Arc At Normal
Inspection history, citations, penalties and survey trends for this long-term care facility in Normal, Illinois.
- Location
- 509 North Adelaide, Normal, Illinois 61761
- CMS Provider Number
- 145732
- Inspections on file
- 62
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Arc At Normal during CMS and state inspections, most recent first.
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.
Multiple residents with dementia, depression, cognitive impairment, or identified abuse risk were involved in incidents of physical and verbal abuse, including one resident kicking another, one resident throwing water and being hit in return, a resident striking another on the buttocks during care, and a staff member slamming doors and shouting near residents. In addition, a CNA who was not a licensed cosmetologist cut a resident’s hair after finding knots during shower care, despite the resident later stating they did not want their hair cut and the guardian reporting that consent had not been given beforehand or informed of the option to use a licensed cosmetologist. Documentation showed the resident had bruising to the hands around the same time, and the resident’s contract and care plan emphasized the right to refuse services and the need for trauma-informed care and protection from abuse.
A CNA, who had not been trained in resident transportation, used a personal vehicle while off duty to take a resident with hemiplegia and wheelchair dependence to the resident’s home without authorization or a physician order, and accepted $50.00 from the resident as compensation. The resident was away from the facility for several hours, yet there was no documentation in the nurse’s notes of the resident being out of the facility, and no incident report or required 72-hour documentation was completed, despite facility policies requiring trained personnel for transport and reporting of unauthorized departures.
A resident admitted with a thoracic vertebra compression fracture and ADL deficits did not have a complete baseline care plan developed and implemented. Although a focus assessment for ADL deficits was initiated, the care plan lacked documented goals and interventions for multiple focus areas. The MDS/care plan coordinator confirmed that the plan was not comprehensive, despite facility policy requiring timely review of a baseline plan of care by the IDT.
A resident with dementia, hip fracture, and multiple chronic conditions experienced escalating pain and new bruising over several days, with CNAs repeatedly observing the resident yelling in pain and noting bruising to the chest and changes such as spitting out food, stopping self-feeding, low-grade temperature, and leg contracture. LPNs were informed of the pain and bruising, and one LPN documented increased pain and began giving pain medication regularly, but did not assess the bruises or notify the physician or other appropriate personnel. The MAR showed frequent high pain scores despite ongoing pain medication, and there was no documented MD notification of the increased pain until several days later, contrary to the facility’s pain management policy requiring MD notification for changes in condition and ongoing assessment of pain control effectiveness.
A resident with moderate cognitive impairment and multiple cardiac-related diagnoses, who required staff assistance for dressing, was repeatedly observed lying in bed wearing only an ill-fitting adult brief, partially covered by a sheet, and visible from an open doorway. The resident reported waiting many hours for help to put on pants and experiencing long waits for dressing assistance several times a week. Facility documents, including the admission packet and resident rights policy, affirmed the right to dignity, bodily privacy, and an environment that supports individuality and respect, while the DON stated that care requests should not exceed a one-hour wait and that dignity must always be considered.
Two residents with dementia and behavioral issues were involved in a physical altercation after one threw a liquid at the other, leading to a choking motion and physical contact. Staff separated the residents and reported the incident, but documentation did not show that the agitated resident was removed from the area prior to the event, despite known behavioral risks.
Two residents with significant fall risks did not have their care plans updated with new interventions after experiencing falls, despite the facility's policy requiring care plan revisions after such events. In both cases, the interdisciplinary team identified new interventions, but these were not transcribed into the care plans, and one intervention was not documented as completed.
A resident with multiple fractures and dependent on a mechanical lift experienced a fall from a wheelchair after the lift sling straps became tangled in the wheel and the seatbelt was found to be broken. The care plan did not include updated interventions to address these risks, and staff were aware of the broken seatbelt but did not notify maintenance for repair.
Several incidents occurred where residents with cognitive impairment physically assaulted other residents, including slapping, hitting with objects, and grabbing, often during routine activities or minor disputes. Staff witnessed and intervened in these altercations, and assessments were conducted to check for injuries. The facility's policy defines and requires investigation of all such willful actions, regardless of the residents' cognitive status.
The facility failed to accurately complete MDS assessments for two residents, including incorrect documentation of antipsychotic medication administration, misclassification of a fall with a fracture, and improper discharge coding for a resident who died after a hospital transfer. These errors were due to reliance on incomplete records and misunderstanding of MDS requirements.
Two residents experienced deficiencies in medical record accuracy and medication documentation. One resident received an anti-anxiety medication beyond the allowed duration due to a transcription error that was not corrected, while another resident's intravenous antibiotic administrations were not documented by the DON, leaving several days unrecorded.
Two residents experienced physical abuse from other residents, resulting in pain and injury. In both cases, residents with dementia and other behavioral disturbances were involved in altercations that led to one resident being struck on the hand and another being scratched. Staff and witness statements confirmed the incidents, and the facility did not prevent these occurrences.
A resident experienced a fall and subsequently reported new and worsening pain, increased confusion, and loss of mobility and continence. Despite these changes, nursing staff did not notify the physician for several days, delaying medical evaluation and treatment. When finally assessed, the resident was found to have a displaced right femoral neck fracture and had suffered a significant decline in cognitive and functional status.
