Arc At El Paso
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Illinois.
- Location
- 555 East Clay, El Paso, Illinois 61738
- CMS Provider Number
- 145319
- Inspections on file
- 27
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Arc At El Paso during CMS and state inspections, most recent first.
Surveyors observed that air conditioner units in two resident rooms had visible mildew and holes in the surrounding foam, with staff unable to provide a cleaning policy for these units. The Maintenance Director reported that cleaning occurs twice per season but was unsure of any formal procedures, resulting in a failure to ensure a clean and safe environment.
A resident with congestive heart failure and physician orders for weekly weights did not have weights obtained as required, with only three weights recorded over several weeks. The resident reported not being weighed because the weighing equipment was broken, and facility staff confirmed the mechanical lift with the scale had been nonfunctional, leading to missed weight monitoring.
Three residents with cognitive and mobility impairments experienced unwitnessed falls, but staff failed to complete thorough post-fall assessments and did not implement new, individualized interventions. Documentation was incomplete, with key risk factors and environmental factors not assessed, and care plan updates were either generic or not carried out as described.
Two residents experienced verbal and physical abuse from a CNA, including the use of profanity, yelling, and rough handling during care. Staff statements confirmed a pattern of abusive behavior, and the incidents were reported and investigated, with the CNA suspended and later resigning.
A resident with cognitive impairment and multiple medical conditions was injured during a haircut and beard trim performed by a CNA who was not a licensed beautician. The CNA removed the guard from electric clippers, resulting in cuts and a rash on the resident's neck and head, despite the resident's protests. Multiple staff and the resident's family observed the injuries, and the facility lacked a policy governing hair or beard cuts for residents.
The facility did not provide the required eight consecutive hours of RN coverage on a specific day, as confirmed by staff schedules and postings. Only LPNs were available, and the absence of an RN was acknowledged by the Administrator and an LPN/Infection Control Preventionist, who noted ongoing RN shortages every other weekend. This deficiency potentially affects all 49 residents.
The facility failed to label and cover refrigerated foods properly and maintain cleanliness in the kitchen and dry storage areas. Observations included unlabeled and uncovered food items, a dirty dry storage room floor with cigarette butts, and a kitchen with dirt, debris, and grease buildup. The cook confirmed these deficiencies, indicating non-compliance with the facility's sanitation policies.
The facility did not offer COVID-19 vaccinations or provide vaccination education to all employees, potentially affecting all 49 residents. The LPN/Infection Control Preventionist confirmed the lack of documentation for offering vaccines or education to staff. Employees are directed to local pharmacies for vaccination at their own expense unless extra vaccines are available after resident vaccinations.
The facility did not ensure CNAs completed required dementia training within a 12-month period, affecting all 49 residents. The facility's assessment tool required dementia management and abuse prevention training as part of the annual 12-hour in-service training. However, training reports for three CNAs showed no completed dementia training. The administrator confirmed the lack of training, despite several residents having dementia.
The facility failed to follow its policy on respiratory equipment management, resulting in undated and un-bagged nebulizer masks and tubing, and missing oxygen signs on resident doors. Residents with conditions like COPD were affected, as their equipment was not properly maintained or labeled, and an LPN confirmed these deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as required by their policy. Staff did not wear gowns during high-contact care activities, and there was a lack of signage and PPE outside residents' rooms. The Infection Control Preventionist confirmed the absence of necessary precautions, indicating a systemic issue in infection control adherence.
A facility failed to refer a resident with new mental illness diagnoses for a Level II PASARR evaluation. The resident was initially admitted with no known mental health issues, but later diagnosed with Major Depressive Disorder and Psychotic Disorder with Hallucinations. Despite these new diagnoses, no further PASARR screening was documented. The Social Service Director acknowledged the oversight, noting the resident was on the list for a new screening but had not yet been submitted.
A facility failed to follow a physician's wound care order for a resident with a non-pressure wound on the right second toe. The order required Betadine application followed by a gauze island dressing. An RN applied Betadine but omitted the dressing, unaware of the correct order. The LPN responsible for entering wound orders admitted to missing the updated order, leading to an incorrect entry in the resident's chart.
