Aperion Care Wilmington
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, Illinois.
- Location
- 555 West Kahler, Wilmington, Illinois 60481
- CMS Provider Number
- 145316
- Inspections on file
- 35
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Aperion Care Wilmington during CMS and state inspections, most recent first.
Surveyors found that shared resident restrooms were not maintained in a safe, sanitary, and comfortable condition, despite a policy requiring daily toilet and lavatory cleaning. In multiple bathrooms, inspectors observed toilet paper and stained footprints on floors, stained cloth pads placed at the base of leaking toilets, black-stained and peeling floor tiles, chipped toilet seats, heavy black buildup inside toilet bowls, and dirty plungers stored on the floor. Several residents reported that housekeeping cleaned their bathrooms only once a week or a few times per week, that toilets were persistently dirty or clogged, and that they had informed staff about these issues over a long period. The Environmental Manager and Maintenance Director acknowledged awareness of leaking toilets, urine-damaged flooring, and the need for tile and toilet seat replacement, while the DON stated that plungers are unsanitary and should not be left in resident restrooms.
A resident with psychiatric diagnoses and an abuse risk care plan was in a dining room when another resident, who had been pacing nearby, approached in a threatening manner and forcefully pushed the resident in the wheelchair, as later confirmed on video review. No staff were present in the dining room at the time, and the affected resident reported feeling attacked and stated that a nurse refused a request to call the police, while a nurse later documented that the aggressor admitted to pushing the other resident. The facility’s abuse policy prohibits physical abuse, yet the incident occurred without staff supervision and involved resident-to-resident physical contact that was characterized by leadership as abuse.
The facility failed to timely and accurately report an allegation of resident-to-resident abuse to the state surveying agency and law enforcement. A resident in a w/c told an RN that another resident had hit him, while the other resident admitted to pushing him away, and the RN notified the administrator and other leadership that morning. The administrator and social services director reviewed camera footage showing one resident approaching and yelling at another, followed by the second resident pushing him, and this was documented in the EMR. Despite a policy requiring abuse allegations, including a resident pushing another resident, to be reported within two hours, the initial abuse report was not submitted until the next day and was inaccurately documented with the wrong occurrence date and description, characterizing it as a behavior reported to a surveyor rather than the original allegation.
The facility failed to follow its abuse policy by not promptly investigating an allegation of resident-to-resident physical abuse. A resident reported that his roommate pushed him out of his wheelchair in the dining room, and a nurse assessed both residents, found no injuries, and notified the administrator, recognizing the event as an abuse allegation. The administrator and social services director reviewed camera footage showing one resident approaching another and then being forcefully pushed, but no abuse investigation or grievance report was initiated at that time, and the incident was treated as a behavioral event rather than an allegation of abuse, contrary to facility policy requiring documentation and investigation of all alleged or suspected abuse.
The facility failed to notify law enforcement and the state surveying agency after an RN discovered two Norco bingo cards for two residents inside another RN’s personal bag, despite only those two nurses having keys to the medication room. The DON removed the narcotics from the bag, and the RN admitted placing them there and stated she was addicted to drugs and had recently been in rehab. The Administrator confirmed the medications belonged to two residents with multiple medical conditions and pain management orders but chose not to report the incident externally because the medications had not left the building, the narcotic count was accurate, and no doses were missed, contrary to facility policy requiring notification of appropriate agencies for suspected diversion.
Controlled substances (Norco) prescribed for two residents with multiple chronic conditions were not securely stored when an RN left two bingo cards on a cabinet in the medication room instead of in a double-locked narcotic storage area. After the RN returned from break, the Norco cards were missing from the cabinet and were later found inside another RN's unzipped personal bag, with narcotic sheets still attached and visible. Leadership staff confirmed that narcotics in the medication room should be double locked in the narcotic drawer of the med cart, consistent with the facility’s medication storage policy.
A resident with dementia, psychiatric disorders, and multiple medical comorbidities told staff that a female staff member with a specific first name had punched him months earlier and stated he had previously informed others. A CNA reported that, months before, the resident disclosed during a shower that a CNA with that same first name had beaten him, but she did not notify the abuse coordinator or administration because she believed it was an old, already resolved case. Another CNA with that first name stated she had never cared for the resident and did not take the allegation seriously when she heard it secondhand. The facility’s abuse policy required employees to immediately report any incident, allegation, or suspicion of abuse to the administrator or designated channels, but this internal reporting did not occur as required.
A resident with intact cognition and a psychiatric history reported to the PRSC that a nurse inappropriately touched her during wound care, which was promptly reported internally. However, the DON was not informed until three days later, and the facility delayed reporting the sexual abuse allegation to the state agency and police for seven days, contrary to policy requiring notification within two hours.
A resident with intact cognition and a history of mental health conditions reported that a nurse inappropriately applied cream to her genital area during wound care, which she perceived as sexual abuse. The incident was promptly reported internally, but the nurse was not suspended until eight days later, and the DON was not informed until three days after the initial report. The facility also failed to notify the state agency within the required timeframe, delaying the report by seven days.
Two residents with severe cognitive impairment and behavioral histories were involved in a physical and emotional altercation, resulting in one resident sustaining scratches, a bite mark, and emotional distress. Despite known risk factors and prior incidents, the facility did not implement effective interventions to prevent abuse, and staff were not present at the time of the incident. The facility's failure to protect vulnerable individuals led to physical and emotional harm.