A resident who suffered a fall and developed new onset pain did not receive any pain medication or treatment for two days, despite repeated complaints and a significant decline in cognitive status. Nursing staff did not notify the physician of the resident's increased pain and confusion until two days after the incident, resulting in delayed diagnosis of a displaced femoral neck fracture and hospital transfer.
A resident who is cognitively intact and dependent for toileting care reported being physically abused by a CNA, who forcefully pressed on the resident's sternum during care. The incident was witnessed by another CNA and reported to the administrator, but was documented as a grievance instead of being investigated as abuse. The DON confirmed that staff are not trained to restrain residents in this manner, and the administrator later acknowledged the incident should have been treated as abuse.
A resident reported being handled roughly by a CNA, resulting in pain to the sternum area. Another CNA present confirmed the use of physical restraint during care. The allegation was reported to the facility administrator by a staff member, but the administrator initially treated it as a grievance rather than an abuse allegation, delaying the required report to the State Agency until the following day.
A resident with multiple medical conditions was not given Lactulose as ordered upon admission, due to a failure in medication reconciliation and review of discharge paperwork. This omission led to a decline in mental status and subsequent hospitalization for hepatic encephalopathy, with improvement only after the medication was administered in the hospital.
A significant number of residents did not have access to necessary towels and washcloths for daily care, as confirmed by staff interviews and observations of empty linen rooms. CNAs reported frequent shortages, leading them to use paper towels or toilet paper for resident hygiene. The housekeeping supervisor acknowledged the issue, and the administrator confirmed that this practice was not acceptable.
A resident with a history of aggression physically struck another resident twice, despite care plan interventions intended to address such behaviors. Staff witnessed and separated the residents, but the aggressor was able to return and strike again. The incident was reported to police, and the administrator was unaware of the full extent of the event or the aggressor's prior history.
The facility failed to conduct quarterly fall risk assessments and implement necessary fall prevention measures for three residents, resulting in a serious fall incident for one resident who was hospitalized. The residents, all with severe cognitive impairments and histories of falls, did not receive the required interventions such as non-skid materials in wheelchairs and proper bed positioning, as outlined in their care plans.
The facility employed a dietary manager who has not completed the required training to qualify for the position, potentially affecting all 105 residents. The DM, who has been in the role since November 2024, was observed supervising staff during meal service without the necessary qualifications, as confirmed by the Regional Dietary Manager.
The facility's kitchen was found to have unsanitary conditions, including rust and grease-like debris on a metal shelf, loose caulking in the sink, and dust-like substances hanging over a food preparation table. These conditions posed a risk of cross-contamination and food-borne illness for all 105 residents. The Dietary Manager acknowledged the potential risk of contamination.
The facility failed to maintain comfortable room temperatures for several residents, with temperatures recorded as low as 63.2°F. Residents reported discomfort and required extra blankets or warm clothing. The Maintenance Director acknowledged the issue, noting the boiler system was functioning but not effectively warming rooms. Consultation with the heating company suggested using the parking garage heating system to help, but no immediate actions were taken.
The facility failed to conduct side rail assessments and obtain informed consent for three residents. One resident had a side rail installed without a recent assessment, while another had side rails despite the care plan indicating otherwise. A third resident also had side rails without recent assessments. The nursing staff confirmed the lack of assessments for all three residents.
A facility failed to properly secure a resident's indwelling catheter tubing to their wheelchair, resulting in the tubing dragging on the floor on two separate occasions. A CNA confirmed the improper positioning, which violated the facility's Catheter Care Policy designed to prevent infections by ensuring urinary drainage bags and tubing do not touch the floor.
The facility failed to administer IV medications on time for two residents with osteomyelitis, leading to significant delays in treatment. One resident received Vancomycin HCl 6 hours late, while another received Ceftriaxone Sodium 9 hours late. The DON left early and was unaware of the issues, and documentation was not completed on time.
A resident with dementia and behavioral disturbances was witnessed by an LPN inappropriately touching another resident with severe cognitive impairment in a common area. The incident resulted in psychosocial harm to the victim, who was unable to consent due to her condition. The facility's policy affirms residents' rights to be free from such abuse, indicating a failure to protect the resident.
A facility failed to update a resident's care plan and behavior monitoring after an incident of inappropriate touching of another resident. Despite the resident's history of making sexual advances, the care plan did not include interventions to address or prevent this behavior, contrary to the facility's Behavioral Health Services Program requirements.
The facility failed to protect residents from sexual abuse, as evidenced by an incident where a resident with dementia entered another resident's room and engaged in non-consensual sexual contact. The incident was reported to the Medical Director and the police, and the resident was placed under 1:1 observation.
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.
