- V26 reviewed all residents to ensure no residents suffered from past abuse.
- The Quality Assessment and Assurance Committee met for an emergency QAPI meeting and developed and implemented plans to ensure no further abuse occurred within the facility and all policies and procedures were followed correctly.
- The facility's abuse policies were reviewed by the QA committee prior to educating staff.
- The facility's staff intimate relationships policy was reviewed by the QA committee.
- V1, V2, and V38 educated all staff on abuse prevention, abuse reporting, and all abuse-related policies and procedures.
- V25 educated V1 on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of abuse, neglect, and exploitation to IDPH.
- V1, V2, and V38 educated all staff on maintaining professional boundaries with residents and that staff are not to have any inappropriate relationship with residents.
- R3 and R6's care plans were updated with safety interventions to protect them from abuse.
Failure to Prevent, Investigate, and Report Staff-to-Resident Sexual and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from staff-to-resident sexual and verbal abuse, to implement safety interventions and adequate supervision, and to promptly investigate and report allegations of abuse to the State Agency. One resident had a plenary guardian due to physical and mental conditions that rendered her unable to manage her person or property or make responsible decisions, and her record lacked any evaluation of her capacity to consent to sexual activity. Despite this, a dietary aide began engaging in boyfriend/girlfriend-type texting, video chatting, and sexually inappropriate communications with her while employed at the facility, including messages expressing love, wanting to get her pregnant, and plans to remove her from the facility. Staff, including the dietary manager, psychosocial rehabilitation coordinator, CNA, and administrator, became aware over time that the aide was spending excessive time with the resident, was texting and video chatting with her, and was attempting to have an intimate relationship, yet the aide was allowed to resign without an abuse investigation or report to the State Agency, and no care plan interventions or supervision measures were implemented to protect the resident. The resident later reported to the administrator and police that the former dietary aide sexually assaulted her on at least three Sundays in a church parking lot, describing non-consensual intercourse, being lured into the aide’s vehicle, feeling woozy after eating food he provided, blacking out, and waking up alone before attending services. Her guardian, who had been told by the administrator that the aide had resigned due to growing feelings for the resident, stated that she had previously informed the facility that the aide was trying to have a sexual relationship with the resident and that this constituted exploitation, and she expected the facility to keep the resident safe and to report the aide’s conduct to the State Agency. The guardian later learned from a van driver that the resident had been sneaking around with the aide at church for weeks and reported that the resident admitted to having intercourse with the aide while he was working at the facility. The resident’s psychotherapy notes documented ongoing stress, fear of the aide approaching her when not with staff or family, night tremors, and a desire to leave town to feel safer, and she told the surveyor she had asked the aide to stop, that the encounters were not consensual, and that she had reported the rapes to both the police and the administrator. The facility also failed to protect the resident’s roommate from verbal abuse and exposure to sexually explicit conduct by the same former staff member and failed to investigate and report these allegations. The roommate reported witnessing the resident and the former aide engaging in sexual conversations and acts via phone video on multiple occasions and stated that when she asked them to stop, the aide cursed at her, called her derogatory names, and threatened that she would get her “a** kicked,” causing her to feel abused and worried. The psychosocial rehabilitation coordinator documented the roommate’s report of sexually inappropriate conversations and acts on video and the aide’s profane verbal abuse, and stated this was reported immediately to the administrator; however, there was no documentation of an abuse investigation, no final report submitted to the State Agency, and no updates to the roommate’s care plan to address safety from the aide’s threats. Additionally, when the resident reported in an emergency department visit that she had been physically assaulted by two other residents, the facility did not initiate an immediate investigation or submit a final report to the State Agency, and the administrator later acknowledged he had not started an investigation into that allegation even after receiving the hospital records. These combined failures led to an Immediate Jeopardy determination related to the ongoing access and exploitation by the former dietary aide and the lack of timely investigation and protective interventions for both residents.
Removal Plan
- Initiate an abuse investigation into R3's abuse allegation and submit the initial report to IDPH, with a final report to follow.
- Initiate an abuse investigation into R3's abuse allegation and submit the initial report to IDPH, with a final report to follow.
- Initiate an abuse investigation into R3 and R6's abuse allegations and submit the initial report to IDPH, with a final report to follow.
- Complete assessments of R3's capacity to consent to sexual relations with involvement of R3's plenary guardian, physician, and psychiatrist.
- Continue evaluating R3's capacity to consent to sexual relations and implement precautions to keep R3 safe.
