Arcadia Care Jacksonville
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, Illinois.
- Location
- 1021 North Church Street, Jacksonville, Illinois 62650
- CMS Provider Number
- 145928
- Inspections on file
- 42
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Arcadia Care Jacksonville during CMS and state inspections, most recent first.
The facility did not ensure that an RN was on duty for at least eight hours each day, as shown by staffing schedules over a two‑month period that documented multiple days without the required RN coverage. During an interview, the Administrator acknowledged there was no staffing policy, stated they followed state guidelines, and confirmed there were days without RN presence in the building. At the time, 63 residents were documented as residing in the facility on the CMS 671 form.
A resident with severe cognitive impairment and a history of psychosis and dyskinesia experienced worsening involuntary movements due to the facility's failure to coordinate a neurology consult and ensure medication delivery. The resident's care plan was not adequately followed, leading to a gagging incident with improperly prepared food. Communication lapses among staff further delayed appropriate medical response.
A resident with multiple health conditions developed a new pressure ulcer due to the facility's failure to adhere to the care plan and promptly report skin changes. Despite interventions like repositioning and using a low air loss mattress, the resident's skin condition worsened, and the issue was not communicated to nursing staff in a timely manner, resulting in a facility-acquired wound.
The facility failed to provide a Registered Nurse (RN) on duty for 8 hours a day, seven days a week, from November 1 to November 18, 2024. The Director of Nurses confirmed the absence of full-time RNs, relying instead on three per diem RNs, resulting in insufficient RN coverage. This deficiency potentially affects all 75 residents, as the facility lacks a specific staffing policy and follows CMS guidelines.
The facility failed to provide 12 hours of annual competency training for three CNAs, as required. The Human Resources Director acknowledged the oversight, stating that while staff were given access to training resources, there was no oversight to ensure completion. This deficiency could potentially affect all 75 residents at the facility.
The facility failed to provide written notification to residents and their representatives before hospital transfers, affecting six residents. Instances included residents with intact cognition and those with dementia or moderately impaired cognition being transferred without written explanations. Staff interviews revealed a lack of awareness of the policy requiring written notices, highlighting a systemic issue in the facility's discharge and transfer procedures.
The facility exhibited multiple infection control deficiencies, including improper hand hygiene, glove use, and PPE adherence. CNAs and LPNs failed to wash hands between glove changes, did not sanitize a blood glucose monitor properly, and neglected to wear gowns during procedures requiring them. These actions were inconsistent with the facility's policies, affecting several residents.
A resident with multiple medical conditions, including MS and quadriplegia, expressed a preference to eat in his room due to the noise in the dining room. Despite being cognitively intact and dependent on staff for eating, the facility required him to eat in the dining room, citing short staffing. This action violated the resident's rights to choose his daily routines, as acknowledged by the facility's administrator.
A resident with severe cognitive impairment and involuntary movements experienced a fall and a gagging incident due to inappropriate meal size. Despite staff awareness, the physician was not notified immediately, contrary to facility policy, resulting in delayed medical intervention.
A resident with Schizoaffective Disorder was involved in a physical altercation, hitting another resident during a Bingo game. Despite staff presence, the incident occurred, indicating a failure to prevent abuse. An investigation was initiated, and the facility's policy prohibits such mistreatment.
The facility failed to provide discharge summaries for two residents, one with sepsis, pneumonia, and cerebral infarction, and another with pneumonia and malignant neoplasms. Despite providing medications and discharge papers, the electronic medical records lacked discharge summaries. Interviews revealed the absence of a policy on discharge summaries.
A resident with multiple health conditions, including MS and quadriplegia, was observed smoking without a protective apron, resulting in cigarette ashes falling on his clothing. Despite the facility's policy requiring safe smoking conditions, staff did not enforce the use of the apron or remove the ashes, leading to a deficiency.
The facility failed to provide complete incontinent care for three residents, leading to deficiencies in their care. A resident with multiple sclerosis was left with soap suds on the skin after care, while another with COPD and schizo-affective disorder did not have all areas cleansed and dried. A third resident with dementia also received inadequate care, with CNAs failing to rinse and dry the peri-area and other parts. These actions were contrary to the facility's incontinence care policy.