The facility failed to inform residents and their representatives about the implications of signing a binding arbitration agreement, affecting all 49 residents. The Social Service Director admitted that residents were not told they were giving up the right to sue the facility. Interviews revealed that residents and a Power of Attorney were unaware of the agreement's meaning, leading to confusion and concern.
The facility failed to provide sufficient staffing, impacting care for all 60 residents. Staffing levels were below the required number, with CNAs unable to complete assignments and residents lacking assistance with activities. The CNA Scheduler scheduled based on census rather than the facility assessment, contributing to the issue.
The facility failed to provide restorative services for three residents, as evidenced by incomplete ROM exercises, inconsistent dressing and grooming assistance, and inadequate ambulation support. Interviews revealed that residents did not receive necessary therapy or assistance, and a CNA admitted to lacking time for restorative tasks. The DON acknowledged the deficiency.
The facility did not post the Daily Staffing Report in a visible location, affecting all 58 residents. The report was obscured by a portable stand and had not been updated since 10/29/24. Several residents were unaware of its location. The DON and Interim Administrator confirmed the issue.
The facility inaccurately reported its PBJ staffing information, affecting all 58 residents. The deficiency was due to the former administrator not including agency nurses and CNAs in the reports, and management staff not clocking in when covering shifts. Observations and interviews indicated adequate staffing levels, but the oversight led to reported staffing levels appearing lower than they were.
A former RN at a facility misappropriated narcotics, resulting in 898 missing pills from nine residents. The issue was discovered after the State Attorney General's office informed the facility of an investigation into the RN's activities at multiple nursing homes. An internal audit revealed that the RN diverted medications during pharmacy deliveries, violating the facility's abuse prevention policy.
A facility failed to secure medications for nine residents, leading to the misappropriation of 898 narcotic pills. The facility's policy required staff to count controlled substances with a partner and verify log sheets, but these guidelines were not followed. An investigation revealed that a staff member misappropriated medications during pharmacy deliveries. The affected residents had various conditions requiring pain management, and the medications involved included Tramadol, Hydrocodone-Acetaminophen, Oxycodone, and Morphine Sulfate.
A resident reported a disrespectful interaction with a CNA during a night shift, where the CNA ignored the resident's instructions regarding a malfunctioning bed remote, leading to a blown breaker and deflated air mattress. The CNA raised her voice and made a dismissive comment, which the resident found disrespectful. The CNA later admitted to trying to fix the remote despite the resident's objections.
A resident identified as an elopement risk exited a facility unnoticed after removing his elopement alert bracelet. Despite verbalizing his intent to leave and having a care plan in place, the facility failed to provide adequate supervision and monitoring. The resident was found near a busy road, highlighting the facility's failure to implement necessary interventions and ensure the functionality of elopement prevention measures.
Failure to Maintain Clean and Safe Resident Rooms Due to Mildew on AC Units
Penalty
Summary
Surveyors found that the facility failed to maintain resident rooms in a clean and safe manner for four residents. Observations revealed that air conditioner units in two resident rooms had vent slats with multiple pinpoint black spots, identified by the Maintenance Director as likely mildew. Additionally, there were foam tubes around the AC units with holes large enough to allow daylight to be seen. The Maintenance Director stated that the units are cleaned twice per season to prevent mildew buildup but was unsure if a formal policy exists for cleaning the air conditioner units. The facility was unable to provide a policy for cleaning these units during the survey. These findings were based on direct observation, staff interviews, and review of facility documentation, and they demonstrate a failure to ensure a safe, clean, and homelike environment as required by regulation.
Failure to Obtain Physician-Ordered Weekly Weights Due to Equipment Malfunction
Penalty
Summary
The facility failed to obtain physician-ordered weekly weights for one resident who was prescribed this monitoring due to a diagnosis of congestive heart failure and related medications, including Torsemide, Diltiazem, Metoprolol Succinate ER, and Aldactone. According to the facility's policy, residents are to be weighed monthly unless otherwise ordered by a physician. In this case, the physician ordered weekly weights to begin on 6/23/25. However, the resident was only weighed on three occasions between 6/23/25 and 8/17/25, and no weights were recorded from 7/8/25 through 9/3/25. The resident reported not being weighed due to a broken weighing machine, and facility staff confirmed that the mechanical lift with the scale had not been functioning since 7/10/25, resulting in the failure to obtain the required weights.