Failure to Prevent Resident Abuse and Obtain Proper Consent for Grooming
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and to honor resident rights related to personal care. Several residents with cognitive impairment, dementia, depression, and high or moderate risk for abuse were involved in incidents of physical and verbal abuse. One cognitively intact resident kicked another resident in the shin after threatening them, and another resident threw water on a peer who then hit them on the arm. In a separate incident, a resident entered a bathroom while a CNA was providing care to another resident and struck that resident on the buttocks twice. Another event involved an assistant dietary manager slamming doors near two residents while loudly asserting authority, behavior that was documented as disorderly and misconduct. These events occurred despite care plans identifying certain residents as being at high or moderate risk for abuse and the facility having an abuse prevention and reporting policy defining physical, verbal abuse, exploitation, and neglect. The facility also failed to protect a resident’s rights regarding grooming and consent. A CNA, who was not a licensed cosmetologist or barber, cut a resident’s hair after knots were found while providing shower care, and the resident later stated that their hair was cut against their wishes and that it was done poorly. The resident’s guardian reported not having given consent prior to the haircut, was unaware that a CNA rather than an LPN or beautician performed the cut, and was not informed of the option to use a licensed cosmetologist who routinely visited the facility. Documentation shows that the guardian’s consent was recorded after the incident and that the resident had existing and new bruising to the hands around the same period. The resident’s admission contract states the right to refuse services unless court ordered, and the care plan notes impaired cognitive function, high risk for abuse, trauma-informed care needs, and impaired visual function, underscoring the importance of obtaining proper consent and protecting the resident from unwanted interventions.
Unauthorized Resident Transport and Misappropriation of Funds by CNA
Penalty
Summary
Facility staff failed to protect a resident from misappropriation of money and unauthorized transport off premises by a CNA. On 12/11/25, a CNA (V6) transported a resident (R13) in the CNA’s personal car approximately 30 miles from the facility to the resident’s home so the resident could obtain clothing. The resident reported being away from the facility from 7:30 a.m. to 11:30 a.m. and stated that the CNA was off duty and had been told several times that the resident was planning to go home. The resident gave the CNA $50.00 as compensation for the trip. The facility file documented that the CNA informed the nurse only after returning to the facility. There was no physician order authorizing the resident to leave the facility, and the resident’s progress notes did not document that the resident was out of the facility at any time. The resident’s MDS dated 12/3/25 documented no cognitive impairment, but the MDS section GG dated 12/2/25 showed the resident ambulated with a wheelchair and required maximum assistance from staff for transfers. The resident’s care plan documented hemiplegia related to a stroke and an increased risk for falls. The facility’s Abuse Prevention and Reporting Policy defined exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The facility’s Transportation for Residents Policy required all personnel to be trained prior to transporting residents, and the Incidents and Accidents Policy required a report and nursing documentation, including 72-hour documentation, for residents leaving the premises without authorization. The CNA had no facility training related to transportation of residents, and no incident report or required nursing documentation was completed for this unauthorized absence.
Failure to Develop Baseline Care Plan With Goals and Interventions
Penalty
Summary
The facility failed to develop and implement a baseline care plan that met all of a resident’s needs, with measurable goals and interventions, for one of three residents reviewed for quality of care. The resident was admitted on 12/24/2025 with diagnoses including a wedge compression fracture of the fourth thoracic vertebra (subsequent encounter with routine healing) and an unspecified fracture of the fourth thoracic vertebra. The resident’s care plan showed that a focus assessment for an ADL (Activity of Daily Living) deficit was initiated on the admission date, but no goals or interventions were documented for this focus area. On 02/03/2025 at 10:30 AM, the MDS/Care Plan Coordinator acknowledged that the resident’s care plan lacked goals and interventions for multiple focus areas and stated that care plans are considered comprehensive only when appropriate goals and interventions are in place. The facility’s comprehensive care plan policy dated 11/2012 states that the interdisciplinary team should attempt to schedule an initial meeting with the resident and/or representative within five days of admission to review the baseline plan of care. This deficiency centers on the absence of documented goals and interventions in the resident’s baseline care plan despite the resident’s identified ADL deficit and fracture-related diagnoses, and the facility’s own policy requiring timely review of a baseline plan of care by the interdisciplinary team.
Failure to Assess and Report Escalating Pain and Bruising
Penalty
Summary
Failure to assess and control a resident’s pain occurred when staff did not adequately evaluate or report escalating pain and new bruising for a resident with multiple complex medical conditions, including dementia, spinal stenosis, osteoarthritis, hip fracture, seizure disorder, and other chronic diagnoses. The resident’s care plan identified dementia with behavioral disturbances, ADL self-care deficits, incontinence, elopement risk, agitation, anxiety, restlessness, aggression, resistance to care, convulsions, restless leg syndrome, hip fracture, and seizure disorder. Facility investigation notes document that on multiple occasions staff and another resident heard or observed the resident yelling or hollering in pain. CNAs reported that the resident was in a lot of pain and had bruising on the left chest, and one CNA reported this to an LPN. Another LPN stated that on two consecutive days the resident was spitting out food, stopped feeding himself, had a low-grade temperature, a left leg contracture, and increased pain, but did not notify anyone of these changes. The Medication Administration Record shows that the resident began receiving pain medication regularly and had repeatedly high pain scores ranging from five to nine out of ten over several days, yet there was no documented physician notification of this increased pain prior to a later date. One LPN acknowledged being told about bruising and significant pain but did not assess the bruises, only gave pain medication, and did not notify anyone. Another LPN noted bruising but stated being unaware that it needed to be reported. The Director of Nursing later stated that bruising was first noticed several days before any notification was made and that the medical doctor should be notified of a change in pain, acknowledging that waiting several days for notification was a delay in care. The facility’s Pain Management Program policy required notifying the physician of a change in condition and assessing and reassessing pain control measures for effectiveness, but the record and interviews show that these steps were not followed for this resident.