A resident with Multiple Sclerosis and severe cognitive impairment had a nonfunctioning G-tube that was not properly addressed by the facility. An LPN was unable to verify the G-tube placement due to difficulty in aspirating residual liquid, a recurring issue that had been reported but not resolved. Despite this, the LPN prepared to flush the tube without consulting the DON or physician, contrary to facility policy. The resident was eventually sent to the hospital for a tube placement check.
A facility failed to administer medications as ordered, resulting in a 16.22% error rate. An LPN gave a resident 10 mg of Lexapro instead of 20 mg of Escitalopram Oxalate. Another resident missed doses of Breo Ellipta, Aspirin, and Cholecalciferol due to unavailability and oversight. The facility's policy requires adherence to physician orders.
A resident with severe cognitive impairment and multiple diagnoses was not provided with the physician-ordered mechanical soft diet, leading to a gagging incident. The resident, who required supervision during meals, was served large pieces of turkey, contrary to the dietary order. Despite staff presence, the incident was not immediately reported to the physician, and the resident required further medical attention. Interviews revealed communication lapses and non-adherence to dietary orders and facility policies.
A facility failed to address residents' needs timely due to a non-functional call system, leading to residents feeling neglected and humiliated. One resident had to urinate in a water pitcher after staff failed to respond for over an hour, resulting in a UTI. Despite alternative alert systems like cow bells, residents reported these were ineffective, especially with closed doors due to COVID isolation. The facility acknowledged the issue, citing a delay in receiving a replacement part for the call system.
The facility failed to ensure proper use of PPE during a COVID-19 outbreak, with staff observed not wearing required equipment and residents expressing concerns about care. Observations showed staff wearing masks improperly and lacking gowns when entering isolation rooms. Interviews revealed inconsistencies in staff understanding of PPE protocols, despite facility policies mandating full PPE for COVID-19 positive rooms.
The facility failed to maintain an effective call system, leaving residents unable to communicate with staff for assistance. Residents were given inadequate alternatives like cow bells and air horns, which did not effectively alert staff. Despite being cognitively intact and requiring assistance, residents experienced delays in care, with some resorting to extreme measures like using an air horn. The call light system had been down for weeks, and the facility had no estimated repair date, leading to significant communication lapses.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) on duty for at least eight hours each day, as required. Review of the facility’s daily staffing schedules for the period from 1/1/2026 through 2/28/2026 showed that no RN worked at least eight hours on multiple specific dates: 1/4, 1/10, 1/11, 1/17, 1/18, 1/24, 1/25, 1/31, 2/1, 2/7, 2/8, 2/14, 2/15, 2/21, 2/22, and 2/28 of 2026. During an interview on 3/3/2026 at 9:40 AM, the Administrator stated that the facility did not have a staffing policy, that they followed state guidelines, and acknowledged there were days without RN coverage in the building. The facility’s CMS 671 form dated 3/1/2026 documented that 63 residents were residing in the facility at the time of the survey. No additional resident-specific clinical details or medical histories were provided in the report beyond the total census of 63 residents who could be affected by the lack of RN coverage.
Failure to Coordinate Neurology Consult and Medication for Resident
Penalty
Summary
The facility failed to coordinate necessary services for a neurology consult for a resident, identified as R30, who was experiencing abnormal movements, falls, and a gagging incident. R30, who has a history of psychosis, schizoaffective disorder, drug-induced subacute dyskinesia, and schizophrenia, was admitted with severe cognitive impairment and required assistance with daily activities. Despite these needs, the facility did not ensure timely follow-up on a neurology consult, which was crucial given the resident's worsening involuntary movements. R30's care plan and medical records indicated a need for close monitoring due to the risk of falls and potential adverse side effects from antipsychotic medications. However, the facility's records showed a gap in documenting the Abnormal Involuntary Movement Scale (AIMS) assessments between November 2023 and October 2024, which could have provided critical insights into the progression of R30's condition. Additionally, there was a failure to ensure the resident received the prescribed Austedo medication, which was intended to manage the involuntary movements, due to insurance issues that were not communicated effectively to the prescribing nurse practitioner. The deficiency was further compounded by an incident where R30 gagged on improperly prepared food that did not meet the mechanical soft diet requirements. Despite staff witnessing the incident, there was a lack of immediate communication to the licensed practical nurse on duty, which delayed appropriate medical response. These failures in coordination and communication contributed to the resident's increased risk and deterioration in condition, highlighting significant lapses in the facility's care protocols.