Failure to Implement New Interventions and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to implement new interventions after falls and did not complete thorough post-fall assessments for three residents with a history of falls. For one resident with dementia, cerebral infarction, and hemiplegia, documentation after an unwitnessed fall was incomplete, with several relevant risk factors such as medication use, impaired vision, and participation in restorative programs not assessed or marked. The care plan intervention added after the fall was not substantially different from existing interventions, and the interdisciplinary team did not identify or implement a new, individualized approach. Another resident with dementia, anxiety, and a thoracic spine fracture experienced an unwitnessed fall, but the post-fall assessment form was inadequately completed, omitting key risk factors such as osteoporosis, pain, and use of anti-hypertensive medication, all of which were present in the resident's medical record. Environmental and situational factors were also not assessed. The care plan referenced a floor bed and mat, but the resident was observed with a regular bed, and the intervention added after the fall was generic and not clearly linked to the specific circumstances of the incident. A third resident with Alzheimer's disease, gait abnormalities, and osteoporosis also had an unwitnessed fall. The post-fall assessment lacked documentation of environmental, physiological, and situational risk factors, and the facility was unable to provide evidence of a 72-hour monitoring assessment as claimed by the DON. The facility's fall prevention policy requires individualized assessment and immediate changes in interventions after falls, but these requirements were not met for the residents reviewed.
Failure to Prevent Staff-to-Resident Verbal and Physical Abuse
Penalty
Summary
Staff failed to prevent verbal and physical abuse towards two residents by a Certified Nursing Assistant (CNA). One resident reported that the CNA used profanity and yelled at her while providing care, as corroborated by another CNA who overheard the incident and reported it to a nurse. Multiple staff statements indicated that the CNA had a pattern of being rude, using curse words, and yelling at residents. The facility's 24-hour Abuse Investigation Report documented that the CNA was suspended immediately pending investigation after the incident was reported. Another resident described being physically handled roughly by the same CNA when she refused to get out of bed, stating that the CNA held her arms down and insisted she get dressed despite her continued refusal. The resident reported the incident to the next shift. The facility's investigation confirmed that the CNA was suspended following these allegations, but the CNA resigned before the investigation was completed. The facility's policy prohibits all forms of abuse, including verbal and physical abuse, and defines verbal abuse as the use of oral, written, or gestured communication that is abusive toward residents.
Untrained Staff Causes Injury During Resident Haircut
Penalty
Summary
A resident with a history of cerebral infarction, vascular dementia, aphasia, and moderate cognitive impairment received a haircut and beard trim from a CNA who was not a licensed beautician. The CNA used electric clippers, removed the guard during the process, and cut the resident under the chin, causing the resident to yell out in pain. Despite the resident's protests, the CNA continued the haircut, resulting in additional discomfort and visible injuries, including a large red area, razor rash, and nicks on the resident's neck and behind the ear. Multiple staff members and the resident's daughter observed and confirmed the injuries and the resident's distress following the haircut. The facility administrator acknowledged that the CNA was not authorized or trained to provide haircuts and that no CNAs in the facility were licensed beauticians. The facility was unable to provide any policy related to hair or beard cuts for residents, though an in-service sign-in sheet indicated that only licensed barbers or hairstylists were permitted to perform such services. The incident was further corroborated by interviews with other CNAs, who reported seeing the resident's injuries and hearing the resident's complaints. The facility's Resident Rights policy requires services to maintain residents' physical and mental health at their highest practical levels, but this standard was not met in this instance.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of a Registered Nurse (RN) daily, as required by CMS minimum staffing requirements. This deficiency was identified through interviews and record reviews, which revealed that on a specific date in March 2025, the facility did not have any RN coverage for the entire day. The facility's nursing staff schedule and daily staff postings confirmed the absence of an RN, with only Licensed Practical Nurses (LPNs) providing care. The Administrator and an LPN/Infection Control Preventionist acknowledged the accuracy of the staffing records and confirmed the lack of RN coverage, citing ongoing RN shortages every other weekend. This failure potentially affects all 49 residents residing in the facility.