- Develop a plan to ensure R3 has staff supervision while using facility phones to ensure safe communication with others.
- Update R3's care plan with interventions to increase R3's safety.
- Hold an emergency QAPI meeting and develop and implement plans to ensure no further abuse occurs within the facility and all policies and procedures are followed correctly.
- Review the facility's abuse policies through the QA committee prior to educating staff.
- Review the facility's staff intimate relationships policy through the QA committee.
- Educate all staff on abuse prevention, abuse reporting, and all abuse-related policies and procedures.
- Educate the administrator on the facility's Abuse, Neglect and Exploitation Policy and compliance with reporting allegations of abuse, neglect, and exploitation to IDPH.
- Educate all staff on maintaining professional boundaries with residents and that staff are not to have any inappropriate relationship with residents.
- Update R3 and R6's care plans with safety interventions to protect them from abuse.
Failure to Safeguard Resident’s Controlled-Substance Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a controlled-substance pain medication was missing after delivery. The facility’s Abuse, Neglect, and Exploitation Policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. The resident involved was cognitively intact and had diagnoses including major depressive disorder, suicidal ideations, anxiety disorder, alcohol abuse with intoxication, insomnia, and muscle spasms of the back. The resident had an order for Norco (hydrocodone-acetaminophen) 10/325 mg, one tablet by mouth every eight hours as needed for pain. Pharmacy records and a proof of delivery/packing slip show that 30 tablets of this medication were delivered to the facility, and video evidence and a signed statement from an agency RN confirm that she received the delivery in the early morning, signed the pharmacy delivery sheets, and placed the 30 tablets in the medication cart. She also stated that when she left her shift, she counted all controlled medication cards and pills and found no discrepancies. The deficiency arose when the medication card for this resident’s Norco was later found to be missing. The DON learned that an LPN had attempted to reorder the Norco, but the pharmacy denied the request because the prescription had already been filled and sent. By the time the DON became aware that the Norco was missing, two days had passed since delivery. An audit of the controlled substance inventory sheets revealed that numerous nurses were not counting controlled substances and cards at the beginning and end of their shifts as required. Video surveillance could not confirm who took the medication because there were times when the medication cart was not visible. The DON reported that, after reviewing video footage, interviews, and medication records, she concluded that the only nurse who could have taken the Norco was a new agency RN, as all other nurses had worked there previously and there had been no prior issues with missing narcotics.
Failure to Secure and Account for Controlled-Substance Medication
Penalty
Summary
The deficiency involves the facility’s failure to properly store and account for a resident’s controlled-substance medication in accordance with its own policies and procedures. The facility’s Controlled Substance Administration and Accountability Policy requires controlled substances to be stored in locked compartments with access limited to approved personnel, and for areas without automated dispensing systems to use a two-lock storage unit and a paper system for 24-hour recording. The policy and the Controlled Substance Inventory Count Sheets further require that the oncoming nurse verify all controlled substances with the offgoing nurse at each shift change, including counting total cards/containers and reconciling actual drug counts against individual resident count sheets, with any discrepancies reported immediately to the DON or nursing supervisor. Review of the inventory sheets from 12/6/25 through 12/9/25 showed that two nurses did not count or verify the number of controlled substances or controlled-substance cards within the medication cart for six oncoming/offboarding shifts during that period. Pharmacy documentation showed that 30 tablets of Hydrocodone-APAP 10/325 mg for one resident (R8) were delivered to the facility and received by an agency RN, who was seen on video placing the medication card in the medication cart. The DON later learned from an LPN that a refill request for this resident’s Norco was denied by the pharmacy because it had already been refilled and sent, prompting review of video footage and records. By the time the DON discovered that the resident’s Norco card of 30 tablets was missing from the medication cart, two days had passed since delivery. An audit of the controlled substance inventory sheets revealed that numerous nurses had not been performing the required beginning- and end-of-shift controlled-substance counts, contributing to the unaccounted-for loss of the resident’s controlled medication.