Surveyors found multiple failures in kitchen sanitation and food safety, including a malfunctioning dishwasher, improper food holding temperatures, unlabeled and undated food items, open containers in storage, dirty utensils, and staff not using required beard guards. The Dietary Director acknowledged these lapses and inconsistent adherence to facility policies.
Multiple residents at risk for falls did not receive appropriate fall prevention measures, including improper mattress fit, missing floor mats, and beds left in high positions after care. Staff and care plans indicated these interventions were required, but observations and interviews confirmed they were not consistently implemented.
Surveyors identified that several vials of Lorazepam, labeled by pharmacy for refrigeration, were stored unrefrigerated in a narcotic box within a medication cart instead of in a locked refrigerator as required. This affected multiple residents with seizure and anxiety disorders who had physician orders for IM Lorazepam. Staff interviews revealed confusion about proper storage, and the medication refrigerator was found to lack a lock, leading to the improper storage practice.
A resident with limited ROM due to multiple medical conditions did not receive the prescribed active assisted ROM program, as there was no documentation of the program being carried out and the resident was not included on the restorative list. The restorative nurse confirmed the absence of a program to guide staff on exercises or frequency, and the resident reported not receiving restorative assistance.
Two residents received improper catheter care, including unsanitary technique, lack of a catheter securing device, and failure to keep the catheter bag off the floor. One resident's catheter care was performed using the same washcloth for multiple wipes and without cleaning between the labia, while another resident's catheter bag was found on the floor instead of being hung on the bed frame, contrary to facility policy.
Two residents did not receive their prescribed medications due to the facility's failure to reorder medications in a timely manner. One resident missed doses of Tramadol for pain management, while another missed a scheduled dose of Aripiprazole for schizophrenia. Nursing staff confirmed that medications were not reordered according to policy, leading to unavailability during medication passes.
The facility did not ensure that CNAs completed the required 12 hours of annual competency training, as documentation for several CNAs showed only 1.5 to 4 hours of in-service training. The administrator was unable to provide proof of compliance due to a recent change in the training platform, affecting all residents receiving care from CNAs.
Several residents repeatedly requested access to the facility's grievance policy and information on filing grievances, but did not receive it. Staff interviews revealed confusion about who was responsible for providing the policy, and a review of bulletin boards showed the policy was not posted. Resident council meeting minutes documented ongoing requests for the policy to be made available.
A resident with cognitive impairment was bitten by another resident in a dementia unit due to inadequate monitoring. The facility was short-staffed, and the resident, known for wandering, entered another resident's room, leading to the incident. Previous similar incidents had occurred, but effective measures were not implemented to prevent further occurrences.
The facility failed to maintain effective infection control during a norovirus outbreak, affecting 165 residents. Surveyors found inconsistencies in isolation protocols, with symptomatic residents not properly isolated and staff not adhering to PPE and hand hygiene guidelines. Housekeeping staff did not consistently use bleach-based cleaning products due to supply shortages, and the Maintenance Director was unsure of the correct bleach-to-water ratio. The facility's Norovirus Outbreak Measures policy was not fully implemented, contributing to the deficiency.
A resident with urinary retention and urethral issues had a 20FR catheter inserted instead of the ordered 16FR, due to a nurse's oversight in checking the physician's order. The facility had the correct catheter size available, but the nurse did not verify the order before insertion.
During a kitchen renovation, a facility failed to maintain safe food handling practices, leading to the revocation of its food preparation permit. The facility continued food preparation without proper refrigeration or sanitation, affecting all residents. Observations showed inadequate equipment and lack of handwashing stations, with meals served in disposable containers. The Dietary Manager did not document food temperatures, violating facility policy.
A resident experienced a delay in receiving a physician-ordered X-Ray after a fall, resulting in a late diagnosis of fractures. The Quality Assurance Nurse acknowledged the delay, which was noticed when the X-Ray service was needed for another resident. The facility's agreement with the X-Ray company requires services within 24 business hours or notification if this cannot be met.
Unsanitary and Poorly Maintained Resident Restrooms
Penalty
Summary
Surveyors identified a failure to maintain safe, functional, sanitary, and comfortable resident restrooms for all 18 residents reviewed for restroom environment. The Environmental Manager stated that housekeepers are assigned to clean resident bedrooms and bathrooms daily, including toilets, sinks, and dispensers. However, during inspection of one shared restroom used by six residents, surveyors observed toilet paper on the floor, scattered black stained footprints, and a blue cloth bed pad with large brown stains placed at the base of a leaking toilet. A dirty plunger was stored on the floor next to the toilet. In another shared restroom used by six different residents, the sink had large areas of stale brown stains and toothpaste buildup, the floor had scattered black stains, the toilet seat was chipped in multiple areas, and the inside of the toilet bowl had large areas of black buildup, with a plunger again stored on the floor. The Environmental Manager acknowledged that the floors needed sweeping and mopping, that the plungers were not clean or hygienic, and that the toilet leakage had been discussed in team meetings and reported to Maintenance. Multiple residents reported that housekeeping did not clean the bathrooms daily and described persistent unsanitary conditions. One resident stated housekeeping came every three days, that black buildup in the toilet had been present as long as she could remember, that she hated it, and that the chipped toilet was not hygienic given it was shared with five others; she also reported the toilet clogged at least once a day and that staff were informed each time. Another resident reported the bathroom was cleaned maybe once a week and that the black buildup and chipped toilet seat had always been present, and that staff were aware of the chipped seat. A third resident stated staff cleaned the bathroom three times a week but that it was always dirty, leading her to sometimes use a shower bathroom down the hall instead. In a third shared restroom, surveyors observed another stained blue cloth bed pad on the floor at the front of the toilet base, with black-stained, peeling tiles beneath it. Residents using this restroom reported the black-stained floor had been present for a long time and that they had informed staff, and one resident reported the toilet sometimes leaked and believed facility staff knew because it had been ongoing. The Maintenance Director stated the black-stained tile was from moisture such as urine, that he had requested tile replacement about two months earlier and it remained on his to-do list, and that the toilet seat and black buildup in another restroom needed replacement and cleaning. The DON acknowledged hearing concerns about toilets clogging and stated plungers were unsanitary and should not be left in resident restrooms, despite the facility’s housekeeping policy requiring daily cleaning of toilets and lavatories.