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that prepared refrigerated foods were labeled and dated with an expiration date, and that opened foods were stored in covered containers to prevent contamination. During an inspection of the kitchen, it was observed that several food items, including green beans, ham salad, fruit crisp, cooked cabbage, peeled potatoes, and green gelatin, were not labeled with expiration dates. Additionally, the fruit crisp was found uncovered. The cook verified these observations and acknowledged that the items should have been labeled and covered as per the facility's policy. The inspection also revealed that the kitchen and dry storage areas were not maintained in a clean and sanitary condition. The dry storage room floor was covered in dirt, debris, and cigarette butts, which the cook confirmed should have been cleaned. The kitchen floor had dirt, debris, old food, and crumbs underneath the preparation tables. The stove had a thick grease splatter, and the oven had black crusted matter built up inside. Dust and debris were also found on a shelf above the stove and underneath the steam table. The cook acknowledged that these areas needed cleaning, indicating a failure to adhere to the facility's sanitation policies.
Failure to Offer COVID-19 Vaccinations and Education to Staff
Penalty
Summary
The facility failed to offer COVID-19 vaccinations and vaccination education to all employees, which has the potential to affect all 49 residents residing in the facility. According to the facility's Interim COVID-19 Vaccination Guidelines, staff should be provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine and offered the vaccine or information on obtaining it. However, the Licensed Practical Nurse/Infection Control Preventionist (V13) stated that there is no documentation to show that COVID-19 vaccinations are offered to all employees or that they are given education related to the vaccine. Staff are instructed to go to the local pharmacy to get vaccinated if they choose, and they are expected to pay for it themselves unless there are extra vaccines available after vaccinating residents.
Failure to Provide Required Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received and completed required dementia training within a 12-month period, potentially affecting all 49 residents. The facility's assessment tool, dated July 1, 2024, indicated the need for dementia management training and resident abuse prevention training as part of the required 12 hours of annual in-service training for nurse aides. However, a review of the training reports for three CNAs (V18, V19, and V20) revealed no documentation of completed dementia training from March 2024 to March 2025. The administrator, who started in January, confirmed the absence of dementia-specific training for CNAs, despite several residents having a dementia diagnosis.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to adhere to its own Oxygen and Respiratory Equipment-Changing/Cleaning Policy, resulting in several deficiencies in respiratory care for residents. Specifically, the facility did not date oxygen tubing and bags when not in use, failed to place oxygen signs on resident doors, and did not change nebulizer facemasks and tubing weekly for four residents. These residents were observed with undated and un-bagged nebulizer masks and tubing, and rooms lacking necessary oxygen signage. The policy clearly outlines the need for weekly changes and proper storage of respiratory equipment to minimize infection risk, but these procedures were not followed. The residents involved had various medical conditions requiring respiratory support, such as Chronic Obstructive Pulmonary Disease and the need for continuous oxygen therapy. For instance, one resident's nebulizer mask and tubing were found lying undated and un-bagged on their bed, while another resident's nasal cannula was undated and un-bagged, with no oxygen sign outside their room. An LPN verified these deficiencies, acknowledging that all respiratory equipment should be changed and dated every seven days, and bagged between uses, with oxygen signs placed outside rooms when residents are on oxygen therapy.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for five residents who required such measures due to chronic wounds or indwelling medical devices. The facility's policy mandates the use of gowns and gloves during high-contact care activities for residents with these conditions, regardless of their multidrug-resistant organism status. However, observations revealed that staff did not adhere to these precautions. For instance, a registered nurse performed wound care on a resident's buttock without wearing a gown, and another nurse treated a wound on a resident's foot without using any personal protective equipment (PPE) aside from gloves. Additionally, the facility did not display signs or provide PPE outside the rooms of residents who required EBP, such as those with enteral feeding tubes or indwelling urinary catheters. This lack of signage and PPE storage was confirmed by the facility's Infection Control Preventionist, who acknowledged that the necessary precautions were not in place for the affected residents. The failure to implement EBP as per the facility's policy was observed across multiple instances, indicating a systemic issue in adhering to infection control protocols.