Failure to Maintain Resident Dignity and Timely Assistance With Dressing
Penalty
Summary
Surveyors identified a failure to maintain a resident’s dignity and quality of life when staff left a cognitively impaired resident in bed wearing only an ill-fitting adult brief, with inadequate covering, and visible from the open doorway on multiple occasions. The resident, admitted with diagnoses including non-ST elevation myocardial infarction, encounter for palliative care, weakness, acute on chronic systolic (congestive) heart failure, and hyperlipidemia, had a care plan indicating the need for assistance from one staff member for dressing and an MDS BIMS score of 8, reflecting moderate cognitive impairment. The admission packet and facility policy documented the resident’s rights to dignity, bodily privacy, respect, and an environment that supports individuality, independence, and choice. On one observed date at 1:06 PM, the resident was found lying in bed in only an ill-fitting adult brief with just one flat sheet available for covering, and the resident was visible from the open entry doorway. At that time, the resident reported having waited since 7:00 AM to have pants put on. Later that afternoon at 2:54 PM, the resident was again observed lying in bed with only a sheet half covering the body, the door open, and no clothing other than the adult brief. The resident reported experiencing long wait times for help with dressing a couple of times a week and expressed that staff did not like them. The DON stated that resident requests for care should not exceed a one-hour wait time and that dignity should always be considered, indicating that the observed delays and lack of privacy were inconsistent with facility expectations and written resident rights policies.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse involving a resident-to-resident altercation. One resident with a history of aggressive behaviors related to dementia, agitation, and physical aggression was involved in an incident with another resident who also had cognitive impairment and behavioral issues. The aggressive resident was documented as being agitated, cussing, and swinging at staff, and was noted to have ongoing behavioral disturbances since admission. The care plan identified the resident as being at risk for abuse and aggressive behaviors, but behavior tracking did not document that the resident was removed from areas causing agitation. On the day of the incident, an LPN heard one resident threaten to throw hot chocolate on the other, followed by the actual act of throwing the liquid. In response, the other resident placed both hands in a choking motion and made contact with the resident's neck. Staff immediately separated the residents, and the resident who threw the liquid was moved to another wing. The incident was reported to the physician, power of attorney, ombudsman, and local police, and an investigation was initiated. Observations after the incident noted a bruise on the cheekbone of the resident with aggressive behaviors, but no other visible injuries. Interviews with staff and residents confirmed the altercation and the ongoing behavioral challenges of the residents involved. The facility's documentation showed that interventions were in place for managing behaviors, but there was no evidence that the resident was removed from the area that was causing agitation prior to the incident. Both residents had complex medical and behavioral diagnoses, including dementia, mood disturbances, and physical health issues, which contributed to the risk of altercations.
Failure to Revise and Implement Comprehensive Fall Care Plans
Penalty
Summary
The facility failed to implement and revise comprehensive care plans to address falls for two residents who were identified as being at risk for falls. For one resident with multiple fractures, diabetes, and muscle wasting, the care plan noted a risk for falls and included interventions such as ensuring the call light was within reach and conducting environmental rounds. However, after the resident experienced a fall while attempting to remove lift sling straps from her wheelchair, the new intervention to tuck the straps under the resident was not added to the care plan. Additionally, the intervention to educate the resident about asking for assistance with sling placement was not documented as completed. For another resident with vascular dementia, behavioral disturbances, and a history of falls, the care plan included several interventions to reduce fall risk, such as keeping supplies within reach and using a floor mat. Despite this, after the resident was observed crawling in the hallway, the root cause was identified as the resident purposefully placing himself on the floor to crawl. The interdisciplinary team determined that the resident should be care planned to crawl on the floor when desired, but this new intervention was not updated in the care plan. In both cases, the facility's fall policy required that care plans be revised with each fall and that new interventions be implemented as appropriate. The failure to update the care plans with new interventions following falls was confirmed by the facility administrator, indicating noncompliance with the facility's own policy and regulatory requirements for comprehensive care planning.
