Allure Of Sterling
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling, Illinois.
- Location
- 612 West St Mary's Street, Sterling, Illinois 61081
- CMS Provider Number
- 145615
- Inspections on file
- 28
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Allure Of Sterling during CMS and state inspections, most recent first.
A resident with multiple comorbidities, fragile skin, and a care plan requiring assistance/escort to activities was placed at the nurses’ station after a meal and left unsupervised. The resident attempted to return to her room independently, became entangled in a meal tray cart, and another resident in a motorized wheelchair tried to help by moving the cart. When the wheelchair’s controller was accidentally bumped, the chair moved and the first resident’s hand became caught, causing a large multilayer right-hand laceration that required emergency room treatment, suturing, splinting, and pain management. Staff and the DON later confirmed that no staff were present in the hallway at the time and that the resident was normally pushed back to her room after meals, demonstrating a failure to provide adequate supervision and to control the hazard posed by the meal cart.
The facility did not ensure that an RN was on duty for at least eight consecutive hours each day as required. Review of the nursing schedule for part of a month showed two days with no RN coverage, and the facility could not produce documentation that an RN worked on those days. The DON confirmed in an interview that there was no RN coverage on those dates and acknowledged the requirement for daily RN presence under the facility’s staffing policy.
Surveyors found that the facility did not consistently post current daily nurse staffing information and did not maintain at least 18 months of these postings as required. On review, the only posted direct care staff report was two days old, and the Regional Nurse Consultant reported that no daily staffing reports were available for more than four months, since late summer. The prior DON had kept copies of daily postings, but the current DON did not, despite an existing policy requiring sufficient licensed nurses and nurse aides on a 24-hour basis to provide care to all residents.
The facility failed to follow its policy requiring nursing staff to offer bedtime snacks daily to all residents according to their needs, preferences, and requests. Multiple residents without cognitive impairment reported they do not receive bedtime snacks unless they specifically ask, that staff do not pass snacks room to room, and that a prior practice of offering bedtime snacks stopped after concerns that staff were taking snacks for themselves. The Dietary Manager stated a snack cart is placed in a locked nutrition room on the LTC unit and that CNAs, not dietary staff, are responsible for passing snacks, while the DON stated CNAs should offer snacks during the water pass. Because the nutrition room is locked with a coded system, residents cannot independently access snacks, resulting in snacks not being routinely offered at bedtime as required.
Surveyors found that staff failed to follow infection control practices during wound care and PPE use for several residents. One resident with separate sacral and coccyx pressure injuries had both wounds cleansed, treated, and covered together, contrary to the facility’s stated practice of treating each wound individually to avoid cross-contamination. An LPN performing multiple dressing changes on another resident did not wear a gown for one wound and did not change gloves between different wounds and body areas, despite facility policy requiring glove changes and appropriate gown use. For a resident on enhanced barrier precautions with a diabetic foot ulcer, a wound nurse performed dressing changes wearing only gloves instead of both gown and gloves as required for high-contact care activities. Another resident on contact isolation for an ESBL wound infection had staff entering the room without gowns or gloves, even though signage and policy required full PPE upon room entry, and the resident’s bleeding toe was not fully covered by the dressing.
A resident who was dependent on staff for personal hygiene, including shaving, was repeatedly observed with coarse, 1–2 inch chin hair despite being otherwise clean and appropriately dressed. Her MDS and care plan documented an ADL self-care deficit and the need for staff assistance with bathing and grooming, with scheduled showers twice weekly and shower sheets requiring notation of facial hair removal. Facility records showed missed or undocumented shower days and indicated that facial hair was not removed on some documented shower days, with no notes of care refusal. The ADON/Infection Preventionist reported that residents are typically groomed on shower days and that any refusal should be charted, and the facility’s policy required assistance with grooming facial hair to maintain proper hygiene.
A resident with type 2 DM, vascular dementia, and a diabetic neuropathic ulcer on the right plantar foot did not receive weekly wound measurements and complete assessments as required by the care plan and facility policy. During wound care, the wound care nurse reported that the resident’s diabetic ulcer was managed by an outside podiatrist but had no wound notes or assessments available, and the ADON later acknowledged that staff should have been monitoring and documenting the wound weekly. Review of weekly skin assessments over several months showed only that the resident was followed by a physician and had a treatment order, without any wound measurements or descriptive details, despite a podiatry note documenting a full-thickness ulcer with specific dimensions and the facility policy requiring ongoing assessment of wound size and characteristics.
A resident with dementia, severe cognitive impairment, and high fall risk was observed seated unsafely at a dining table wearing worn slipper socks with most grip dots missing, despite a care plan intervention for nonslip footwear. Staff acknowledged the socks were unsafe, and the DON reported that high fall-risk residents should have individualized interventions followed as care planned, yet the facility lacked a dedicated fall-prevention policy and relied only on an incidents/accidents policy used after events. In a separate observation, the same resident, care planned as dependent for transfers and requiring two-person assistance with a mechanical lift, was transferred from wheelchair to bed by a single CNA using the lift while the second CNA was in the bathroom, contrary to facility policy requiring two staff for all mechanical lift transfers.