Immediate Jeopardy Due to Medication Administration Error and Failure to Follow Policy
Penalty
Summary
A significant medication administration error occurred when a nurse pre-prepared and stacked multiple residents' medications, resulting in one resident receiving another resident's medications. The nurse failed to follow the facility's medication administration policy, which requires verification of the six rights of medication administration and prohibits pre-popping and stacking medications. The error was not immediately reported by the nurse involved, and the resident was subsequently given their own scheduled medications as well. The affected resident, who had a complex medical history including hemiplegia, bradycardia, Parkinson's disease, and other serious conditions, was found to be lethargic, hard to arouse, and had a heart rate in the 40s after receiving the wrong medications. The error was discovered when another resident reported to a different nurse that he had witnessed his medications being given to the wrong person. Upon assessment, the resident was sent to the emergency room, where he required critical care, including intubation, due to medication overdose and associated complications. Further investigation revealed that the practice of pre-preparing and stacking medication cups was ongoing, as observed by surveyors during their visit. Staff involved in medication administration confirmed that medications, including controlled substances, were being pre-popped and stacked in advance, contrary to facility policy. The incident was not promptly reported to supervisory staff or the physician as required by the facility's medication error policy.
Removal Plan
- R4 was sent to the emergency room for treatment and remained in the hospital.
- V3's employment with the facility was terminated and the incident reported to the State Nursing Board.
- An emergency Quality Assurance Performance Improvement (QAPI) meeting was held to review and interpret all audit findings, review all procedures, review investigation, review root cause analysis, and review all facts surrounding the incident. Findings will be reported at the monthly QAA meeting for a minimum of 3 months. All applicable facility policies and procedures for medication administration were reviewed/revised by the QAPI team.
- V11/Assistant Director of Nursing re-educated licensed nurses on facility policies regarding Medication Administration as well as medication errors and medication administration reconciliation guidelines. All nurses were educated prior to working their next shift including agency nurses. Sign-in sheets were utilized.
- An audit of all med carts to ensure no other medications were opened in advance of administering to residents was completed by V11 and continued.
- The facility's contracted pharmacy service performed a med cart audit and medication administration audit.
- The DON or designee will audit med carts on all shifts to ensure medications are being prepped and administered accordingly weekly for 4 weeks then bi-weekly for 2 months. The audits will continue until compliance can be maintained for 3 consecutive months.
- The DON or designee will educate all new hire licensed nurses on medication administration and reconciliation guidelines.
- Education on Medication Administration and Medication Error sign in sheets and course material reviewed with no concerns.
- Medication Cart Audit was completed by and observed by the State Agency V12, V13, and V14's med carts. No concerns.
Improper Pre-Preparation and Storage of Medications by Nursing Staff
Penalty
Summary
Nursing staff failed to comply with facility policy and professional standards regarding the storage and preparation of medications. During an early morning observation, a registered nurse and an LPN were found to have pre-prepared and stacked clear medication cups containing both controlled and non-controlled drugs on and inside their medication carts. This practice was confirmed by both staff members, who acknowledged that medications for multiple residents were prepared in advance and left unattended, rather than being administered directly from secured storage at the time of medication pass. The facility's policy requires all drugs and biologicals to be stored in locked compartments and to remain under the direct observation of authorized personnel during medication administration. Among the pre-prepared medications, several cups contained controlled substances such as Clonazepam, Ativan, and Tylenol with Codeine, which had been signed out on the Controlled Drug Received/Record/Disposition Form. The staff involved stated that they resorted to this practice due to time constraints and resident behaviors, but acknowledged it was not in accordance with policy. The administrator confirmed that the pre-preparation and stacking of medication cups was not permitted and that the involved staff would not return.
Failure to Properly Store Refrigerated Food Items
Penalty
Summary
The facility failed to store refrigerated food in accordance with professional standards for food service safety. During observation, surveyors found 11 individual servings of mixed fruit and two cups of applesauce that were uncovered and undated on a shelf in a kitchen refrigeration unit. Additionally, six cooked chicken breast servings were found undated and wrapped in foil with open areas exposing the chicken in another refrigerated unit. The facility's Food Safety Requirements policy requires that refrigerated foods be labeled, dated, and kept covered or in tight containers. The Dietary Manager confirmed that refrigerated foods should not be stored undated or uncovered. At the time of the survey, 91 residents were residing in the facility.
Failure to Refer for PASRR Reevaluation After Short-Term Approval Expired
Penalty
Summary
The facility failed to notify the state mental health authority for reevaluation when the Preadmission Screening and Resident Review (PASRR) short-term approvals ended for six residents. According to the facility's policy, all applicants are to be screened for serious mental disorders or intellectual disabilities, and a PASRR Level II evaluation determines the need for specialized services and the appropriate setting. For each of the six residents, documentation showed that their short-term PASRR approvals had expired, but there was no evidence in their medical records that a referral for reevaluation was made or that the state mental health authority conducted a reevaluation after the approval period ended. This deficiency was confirmed through both interview and record review. The Social Services Director acknowledged that the affected residents were not reevaluated by the state mental health authority as required when their short-term PASRR approvals expired. The lack of timely referral and reevaluation was identified for each resident based on the expiration dates listed in their PASRR Level II Outcome Notices and the absence of corresponding documentation in their records.