Failure to Implement Fall Prevention Interventions and Address Equipment Hazards
Penalty
Summary
The facility failed to implement resident-centered interventions to prevent falls for one resident, resulting in the resident falling from a wheelchair. The facility's fall policy requires individualized assessment and intervention, including the use of assistive devices and prompt repair or removal of malfunctioning equipment. Despite this, the resident's care plan did not include specific interventions to address the risk of falling from the wheelchair, and the intervention to tuck the lift sling straps under the resident was not transcribed to the care plan after the incident. The resident had multiple diagnoses, including fractures, diabetes with skin ulcer, and muscle wasting, and was dependent on a total body mechanical lift for transfers. The resident was cognitively intact and reported that the seatbelt on the power wheelchair was broken and could not be fastened. Staff were aware of the broken seatbelt, but maintenance was not notified, and the seatbelt was not repaired. The resident stated that the seatbelt was functional upon admission and that it was always worn when in the wheelchair. On the day of the incident, the resident was outside waiting for transportation to dialysis when the straps of the lift sling became tangled in the wheelchair's front wheel. While attempting to remove the straps, the resident slipped forward and fell from the wheelchair. The incident was reported to staff, and the resident was assessed and returned to the wheelchair. The lack of a functioning seatbelt and the absence of updated care plan interventions contributed to the fall.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
Multiple incidents of resident-to-resident physical abuse occurred within the facility, involving residents with varying degrees of cognitive impairment. In one instance, a resident with severe cognitive impairment was seated in a hallway when another resident, also severely cognitively impaired, approached and deliberately slapped her in the face. The incident was witnessed by a CNA, who reported that the resident who was struck appeared to be in pain but was unable to verbalize it due to her cognitive status. Both residents involved were unable to recall the incident during subsequent interviews. Another event involved a resident with no cognitive impairment being struck by a resident with severe cognitive impairment. The altercation occurred after the cognitively intact resident asked the other to move out of the way, resulting in the latter hitting her with a book. Witnesses confirmed the physical contact, and the resident who was struck reported minor pain but no lasting injury. The aggressor was described as often paranoid and confused, with a history of making accusatory remarks toward others. Additional incidents included a resident with severe behavioral symptoms hitting another resident on the head with a bingo card during an activity, and a resident grabbing another's wrist after a minor dispute over a dropped fork. In each case, the aggressors and victims had varying levels of cognitive impairment, and some were unable to recall the events. Facility staff observed and intervened in these altercations, and skin assessments were performed to check for injuries. The facility's policy defines abuse as any willful infliction of injury or pain, regardless of cognitive status, and requires all such incidents to be investigated and reported.
Inaccurate MDS Coding for Medications, Falls, and Discharge
Penalty
Summary
The facility failed to accurately complete and encode Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to antipsychotic medication administration, fall reporting, and discharge documentation. For one resident, the MDS Coordinator incorrectly documented that the resident had not received antipsychotic medication since admission, despite physician orders and medication administration records confirming daily administration of Quetiapine. Additionally, the same resident experienced a fall resulting in a right humerus fracture, but the MDS was coded to indicate a non-major injury, omitting the fracture. The MDS Coordinator stated that she relied on incomplete information from the electronic medical record and missed the documentation of the fracture, leading to inaccurate MDS coding. Another resident was sent to the hospital and died there after more than 24 hours, but the MDS Coordinator completed a 'Death in Facility' assessment instead of the required 'Discharge with Return Anticipated' assessment. The Coordinator referenced the CMS RAI User's Manual, which specifies that a discharge assessment is required if a resident is in the hospital for observation for more than 24 hours, regardless of admission status. The Coordinator acknowledged the error after reviewing the timeline and documentation, confirming that the incorrect MDS assessment was completed.
Failure to Maintain Accurate Medical Records and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Physician Order Sheet documented an order for Ativan (Lorazepam) to be administered every eight hours as needed for anxiety, with an incorrect duration of 14 months, exceeding the 14-day limit for PRN anti-anxiety medication. The consent form for this medication was incomplete, lacking documentation of the duration. The error in duration was repeated throughout the resident's chart, including the medication administration record (MAR), which was not revised or discontinued as required. As a result, the resident received a dose of Ativan after the order should have been discontinued. The Director of Nursing confirmed the error was due to a transcription mistake that was not identified in a timely manner. For another resident, hospital discharge orders required the continuation of intravenous Ceftriaxone following treatment for a urinary tract infection, sepsis, and a bacterial infection of the knee. The MAR did not document administration of the antibiotic on several days, with blank spaces where nurse initials should have been recorded. The Director of Nursing, who administered the medication, admitted to not documenting the administrations in the resident's record, resulting in several days of undocumented antibiotic administration.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse, as evidenced by two separate incidents involving physical altercations between residents. In the first incident, a resident with a history of atherosclerotic heart disease and developmental delays reported being struck on the hand by another resident diagnosed with vascular dementia, agitation, autism, and dysphagia. The injured resident experienced pain and redness, and staff applied an ice pack to the affected area. Witness statements and a police report confirmed the altercation, with staff noting that the two residents were in close proximity and waving their arms at the time of the incident. In the second incident, a resident with severe unspecified dementia and major depressive disorder was scratched on the hand by another resident with moderate dementia, cognitive communication deficit, and dysphagia. Witness statements indicated that the resident who was scratched did not provoke the other resident. Both incidents were documented in care plans and reported to the appropriate authorities, but the facility's actions were insufficient to prevent these occurrences of physical abuse between residents.