Failure to Prevent Pressure Ulcer in Resident
Penalty
Summary
The facility failed to prevent a pressure injury for a resident who was admitted with multiple health conditions, including cerebrovascular disease, femur fracture, mild protein-calorie malnutrition, and joint replacement surgery aftercare. The resident was cognitively intact but dependent on staff for mobility and had a care plan in place to manage skin integrity, which included turning and repositioning every two hours, using a low air loss mattress, and floating heels while in bed. Despite these interventions, the resident developed a new pressure ulcer on the left buttock, which was not promptly identified or treated by the staff. Observations revealed significant redness and skin tears on the resident's buttocks, which had been present for about a week before being reported. The lead CNA and another CNA observed the condition during peri-care, but it was not communicated to the nursing staff until later. When the LPN was informed, she acknowledged the skin breakdown and initiated treatment. The facility's policy required daily skin assessments and prompt reporting of changes, which were not adhered to in this case, leading to the development of a new facility-acquired wound.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for 8 hours a day, seven days a week, for the period from November 1, 2024, to November 18, 2024. This deficiency was observed during a survey, where it was noted that on November 18, 2024, at 9:00 AM, no RN was on duty. Additionally, on November 19, 2024, at 10:14 AM, the Director of Nurses (DON) confirmed that the facility does not employ any full-time RNs and relies on three per diem RNs, which results in the inability to provide consistent RN coverage as required. The facility's daily staffing schedule from November 1, 2024, to November 18, 2024, documented the absence of an RN for the required hours. The DON also stated that the facility does not have a specific staffing policy and follows Central Management Services (CMS) guidelines. This lack of RN coverage has the potential to affect all 75 residents at the facility, as documented in the CMS 671 Long Term Care Application for Medicare and Medicaid.
Deficiency in CNA Annual Training
Penalty
Summary
The facility failed to provide the required 12 hours of annual competency training for Certified Nursing Assistants (CNAs) to three out of five CNAs reviewed (V13, V31, and V36). This deficiency was identified through interviews and record reviews, which revealed that the training records did not document the completion of the necessary training hours. The Human Resources Director, V35, acknowledged that these CNAs did not receive the required in-service training. V35 explained that while she provides staff with access to the training site and login information, she does not oversee the completion of the training, expecting staff to fulfill the requirement independently. The facility's policy on employee training, dated September 2023, states that all workforce members will be trained on policies and procedures related to protected health information as necessary for their job functions. However, the policy does not appear to have been effectively implemented in this case, as evidenced by the lack of documented training for the CNAs. The facility has a census of 75 residents, all of whom could potentially be affected by this training deficiency.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives before transferring them to the hospital, as required by regulations. This deficiency was identified for six residents (R7, R12, R17, R36, R54, R72) out of a sample of 35. The report highlights multiple instances where residents were transferred to the hospital without receiving a written explanation of the reasons for their transfer, nor were their representatives or the ombudsman notified in writing. For instance, R17 was transferred to the hospital on three separate occasions without receiving a written notice explaining the reasons for the transfers, despite having intact cognition as per his Minimum Data Set. Similarly, R54, who had moderately impaired cognition, was transferred multiple times without written notification being provided to the resident or their family. In another case, R12, who has a diagnosis of dementia, was sent to the emergency room following a fall, but there was no documentation of a bed hold or written notice of the transfer. The facility's policy, revised in October 2022, mandates that residents and their representatives be notified in writing of any transfer or discharge, including the reasons for such actions. However, interviews with staff, including LPNs and the Regional Nurse, revealed a lack of awareness and adherence to this policy, as they admitted to not providing written explanations to residents being transferred to the hospital. This systemic failure to comply with notification requirements constitutes a significant deficiency in the facility's discharge and transfer procedures.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple instances of inadequate hand hygiene, improper glove use, and failure to wear appropriate personal protective equipment (PPE). During the toileting of a resident, two CNAs donned gloves without performing hand hygiene. Similarly, an LPN was observed administering medication and using a blood glucose monitor without sanitizing hands between glove changes. The LPN also failed to properly sanitize the blood glucose monitor after use, which was used for multiple residents, contrary to the facility's policy requiring thorough disinfection. Another incident involved an LPN providing tube feeding to a resident with a gastrostomy tube without wearing a gown, which is required for such procedures. Additionally, a CNA was observed performing incontinent care on a resident without changing gloves or performing hand hygiene between tasks, despite handling soiled materials. This practice was inconsistent with the facility's policy, which mandates handwashing and glove changes when moving from contaminated to clean tasks. Further deficiencies were noted during catheter and peri care for a resident, where CNAs failed to perform hand hygiene between glove changes and touched clean items with contaminated gloves. The facility's policies on glove use and hand hygiene were not followed, as staff did not wash hands before donning gloves or after removing them, nor did they change gloves after touching contaminated surfaces. These lapses in infection control practices were observed across multiple staff members and residents, indicating a systemic issue within the facility.