Failure to Implement Fall Prevention and Smoking Safety Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for multiple residents who had documented falls. Despite having a Fall Prevention Program that required individualized assessment and intervention, several residents experienced repeated falls, and the interventions documented in their care plans and fall reports were not in place during a subsequent survey. For example, one resident had multiple falls in the bathroom and bedroom, with interventions such as non-skid strips and non-adhesive pads documented but not present during inspection. Another resident who fell in front of a recliner did not have the prescribed non-skid strips in place, and a third resident who fell out of bed did not have the required perimeter mattress in use. The Director of Nursing confirmed during the tour that these interventions were missing and was unable to explain why they had not been implemented. Additionally, the facility failed to accurately assess and enforce smoking safety policies for a resident with significant psychiatric diagnoses, including schizoaffective disorder, bipolar disorder, depression, and a history of suicidal ideation. The resident had multiple documented incidents of possessing and using prohibited smoking materials, such as marijuana vapes, nicotine vape juice, lighters, and edibles, in violation of the facility's smoking policy. Despite these incidents, the resident's Smoking and Safety Assessment was not updated to reflect noncompliance, and there was no documentation that the facility followed its own policy to ensure the resident's safety regarding smoking materials. These deficiencies were identified through record review, staff interviews, and direct observation, which confirmed that required safety interventions and policy enforcement were not consistently carried out for residents at risk of falls and those with smoking-related safety concerns.
Failure to Change and Date Oxygen Supplies per Policy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for four residents who were receiving oxygen therapy. Surveyors observed that oxygen humidification bottles and tubing were not changed according to facility policy, which requires weekly changes and dating of equipment. Specifically, two residents were found with humidification bottles dated over two weeks prior to the observation, and their oxygen tubing was not dated. Another resident was using oxygen equipment that was not dated, and there was no documented physician order for oxygen or for changing the tubing and humidification bottle. A fourth resident had an order to change oxygen supplies weekly, but the humidification bottle was dated a week prior and the tubing was not dated. Interviews with facility staff confirmed that the policy is to change oxygen humidification bottles and tubing weekly, every Sunday by the night shift. However, observations and record reviews indicated that this policy was not consistently followed for the residents reviewed. The affected residents had diagnoses or orders indicating the need for oxygen therapy, including chronic obstructive pulmonary disease and orders for oxygen at specific flow rates. The lack of adherence to the facility's policy for changing and dating oxygen supplies constituted a failure to provide safe and appropriate respiratory care as required.
Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were properly offered and documented for four out of five residents reviewed for immunization compliance. Specifically, the Immunization Audit Report sheets for these residents did not include any history of receiving the pneumococcal vaccine, nor was there evidence that the vaccine was offered, declined, or administered. In one case, there was also no documentation regarding the influenza vaccine. The facility's policies require annual offering of the influenza vaccine and assessment for pneumococcal immunization upon admission, but these procedures were not followed or recorded for the affected residents. This deficiency was confirmed by the Regional Nurse Consultant during the survey.
Failure to Timely Assess Residents for Walking Pass Privileges
Penalty
Summary
The facility failed to assess two residents for participation in the Walking Pass Program, which is designed to promote resident independence and self-determination. One resident, with diagnoses including depression, schizoaffective disorder, narcissistic and antisocial personality disorders, reported requesting a walking pass multiple times but had not been assessed for eligibility. The Social Service Director confirmed the resident's request was made months prior and acknowledged that no assessment had been initiated due to workload constraints. Another resident, with a history of schizoaffective disorder, depression, bipolar disorder, and suicidal ideations, experienced a significant delay in regaining walking pass privileges after they were rescinded due to a program violation. The resident stated that the process took a long time, and records showed a gap of several months between the request and reinstatement of privileges. The facility's administrator confirmed that assessments should be completed within thirty days of a resident's request, and acknowledged that a three-month delay was excessive.
Failure to Prevent Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as required by its Abuse, Neglect, and Exploitation policy. According to interviews and record reviews, a Certified Nurse Aide (CNA) was overheard by a Registered Nurse and another CNA telling a resident to 'shut the f*ck up.' The resident later confirmed that the CNA had yelled and cursed at him, expressing that he did not like the way he was spoken to and felt it was unprofessional. The incident was documented in the facility's Serious Injury Incident Communicable Disease Report, and the resident stated that staff should not be allowed to speak to residents in such a manner.