A resident with severe cognitive impairment was not protected from sexual abuse by another cognitively impaired resident. Staff discovered both individuals naked in a compromising situation, but the incident was not promptly reported to the state, and documentation and investigation were incomplete. Multiple staff and family members expressed concerns about the residents' inability to consent, and the facility's response was delayed and inconsistent.
Staff failed to report allegations of sexual abuse involving two cognitively impaired residents after a CNA found them partially undressed together. Despite facility policy requiring immediate reporting to authorities, the administrator chose not to report the incident, and no documentation was found of any report or investigation. A review of prior incidents revealed a similar failure to report and investigate when two other cognitively impaired residents were found together in a private room.
A facility failed to investigate an incident where two cognitively impaired residents were found together in a private room, despite staff reporting the event to management. The incident was not documented or formally investigated, contrary to facility policy requiring immediate action and thorough documentation for suspected abuse.
A resident's medical record lacked complete and accurate documentation regarding an incident involving two residents in the memory care unit. Staff and a family member described the residents being found together in bed, but the chart only noted a romantic interest and omitted key details. An LPN reported being told by the previous administrator not to document the incident, resulting in a record that did not reflect the actual events as required by facility policy.
A resident with a history of elopement and a diabetic foot ulcer was not properly assessed or care planned for elopement risk. After being observed seeking to leave, a wander guard was placed without proper documentation or orders. The resident removed the device, exited the facility, and traveled to a gas station before being located and returned by staff, highlighting a failure in supervision and adherence to elopement protocols.
A resident with moderate cognitive impairment and physical limitations reported being hit by her roommate, who had a history of behavioral issues. Staff interviews referenced the alleged incident, but there was no documentation in the progress notes about the altercation or the circumstances leading to the room change, despite facility policy prohibiting abuse.
The facility did not timely report allegations of abuse and a resident-to-resident altercation to the appropriate authorities as required by policy. A resident with cognitive impairment reported being thrown against a wall by a CNA, and two other residents were involved in an unreported physical incident. Staff were aware of these allegations but failed to escalate or document them until notified by a surveyor.
A resident alleged that a night shift CNA threw her against the wall while assisting her to bed, but the CNA continued to work with the resident after the allegation was reported to multiple staff members. Required protective measures, such as suspension of the alleged perpetrator and increased supervision, were not implemented, and several staff failed to report the allegation to administration as required by facility policy.
A resident with severe cognitive impairment experienced two falls, with the second resulting in injury and transfer to a hospital. The LPN involved could not confirm that the resident's representative was notified, and the family only learned of the hospital transfer from the emergency room doctor. Facility records did not document any notification to the family, despite policy requiring prompt notification after such incidents.
A resident with multiple health issues developed a Stage 3 pressure injury due to the facility's failure to assess and implement pressure-relieving interventions. The resident was observed leaning in her wheelchair, causing a wound on her back, which was not assessed or documented for a week. The facility's policy for prompt assessment and treatment was not followed, and the care plan was not updated.
The facility failed to monitor and record food and dishwasher temperatures, crucial for preventing foodborne illnesses. The Dietary Manager noted the dishwasher should reach 200 degrees, but logs showed gaps in temperature monitoring. Similarly, food temperatures were not consistently logged before serving, as required by facility policy. These deficiencies affected all 90 residents.
The facility failed to secure hazardous materials in a dementia unit shower room, leaving items like mouthwash and razors accessible to residents. Additionally, staff did not use a gait belt during the transfer of a resident with coordination issues, despite the resident's risk for falls and the presence of a gait belt in the room.
A resident, who is cognitively intact, was denied privacy during medical appointments as the transportation coordinator insisted on accompanying her despite her requests to be alone. The facility's administrator confirmed that residents who are alert and oriented have the right to privacy, aligning with the facility's policy supporting residents' privacy in communications.
The facility failed to provide proper respiratory care for residents, including a lack of physician orders for oxygen therapy and improper handling of equipment. A resident received oxygen without a current order or care plan, while another had undated and improperly stored oxygen tubing. A third resident's breathing treatment equipment was not dated or stored correctly, with the LPN unaware of proper procedures.
A resident with a history of UTIs and other medical conditions returned to the facility with a discharge order for amoxicillin. The facility failed to administer two doses of the antibiotic, despite having it available in their stock drug convenience box. The DON acknowledged the oversight, which violated the facility's Medication Administration Policy.
The facility failed to ensure proper use of PPE for infection control, as staff did not adhere to required protocols for residents under modified droplet and enhanced barrier precautions. Despite clear signage and policy guidelines, staff entered COVID-19 positive rooms wearing only surgical masks instead of the required N-95 masks, eye protection, gowns, and gloves. Additionally, during high-contact care activities for a resident on enhanced barrier precautions, staff wore gloves but failed to wear gowns.