Failure to Prevent and Respond to Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to protect a resident from resident-to-resident physical abuse when one resident pushed another resident in the dining room without staff present. One resident (R2) reported that he and his roommate (R1) had a fight in the dining room and that he pushed R1, causing R1 to fall from his wheelchair, although R1 was able to get up on his own. R1 stated that he had been in the dining room when R2 approached, yelled at him, and suddenly pushed him out of his wheelchair, and that there were no staff present and no staff witnessed the incident. R1 reported feeling bad that someone attacked him in his place of residence and said he asked a nurse to call the police, but the nurse refused. R1 denied pain and had no visible injuries or bruising. R1’s EMR showed diagnoses of paranoid schizophrenia and delusional disorder, and his abuse care plan, which identified him as at moderate risk for abuse due to psychiatric issues, included interventions such as observing him when in the company of peers and ensuring safety if he felt unsafe. The Social Services Director (V18) stated he was notified by the Administrator (V1) that there had been an altercation between R1 and R2 and that he and V1 reviewed dining room camera footage. The footage, later reviewed without audio, showed R2 pacing in the dining room, then approaching R1 in a threatening manner with repeated forward upper body movements, and then forcefully pushing R1 with two flat hands; the camera view of R1 was partially blocked and did not show whether he fell. V1 characterized the push as forceful and as abuse of R1. A nurse (V9) reported that R1 came down the hallway saying, “he hit me,” and that after assessing R1 and finding no injuries, she spoke with R2, who admitted, “He got in my face, and I pushed him out of my face,” while demonstrating a flat-handed pushing motion. V9 stated that once a resident says they pushed another resident, it is an abuse allegation that must be reported immediately. The facility’s Abuse and Retaliation Prevention and Reporting Policy affirmed residents’ right to be free from abuse and prohibited physical abuse, including hitting and controlling behavior through corporal punishment, yet the incident occurred in the dining room without staff supervision and resulted in resident-to-resident physical abuse.
Failure to Timely and Accurately Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report an allegation of resident-to-resident abuse to the state surveying agency and law enforcement. On the morning of March 12, 2026, a nurse (V9) was approached by R1, who propelled his wheelchair down the hallway stating, "he hit me, he hit me." V9 followed R1 to his room, attempted to clarify what happened, and assessed R1 for injuries, finding none and with R1 denying pain. V9 then spoke with R2, who reported that R1 had gotten in his face and that he pushed R1 away, demonstrating a flat-handed pushing motion. Recognizing this as an abuse allegation under facility protocol, V9 notified the Administrator (V1) at approximately 6:40–6:45 AM that R1 alleged R2 had hit him and that R2 admitted to pushing R1. V1, in turn, notified the Social Service Director (V18) and the DON (V2) via text message that morning, describing that R2 allegedly pushed R1 in the dining room because R1 was yelling at him. V1 and V18 reviewed the dining room camera footage later that morning. The view was partially blocked, but they observed R1 approaching R2, yelling and waving his arms, and R2 becoming agitated and pushing R1 away. V18 documented a behavioral progress note in R1’s EMR at 10:11 AM, describing R1 approaching R2, yelling and waving his arms, R2 reporting that R1 grasped his arm, and R2 pushing R1 away. The note also documented that the camera view was partially blocked and they could not verify whether R1 grasped R2’s arm. Despite this information and the facility’s policy that an allegation of abuse, such as a resident pushing another resident, must be reported to the state surveying agency within two hours, V1 did not submit an initial abuse allegation notification or notify the police on March 12, 2026. On March 13, 2026, R1 reported to surveyors that on the previous morning in the dining room, R2 approached him, yelled at him, and suddenly pushed him out of his wheelchair, with no staff present and no staff witnessing the event. R1 stated he felt bad that someone attacked him in his place of residence and that he had asked a nurse to call the police, which he said was refused, and that he had reported the incident to V1 around 11:00 AM on March 12. R2 also told surveyors that he had gotten into a fight with his roommate in the dining room and that he pushed him, causing him to fall out of his wheelchair and get up on his own. When V1 eventually submitted the Facility Reported Incidents form to the state surveying agency on March 13, 2026, the report inaccurately listed the occurrence date as March 13 instead of March 12 and described the event as both residents alleging a resident-to-resident behavior to a surveyor, rather than reflecting the original allegation and occurrence date. The facility’s Abuse and Retaliation Prevention and Reporting Policy required any allegation of abuse to be reported immediately, but not more than two hours after the allegation, which was not followed in this case.