Failure to Implement Effective Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, antibiotic stewardship, and adherence to enhanced barrier precautions (EBP). For one resident with a stage 3 sacral pressure ulcer and an open surgical wound, staff did not follow EBP protocols during wound care. Specifically, gowns and gloves were not available near or outside the resident's room, there was no signage indicating EBP was in place, and staff, including an LPN and two CNAs, did not don protective gowns while performing and assisting with wound care. The facility's regional nurse consultant confirmed that EBP should have been in place for this resident due to the presence of open wounds. Additionally, the facility did not maintain complete and accurate infection surveillance records. The Monthly Infection Logs were not completed for several consecutive months, and the Antimicrobial Days of Therapy Reports lacked critical information such as infection site, pathogen, signs and symptoms, resident location, diagnostic reports, and analysis. Several residents who received antibiotics for urinary tract infections were not included in the UTI log, and the infection preventionist acknowledged that while McGeer criteria were reviewed, this was not documented. The facility also failed to follow manufacturer guidelines for disinfecting blood glucose monitors. After performing blood glucose monitoring on a resident, an LPN cleaned the meter with an alcohol wipe instead of the required disinfectant wipe, and the device was returned to the medication cart. The DON confirmed that the correct disinfectant wipes should have been used. This practice potentially affected multiple residents who required blood glucose monitoring from the same medication cart.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily and made accessible to residents and visitors. During an observation, it was found that the nurse staffing sheet displayed was dated 21 days prior and was placed behind another document, making it not viewable. The administrator confirmed that the nurse staffing sheet was not posted at the beginning of each shift and was not visible as required. This deficiency had the potential to affect all 91 residents currently residing in the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident-to-resident physical abuse incident occurred when one resident with a history of severe mental illness, but no recent aggressive behavior, threw a canister at another resident, hitting him in the knee, and then punched him in the chest. The incident took place near the drink station by the patio door, and was partially captured on facility camera footage, although the video was blurry and lacked audio. The resident who was struck was assessed for injuries, with no injuries or redness noted, and declined further medical attention. The incident was reported to the facility administrator and physician. Witness accounts confirmed that the aggressor slapped a cup of coffee out of the other resident's hand and then hit him in the chest, accompanied by a verbal statement. Staff, including an LPN, responded immediately after being notified by another resident who witnessed the event. The aggressor refused to be interviewed by the surveyor and was not observed near the victim following the incident. The facility's policy prohibits all forms of abuse, including resident-to-resident altercations, but the event demonstrates a failure to prevent such abuse in this instance.
Failure to Prevent Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident sexual and mental abuse involving a resident, identified as R1, and a Certified Nursing Assistant (CNA), identified as V3. Over a period of six months, V3 engaged in sexual activities with R1 on more than 100 occasions, often bribing R1 with alcohol, drugs, and vapes in exchange for sexual favors. R1, who has a history of serious mental illness, including Bipolar Disorder with Psychotic Features and Major Depressive Disorder, was coerced into these encounters under the threat of being cut off from these substances. The abuse occurred within the facility, sometimes in the presence of other residents, and extended to locations outside the facility. R1's mental health history includes suicidal ideation and non-adherence to medication, which were exacerbated by the abuse. The abuse led to R1 experiencing fear, depression, and the need for prophylaxis to prevent sexually transmitted diseases. R1 reported feeling threatened by V3, who claimed she could have R1 removed from the facility if he did not comply with her demands. The situation was further complicated by R1's sharing of videos of the encounters with other facility staff, which were requested by several employees. The facility's policies explicitly prohibit staff from engaging in sexual or romantic relationships with residents, yet V3's actions went unchecked for an extended period. The facility was notified of the abuse after R1 disclosed the encounters to another employee, prompting an investigation. Despite V3's resignation prior to the report, the facility's failure to detect and prevent the abuse resulted in an Immediate Jeopardy situation, highlighting significant lapses in safeguarding resident welfare and enforcing staff conduct policies.
Removal Plan
- The Administrator or designee ensured the safety and well-being of the resident. The staff member was no longer employed with the facility.
- The Administrator initiated an abuse investigation into the resident's abuse allegation.
- Police were notified and the resident was sent to the emergency room for evaluation and examination.
- The Administrator or designee educated all staff on what constitutes all forms of abuse and bribery.