Failure to Supervise Resident and Manage Meal Cart Hazard Resulting in Severe Hand Laceration
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of accident hazards, resulting in a resident sustaining a significant right-hand laceration. The resident had multiple diagnoses, including heart disease, long-term use of anticoagulants, diabetes mellitus, major depressive disorder, anxiety disorder, morbid obesity, a need for assistance with personal care, a history of falling, muscle wasting, and fragile skin. Her care plan identified potential and actual impairment to skin integrity related to these conditions and documented that she required assistance or an escort to activity functions. Despite these identified needs, the resident was placed at the nurses’ station and later attempted to return to her room independently. On the date of the incident, nursing notes document that staff were called to the hallway and found the resident bleeding on the floor and from her hand. Assessment revealed a large skin tear and laceration on the right hand extending from the middle finger knuckles up between the second and middle finger to the wrist, with some areas too deep to approximate with steri-strips. The resident was transported to a local emergency room, where hospital records described a significant multilayer laceration exposing extensor tendons over the second and third metacarpals, measuring approximately 12 cm by 6 cm. The resident required 19 sutures, a nonstick dressing, and a splint to promote healing and prevent disruption of the sutures, and was started on antibiotics and narcotic pain medication. The facility’s root cause analysis and interviews show that the resident became entangled in a food tray cart while attempting to move herself from the nurses’ station back to her room without staff assistance. Another resident using a motorized wheelchair attempted to help by moving the food cart when he accidentally bumped his wheelchair controller, causing the chair to move and the first resident’s hand to become caught under the wheelchair controller, resulting in the laceration. Both the injured resident and the assisting resident reported that there were no staff present in the hallway at the time. The DON stated that staff usually push the injured resident back to her room after meals and that staff had placed her at the nurses’ station but were called away, and no staff observed that she was stuck in the tray cart. This sequence of events demonstrates that the resident was not adequately supervised in accordance with her assessed needs and the facility’s policy on accidents and supervision.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was scheduled and on duty for at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own Nursing Services and Sufficient Staff policy. The CMS-671 form dated 12/16/25 documented that 84 residents resided in the facility at the time of the survey. Review of the December 2025 nursing schedule for the period 12/1/25 through 12/16/25 showed there was no RN coverage on 12/6/25 and 12/13/25, and the facility was unable to provide any documentation that an RN worked on either of those days. During an interview on 12/18/25 at 12:19 PM, the Director of Nurses confirmed that there was no RN coverage on those two Saturdays and acknowledged the requirement to have an RN in the facility for at least eight consecutive hours each day.
Failure to Post and Maintain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nursing staff information and to maintain at least 18 months of daily staffing postings as required. Surveyors noted that the CMS 671 form dated 12/16/25 documented 84 residents in the building, but on 12/18/25 at 10:20 AM the posted direct care staff daily report was still dated 12/16/25. During the survey, the Regional Nurse Consultant stated there were no daily staffing reports available after 7/31/25, indicating a gap of over four months without maintained postings, and explained that the prior DON had kept copies of the daily posted reports but the current DON did not. The Administrator acknowledged the importance of posting daily staffing numbers to know who is working and to ensure appropriate staffing for the day. The facility’s undated Nursing Services and Sufficient Staff policy states that the facility will supply services by sufficient numbers of licensed nurses and nurse aides on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. This failure to post and maintain daily staffing information had the potential to affect all 84 residents residing in the facility, as identified in the CMS 671 form.
Failure to Routinely Offer and Provide Bedtime Snacks to Residents
Penalty
Summary
The deficiency involves the facility’s failure to offer bedtime snacks to residents in accordance with their needs, preferences, and requests, as required by facility policy. During a group meeting with residents and the facility ombudsman, residents reported that they do not receive bedtime snacks unless they specifically ask for them, and that staff do not routinely offer or pass snacks room to room. Residents stated that bedtime snacks had been offered in the past but this practice stopped after staff were allegedly taking snacks for themselves, and that this change occurred a long time ago. Residents also reported that if they want a snack after dinner, they must bring something back from lunch and keep it in their rooms until evening. Record review showed there were 84 residents in the facility, and assessment review for residents present at the group meeting revealed no cognitive impairment among them. The Dietary Manager reported that kitchen staff take a snack cart to the resident units daily and place it in the nutrition room on the LTC unit, and that CNAs are responsible for passing the snacks rather than dietary staff. Observation showed the nutrition room had a number-coded locking system, preventing residents from accessing snacks without staff assistance. The DON stated that CNAs should be offering bedtime snacks during the water pass because it is important for residents to have substance between the evening and morning meals. The facility’s undated “Offering/Serving Bedtime Snacks” policy states that nursing staff will offer bedtime snacks to all residents daily in accordance with their needs, preferences, and requests, which was not occurring as described by residents and staff.