Failure to Accommodate Resident's Dining Preference
Penalty
Summary
The facility failed to accommodate a resident's preference to eat in his room, which is a violation of Resident's Rights. The resident, who is cognitively intact, has multiple medical conditions including multiple sclerosis, quadriplegia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. He is dependent on staff for all activities of daily living, including eating, and prefers to eat in his room due to the noise and commotion in the dining room. Despite his preference, the resident was observed eating in the dining room on multiple occasions. The resident expressed dissatisfaction with being required to eat in the dining room, stating that the facility cited short staffing as the reason for not accommodating his preference. The facility's Statement of Resident Rights affirms that residents have the right to choose their daily routines, including where they eat. The administrator acknowledged that residents have the right to eat in their rooms if they choose, yet the facility did not honor this right for the resident in question.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to report changes in condition to the physician for a resident, identified as R30, who was observed with severe spastic jerky movements and involuntary motions. R30, who has diagnoses including Psychosis, Schizoaffective Disorder, and Schizophrenia, was seen in the hallway with unsteady movements, resulting in a fall into a surveyor. Despite assistance from an LPN, R30 remained unsteady and nearly fell again while attempting to sit. This incident was not immediately reported to the physician as required by the facility's policy. Additionally, R30 experienced a gagging incident during a meal, where she was served large pieces of turkey instead of a mechanical diet. Despite the CNAs informing the LPN about the gagging incident, the physician was not notified until later in the evening. The facility's policy mandates immediate notification of the physician in such cases, but this was not adhered to, leading to a delay in medical intervention for R30.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to prevent abuse for one resident, identified as R52, who was involved in a physical altercation with another resident. R52, who has a diagnosis of Schizoaffective Disorder and is cognitively intact, was reported to have intentionally hit another resident on the hand during a Bingo game. The incident was documented in R52's General Note, and an investigation was initiated, with staff and resident interviews conducted. The facility's Abuse Prevention and Reporting Policy prohibits abuse, neglect, and mistreatment of residents, yet the incident occurred despite staff presence at the time.
Failure to Provide Discharge Summaries for Residents
Penalty
Summary
The facility failed to provide discharge summaries for two residents, which was identified during a review of discharge procedures. One resident was admitted with diagnoses including sepsis, pneumonia, and cerebral infarction. Upon discharge, the resident's progress notes indicated that medications and discharge papers were given to the resident and their daughter, but the electronic medical records lacked a discharge summary. Another resident, admitted with diagnoses such as pneumonia and malignant neoplasms, also had no discharge summary documented in their electronic medical records. Interviews with the Social Services Director and the Regional Nurse Consultant revealed that discharge summaries were not documented for these residents, and the facility did not have a policy in place regarding discharge summaries.
Failure to Ensure Smoking Safety for Resident
Penalty
Summary
The facility failed to protect a resident, identified as R8, while smoking, which was observed during a survey. R8, who is cognitively intact but has multiple sclerosis, quadriplegia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, is dependent on staff for all self-care activities. Despite having a care plan that includes wearing a smoking apron for safety, R8 refuses to wear it due to discomfort, particularly in hot weather. The facility's policy requires safe smoking conditions, but R8 was observed smoking without the apron, resulting in cigarette ashes falling on his clothing. On multiple occasions, staff members, including an Activity Aid and the Activity Director, supervised R8 while smoking but did not enforce the use of the smoking apron or remove the ashes from his clothing. The Social Services Director acknowledged R8's refusal to wear the apron and his right to smoke, but no alternative measures were implemented to prevent ashes from falling on him. The facility's Smoking Safety Policy allows for the restriction of smoking privileges in cases of hazardous behavior, but this was not enforced in R8's case, leading to the deficiency.