Failure to Conduct PASARR Level II Evaluation for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with new diagnoses of mental illness after admission was referred to the state agency for a Level II PASARR evaluation. The facility's policy requires screening all potential admissions on an individualized basis and conducting PASARR Level I for all new and readmissions to determine if the individual meets the criteria for mental disorder, intellectual disability, or related condition. Annually and with any significant change of status, the facility is required to complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The resident in question was admitted to the facility with no known or suspected mental health diagnosis according to the most recent Level I PASARR evaluation. However, after admission, the resident was diagnosed with Major Depressive Disorder and Psychotic Disorder with Hallucinations due to a known physiological condition. Despite these new diagnoses, the resident's medical record did not document any further PASARR screening or evaluation since admission. The Social Service Director confirmed that the resident had not had a PASARR re-screen or a Level II screening, acknowledging that the resident was on the list for a new screening due to the new diagnoses but had not yet been submitted for it.
Failure to Follow Physician's Wound Care Order
Penalty
Summary
The facility failed to adhere to a physician's wound care order for a resident with a non-pressure wound on the right second toe. The physician's order, dated 3/19/2025, specified that Betadine should be applied once daily, followed by a gauze island dressing with a border. On 3/25/2025, a registered nurse (RN) cleansed the wound with normal saline and applied Betadine but did not apply the required protective island dressing. The RN acknowledged the omission, stating she was unaware of the correct order. Additionally, the licensed practical nurse (LPN) responsible for reviewing and entering wound orders admitted to missing the updated order, resulting in the incorrect entry in the resident's chart.
Failure to Inform Residents About Arbitration Agreement
Penalty
Summary
The facility failed to adequately inform residents or their representatives about the binding arbitration agreement, which had the potential to affect all 49 residents residing in the facility. The Administrator admitted there was no policy in place for the arbitration agreement, and the Social Service Director revealed that residents and their representatives were shown a video and given a contract to sign, but were not explicitly informed that signing the agreement meant giving up the right to sue the facility. This lack of clear communication was evident in interviews with residents and a Power of Attorney, who expressed confusion and lack of understanding about the arbitration agreement. During a Resident Council Meeting, several residents confirmed they did not understand what an arbitration agreement was and that it was never explained to them. One resident, who had recently been admitted, expressed a desire to change the agreement upon learning its implications. The Ombudsman reported that this resident was shocked and upset upon discovering the meaning of the arbitration agreement, indicating a significant gap in the facility's communication and consent process regarding arbitration agreements.
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to care for dependent residents, affecting all 60 residents residing in the facility. The Facility Assessment Tool indicated that staffing should include one RN, one LPN, and six CNAs for both day and evening shifts, and one LPN and five CNAs for night shifts. However, on the day in question, the facility's Daily Staffing Sheet documented that the first shift was staffed with one RN, one LPN, and five CNAs, while the second shift had two LPNs and five CNAs. This staffing level was below the required number as per the facility's assessment. Interviews with staff and residents revealed the impact of insufficient staffing. CNAs reported being unable to complete their assignments, with each caring for 10-15 residents, leaving no time for restorative or walking activities. Residents confirmed the lack of assistance with walking or range of motion activities. Additionally, a strong urine smell was noted in one of the rooms, which was later addressed by the staff. The CNA Scheduler admitted to scheduling based on census rather than the facility assessment, leading to inadequate staffing levels. The Director of Nursing acknowledged the issue and indicated awareness of the urine smell problem.