Failure to Obtain Timely Medical Evaluation After Resident Fall
Penalty
Summary
The facility failed to obtain timely medical evaluation and treatment for a resident following a fall. After the fall, the resident began experiencing new onset pain, initially described as an ache and later as sharp pain, with increasing severity. Nursing staff observed right hip pain, abnormal gait, and increased confusion in the resident, but did not notify the physician until several days later. During this period, the resident also exhibited increased confusion and a decline in functional abilities, including new incontinence and increased dependence for activities of daily living. The physician was eventually notified, and x-rays revealed a displaced right femoral neck fracture. Prior to the fall, the resident was cognitively intact, ambulatory with a walker, and required only setup assistance for daily activities. Following the incident and delayed intervention, the resident's condition declined significantly, with severe cognitive impairment, loss of mobility, and total dependence on staff for care. The failure to promptly assess and treat the resident's post-fall symptoms resulted in a significant deterioration in her health status.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident experienced a fall while ambulating with a walker, resulting in new onset pain that was documented as achy and later as sharp pain in the right hip. Despite repeated complaints of pain and a significant change in cognitive status, no pain medication or treatment was administered from the time of the fall until the resident was sent to the emergency room two days later. Nursing notes and medication administration records confirm that the resident's pain ratings increased from zero to four out of ten following the fall, but no interventions were initiated. The resident's physician was not notified of the increased pain and confusion until two days after the fall, at which point diagnostic imaging and hospital transfer were ordered. Staff interviews revealed that the resident was alert and able to communicate pain after the fall, but continued to experience worsening pain, increased confusion, and new incontinence over the weekend. The resident was found to have a displaced fracture of the right femoral neck and was admitted to the hospital for pain management and further evaluation. The resident's cognitive status declined significantly during this period, as documented by a drop in the Brief Interview for Mental Status (BIMS) score from 12 to 1.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A cognitively intact resident, who is dependent on staff for toileting care, reported being physically abused by a Certified Nurses Aide (CNA) during a care episode. The resident described that while being changed by two CNAs, one CNA pushed down hard on her sternum, an area noted to be very bony and sensitive, which the resident perceived as abusive. This incident was corroborated by the resident's family member, who was informed by the resident about the rough handling and subsequently reported the concern to facility administration. The CNA who was later informed by the resident about the alleged abuse reported the incident to the facility administrator, but was not further involved in any investigation. The facility administrator, upon being notified of the incident, chose to document the event as a grievance rather than initiate an abuse investigation as required by policy. Another CNA present during the incident confirmed that the resident was held down with arms crossed over her chest to facilitate care, acknowledging that this was not standard practice and that alternative actions should have been taken. The Director of Nursing stated that staff are not trained to restrain residents in this manner and recognized the need for further education on abuse prevention. The failure to immediately investigate the allegation as abuse and the use of physical force during care led to the deficiency.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency in a timely manner for one resident. According to the facility's own policy, any allegation of abuse must be promptly reported to the State Agency and the resident's representative. On the date in question, a resident reported sensitivity and pain in the breastbone area, stating that a CNA had been too rough and had pushed down hard on her sternum during care. Another CNA present during the incident confirmed that the accused CNA held the resident down with her arms crossed over the resident's chest to facilitate care, rather than seeking alternative assistance or de-escalating the situation. The resident expressed feeling that the action was abusive and upsetting. A third CNA reported that the resident had informed her of the alleged abuse shortly after breakfast, and this CNA relayed the information to the facility administrator. However, the administrator initially chose to document the incident as a grievance rather than initiating an abuse investigation or reporting it to the State Agency as required. The administrator only began the abuse investigation and reported the incident to the State Agency the following day, after speaking with the resident's family. The administrator later acknowledged that the allegation should have been reported immediately upon receiving the report from the CNA.
Failure to Administer Discharge-Ordered Medication Resulting in Hospitalization
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with multiple diagnoses, including hepatic encephalopathy risk factors. Upon admission, the resident's hospital discharge orders included a prescription for Lactulose to be administered three times daily. However, the facility did not include this medication in the resident's physician orders for February, nor was it documented as administered in the Medication Administration Record. Staff failed to review both the paper and electronic discharge records as required, resulting in the omission of Lactulose from the resident's care. As a result of not receiving Lactulose, the resident experienced a significant decline in mental status, including confusion, weakness, and inability to hold up their head. The family noticed these changes and requested hospital evaluation, where the resident was found to have elevated ammonia levels and was diagnosed with hepatic encephalopathy. Hospital records confirmed that the lack of Lactulose administration at the facility led to the resident's condition, which improved only after receiving the medication in the hospital.