Infection Control Failures in Wound Care and PPE Use
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control practices related to wound care and use of personal protective equipment (PPE) for multiple residents. For one resident with a stage 4 sacral pressure injury and a separate pressure injury to the coccyx, the wound care nurse cleansed and treated both wounds using the same gauze pad and the same sequence of products, and then covered both wounds with a single bordered foam dressing. The nurse confirmed that the sacral and coccyx wounds were considered two separate wounds that were measured and assessed individually, yet she routinely cleansed and treated both areas at the same time. The Assistant Director of Nursing and Infection Preventionist later stated that when a resident has multiple wounds, each wound should be cleansed, treated, and covered individually, starting with the cleanest to the dirtiest wound to avoid cross contamination and prevent infection. The facility’s wound treatment management policy stated that wound treatments would be provided in accordance with physician orders and current standards of practice. Additional deficiencies were observed in wound care and PPE use for another resident receiving multiple dressing changes. An LPN performed a dressing change on a leg wound wearing gloves but no gown, removed the soiled dressing, cleansed the wound, applied skin prep, and completed the treatment without changing gloves at any point. He then acknowledged he should have worn a gown. For the same resident’s subsequent wounds on the upper back and lower buttocks, the LPN donned a gown and gloves but again failed to change gloves between removing soiled dressings, cleansing wounds, applying skin prep, repositioning the resident, handling supplies, and repacking a wound. The facility’s PPE policy required changing gloves and performing hand hygiene between clean and dirty tasks, when moving from one body part to another, and wearing gowns to protect exposed body areas and clothing from contamination with blood, body fluids, and other potentially infectious material. Surveyors also found failures to follow enhanced barrier precautions and contact isolation requirements. For a resident on enhanced barrier precautions due to skin integrity issues and a diabetic foot ulcer, the wound nurse performed a dressing change and treatment to the diabetic foot ulcer wearing only gloves and no gown, despite an enhanced barrier precautions sign on the door specifying that gowns and gloves must be worn for high-contact care activities including wound care for any skin opening requiring a dressing. For another resident on contact isolation for an ESBL infection in a right lower extremity wound, a sign on the door instructed staff to wear gowns and gloves before room entry. A CNA entered the room twice to drop off bed sheets without wearing a gown or gloves, and the resident’s right lower leg dressing did not fully cover the toes, leaving a bleeding toe exposed. While one staff member stated gowns and gloves were only necessary for direct care, the Infection Preventionist stated that staff must wear gowns and gloves before entering the room, consistent with the facility’s transmission-based precautions policy requiring gown and glove use for contact precautions when interacting with the resident or potentially contaminated areas in the resident’s environment. The report also documented that the wound nurse who performed the wound care for the resident with sacral and coccyx pressure injuries did not have a current nursing license at the time of the survey. A license verification printout provided by the facility showed that this nurse’s license status was "not renewed," with an expiration date earlier in the year. This issue was cited separately under a different regulatory reference.
Failure to Provide Grooming Assistance for Dependent Resident’s Facial Hair
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate grooming assistance for a dependent female resident by not removing coarse facial hair from her chin. On multiple observations over two consecutive days, the resident was seen in her wheelchair, appropriately dressed and appearing clean, but with visible coarse chin hair approximately 1–2 inches in length that remained unshaved throughout the day. The resident’s Minimum Data Set (MDS) indicated she was dependent on staff for personal hygiene tasks, including shaving, and her care plan documented an ADL self-care performance deficit related to impaired balance, with restorative programming for dressing, grooming, and bed mobility. Her care plan interventions specified that she required staff assistance with bathing and showering. Record review showed that the resident’s shower schedule was twice weekly, on Wednesdays and Sundays, with shower sheets requiring staff to indicate whether facial hair was removed. The facility-produced shower sheets for several dates over the prior three months showed that facial hair was not removed on at least two documented shower days, and there were no shower sheets provided for several other scheduled shower days immediately preceding the survey observations. Progress notes for the prior 30 days contained no documentation of the resident refusing care. The Assistant DON/Infection Preventionist stated that residents are typically groomed or shaved on shower days and that female residents should not have facial or chin hair, adding that any refusal of grooming should be charted. The facility had a policy stating it would assist residents with grooming facial hair to maintain proper hygiene, but the observed and documented care did not reflect consistent implementation of this policy for this resident.
Failure to Perform and Document Weekly Assessments of Diabetic Foot Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to complete weekly measurements and comprehensive assessments of a resident’s diabetic ulcer as required by facility policy and the resident’s care plan. During observation, the resident was seen seated in his room while the wound care nurse removed the dressing from the bottom of his right foot, revealing a large, round, dark-colored area on the ball of the foot below the right great toe with raised edges. The wound care nurse stated the wound was a diabetic ulcer related to a bone deformity and that the resident went out to a podiatrist for wound care, but she did not have any wound notes or assessments for the resident and deferred to the ADON for the location of podiatry notes. The ADON later stated that wound documentation should be scanned into the electronic medical record and that staff should be monitoring and documenting the wound weekly using the wound observation tool, acknowledging that the lack of documentation was likely a mistake. Record review showed that weekly skin assessments over several months documented that the resident was being followed by a physician for a diabetic wound to the right plantar foot and that a treatment order was in place, but these assessments did not include measurements or descriptions of the wound. The podiatrist’s note, which the ADON produced, documented a full-thickness diabetic neuropathic ulcer on the bottom of the resident’s right foot, with specific post-debridement measurements, confirming the presence and severity of the wound. The resident’s diagnoses included type 2 DM with foot ulcer and vascular dementia, and physician orders directed daily betadine application and use of a post-op shoe. The resident’s care plan and the facility’s wound treatment management policy required monitoring and documentation of wound location, size, and characteristics, including measurements and detailed assessment, but the facility’s own documentation lacked these required elements for this resident’s diabetic ulcer.