Failure to Provide Restorative Services for Residents
Penalty
Summary
The facility failed to provide restorative services for three residents, as observed through a combination of observation, interviews, and record reviews. The facility's Restorative Nursing Program policy, revised in January 2019, aims to promote residents' independence through various programs, including range of motion (ROM) exercises, dressing and grooming, and mobility assistance. However, the records for three residents showed significant gaps in the implementation of these restorative services. For instance, one resident's active ROM exercises were not completed on several shifts, and their dressing and grooming assistance was also inconsistent. Another resident's bed mobility and ambulation with staff were not performed as required, with ambulation distances falling short of the prescribed 100-200 feet. The third resident did not receive daily restorative programs for dressing and grooming, with staff performing these tasks for them instead. Interviews with the residents and staff further confirmed the lack of restorative care. One resident reported not receiving therapy or walking assistance with their wheeled walker, relying solely on a wheelchair. Another resident stated that no staff assisted them with moving their arms or legs or dressing. A third resident, who required a mechanical lift for mobility, mentioned that staff did not engage them in any restorative program for dressing and grooming. A CNA admitted to not having time to complete restorative tasks or assist residents with walking. The Director of Nursing acknowledged the deficiency, agreeing that restorative services were not being adequately provided.
Failure to Post Daily Staffing Report
Penalty
Summary
The facility failed to post the Daily Staffing Report in a location visible to all residents and visitors, affecting all 58 residents. On 11/6/24, the Nurse Staffing posting was found near the Receptionist desk, obscured by a portable stand, and had not been updated since 10/29/24. Residents R2, R9, R10, and R12 were unaware of the posting's location. The Director of Nursing confirmed the posting's location and acknowledged it had not been updated. The Interim Administrator also confirmed the posting was not easily visible and should be updated daily.
Inaccurate PBJ Staffing Reporting
Penalty
Summary
The facility failed to accurately report its Payroll-Based Journal (PBJ) staffing information, affecting all 58 residents. The deficiency was identified through a review of the facility's PBJ Staffing Data Report for fiscal year Quarter 3, 2024, which indicated excessively low weekend staffing. Observations and interviews with residents and staff revealed that the facility was generally perceived to have adequate staffing levels, with six CNAs, two RNs, and one LPN working on the day shift. Residents and staff reported that their needs were being met, and no complaints about staffing were raised during Resident Council meetings. The issue arose because the former administrator did not include the hours worked by agency nurses and CNAs in the PBJ staffing reports. Additionally, management staff, who were salaried, did not clock in when covering shifts, leading to their hours not being counted in the PBJ reports. This oversight resulted in the facility's reported staffing levels appearing lower than they actually were. The VP of Clinical Operations discovered these discrepancies after comparing staff timecard reports to daily schedules and confirmed that the facility had more staff than reported.
Misappropriation of Narcotics by Former RN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically narcotics, by a former employee, a registered nurse (RN) identified as V6. The issue was discovered when the facility was informed by the State Attorney General's office that V6 was under investigation for narcotic diversion at multiple nursing homes. The facility's own investigation revealed that V6 had misappropriated full cards of narcotics during the time they worked at the facility, resulting in 898 missing narcotic pills from nine residents. The medications involved included Norco and Oxycontin, which were dispensed to residents but went missing. The facility's policy on abuse prevention and reporting, which includes the protection of residents from misappropriation of property, was not followed. The missing medications were identified through an audit conducted by the Regional Director of Operations, who found that the misappropriation occurred when the local pharmacy made deliveries. The residents affected by the missing medications were reimbursed by the facility, and the incident was reported to the residents' medical doctors, the local police department, and the Ombudsman. The facility suspended V6 pending the investigation, but V6 did not participate in the investigation and was subsequently terminated.
Medication Security Breach in LTC Facility
Penalty
Summary
The facility failed to maintain secure storage of medications for nine residents, as identified in a sample of 15. The facility's policy on narcotic and controlled substances counting requires staff to count controlled substances with a partner and verify the accuracy of log sheets at the beginning and end of each shift. However, the facility did not adhere to these guidelines, leading to the misappropriation of medications. The investigation revealed that during the days a specific staff member, identified as V6, worked, there were discrepancies in medication counts. This staff member was able to misappropriate full medication cards of narcotics during pharmacy deliveries by not following the facility's policy. The investigation, conducted by the Regional Director of Operations, found that 898 narcotic pills were missing from nine different residents. The residents affected had various medical conditions requiring pain management, including peripheral vascular disease, osteoarthritis, joint replacement aftercare, and multiple sclerosis. The medications involved included Tramadol, Hydrocodone-Acetaminophen, Oxycodone, and Morphine Sulfate, which were prescribed for pain management. The failure to secure these medications compromised the facility's ability to provide appropriate care to these residents.