- The Social Service Director completed an Abuse/Neglect/Trauma screening on all residents and any resident who triggered at risk for abuse neglect, or trauma was educated on what to report and who to report to.
- The quality assessment and assurance committee developed and implemented plans to ensure further abuse and bribery of the residents does not continue within the facility.
- The abuse policies were reviewed and revised by the quality assurance committee prior to educating staff.
- A root cause analysis was completed for the alleged sexual relationship that occurred between the resident and the staff member.
- The Administrator received education from the Regional Director of Operations on reporting abuse timely and thoroughly investigating all abuse allegations.
- All newly hired staff and agency staff will be educated by the Administrator, Director of Nursing, or designee prior to the start of their shift on abuse prevention and reporting as well as what constitutes bribery, prohibiting staff from providing contraband to residents, and maintaining professional boundaries with residents, staff not having a physical relationship with residents, and for staff to not request or view photos or videos of residents.
Failure to Provide Annual QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received the mandatory annual Quality Assurance and Performance Improvement (QAPI) in-service training. This deficiency was identified through a review of the facility's Staff Training and Staff In-Service Logs, which covered the period from January 1, 2024, to February 3, 2025. The logs did not contain any documentation indicating that the staff had completed the required QAPI training. During an interview on February 4, 2025, the Corporate Nurse confirmed that no staff at the facility had received the annual QAPI training, as the training program did not list it as a required yearly training. This oversight has the potential to impact all 93 residents currently residing in the facility, as documented in the facility's Resident Roster dated January 31, 2025.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Policy by not immediately reporting an allegation of staff-to-resident sexual abuse to the State Agency. The policy mandates that any allegations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. In this case, a resident reported inappropriate sexual encounters with a CNA, who had already resigned. The facility's Administrator was informed of the allegation by an LPN but did not report it to the State Agency until two days later, when the resident clarified that the encounters were not consensual. This delay in reporting constitutes a failure to comply with the facility's established procedures for handling abuse allegations.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, as evidenced by two separate incidents involving a resident identified as R2. In the first incident, R2 was involved in a verbal altercation with another resident, R1, which escalated when R2 smacked R1 in the face, causing his glasses to fall off and resulting in a minor injury above his right eye. R1 expressed confusion about why R2 became upset, while R2 admitted to smacking R1 because she perceived him as acting foolishly. R2's cognitive status was assessed as intact, with a BIMS score of 15/15, indicating she was aware of her actions. In a second incident, R2 smacked her roommate, R5, after mistakenly believing R5 was attempting to get into her bed. This misunderstanding occurred because R2's bed had been moved earlier that day, and she forgot about the change. R2 was apologetic after realizing her mistake. R2 acknowledged that having roommates often leads to conflicts, suggesting a pattern of behavior that the facility staff was aware of. These incidents highlight the facility's failure to prevent resident-to-resident physical abuse, as outlined in their Abuse, Neglect, and Exploitation policy.
Failure to Document Significant Incidents in Resident Records
Penalty
Summary
The facility failed to maintain accurate clinical records for four residents, as evidenced by the absence of documentation regarding significant incidents. In one case, two residents were involved in a verbal disagreement that escalated when one resident smacked the other, causing a minor injury. Despite the incident being documented in an abuse investigation, it was not recorded in the medical records of either resident involved. The Licensed Practical Nurse/Assistant Director of Nursing confirmed the lack of documentation and noted that the incident was only recorded in a part of the medical record accessible to managers, not in the general medical records. In another incident, two residents went on a home visit, during which one resident reported inappropriate sexual behavior by the other. This led to an abuse investigation, police involvement, and the implementation of 1:1 supervision for the accused resident. However, there was no documentation in the medical records of either resident regarding the allegation, the intervention, or the decision-making process to discontinue the supervision. The facility's administrator confirmed that the interdisciplinary team discussed the situation but did not document their meeting or the rationale for ending the supervision.
Failure to Identify and Treat Pressure Wounds
Penalty
Summary
The facility failed to properly identify, monitor, and treat pressure wounds on a resident's feet, leading to the development of unstageable wounds on both the right outer lateral foot and the left outer lateral heel. Observations revealed that the resident's feet were not offloaded as required, despite the presence of a pressure reduction boot and instructions to use a pillow for offloading. The resident was observed multiple times with their feet in contact with the mattress, contrary to the care plan. The facility's wound treatment management policy requires evidence-based treatments and adherence to physician orders, but these were not followed in this case. The LPN assisting with the assessment was unaware of the resident's wounds, and the current care plan did not document the wounds or any interventions. The Assistant Director of Nursing also confirmed a lack of awareness regarding the resident's foot wounds, indicating a breakdown in communication and care planning within the facility.