Incomplete Incontinent Care for Residents
Penalty
Summary
The facility failed to provide complete incontinent care for three residents, leading to deficiencies in their care. Resident R16, who has multiple sclerosis and is severely cognitively impaired, was observed receiving incomplete care when a CNA failed to rinse and dry the peri-area and buttocks after cleansing, leaving soap suds on the skin. This was contrary to the facility's policy, which requires rinsing and drying after washing. Similarly, Resident R31, with diagnoses including COPD and schizo-affective disorder, did not receive complete care as the CNA did not cleanse or dry the right hip, buttock, and thigh after changing the saturated incontinent brief. The care plan for R31 indicated a need for assistance with toileting and regular checks, which were not fully adhered to during the observed care. Resident R43, diagnosed with COPD and dementia, also received inadequate care. The CNAs involved did not rinse or dry the soapy suds from the peri-area, abdominal fold, and groins, and failed to cleanse the left hip, buttock, and back of the thigh. The facility's incontinence care policy outlines specific steps for washing, rinsing, and drying, which were not followed in these instances. Interviews with other CNAs and the Director of Nurses confirmed the expectation that all areas should be cleansed and dried during incontinent care, highlighting a discrepancy between expected and actual care practices.
Failure to Address Nonfunctioning Gastrostomy Tube
Penalty
Summary
The facility failed to recognize and address a nonfunctioning Gastrostomy tube (G-tube) for a resident diagnosed with Multiple Sclerosis, who was severely cognitively impaired and reliant on a feeding tube. During an observation, a Licensed Practical Nurse (LPN) attempted to aspirate residual liquid from the resident's stomach to verify the G-tube placement but was unable to pull back the plunger more than 0.25 to 0.5 centimeters. The G-tube visibly closed in on itself during the attempt, indicating a malfunction. The LPN acknowledged that the G-tube was often difficult to aspirate but stated it always flushed well, and mentioned having requested a replacement for the G-tube multiple times without success. Despite being unable to verify the G-tube placement, the LPN prepared to instill a water flush, but was stopped by the surveyor, who advised consulting the Director of Nurses or the Physician. The LPN agreed that she was unable to check the placement at that time. The resident's nurse notes documented the inability to collect residual prior to tube feeding and indicated that the Primary Care Provider ordered the resident to be sent to the hospital for a tube placement check or new tube installation. The facility's policy required notifying a physician to request an X-ray if there was suspicion of feeding tube misplacement, which was not initially followed by the LPN.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 16.22%, which is significantly higher than the acceptable threshold of 5%. This deficiency affected two residents. One resident was administered 10 mg of Lexapro instead of the prescribed 20 mg of Escitalopram Oxalate for major depressive disorder. This error occurred during the morning medication pass by an LPN. Another resident did not receive their prescribed Breo Ellipta inhalation for chronic obstructive pulmonary disease because the medication was not available. Additionally, this resident did not receive their prescribed doses of Aspirin and Cholecalciferol during the medication pass. The LPN acknowledged the unavailability of Breo Ellipta and confirmed that the resident missed their dose. The facility's policy mandates that medications be administered according to the physician's orders, which was not adhered to in these instances.
Failure to Provide Physician-Ordered Diet
Penalty
Summary
The facility failed to provide diets as ordered by the physician for a resident, identified as R30, who was reviewed for quality of care. R30 was admitted with multiple diagnoses including Psychosis, Schizoaffective Disorder, and Schizophrenia, and was noted to be severely cognitively impaired. The resident's care plan indicated an increased nutritional risk due to various conditions and required a mechanical soft diet with ground meat texture and thin liquids, along with staff supervision during meals. However, during an observation, R30 was served a meal that did not meet these dietary requirements, leading to a gagging incident. On the day of the incident, R30 was observed eating a meal that included large pieces of turkey, which was not cut into bite-sized pieces as required by the mechanical soft diet order. The resident, who exhibited spastic and jerky movements, attempted to eat the turkey using a plastic fork and subsequently began to gag. Despite the presence of staff, the resident was not provided with the necessary supervision and assistance, resulting in the resident spitting out the food and drink. The incident was not immediately reported to the physician, and the resident's condition worsened, necessitating a chest x-ray and transport to a local hospital. Interviews with facility staff revealed a lack of communication and adherence to dietary orders. A CNA reported the incident to an LPN, but the LPN was initially unaware of the gagging incident. The facility's policies on diet orders and fall prevention were not effectively implemented, as evidenced by the failure to provide the correct diet and necessary supervision for R30. The facility's quality assurance programs were expected to monitor such issues, but the deficiency in care for R30 highlighted a lapse in following established protocols.