Failure to Implement Fall-Prevention Measures and Safe Mechanical Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and effectively implement fall-prevention interventions for a resident at high risk for falls. During breakfast observation, the resident was seated forward in a dining chair with her buttocks not against the back of the chair, prompting a CNA to instruct her to scoot back due to safety concerns. The resident was wearing slipper socks that were worn on the bottom, with holes forming and very few grip dots remaining. Upon further inspection, staff acknowledged that the grips were worn off and that it would be safer for the resident to have socks with grips. The resident’s fall risk assessment showed a high-risk score of 15, and the care plan identified her as at risk for falls related to deconditioning and dementia, with an intervention specifying nonslip footwear as tolerated. The DON stated that residents with high fall risk scores should have specific interventions on the care plan that are to be followed. The facility did not have a fall prevention policy and instead had only an Incidents and Accidents policy that applied after an incident occurred. The facility also failed to provide a safe mechanical lift transfer consistent with its own policies and the resident’s care plan. The resident, who had diagnoses including dementia, lack of coordination, Alzheimer’s disease, depression, anxiety disorder, hyperlipidemia, hypertension, hypothyroidism, and sepsis, was documented on the MDS as having severe cognitive impairment, requiring substantial/maximal assistance for rolling in bed, and being dependent for transfers. The care plan specified that the resident required assistance by two staff for transfers and used a mechanical lift. During observation, two CNAs brought the resident to her room for incontinence care, with the resident seated in a wheelchair and a mechanical lift sling under her. After attaching the sling to the lift, one CNA went into the bathroom, and the remaining CNA completed the mechanical lift transfer from wheelchair to bed alone, without assistance. The CNA later stated that facility policy requires two staff for mechanical lift transfers for safety, and the DON confirmed that the mechanical lift policy mandates two staff members—one to maneuver the lift and one to watch and guide the resident—when using a mechanical lift.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another cognitively impaired resident. Both individuals resided in the memory care unit and lacked the capacity to consent to sexual activity, as confirmed by medical documentation and staff interviews. The incident occurred when a CNA entered the resident's room and found both residents naked, with one resident standing over the other and engaging in thrusting motions. The CNA intervened and separated the residents, but the event was not immediately reported to the state, and there was confusion and inconsistency in the accounts provided by facility staff and administration regarding the nature of the incident. The administrator conducted an internal investigation but did not report the incident to the state, reasoning that no intercourse had occurred. Documentation of the incident, including risk assessments and family notifications, was incomplete or missing from the resident's chart. Staff interviews revealed that the normal protocol for documenting and assessing such incidents was not followed, and there was a lack of clarity and consistency in communication with the resident's family. Multiple staff members, including the CNA and LPN involved, expressed concerns about the residents' inability to consent and described the event as sexual abuse, yet the facility's response was delayed and inadequately documented. Further interviews with the resident, her family, and other staff indicated that the resident reported being raped and expressed distress about the incident. The medical director and psychiatric nurse practitioner confirmed the resident's inability to consent due to her cognitive status. The facility's staffing levels were also called into question, as only one CNA was present on the unit during certain shifts, limiting the ability to monitor residents effectively. The failure to protect the resident from abuse, promptly report the incident, and properly document and investigate the event constituted a deficiency and resulted in an Immediate Jeopardy finding.
Removal Plan
- R1 and R2 were immediately assessed for injury, changes in condition and psychosocial impact.
- R1 and R2 POAs, Police and MD were notified of the incident.
- R1 was sent to the ER for evaluation.
- R1 and R2 care plans were updated to reflect enhanced safety interventions.
- R1 and R2 had the Abuse, Neglect and Trauma assessment and Trauma Informed Care Assessment / PTSD was completed.
- The Social Services Director interviewed/assessed all residents with BIMS scores of 8 and above for potential abuse.
- All residents with a BIMs score of 7 or less were assessed using the Abuse Screening Adapted for Cognitive Impairment form.
- A hall monitor was added to the memory care unit to ensure no resident enters another resident's room.
- The Hall Monitor is a dedicated staff member and will have no other duties.
- R2 was immediately placed on a 1:1 until hall monitor was established.
- Abuse investigation procedure and documentation process were reviewed.
- DON, ADON, and Administrator re-educated all staff on facility abuse policies.
- DON, ADON, and Administrator educated all staff on the Intimate Resident Behavior, Privacy and Relationships policy updated to reflect residents within the memory care unit do not have the capacity to consent to sexual relationships.
- In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete.
- Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management.
- DON, ADON, and Administrator educated staff on the Hall Monitor duties and responsibilities and that the Hall Monitor is a dedicated individual with no other responsibilities.
- Administrator was educated by Regional Nurse on abuse policy which includes thorough investigation immediately upon receiving report or allegation of abuse.
- Emergency QAPI meeting was held where the abuse policy and intimate relations policy were reviewed along with incident and root cause analysis.
- The Social Services Director or designee will continue to interview residents with BIMs score of 8 or higher on a monthly basis to ensure they have not experienced abuse.
- All residents with a BIMs score of 7 or less will be assessed using the Abuse Screening Adapted for Cognitive Impairment form.
- Any reports of abuse will be immediately reported and investigated.
- The finding to be presented to the Quarterly QAA Committee.