Improper Disposal of Kitchen Waste
Penalty
Summary
The facility failed to ensure proper disposal of kitchen waste by leaving the lids open on the trash receptacle located outside. This deficiency was observed during an initial kitchen tour, where the outside trash dumpster lids were found to be left open. The facility's policy on the disposal of garbage and refuse requires that refuse containers and dumpsters outside the facility have tightly fitting lids and be kept covered when not being loaded. The Head Cook confirmed that the lids should be closed to prevent animals from accessing the trash. This failure has the potential to affect all 90 residents residing in the facility.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the food service areas, as evidenced by the presence of gnats on and around the juice dispenser spigot/handle in the kitchen. This observation was made during an initial kitchen tour conducted with the Head Cook. The facility's policy on sanitation inspection mandates that all food service areas be kept clean, sanitary, and free from pests such as rodents, roaches, flies, and other insects. Despite this policy, the Head Cook confirmed the presence of gnats, acknowledging that they should not be present and that the facility had attempted extermination efforts.
Deficient Conditions in Women's Shower Room
Penalty
Summary
The facility failed to maintain a clean, functional, and private environment in the women's shower room, affecting all sixteen female residents on the E Wing. Observations and interviews revealed multiple issues, including broken shower heads, minimal water pressure, and non-functional toilets. Residents reported that the showers and toilets have been in disrepair for an extended period, with one resident stating the issues have persisted for three years. The shower room was observed to have black stains, debris, and broken fixtures, with no soap available in the dispensers. The maintenance director acknowledged the age and difficulty in maintaining the bathroom, noting that corporate plans for a full remodel. However, the current state of the facilities includes non-functional sinks, missing faucets, and a lack of privacy due to broken shower curtains. The cabinet labeled for towels contained unrelated items such as broken PVC pipe and shower curtain hangers, further indicating neglect in maintaining a safe and clean environment for the residents.
Hazardous Item Found in Shower Room
Penalty
Summary
The facility failed to ensure the women's shower room was free from hazards, specifically a 2-blade disposable razor left on the counter. This oversight potentially affects all sixteen female residents on the E-Wing who utilize the shower room. During an observation, the razor was found accessible to residents, which contradicts the facility's protocol that razors should be kept locked up and only accessible to residents when provided by staff. An LPN confirmed that the razor should not have been in the shower room, indicating a lapse in supervision and adherence to safety protocols.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific medical needs. One resident, identified as R30, exhibited discoloration and lesions on their bilateral upper extremities, which were not included in their care plan. Despite the discoloration being noted in a CNA shower sheet and a wound physician identifying a pre-cancerous lesion, the facility's Assistant Director of Nursing (ADON) and Administrator stated that these skin issues did not need to be included in the care plan. The discoloration was attributed to the resident's medication, Plavix, and an order for protective sleeves was only obtained after the physician's assessment. Another resident, R13, had physician orders for antifungal cream due to skin conditions on their lower back, groin, and sacrum, as well as wounds on their feet. Observations revealed bright red, shiny areas on the buttocks and groin, and scabbed areas on the feet, which were not addressed in the care plan. The CNA noted that R13's heels should be offloaded, but the necessary boots were not found in the resident's room. The ADON was unaware of the foot wounds, and the Director of Nursing acknowledged the absence of care plans for R13's skin conditions.
Failure to Address Skin Care Concerns for Resident
Penalty
Summary
The facility failed to address skin care concerns for a resident, identified as R30, who exhibited discoloration and lesions on both upper extremities. Despite the facility's policy requiring regular skin assessments, R30's Treatment Administration Record and Care Plan lacked documentation of skin treatments or physician orders for the affected areas. Observations on 7/9/24 revealed that R30 had not received treatment or protective sleeves for her arms, and the Weekly Skin Assessments consistently noted no skin issues. Interviews with facility staff, including LPNs and the Assistant Director of Nursing, confirmed the absence of treatment orders and the oversight in providing protective measures for R30's fragile skin. Subsequent evaluation by a wound physician on 7/10/24 diagnosed R30 with Actinic Keratosis, a condition that can develop into skin cancer, and noted the presence of purpura due to anticoagulant use and capillary fragility. The physician recommended the use of arm skin protectors to mitigate the extent of purpura. This deficiency highlights the facility's failure to adhere to its own skin assessment policy and to provide necessary care and treatment for R30's skin condition, resulting in a delay in addressing a potentially serious medical issue.