Resident Rights Violation Due to Disrespectful Staff Interaction
Penalty
Summary
The facility failed to ensure that a staff member treated a resident with respect, violating the resident's rights. The incident involved a cognitively intact resident who reported that a Certified Nursing Assistant (CNA) acted disrespectfully during a night shift. The resident had requested assistance with a urinal, and the CNA attempted to adjust the bed using a remote control that the resident had informed her worked in reverse. Despite the resident's instructions to leave the remote alone, the CNA proceeded to tamper with the cords under the bed, resulting in a blown breaker and a deflated air mattress. The resident expressed feeling disrespected when the CNA raised her voice and made a dismissive comment, telling the resident to "get your big boy pants on." The CNA admitted to trying to fix the remote despite the resident's objections and mentioned that she speaks loudly due to hearing issues. The Director of Nursing confirmed that the CNA received education on resident rights and the importance of treating residents with dignity and respect.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement risk, leading to an incident where the resident exited the facility unnoticed. The resident, who had been exhibiting increased verbalizations of exit-seeking behavior, managed to remove his elopement alert bracelet and left the facility. He was later found propelling his wheelchair towards a busy road, posing a significant risk to his safety. This incident was part of a review of three residents identified for wandering or elopement risks. The resident's medical record indicated a history of cognitive impairment, including diagnoses of vascular dementia and delusional disorder, which contributed to his elopement risk. Despite being assessed as at risk for elopement and having a care plan in place, the facility failed to implement necessary interventions such as frequent monitoring and ensuring the functionality of the elopement alert bracelet. On the day of the incident, the bracelet was not checked during the day shift, and the resident was able to exit the building without triggering an alarm. Interviews with staff revealed that the resident had been verbalizing his intent to leave the facility, and his personal belongings were packed, indicating a plan to elope. However, staff did not provide the required 1:1 supervision or increased monitoring, despite being aware of the resident's intentions. The facility's failure to act on these warning signs and ensure the proper functioning of elopement prevention measures resulted in the resident's unsupervised departure and subsequent immediate jeopardy.
Removal Plan
- R1 was assessed by nursing and no pain or skin issues were identified.
- R1 was reassessed for risk of elopement and community survival skills.
- R1 was placed on 1:1 supervision that later decreased to 15 minute checks, documented on Monitoring logs.
- Maintenance staff checked the functionality of the exit door and elopement alert bracelet alarm system.
- The front door alarm code was changed and the keypad code posting was removed.
- All facility residents' most current Elopement Risk Assessments were reviewed for accuracy.
- New Elopement Risk Assessments were completed for every resident in the facility.
- Residents will be evaluated for elopement risk at admission, readmission, quarterly, annually, with a significant change, and incidentally if risk behaviors are identified.
- Elopement Drill/Post-Elopement Checklist logs were completed.
- Nursing staff check residents with elopement alert bracelets each shift to ensure the bracelet is in place.
- Elopement alert bracelets are checked for functionality by nursing and maintenance.
- Facility staff and agency staff have binders to access at the nurse's station containing the facility's Elopement Device policy and Code Pink-Missing Resident/Elopement policy.
- In-services were conducted on Elopement Policy & Procedure, Identifying Risks of Elopement, Wandering/Exit Seeking Behavior, and When to Provide/Implement Increased Supervision.
- In-services were conducted on Elopement and Elopement Alert Bracelets.
- In-services were conducted on 1:1 Supervision specific to nursing staff who provide 1:1 supervision.
- In-services were conducted on Supervision of Elopement Risk Residents Outdoors.
- Staff members were called and given in-service education over the phone.
- A Quality Assurance form titled 'Ad Hoc Quality Assurance (Plan of Correction)' was completed regarding the facility's elopement policy and procedure.
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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