Failure to Report Allegations of Sexual Abuse Involving Cognitively Impaired Residents
Penalty
Summary
The facility failed to report allegations of sexual abuse involving residents with cognitive impairments. In one incident, a CNA entered a resident's room and observed two residents, both partially undressed, in a compromising position. The CNA reported the situation to a nurse, and the administrator later conducted an internal investigation. Despite the facility's policy requiring immediate reporting of all abuse allegations to state authorities, the administrator decided not to report the incident, reasoning that no intercourse had occurred. The administrator later acknowledged that the incident should have been reported, as any allegation is required to be reported and then investigated. The residents involved had significant cognitive impairments. One resident had diagnoses including dementia, sleep disorder, general anxiety disorder, and severe cognitive impairment as documented in the Minimum Data Set (MDS). The other resident involved in the incident had moderate cognitive impairment and similar diagnoses. The facility's own policy mandates reporting all alleged violations to the administrator, state agency, and other required agencies within specified timeframes, but there was no documentation that the Illinois Department of Public Health was contacted regarding the initial allegation or the results of the investigation. A review of prior incidents revealed another episode involving two cognitively impaired residents found together in a private room. Staff separated the residents and reported the situation to the nurse, who then informed the previous administrator. However, the administrator instructed staff not to document the incident in the residents' charts, and there was no evidence of an abuse investigation or reporting to authorities. Interviews with staff and review of facility records confirmed that no abuse investigations had been conducted in the last six months, despite these incidents.
Failure to Investigate Alleged Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents with cognitive impairment in the memory care unit. In June 2025, a CNA discovered one resident in another resident's room and bed, with both residents present but clothed. The CNA immediately separated them and reported the incident to the nurse, who then informed the Administrator. However, the Administrator instructed the nurse not to document the incident in the residents' charts and indicated that Social Services would handle the situation. There was no evidence of a formal investigation, and no abuse investigation was initiated or documented for this incident. Interviews with staff and review of records revealed that key personnel, including the current Administrator and previous Social Services staff, were either unaware of the full details or could not recall the specifics of the event. The residents involved had diagnoses of dementia and demonstrated severe to moderate cognitive impairment, with one resident unable to consent for herself. The facility's policy required immediate investigation and thorough documentation of any suspected abuse, neglect, or exploitation, but this was not followed in this case.
Incomplete and Inaccurate Documentation of Resident Incident
Penalty
Summary
The facility failed to ensure that a resident's medical record contained complete and accurate information regarding an incident involving two residents in the memory care unit. According to the documentation, a social service note indicated that the residents were interested in a romantic relationship and were advised to spend time together only in public spaces, with both agreeing to this guidance. However, interviews with staff and the resident's power of attorney revealed that the actual incident involved the two residents being found together in bed, with conflicting accounts about whether they were clothed or unclothed. The note in the medical record did not accurately reflect the details of the incident as described by staff and the resident's family member. Further review showed that the LPN involved was instructed by the previous administrator not to document the incident in the residents' charts, and the previous social services staff could not recall specific details without her notes. The facility's policy requires that all assessments, observations, and care provided be documented accurately, objectively, and completely in the resident's medical record. The lack of accurate and complete documentation in this case resulted in a deficiency, as the medical record did not contain sufficient details about the incident or the residents' responses to care.
Failure to Supervise and Prevent Elopement for At-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident at risk for elopement. The resident, admitted with a diabetic foot ulcer and cellulitis, had a documented history of elopement or attempted elopement at home. Despite this, the elopement evaluation did not identify risk factors or suggest interventions. Staff observed the resident attempting to leave the facility and placed a wander guard bracelet on him, but there was no clear documentation of who ordered or applied the device, and no corresponding assessment, care plan, or physician order was completed as required by facility policy. The resident was able to remove the wander guard and exit the facility in his wheelchair without staff knowledge. He traveled to a nearby gas station, crossing a highway with the assistance of bystanders, before being located and returned by staff and family. Interviews confirmed that staff were unaware of the resident's whereabouts until after he had left, and the incident was not immediately reported to the administrator. The resident was found without injury, but the lack of supervision and failure to follow established protocols for elopement risk contributed to the deficiency.
Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving a resident with moderate cognitive impairment and mild intellectual disabilities. According to the comprehensive cognitive assessment, this resident required total assistance with transfers and had limited use of her right arm due to hemiplegia/hemiparesis. Incident investigation reports and interviews revealed that the resident stated her roommate had hit her "all over," although she denied being physically hurt. The roommate, who was independent with mobility and had a history of manipulative and rude behavior toward past roommates, denied hitting the resident but stated that if she did, it was unintentional. Documentation showed that the two residents were roommates until one was moved to another room, with the move attributed to roommate preferences and behavioral concerns. Staff interviews indicated that there were reports and gossip among staff about the alleged physical altercation, with some staff recalling hearing that one resident was on the other's bed and may have hit her. However, there was no documentation in the progress notes regarding the potential physical altercation or the behavioral incidents leading up to the room change. The facility's policy prohibits abuse, neglect, and exploitation, including physical abuse such as hitting, slapping, and punching, but the lack of documentation and follow-up on the reported incident demonstrates a failure to fully investigate and address the alleged abuse.
Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report allegations of abuse involving three residents to the Abuse Coordinator as required by policy. One resident, who was moderately cognitively impaired and diagnosed with mild intellectual disabilities, consistently reported that a female CNA had thrown her against a wall, causing her to hit her head. The resident relayed this allegation to multiple staff members, including a hospice RN and an LPN, but the information was not reported to the Administrator or properly escalated internally. Staff interviews revealed confusion about the identity of the alleged perpetrator and a lack of clarity regarding reporting responsibilities. Internal reporting of the abuse allegation only occurred after the State Agency surveyor brought it to the Administrator's attention. Additionally, two other residents who were previously roommates were involved in an unreported incident where one resident allegedly hit the other. Staff members were aware of rumors or gossip about the incident, and one resident confirmed being hit by her former roommate, though she denied being physically hurt. There was no documentation in the progress notes regarding this potential physical altercation, and no internal report was made until the State Agency surveyor informed facility leadership. The facility's own policy requires immediate reporting of such allegations, but this was not followed in these cases.
Failure to Protect Resident from Further Potential Abuse
Penalty
Summary
The facility failed to protect a resident from further potential abuse after the resident alleged that a night shift CNA had thrown her against the wall while assisting her to bed, causing her to hit the left side of her head. The resident reported the incident to multiple staff members, including a hospice RN, an LPN, and another CNA. Despite these reports, the alleged perpetrator, identified by the resident as a night shift CNA (though the name used was not found on the staff roster), continued to work primarily as the resident's CNA until resigning from the facility. The facility did not suspend the alleged perpetrator pending investigation, nor did they implement protective measures such as increased supervision or staffing changes as outlined in their abuse prevention policy. Multiple staff members failed to report the resident's allegations to facility administration as required. The hospice RN stated she reported the allegation to the ADON, who denied receiving it, and another CNA admitted to not reporting the allegation at all. The facility's policy requires immediate action to protect residents from further harm during abuse investigations, including examining the alleged victim and making staffing changes if necessary. However, these steps were not taken, and the alleged perpetrator remained in contact with the resident until her resignation.
Failure to Notify Resident Representative After Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative after the resident experienced a fall with injury and was subsequently sent to a local hospital. The resident, who had diagnoses including unspecified dementia, malignant neoplasm of the head, face, and neck, and hypertension, was assessed as confused with severe cognitive impairment affecting all areas of judgment. The clinical admission assessment also noted wandering behaviors and incontinence. On the day in question, the resident had two falls: the first occurred while family was present in the building, and the second happened later that night after the resident was put to bed. After the second fall, the resident complained of left hip and knee pain and was sent to the emergency room. The LPN involved stated she believed she had notified the family but could not recall specific details and admitted uncertainty about whether the notification occurred. Interviews with the resident's daughters, who are also the resident's powers of attorney, revealed that they were not informed by the facility about the second fall or the transfer to the hospital. They only learned of the hospital transfer when contacted by the emergency room doctor regarding surgery for a fractured hip. Review of the resident's progress notes and incident reports confirmed that there was no documentation of family notification regarding the fall or hospital transfer. The facility's policy requires prompt notification of the resident's representative in the event of accidents resulting in injury or transfer, but this was not followed in this instance.
Failure to Assess and Intervene in Pressure Injury
Penalty
Summary
The facility failed to identify and assess a pressure injury on a resident, which progressed to a Stage 3 pressure injury before any assessment or intervention was conducted. The resident, a female with multiple diagnoses including mild protein calorie malnutrition, intellectual disabilities, and cognitive communication deficit, was observed leaning to the left in her wheelchair over several days. Despite the presence of a wound on her left mid-back, no assessment was performed until a week later when the wound doctor identified it as a Stage 3 pressure injury. The wound was attributed to the resident's back rubbing against a metal bar on the wheelchair, and no pressure-relieving interventions were implemented until after the wound was assessed. The Director of Nursing confirmed that there was no documentation or care plan interventions initiated after the wound was discovered. The facility's policy requires prompt assessment and treatment of pressure injuries, but this was not followed. The resident's care plan had not been updated since May, and there was no documentation of the wound in the wound doctor's notes. The facility's failure to assess and document the wound promptly, as well as to implement necessary interventions, contributed to the deterioration of the resident's condition.
Failure to Monitor Food and Dishwasher Temperatures
Penalty
Summary
The facility failed to adequately monitor and record both food and dishwasher temperatures, which are critical for ensuring sanitary conditions and preventing foodborne illnesses. The Dietary Manager, identified as V14, acknowledged that the dishwasher is a hot water sanitizer with a booster to reach temperatures up to 200 degrees. However, the dishwasher logs for September 2024 revealed gaps in temperature monitoring, with no records from September 6 to September 11 and on September 17. The facility's policy mandates that water temperatures be measured and recorded before each meal or after the dishwasher is emptied or refilled, but this was not consistently followed. Additionally, the facility did not consistently log food temperatures before serving meals. The Cook, identified as V16, stated that it is their responsibility to check and log food temperatures prior to serving. However, the food temperature log for the week of September 22, 2024, showed missing entries for dinner temperatures over the past two nights. The facility's policy requires that food temperatures be checked before serving and again after half of the meals have been served to ensure proper serving temperatures. These lapses in monitoring and recording temperatures for both food and dishwashing processes apply to all 90 residents residing in the facility.