Failure to Investigate Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse and Retaliation Prevention and Reporting Policy by not investigating an allegation of resident-to-resident physical abuse. One resident (R1) reported that another resident (R2) pushed him out of his wheelchair in the dining room, with no staff present, and stated he felt bad that someone attacked him in his place of residence. R1 said he asked a nurse to call the police and reported the incident to the Administrator (V1) later that morning. On the same day, R2 told staff that R1 got in his face and that he pushed R1, and a nurse (V9) recognized this as an abuse allegation per facility protocol, immediately notifying the Administrator. Despite this, the Administrator stated she was unaware that R2 had pushed R1 and believed the situation to be only a behavioral event. The Social Service Director (V18) reported that he was notified by the Administrator early that morning that there had been an altercation between the two residents, and that he and the Administrator reviewed dining room camera footage. The behavioral progress note he entered described R1 approaching R2, yelling and waving his arms, and R2 becoming agitated and pushing R1 away. The camera view was partially blocked, and they could not verify whether R1 fell from his wheelchair. The Director of Nursing (V2) also received a text from the Administrator stating that R2 allegedly pushed R1 because R1 was yelling at him, but V2 was not involved in any investigation. Video footage later reviewed by surveyors showed R2 pacing in the dining room, then moving toward R1 in a threatening manner and forcefully pushing him with two flat hands, with the view of R1 partially blocked so it was unclear if he fell. The Administrator acknowledged that the push was forceful and constituted abuse of R1. However, no abuse investigation or grievance report was initiated at the time of the incident, and the Administrator stated she did not complete an investigation because she considered it only a behavioral event. The facility’s written policy required that all incidents involving alleged or suspected abuse be documented and result in an investigation, but this was not done until more than a day later, after surveyors were informed by R1 that he had been pushed out of his wheelchair by R2.
Failure to Report Attempted Narcotic Diversion to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to notify law enforcement and the state surveying agency of an attempted diversion of narcotic medications involving two residents. A registered nurse (V3) reported that on 08/09/25 he left two bingo cards of Norco, one for resident R7 and one for resident R8, on top of a cabinet in the medication room while he went on break. When he returned, the medications were no longer where he had placed them. V3 stated that only he and another RN (V4) had keys to the medication room. After searching the medication room, V3 found both bingo cards containing Norco inside V4’s unzipped personal shoulder bag. V3 notified the DON (V2), who, along with the Administrator (V1), came to the unit. V2 stated she removed the medications from V4’s bag and that V4 admitted placing the narcotics in her bag and reported she was addicted to drugs and had recently been in rehab. V1 confirmed that the narcotic medications found in V4’s personal bag belonged to R7 and R8 and stated that the police were not called because the medications had not left the facility, the narcotic count was accurate, and no residents missed any medications. V1 also stated that V4 was not reported to the state licensing agency or the state surveying agency for the same reasons. R7 had diagnoses including major depressive disorder, bipolar disorder, anxiety, osteoarthritis, cervicalgia, and a left-hand contracture, and had discontinued orders for Norco 10-325 mg as needed for pain with start dates in July and August 2025. R8 had diagnoses including acquired absence of the right leg below the knee, cognitive communication deficit, end stage renal disease, anxiety disorder, gout, and diabetes, and had an order for Norco 5-325 mg every 12 hours as needed for severe pain for five days in August 2025. The facility’s policy on discrepancies, loss, and/or diversion of medications required that all suspected loss or diversion be immediately investigated and that appropriate agencies required by state regulation be notified, but law enforcement and the state surveying agency were not notified in this incident.
Failure to Securely Store Controlled Substances in Medication Room
Penalty
Summary
The deficiency involves the failure to securely store controlled substances in the medication room, specifically Norco prescribed for two residents. A registered nurse (V3) reported that on 08/09/25 he left two bingo cards of Norco, one for R7 and one for R8, on top of a cabinet in the medication room while they were due to be wasted. When V3 returned from break, the medications were no longer where he had placed them. V3 stated that only he and another RN (V4) had keys to the medication room. After searching the medication room, V3 found both bingo cards containing Norco inside V4's unzipped personal shoulder bag, with the narcotic sheets still attached and visible. The Director of Nursing (V2) confirmed that she removed the medications from V4's personal bag and stated that narcotic medications in the medication room should be double locked. The Assistant Director of Nursing (V12) stated that narcotic medications stored in the medication room should not have been left on the cabinet and should have been placed back in the locked narcotic drawer in the medication cart. The Administrator (V1) confirmed that the narcotic medications found in V4's personal bag belonged to R7 and R8. R7 had multiple diagnoses including major depressive disorder, bipolar disorder, anxiety, osteoarthritis, cervicalgia, and a left-hand contracture, and had discontinued orders for Norco 10-325 mg with different dosing frequencies in July and August 2025. R8 had multiple diagnoses including acquired absence of the right leg below the knee, cognitive communication deficit, end stage renal disease, anxiety disorder, gout, and diabetes, and had an order for Norco 5-325 mg every 12 hours as needed for severe pain for five days in early August 2025. The facility’s Storage of Medications Policy stated that medications and biologicals are to be stored safely, securely, and properly, but the handling and storage of these Norco bingo cards did not comply with those requirements.