Failure to Provide Adequate Linen Supplies for Resident Care
Penalty
Summary
The facility failed to provide adequate linen supplies, specifically towels and washcloths, for 97 out of 103 residents reviewed. Multiple grievances from the resident council documented ongoing complaints about delays in laundry service and the lack of necessary linens for morning care. On several occasions, both linen rooms and the laundry room were observed to have insufficient or no towels and washcloths available. Certified Nurses Assistants (CNAs) confirmed that shortages occurred regularly, particularly during the second shift, and reported having to use wet paper towels or toilet paper to clean residents due to the lack of proper linens. Staff interviews further corroborated the persistent shortage, with one CNA stating that towels and washcloths were unavailable for two out of seven day shifts each week, and another indicating daily shortages on the second shift. The housekeeping supervisor acknowledged awareness of the issue and noted that additional linens were stored in the basement, but staff were unaware of their location. The administrator confirmed that the use of paper towels or toilet paper for resident care was unacceptable and that towels and washcloths should always be available.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident (R1) with a history of cognitive communication deficit, major depressive disorder, type 2 diabetes with polyneuropathy, and lack of coordination was physically struck in the face and legs by another resident (R2). R2 had a documented history of unspecified dementia, psychotic and mood disturbances, and was previously identified as having the potential for physical and verbal aggression, with interventions noted in the care plan to address these behaviors. On the day of the incident, a CNA (V3) witnessed R2 hit R1 in the face, separated the residents, and after assisting another resident, returned to see R2 strike R1 again. R1 reported not being injured during the incident. The facility's abuse prevention policy requires identification of residents at risk for abuse and implementation of care plan interventions to reduce such risks. Despite this, R2, who had a known history of aggression and a prior incident of striking another resident at a previous facility, was able to physically abuse R1 on two occasions during the same event. The administrator was unaware of the second strike and of R2's prior aggressive behavior at another facility. The incident was reported to the police, and witness statements were collected, but the report does not mention any corrective actions taken following the event.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to complete quarterly fall risk assessments and implement fall interventions for three residents, leading to significant incidents. One resident, who was cognitively impaired and had multiple diagnoses including vascular dementia and Alzheimer's disease, fell from a high bed onto a tile floor. This resident was hospitalized overnight due to a subarachnoid hemorrhage sustained from the fall. The fall occurred because the bed was not in the lowest position, and the head of the bed was elevated, which increased the risk of injury. The resident's care plan indicated a risk for falls, but the necessary precautions were not followed. Another resident, with severe cognitive impairment and a history of falls, was found without the required non-skid material on top of his wheelchair cushion, as specified in his care plan. This oversight was confirmed by a Certified Occupational Therapy Assistant and family members, who noted the facility's failure to adhere to the prescribed interventions to prevent falls from the wheelchair. A third resident, admitted with neurocognitive disorder and dementia, also lacked the necessary non-skid material in their highback wheelchair, despite a documented history of falls and a care plan intervention requiring it. This deficiency was confirmed by a Certified Nursing Assistant, indicating a pattern of neglect in implementing fall prevention measures across the facility.
Unqualified Dietary Manager Employed
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, which has the potential to affect all 105 residents residing in the facility. During an observation on February 18, 2025, the Dietary Manager (DM), identified as V7, was seen actively supervising dietary staff during breakfast meal service. V7 stated that he has been working at the facility as the dietary manager since November 2024 but has not taken the required classes to qualify for the position. This was confirmed by V14, the Regional Dietary Manager, on February 19, 2025, who acknowledged that V7 has not had the necessary training to qualify as the dietary manager.
Unsanitary Kitchen Conditions Risking Cross-Contamination
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the kitchen, which could potentially lead to cross-contamination and food-borne illness affecting all 105 residents. During a follow-up kitchen tour, it was observed that an eight-foot-long metal shelf above the three-well sink was covered with rust and brown and black grease-like debris. Below this shelf, approximately twenty hanging brackets held presumably clean kitchen serving utensils, such as spoons, tongs, and whisks, which were at risk of contamination from the soiled shelf above. Additionally, the three-well sink had loose chipped caulking dangling into the wash and sanitization wells, and two electrical outlet boxes above the sink were covered with thick grease-like buildup and crusted food-like substances. A metal food preparation table adjacent to the sink was situated under a suspended metal pipe with stringy dust-like substances hanging over it, and the ceiling above had a cluster of hanging paint strips. The Dietary Manager acknowledged the unsanitary conditions and confirmed that these areas posed a risk of contaminating food served to the residents.
Facility Fails to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for seven residents, as observed during a survey. Residents consistently reported their rooms being too cold, with temperatures recorded as low as 63.2 degrees Fahrenheit. The issue was documented in Resident Council Meeting Minutes over several months, indicating ongoing complaints about cold conditions. Residents expressed discomfort, with some needing extra blankets or warm clothing to cope with the low temperatures. The Maintenance Director acknowledged the problem, noting that the heating system, a boiler unit, was functioning correctly but still resulted in chilly rooms. The director mentioned consulting with the heating company, which suggested turning on the heating system in the parking garage to potentially warm the building's concrete floors and, consequently, the resident rooms. However, no immediate actions had been taken to address the cold temperatures at the time of the survey.
Failure to Conduct Side Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to implement side rails only after completing a side rail assessment and obtaining informed consent for three residents. For Resident 79, the facility did not conduct a recent quarterly side rail assessment, and the last assessment indicated that side rails were not necessary. Despite this, Resident 79 had a side rail installed prior to a new assessment being completed. The Director of Nurses confirmed the lack of a recent assessment and acknowledged that the side rail was in place before the assessment was conducted. Resident 10 had bilateral quarter side bedrails attached to their bed, but there were no quarterly side rail assessments since July 2024, despite the care plan indicating the use of side rails. The Assistant Director of Nursing confirmed the absence of recent assessments and noted that the previous assessment was incorrect. Similarly, Resident 88 had bilateral quarter side rails without any quarterly assessments since June 2024. The Assistant Director of Nursing confirmed the lack of assessments for Resident 88 as well.