Failure to Secure Hazardous Materials and Use Gait Belt
Penalty
Summary
The facility failed to ensure the safety of residents by not securing hazardous materials and not using proper transfer techniques. On the dementia unit, a shower room door with a keypad lock was found unlocked on multiple occasions, allowing access to hazardous liquids and disposable razors. These items, which included mouthwash, skin and hair cleanser, hand sanitizer, body lotion, baby powder, shaving cream, and a glass and surface cleanser, were labeled with warnings to keep out of reach of children. Staff acknowledged that the door should always be locked to prevent residents, who are known to wander and take items, from accessing these potentially dangerous supplies. Additionally, the facility did not use a gait belt during the transfer of a resident with a history of lack of coordination, hypertension, and obesity, who was at risk for falls due to deconditioning and gait/balance problems. During a toileting and peri care session, the resident was unsteady and required verbal cues to use a walker and transfer to a wheelchair. Despite the presence of a gait belt in the room, staff did not use it, which the Director of Nurses later confirmed was necessary for the resident's safety during transfers. The facility's policy mandates the use of gait belts for residents who cannot independently ambulate or transfer.
Failure to Ensure Resident Privacy During Medical Appointments
Penalty
Summary
The facility failed to ensure privacy for a resident, R13, during physician appointments. R13, who is cognitively intact and has multiple diagnoses including spinal stenosis and difficulty walking, expressed that the transportation coordinator, V5, accompanied her into the doctor's office despite her requests for privacy. R13 stated that she asked V5 to remain in the lobby, but V5 insisted on accompanying her, citing responsibility for R13's safety. V5 claimed that no resident had ever requested privacy during appointments. The facility administrator, V1, acknowledged that residents who are alert and oriented, like R13, have the right to decide whether they want privacy during medical appointments. The facility's policy supports residents' rights to privacy in communications, both within and outside the facility.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for residents requiring oxygen therapy, as evidenced by the lack of physician orders and improper handling of oxygen and breathing treatment equipment. One resident, a female with acute respiratory failure and other chronic conditions, was observed receiving oxygen without a current physician order or a care plan for oxygen administration. The facility's policy mandates that oxygen therapy must be administered under a physician's order and that equipment should be changed weekly and stored properly to prevent contamination. However, the resident's oxygen tubing was not dated or stored correctly, indicating a lapse in adherence to these guidelines. Another resident, a female with acute respiratory failure and other health issues, had an oxygen tank attached to her wheelchair with undated tubing that was not stored in a plastic bag, as required. Additionally, the oxygen concentrator in her room had a nasal cannula lying on the floor, also undated and improperly stored. A third resident, with asthma and other chronic conditions, had a breathing treatment machine with tubing that was not dated or stored in a bag. The LPN administering treatments was unaware of the tubing's age or the need for proper storage, further highlighting the facility's failure to follow its own infection control policies.
Failure to Administer Antibiotic to Resident
Penalty
Summary
The facility failed to administer two doses of an ordered antibiotic to a resident, identified as R32, who was reviewed for hospitalization. R32, a male resident with a history of urinary tract infection, multiple sclerosis, neuromuscular dysfunction of the bladder, calculus of the kidney and ureter, and chronic obstructive pulmonary disease, was diagnosed with sepsis likely sourced from a urinary tract infection, osteomyelitis, and infected decubitus ulcers. After a 14-day hospital stay, R32 returned to the facility with a discharge order to receive amoxicillin 500 mg by mouth three times a day for eight days. However, the facility's records showed that the amoxicillin was not administered on the evening of his return or the following morning. The Director of Nursing acknowledged that there was no excuse for the missed doses, as the facility had amoxicillin available in their stock drug convenience box. The facility's Medication Administration Policy requires medications to be administered by a licensed nurse as ordered by the physician and in accordance with professional standards of practice. Despite this policy, the failure to administer the antibiotic as ordered represents a deficiency in the facility's pharmaceutical services, impacting the resident's care and treatment.
Failure to Adhere to PPE Protocols for Infection Control
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) to prevent cross-contamination for two residents within the sample and one resident outside the sample. Specifically, residents R71 and R72 were under modified droplet precautions due to COVID-19, requiring the use of N-95 masks, eye protection, gowns, and gloves by anyone entering their room. Despite clear signage indicating these requirements, staff members V11 and V13 entered the room wearing only surgical masks, failing to don the necessary PPE. This occurred during multiple interactions, including delivering meals and engaging in close contact with the residents. Additionally, resident R84 was on enhanced barrier precautions due to a wound on his left foot, necessitating the use of gloves and gowns during high-contact care activities such as transfers and toileting. However, staff members V11 and V12 only wore gloves while performing these activities, neglecting to wear gowns as required. The facility's policies clearly outlined the PPE requirements for both COVID-19 precautions and enhanced barrier precautions, yet these were not adhered to by the staff, as confirmed by the Administrator/Infection Control Preventionist.
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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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