Failure to Report Resident’s Allegation of Physical Abuse per Facility Policy
Penalty
Summary
The facility failed to follow its abuse reporting policy when staff did not report a resident’s allegation of physical abuse to administration. The resident had multiple diagnoses including type 2 DM with hyperglycemia, unspecified dementia with moderate cognitive impairment, psychotic and mood disturbances, anxiety, cognitive communication deficit, recurrent moderate major depressive disorder, alcohol dependence with alcohol-induced disorder, and alcoholic cirrhosis. In December 2025, the resident told an insurance representative that he had been abused by a female staff member months earlier but could not provide a description or details. The administrator reported that this allegation was investigated by the state surveying agency with no findings, and the facility’s social service director and the resident’s case manager spoke with him about it. During that prior investigation, according to the administrator, no staff names were given by the resident. On a later date, during an interview, the resident was lying in bed and answered only closed-ended questions. He stated that months ago a female staff member had physically abused him, saying she punched him, and he believed it was a staff member with a specific first name. He reported that he had told someone at the facility and that a male, whom he believed might be staff, had talked to him about it. When asked if he was afraid the staff member would do it again, he hesitated and said “probably.” The administrator was informed that the resident had now identified a staff first name, and she acknowledged that there were both a CNA and an RN with that first name, noting that the CNA was working that day and the RN was scheduled later. The administrator stated that previously no names had been provided in connection with the allegation. Interviews with staff revealed that a CNA (V6) had been told of the abuse allegation by the resident months earlier but did not report it to administration as required by facility policy. V6 stated that while giving the resident a shower, he reported that months ago a CNA had beaten him and identified the first name shared by the CNA (V5) and RN (V7). V6 responded that she was sorry to hear it and did not notify the abuse coordinator or administration because the resident said it had happened months ago and had already been reported and “taken care of,” and because she believed it was an old, resolved case. V6 also stated she had heard about the allegation about eight months prior, believed it related to the unit where V5 worked, and thought the case was clear since V5 was still working there. V5 reported that she first heard of the allegation when V6 told her, after a shared shift, that the resident said someone with her first name had hit him; V5 said she did not take it seriously because she had never worked with the resident. The facility’s written policy required employees to immediately report any incident, allegation, or suspicion of potential abuse they observe, hear about, or suspect to the administrator or through designated channels, which did not occur in this case.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required timeframes to both the state surveying agency and local law enforcement. The incident involved a resident with intact cognition and a history of major depressive disorder, bipolar disorder, anxiety disorder, and suicidal ideations. The resident reported that a nurse applied cream to her buttocks during wound care and then to her vaginal area and labia, which made her feel violated. The resident disclosed the incident to the Psychiatric Rehabilitation Service Coordinator (PRSC), who immediately informed the Social Service Director, and together they reported it to the Administrator on the same day. Despite the prompt internal reporting, the Director of Nursing (DON) was not informed until three days later, and the facility did not notify the state surveying agency or the police until seven days after the initial report was made to facility staff. The facility's own policy requires allegations of abuse to be reported to the Department of Public Health within two hours and to local law enforcement in cases of sexual abuse. The delay in external reporting constituted a failure to follow both regulatory requirements and facility policy.
Failure to Timely Investigate and Suspend Staff Following Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention and reporting policy by not promptly investigating an allegation of sexual abuse and not immediately suspending the alleged perpetrator. A female resident with intact cognition and a history of major depressive disorder, bipolar disorder, anxiety disorder, and suicidal ideations reported that a nurse inappropriately applied cream to her genital area during wound care, which made her feel violated. The resident reported the incident to the Psychiatric Rehabilitation Service Coordinator (PRSC), who immediately informed the Social Service Director, and both reported the allegation to the Administrator on the same day. Despite the facility's policy requiring immediate removal of employees accused of abuse from resident contact, the nurse continued to work for eight days after the allegation was reported. The Director of Nursing (DON) was informed of the incident three days after it was reported to the Administrator, and the nurse was not suspended until eight days after the initial report. Additionally, the facility did not report the allegation to the state surveying agency within the required two-hour timeframe, instead reporting it seven days after the incident was brought to the facility's attention.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident from physical and emotional abuse by another resident. Both residents involved had severe cognitive impairment and histories of behavioral issues, including dementia and aggressive or agitated behaviors. The incident occurred when one resident physically assaulted the other, resulting in scratches, a bite mark, and emotional distress. Staff found both residents on the floor, with one resident biting the other's fingers and subsequently slapping him on the face. The assaulted resident was observed to be crying, scared, and visibly upset, with multiple minor injuries documented. Prior to the incident, the care plans for both residents identified significant risk factors. One resident had a documented history of childhood abuse, severe cognitive impairment, and a pattern of wandering into peers' rooms, which was known to startle or upset others. The other resident had a history of aggressive behavior, agitation, and resistance to care, as well as recent medication orders for agitation and anxiety. Despite these known risks, the facility did not implement effective interventions to prevent resident-to-resident altercations or address the potential for abuse between these two individuals. Staff interviews revealed that the two residents had a history of negative interactions, with one resident frequently being mean and attempting to exclude the other from their shared room. On the day of the incident, staff were not present in the room at the time of the altercation and were alerted by another resident. Upon intervention, staff observed the aggressor laughing and making statements that the victim "deserved it." The facility's abuse policy affirms the right of residents to be free from abuse and requires the prevention of mistreatment, but the lack of adequate interventions and supervision led to the occurrence of abuse and emotional harm.