Improper Securing of Indwelling Catheter Tubing
Penalty
Summary
The facility failed to properly secure the indwelling catheter tubing of a resident, identified as R96, to their wheelchair. This deficiency was observed on two separate occasions, with the catheter tubing dragging on the floor underneath the resident's high back wheelchair. On February 18, 2025, at 12:15 PM, and again on February 19, 2025, at 10:32 AM, the tubing was noted to be improperly positioned. A Certified Nursing Aide, identified as V25, confirmed the improper positioning of the catheter tubing on February 19, 2025, at 10:38 AM, acknowledging that it should not be dragging on the floor. The facility's Catheter Care Policy, dated October 2024, specifies that urinary drainage bags and tubing should be positioned to prevent contact with the floor, indicating a failure to adhere to established guidelines aimed at reducing infection risks.
Failure to Administer IV Medications on Time
Penalty
Summary
The facility failed to administer intravenous medications as ordered by the physician for two residents, affecting their treatment for osteomyelitis. One resident was admitted with acute osteomyelitis of the left ankle and foot, requiring intravenous Vancomycin HCl to be administered daily at 1:00 PM. However, the medication was administered 6 hours and 11 minutes late on one occasion. Another resident, admitted with osteomyelitis requiring intravenous Ceftriaxone Sodium for a sepsis-elbow infection, had their medication administered 9 hours and 36 minutes late. The facility's medication administration policy mandates that medications be administered according to the physician's order, including the right time. On the day of the incident, there were two registered nurses on duty, but the Director of Nursing left work early and was unaware of the medication administration issues. The Director of Nursing later logged into the medical chart remotely to document the administration, but it was not documented on time, and no progress note was entered to reflect the timely administration.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident, resulting in psychosocial harm. On June 18, 2024, a Licensed Practical Nurse (LPN) witnessed a resident (R1) touching another resident's (R2) breast in a common area. R1, who has a history of dementia with behavioral disturbances and a care plan noting a tendency to express sexual advances, was seen with his hand down R2's blouse. Despite being separated immediately by the LPN, R1's actions were inappropriate and non-consensual, as R2 has severe cognitive impairment and cannot consent to intimate touching. R2, diagnosed with aphasia and Alzheimer's disease, has significant cognitive impairments, including memory issues and an inability to understand or communicate effectively. The incident was reported to R2's family, who expressed that R2 would have been mortified and afraid if she had the cognitive ability to understand the situation. The facility's policy on abuse prevention clearly states that residents have the right to be free from unwanted intimate touching, highlighting the deficiency in protecting R2 from sexual abuse.
Failure to Update Care Plan for Inappropriate Behavior
Penalty
Summary
The facility failed to adequately care plan and implement behavior tracking and interventions for a resident, R1, who was involved in an incident of inappropriate touching/sexual abuse of another resident, R2. On June 18, 2024, an LPN witnessed R1 touching R2 inappropriately in a common area. Despite R1's history of making sexual advances towards staff and watching pornography, the care plan was not updated to include this new behavior of inappropriate touching of other residents. The facility's Behavioral Health Services Program requires that care plans be updated with new or worsening behaviors, but this was not done in R1's case. R1's care plan, revised on June 20, 2024, did not document the incident or include interventions to prevent future occurrences. The Behavior Monitoring and Interventions Report for June 2024 also failed to document the targeted behavior or specific interventions. Interviews with facility staff confirmed that R1's care plan and behavior monitoring did not address the inappropriate touching incident, despite the facility's policy to establish a system for identifying behaviors and implementing appropriate interventions. This oversight represents a deficiency in the facility's responsibility to provide necessary behavioral health care and services to its residents.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse, as evidenced by an incident involving two residents. One resident (R1) reported that another resident (R2) entered R1's room, placed R2's hand on R1's chest, and guided R1's hand to R2's groin. This incident was reported by R1 to the Medical Director the following day, who then informed the facility. The police were notified, and R2 was placed on 1:1 observation. R1 did not wish to press charges and wanted to forget the incident. R2, who has a diagnosis of Metabolic Encephalopathy, Parkinson's, Dementia, and Cognitive Communication Deficit, was unable to recall the incident due to their cognitive condition. The Director of Nursing (DON) confirmed the incident and stated that R2 had no prior history of sexual inappropriateness and believed R2 mistook R1 for R2's spouse. The facility's Abuse Prevention and Reporting Policy, dated October 2022, affirms the residents' right to be free from abuse, including sexual abuse, which is defined as non-consensual sexual contact of any type. Despite this policy, the facility failed to protect R1 from sexual abuse by R2. The incident highlights a deficiency in the facility's ability to prevent and address such occurrences, particularly involving residents with cognitive impairments. The facility's response included notifying the police, assessing R1 through Social Services, and placing R2 under 1:1 observation, but the initial failure to prevent the abuse remains a significant concern.
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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