Failure to Provide Physician Orders and Change Oxygen Equipment
Penalty
Summary
The facility failed to provide physician orders for the administration of oxygen and did not change oxygen tubing and humidifier bottles according to facility policy for a resident receiving oxygen therapy. Observations over three days revealed that the resident was in bed with an oxygen cannula administering oxygen at 3.5 liters. The oxygen tubing was dated from a previous date, and the humidification bottle was not dated, indicating they were not changed weekly as required. A Licensed Practical Nurse confirmed that the tubing and bottles should be changed weekly. The Assistant Director of Nursing was unaware that the resident was receiving continuous oxygen and confirmed that a physician order was necessary. No physician order was found until later on the third day of observation.
Deficiency in Antipsychotic Medication Management
Penalty
Summary
The facility failed to identify an appropriate indication for the use of an antipsychotic medication for a resident, leading to a deficiency in medication management. The resident, who is on hospice care and has diagnoses including anxiety disorder, Major Depressive Disorder, Chronic Viral Hepatitis, Cirrhosis of the Liver, Chronic Pain Syndrome, and Emphysema, was prescribed Seroquel, an antipsychotic medication, without a documented diagnosis or indication for its use. The care plan did not reflect the use of an antipsychotic medication or identify target behaviors that would necessitate such medication. Despite the resident's psychiatric evaluation indicating no hallucinations, delusions, or suicidal ideation, and behavior monitoring over three months showing no identified behaviors, the medication was still administered. The Director of Nursing was unable to provide a reason for the resident receiving Seroquel, further highlighting the lack of documentation and justification for the medication's use. This oversight in medication management was observed during a survey, where the resident was seen answering questions appropriately without displaying any inappropriate behaviors or signs of psychosis.
Deficiency in Room Square Footage
Penalty
Summary
The facility failed to ensure that rooms provided at least 80 square feet per resident in multiple resident rooms, affecting fourteen residents in a sample of 53. On July 10, 2024, the Maintenance Director confirmed that some rooms did not meet the required square footage. Observations on July 11, 2024, confirmed that the affected residents occupied rooms identified as less than 80 square feet per resident according to the facility floor plan. A letter from the previous administrator dated January 29, 2019, indicated that a waiver had been submitted to the State Agency regarding the square footage requirement. However, the current administrator stated that this was the last waiver sent to the State Agency. A letter from the State Agency dated April 3, 2019, confirmed that certain rooms were waivered for not meeting the square footage requirement.
Verbal Abuse by RN
Penalty
Summary
The facility failed to ensure that two residents, R1 and R3, were free from verbal abuse by an employee. According to the facility's policy on abuse, neglect, and exploitation, verbal abuse includes the use of oral, written, or gestured communication that includes disparaging and derogatory terms to residents or their families. On 5/10/24, an RN (V5) was overheard being verbally inappropriate with R3, which included cussing and yelling. V5 also yelled at R1, blaming them for the situation. The incident was reported, and an investigation concluded that the allegations were substantiated. V5 was immediately separated from all residents, suspended, and subsequently terminated from employment. Statements from witnesses and the residents involved confirmed the verbal abuse incident.
Failure to Revise Care Plans for Residents with Revoked Smoking Privileges
Penalty
Summary
The facility failed to revise care plans for three residents who smoke, despite their smoking privileges being revoked due to non-compliance with smoking rules. The facility's policy mandates that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. However, the care plans for these residents were not updated to reflect the revocation of their smoking privileges. Specifically, Resident 1's care plan did not include the revocation of smoking privileges despite the resident's repeated non-compliance and continued attempts to obtain contraband. Resident 3's care plan failed to address non-compliance with smoking rules and the revocation of smoking privileges, even though the resident had been caught giving cigarettes to another resident. Resident 4's care plan also did not reflect the revocation of smoking privileges or the specific incidents of non-compliance, such as taking drags off other residents' cigarettes during smoke breaks. The Director of Nursing (DON) confirmed that the smoking privileges for these residents had been revoked for several months, yet the care plans remained unchanged. The Social Service Director was identified as the person responsible for revising the smoking care plans, but the revisions were not completed. This oversight indicates a failure to adhere to the facility's policy on care plan revisions, potentially compromising the effectiveness of the care provided to these residents.
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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