Failure to Maintain Kitchen Sanitation and Food Safety Standards
Penalty
Summary
The facility failed to maintain the kitchen in a manner that would prevent foodborne illness for all residents receiving dietary services. Surveyors observed that the kitchen dishwasher, which is supposed to disinfect by reaching 180 degrees Fahrenheit, only reached 150 degrees during the wash and 160 degrees during the rinse. The dishwasher gauges had not worked properly for over a year, and staff relied on temperature test strips instead of recording gauge temperatures. Additionally, a cook was found holding coleslaw at 48.5 degrees Fahrenheit, above the required 41 degrees or below, and the Dietary Director acknowledged that improper holding temperatures could lead to foodborne illness. Further observations revealed multiple food storage and sanitation issues. Unlabeled and undated containers of food and thickener were found in dry storage and the walk-in cooler, and several large bags of frozen food were left open to air in the freezer. The kitchen and utensils were found dirty with crusted debris, and a bottle of lemon juice requiring refrigeration was left out at room temperature. The Dietary Director admitted that labeling, dating, and proper storage were not consistently followed, and that cleaning responsibilities were not always met due to time constraints. Additionally, the Dietary Director was observed in the kitchen without a beard guard, contrary to facility policy requiring facial hair coverage to prevent food contamination.
Failure to Implement Fall Risk Precautions and Maintain Safe Environment
Penalty
Summary
The facility failed to implement appropriate fall risk precautions for multiple residents identified as being at risk for falls. One resident was observed with a mattress that was significantly larger than the bed frame, causing the mattress to hang off and angle downward. This resident reported ongoing issues with the mattress, including slipping while trying to get out of bed, and stated that complaints about the mattress had been made for months. Both nursing and maintenance staff confirmed that the mattress did not fit the bed frame and acknowledged the risk of falls associated with this improper fit. The resident's care plan documented a risk for falls due to multiple medical conditions, and facility policy required that malfunctioning equipment be reported or removed from service immediately. Another resident, who was severely cognitively impaired and at high risk for falls, was observed in bed without the required floor mat in place. The floor mat, intended to minimize injury in the event of a fall, was found either under the bed or standing against the wall during multiple observations. Staff interviews confirmed that the floor mat should have been positioned at the bedside whenever the resident was in bed, as specified in the resident's care plan and the facility's fall prevention guidelines. The lack of proper placement of the floor mat represented a failure to follow the prescribed fall prevention interventions. Additional deficiencies were noted for other residents at risk for falls, including beds left in a high position after care was provided. Several residents, who were dependent on staff for activities of daily living and unable to adjust their own beds, were found with their beds elevated, contrary to their care plans and facility policy. Staff acknowledged that beds should have been returned to a low and safe position after care to reduce the risk of injury from falls. One resident was also found to lack a care plan with fall prevention interventions despite being assessed as at risk for falls.
Improper Storage of Refrigerated Controlled Medications
Penalty
Summary
Surveyors found that the facility failed to store resident medications, specifically Lorazepam vials, according to pharmacy labeling and manufacturer recommendations. Multiple vials labeled as requiring refrigeration were instead kept unrefrigerated in the narcotic box within the nurse's medication cart. This was observed for four residents with diagnoses including seizure disorders, epilepsy, and anxiety disorder, all of whom had physician orders for Lorazepam to be administered intramuscularly as needed. The medication refrigerator in the medication room was found to lack a lock, and staff reported that this was the reason for storing the vials in the cart rather than in the refrigerator. Interviews with nursing staff revealed a lack of clarity regarding proper storage procedures, with one agency nurse unaware of the requirement to refrigerate the Lorazepam vials. The Director of Nursing confirmed that medications labeled for refrigeration must be stored accordingly and acknowledged that improper storage could affect medication potency. The facility's policy requires refrigerated medications to be kept at specific temperatures in a locked box within the refrigerator, but this was not followed for the Lorazepam vials in question.
Failure to Provide and Document Range of Motion Services
Penalty
Summary
A resident with diagnoses including Parkinson's disease, anemia, slow transit constipation, and osteoarthritis was identified as having limited range of motion (ROM) in both upper and lower extremities. The resident's care plan specified an active assisted ROM (AAROM) program, with a goal of performing one set of five repetitions to all extremities with limited staff assistance one to two times daily. However, there was no documentation in the electronic medical record (EMR) that the ROM program was being implemented. The restorative nurse confirmed that the last restorative assessment was completed several months prior, and although recommendations for active ROM and bed mobility were made, the resident was not included on the restorative list and had no program in place to guide staff on exercises or frequency. The resident also reported not receiving restorative assistance from staff, and the facility's policy required regular screening and implementation of restorative nursing programs.