Failure to Address Residents' Needs Timely Due to Non-Functional Call System
Penalty
Summary
The facility failed to promote residents' dignity by not addressing their needs in a timely manner, as evidenced by the experiences of four residents. One resident, R2, reported that due to non-functional call lights, she was forced to urinate in her water pitcher after staff failed to respond to her needs for over an hour and a half. This incident left her feeling humiliated and subsequently led to a urinary tract infection. Despite being provided with alternative alert systems like a cow bell and an air horn, these measures were ineffective in gaining staff attention, especially with her room door closed due to COVID isolation. Another resident, R3, also experienced issues with the non-functional call system and had to resort to contacting hospice to get assistance from the facility staff. R3, who is cognitively intact and requires substantial assistance with toileting, reported that the bell provided as an alternative was not effective in summoning help. Similarly, R4 and R5 faced challenges with the call system, relying on cow bells that were not audible enough to alert staff, leading to delays in receiving care. R4 expressed dissatisfaction with the care, comparing the facility to a psych ward, and noted that staff only entered the room for essential tasks like meals and medications. The facility's administrator acknowledged the ongoing issue with the call light system, which had been down since early August, and stated that they were waiting for a replacement part. In the interim, residents were provided with cow bells, and staff were instructed to perform extra rounds and 15-minute checks on residents unable to use the bells. However, these measures were insufficient, as residents continued to report unmet needs and feelings of neglect.
Inadequate PPE Usage During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) to prevent the spread of COVID-19. Observations revealed that staff did not consistently wear the required PPE when entering rooms of residents on droplet/contact precautions. For instance, a surveyor noted the absence of gowns outside a resident's room, despite signage indicating their necessity. Additionally, staff members were observed wearing masks improperly, such as below the nose, which compromises their effectiveness. Several residents, including those with confirmed COVID-19 diagnoses, expressed concerns about the care they received. One resident, who was on droplet/contact precautions, reported feeling neglected and believed that the virus was brought into the facility by staff. Another resident, also on precautions, mentioned experiencing delays in assistance from staff since testing positive. These accounts highlight the residents' perception of inadequate care and potential exposure due to lapses in infection control practices. Staff interviews further revealed inconsistencies in understanding and implementing PPE protocols. Some staff members incorrectly stated that no residents on their hallway had COVID-19, while others admitted to not wearing full PPE when required. The facility's policy, dated March 2020, mandates the use of N95 respirators, gowns, gloves, and eye protection for healthcare personnel entering rooms of residents with confirmed or suspected COVID-19. Despite this, observations and staff statements indicate a lack of compliance with these guidelines, contributing to the facility's ongoing COVID-19 outbreak.
Deficient Call System in LTC Facility
Penalty
Summary
The facility failed to maintain an effective call system, impacting the ability of residents to communicate with staff when assistance was needed. This deficiency was observed through multiple instances where residents were provided with inadequate alternatives, such as cow bells and air horns, which were not effective in alerting staff. Residents reported that the call lights had not been functioning for some time, and despite being given various tools to signal for help, staff did not respond promptly or at all. One resident, who was cognitively intact and required substantial assistance with toileting, resorted to using an air horn after a cow bell and pressure pad alarm failed to summon help. This resident expressed feelings of humiliation after being left in urine and having to urinate in a water pitcher due to the lack of response from staff. Another resident, also cognitively intact and requiring maximal assistance, had to call hospice to get help because the staff did not respond to the bell provided. Similar issues were reported by other residents, who stated that staff only entered their rooms for essential tasks like meals and medications. The facility's administrator and maintenance director acknowledged the ongoing issue with the call light system, which had been down since early August. Despite ordering a replacement part, there was no estimated delivery date, leaving residents to rely on ineffective cow bells. The facility's policy required hourly room checks until the system was repaired, but residents continued to experience delays in receiving care, highlighting a significant lapse in ensuring timely and effective communication between residents and staff.
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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