Deficient Catheter Care and Improper Catheter Bag Placement
Penalty
Summary
The facility failed to provide proper catheter care for two residents, resulting in deficiencies related to sanitary technique, use of securing devices, and catheter bag placement. For one resident with diagnoses including bipolar disorder, type 2 diabetes, tremor, and neuromuscular dysfunction of the bladder, catheter care was observed to be performed using the same washcloth multiple times for different areas, and the washcloth was re-wetted in the same basin of water. The CNA did not clean between the labia, and no catheter securing device was in place during the procedure. The Director of Nursing confirmed that proper technique requires a fresh washcloth for each wipe, opening the labia for cleaning, and using more than two washcloths for the procedure. In another instance, a male resident with severe cognitive impairment was observed with his indwelling catheter bag placed directly on the floor. A CNA later picked up the bag and acknowledged it should not have been left on the floor, stating it should be hung on the bed frame. The Director of Nursing confirmed that catheter care is provided every shift and as needed, and that catheter bags should not be on the floor. The facility's policy also specifies that indwelling catheters should be secured to prevent trauma and that drainage bags and tubing should not touch the floor.
Failure to Ensure Timely Availability of Resident Medications
Penalty
Summary
The facility failed to ensure that medications were available for administration to residents, resulting in two residents not receiving their prescribed medications as ordered. One resident, who had a history of chronic pain and migraines, reported running out of Tramadol, a pain medication she routinely took twice daily. She stated that it sometimes took days for the facility to obtain her medication and that she was informed the previous night that she was on her last pill. The medication was not available during the morning medication pass, and the nurse confirmed it had last been administered the previous evening. The nurse also indicated that medications should be reordered when there are eight pills remaining, but this was not done in time for this resident. Another resident, with diagnoses including schizophrenia, anxiety disorder, and psychosis, did not receive her scheduled dose of Aripiprazole because the medication was not available during the morning medication pass. The LPN responsible for her care stated she was not notified by the night shift that the medication had run out and only reordered it that morning. The facility's policy requires medications to be reordered according to the pharmacy provider's schedule, but this was not followed, resulting in missed doses for both residents.
Failure to Maintain Annual CNA Competency Training Requirements
Penalty
Summary
The facility failed to maintain the required minimum of 12 hours per year of competency training for Certified Nurse Assistants (CNAs), as mandated for all staff providing care to residents. During the survey, the administrator confirmed that all 164 residents received care from CNAs. When proof of annual CNA competency training was requested for several CNAs, the administrator was unable to provide documentation of the required hours due to a recent change in the computer-based training platform, resulting in incomplete records. The available in-service training hours for the reviewed CNAs ranged from 1.5 to 4 hours, which is significantly below the required 12 hours. The administrator acknowledged the inability to provide proof of compliance with the annual training requirement.
Failure to Provide Grievance Policy to Residents
Penalty
Summary
The facility failed to provide residents with access to the grievance policy, as required. Four residents reported during a resident meeting that they had been requesting copies of the grievance policy and information on how to file a grievance since November 2024, but had not received it. One resident stated that staff only advised them to speak to a staff member if they had a grievance, and that the Social Service Director was invited to explain the policy but did not do so. A review of facility bulletin boards confirmed that the grievance policy was not posted in any location. Interviews with facility staff revealed confusion and lack of clarity regarding who was responsible for providing the grievance policy to residents. The Social Service Director stated that the administrator had given the policy to the resident council, while the administrator said the policy was reviewed with the council but not personally distributed. The Activities Director reported notifying the administrator about the request but did not provide the policy herself. The Director of Nursing confirmed that any policy requested by residents should be provided. Resident council meeting minutes from January and February 2025 documented ongoing requests for the grievance policy to be posted throughout the facility, with responses indicating that the administrator would provide it and that it was posted on each unit, though this was not observed.
Resident Biting Incident Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a resident being bitten by another resident. The incident involved a resident with moderate cognitive impairment who was bitten by another resident with similar cognitive challenges. The biting incident led to the victim being hospitalized and receiving antibiotic treatment for the injuries sustained. The report highlights that the resident who was bitten had a history of wandering into other residents' rooms, which triggered aggressive responses from other residents. On the day of the incident, the facility was short-staffed due to a call-off, which left the dementia unit understaffed. The resident who was bitten was not adequately monitored, allowing him to enter another resident's room, leading to the biting incident. Staff members reported hearing shouting and commotion but were not present in the room to prevent the incident. The lack of sufficient staff coverage and monitoring contributed to the failure to prevent the abuse. The report also notes previous incidents where the same resident had entered other residents' rooms, leading to aggressive interactions. Despite these prior occurrences, the facility did not implement effective measures to monitor and redirect the resident to prevent further incidents. The facility's failure to ensure adequate supervision and protection for residents in the dementia unit resulted in the physical abuse incident.
Inadequate Infection Control During Norovirus Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a norovirus outbreak, which had the potential to affect all 165 residents. Upon entering the facility, the surveyor did not observe any signs indicating a current norovirus outbreak. The Director of Nursing (DON) confirmed the outbreak and mentioned that some residents were on isolation, but there were inconsistencies in the implementation of isolation protocols. Several residents with symptoms were not properly isolated, as evidenced by the lack of contact isolation signs and personal protective equipment (PPE) outside their rooms. The facility's staff, including CNAs and housekeepers, demonstrated a lack of adherence to infection control measures. Some staff members were observed interacting with symptomatic residents without wearing appropriate PPE, and there were instances where hand hygiene protocols were not followed. Additionally, the housekeeping staff was not consistently using bleach-based cleaning products as required, due to a shortage of supplies. The Maintenance Director, who was overseeing housekeeping, was unsure of the correct bleach-to-water ratio for disinfection. The facility's Norovirus Outbreak Measures policy outlined specific guidelines for controlling the spread of the virus, including isolation of symptomatic residents, proper hand hygiene, and the use of bleach solutions for cleaning. However, these measures were not fully implemented, as evidenced by the lack of isolation signs, inadequate PPE usage, and insufficient cleaning practices. The facility's failure to adhere to its own policy and the lack of communication with the health department regarding cleaning practices contributed to the deficiency.
Failure to Follow Catheter Size Order
Penalty
Summary
The facility failed to adhere to its policy regarding the insertion of an indwelling catheter for a resident with specific medical conditions, including urinary retention, urethral stricture, and urethral erosion. The physician's order specified the use of a 14FR or 16FR Foley catheter, but a 20FR catheter was inserted instead. This incident involved a registered nurse who, upon finding the resident's catheter dislodged with the balloon intact, replaced it without verifying the correct size as per the physician's order. The nurse acknowledged the oversight, stating that they did not check the order for the catheter size before proceeding with the insertion. The facility's medical supply storage was adequately stocked with catheters of various sizes, including the ordered 16 French size. The Medical Records/Supply Director confirmed that nurses could access catheters of all sizes and seek assistance if needed. Despite the availability of the correct catheter size, the nurse's failure to follow the physician's order and the facility's policy resulted in the use of a larger catheter than prescribed. The nurse practitioner confirmed that the larger catheter was not in accordance with the order, although no trauma was reported as a result of the incident.
Facility Fails to Maintain Safe Food Handling During Kitchen Renovation
Penalty
Summary
The facility failed to ensure food was stored, distributed, and served to residents in a manner that prevented food contamination during a kitchen renovation. The kitchen was closed for floor repair, but food preparation continued without the ability to maintain safe food temperatures or sanitize dishware and equipment. This led to the local health department revoking the facility's permit to prepare food on site, resulting in an Immediate Jeopardy situation affecting all 161 residents who consumed food from the facility. The Immediate Jeopardy began when the facility's kitchen was closed, and food preparation continued in inadequate conditions. The facility rented a refrigerated storage container, which failed to maintain proper temperatures due to warm weather and frequent door openings. Additionally, there were no handwashing stations available for dietary staff, and the facility attempted to prepare puree and mechanically altered food onsite using inadequate equipment and sanitation methods. The local health department documented the suspension of food service operations due to inadequate refrigeration and lack of handwashing sinks. Observations revealed that the facility was serving meals in take-out containers with disposable cups, and staff were using a single handwashing sink for both hand hygiene and cleaning equipment. The facility's policy required food temperatures to be documented, but the Dietary Manager admitted to not recording them. The facility's actions and lack of planning for the kitchen renovation led to unsafe food handling practices, which were confirmed by interviews with staff and the local health department.
Removal Plan
- Facility will utilize a local organization's kitchen to prepare mechanical and puree diets for residents that are on puree or mechanically altered diets to have their food safely prepared. This will be managed by the Dietary Director/Designee.
- Facility has 1 handwashing sink in each serving room; a total of 1 of operational handwashing sinks since there are two serving rooms in the facility. In addition, the facility will obtain 2 portable hand washing stations to ensure that dietary staff is able to perform appropriate hand washing process. The portables were on site.
- The facility will obtain disposable foil pans. For Utensils, 3 containers will be provided to rinse, wash and sanitize to ensure a method for sanitizing food service equipment and service items between meals to prevent food borne illnesses. This will be on site at local organization's kitchen. Once sanitized the equipment will be transported back to the facility. Facility will utilize test strips to ensure proper Ph for sanitation. This will be managed by the Dietary Director/Designee and monitored by the facility Administrator.
- The facility is only storing milk products in the cooler located in the dining room. The cooler temperature is being monitored to maintain at safe temperatures during holding. A log for temperatures will be maintained by the Dietary Director/Designee and is being checked every shift. The facility will continue to cater food for the residents until the project has been completed. Administrator will maintain documentation of temperatures.
- The facility is having food delivered from vendor in insulated bags via private vehicle to the facility. Food is then transferred back and forth to local organization's kitchen via private vehicle in insulated bags. The facility has developed a temperature tool to monitor and document temperatures of food - pick up time and temps, after transfer time and temps.
- Prior to start of shift, the Dietary Director/Designee will monitor food temperatures and document temperature on the newly developed log. The Administrator will monitor and maintain these logs daily during the kitchen closure and make immediate corrective action if not complete.
- An emergency QA meeting has been conducted with facility medical director and IDT team to review the incident and action plan. The facility has reviewed the policies and procedures and has developed and amendment on how the facility will monitor temperatures during this interim. The QA team will also refer this incident for review of emergency action plan for any changes.
Delay in Completing Physician-Ordered X-Ray
Penalty
Summary
The facility failed to timely complete a physician order for an X-Ray for one resident who experienced a change in condition. On 04/13/2024, the resident had a witnessed fall in the bathroom and later complained of pain and swelling in her right ankle. An X-Ray was ordered by the physician to be completed by the on-call X-Ray service. However, the X-Ray was not performed until 04/17/2024, revealing an oblique fracture of the distal fibula and a distal tip fracture of the medial malleolus. The Quality Assurance Nurse acknowledged that the delay was noticed on 04/16/2024 when the X-Ray service was needed for another resident. The facility's agreement with the portable X-Ray company stipulates that services should be provided within 24 business hours or a scheduled time, and the provider should notify the facility if this timeframe cannot be met.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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