Arcadia Care Morton
Inspection history, citations, penalties and survey trends for this long-term care facility in Morton, Illinois.
- Location
- 190 East Queenwood Road, Morton, Illinois 61550
- CMS Provider Number
- 145248
- Inspections on file
- 33
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Arcadia Care Morton during CMS and state inspections, most recent first.
The facility did not maintain a full-time DON who was a Registered Nurse (RN), as required by its own job description and regulatory standards. The facility assessment identified a DON role responsible for providing resources and support for all residents, and the census showed 78 residents in care. After the prior DON’s employment ended, the Administrator acknowledged that there had been no full-time RN DON in place, and the Assistant DON, who had been acting as DON, held only an LPN license according to state license verification.
A resident with an indwelling suprapubic catheter had a care plan requiring Enhanced Barrier Precautions, including gown and glove use during high-contact care, but an LPN performed catheter care without wearing a gown or mask, despite facility policy requiring adherence to infection control practices and the administrator’s expectation that staff use full PPE for catheter care. In a separate issue, two residents’ shared room was found with a wet incontinence brief, a towel with brown matter, and soiled clothing and socks left on the bathroom floor for hours, and later the soiled clothing was observed in a clear bag on the floor by the sink, contrary to housekeeping and administrative responsibilities to keep resident areas clean and waste discarded properly.
Multiple residents reported not receiving weekly showers and being left in urine and feces for prolonged periods despite facility policies requiring regular incontinence checks and hygiene care. Cognitively intact residents described waiting from 35 minutes to over 90 minutes after activating call lights for toileting assistance, sometimes putting wet briefs back on or remaining soiled when staff did not respond, and one resident reported linens not being changed after a bowel movement. Another resident dependent on toileting and with an ostomy stated that a family member routinely had to provide showers and incontinence care because staff relied on that person, and when the family member was absent, staff attempted bed baths instead of scheduled showers. One resident was later found by a CNA to be saturated with urine from neck to feet with reddened skin after reporting having asked all day to be changed. CNAs reported staffing shortages, delayed agency staff, and competing dietary duties that limited their ability to answer call lights and complete resident care, while the Administrator acknowledged staff were overworked and the Ombudsman confirmed frequent complaints about unanswered call lights.
A deficiency was identified in which residents’ rights to dignity, self-determination, and timely care were compromised by chronic food shortages and delayed call light responses. Facility policies required that call lights be answered promptly and that meals be prepared and served according to planned menus, yet residents reported that the kitchen frequently ran out of main menu items and desserts, resulting in substitutions such as toast or peanut butter and jelly instead of the listed foods. Several residents with intact cognition described not receiving the posted menu items, receiving smaller portions, and having to keep personal food supplies in their rooms to avoid hunger. Staff, including CNAs and dietary personnel, confirmed that there was often not enough food for all residents, particularly for those eating in their rooms, and that residents sometimes received whatever could be found rather than the planned meal. At the same time, multiple residents and family members reported long call light wait times ranging from many minutes to hours, with some residents remaining in soiled briefs or relying on family to provide showers, toileting, and ostomy care because staff said they were short-staffed. Resident council minutes, grievance forms, and statements from the ombudsman documented ongoing complaints about untimely call light responses and dissatisfaction with dietary services.
The facility failed to ensure daily room cleaning and trash removal for multiple residents, despite policies requiring adherence to cleaning schedules and proper waste disposal. Resident council minutes documented grievances about soiled items and rooms not being cleaned when housekeepers were off. Cognitively intact residents reported that their rooms were not cleaned for several days, trash was only removed on request, and one resident resorted to using a t‑shirt to mop bathroom water; surveyors observed strong urine odors, full wastebaskets with soiled briefs, dried spills on the floor, and unswept, unmopped floors. Staff interviews and staffing schedules showed inadequate housekeeping coverage on certain days and shifts, and staff confirmed that when the primary housekeeper was absent, rooms on one side of the building were not cleaned, even though leadership acknowledged rooms and trash should be addressed daily.
The deficiency centers on chronic understaffing and inaccurate staffing records that resulted in delayed call light response, missed or delayed showers, inadequate incontinence care, and inconsistent room cleaning for more than 80 residents. The facility’s own assessment and staffing calculator showed CNA hours below calculated needs on multiple days, while therapy and activity hours were overstated on daily reports. Staff and residents reported that on some shifts only two CNAs were present when many more were scheduled, that agency staff frequently filled in but did not consistently provide care or answer call lights, and that residents sometimes waited up to several hours for assistance, including one resident who remained soiled after a laxative and another who relied on family for showers and toileting. Resident Council minutes and grievances repeatedly documented concerns about call lights, showers, soiled items in rooms, and lack of housekeeping coverage, and one resident experienced multiple unwitnessed falls in common areas during this period.
A resident with severe cognitive impairment and total dependence for ADLs experienced multiple falls in a short period, including in the nurses’ station and an assisted dining room. Despite facility policies requiring incident reports, assessments, physician and family notification, and care plan updates after each fall, staff did not complete an incident report, nursing note, or notifications for at least one fall in the dining room, and no new interventions were implemented after that fall or a later fall. Witnesses reported the resident fell in the dining room when no staff were present and that other residents had to yell for help. The incident/accident log omitted this fall, and the resident’s representative reported being told of only some of the falls, demonstrating failures in supervision, documentation, investigation, and communication.
A resident with dementia, urinary retention, obstructive/reflux uropathy, and a history of UTI had physician orders and a care plan for Enhanced Barrier Precautions (EBP) related to an indwelling urinary catheter. During observed catheter care, a CNA entered the room, put on gloves without performing hand hygiene, and did not wear a gown, while another CNA assisted with repositioning the resident without gloves or a gown. The CNA used multiple washcloths from a single basin to clean the resident’s genital area, catheter tubing, and catheter bag, then changed gloves once without hand hygiene and adjusted the resident’s clothing. The CNA later stated that a gown was not required for catheter care, contrary to facility policy requiring gown and gloves for high-contact care and medical device care under EBP, and hand hygiene before and after contact with the catheter system.
The facility did not ensure adequate nursing staff coverage, leading to prolonged wait times for residents needing assistance with call lights and toileting. Multiple staff members, including LPNs and CNAs, reported frequent understaffing, and residents described waiting for hours in soiled briefs due to delayed responses. Facility records confirmed consistent nursing hour shortages, and concerns about delayed care were raised but not formally documented in resident council minutes.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility failed to serve visually appealing and palatable food, affecting 78 residents. Observations showed that meals were served with improperly drained zucchini, resulting in a watery appearance. Several residents expressed dissatisfaction with the food's temperature, taste, and saltiness. The Ombudsman noted that food palatability is a recurring issue not addressed by staff.
The facility failed to secure two large trash dumpsters from pests and rodents, as observed during a follow-up tour with the Regional Dietary Manager. The dumpsters had open lids, with one being overfilled with trash, contrary to the facility's policy requiring closed lids to prevent infection spread and deter pests. The Regional Dietary Manager confirmed the lids should have been closed.
The facility failed to conduct required PASARR screenings for three residents diagnosed with mental illnesses, including Schizoaffective and Schizophreniform Disorders. The absence of these screenings was confirmed by the Business Office Manager and Administrator, indicating non-compliance with the facility's policy and regulatory requirements.
The facility failed to notify state authorities of significant changes in mental health conditions for two residents diagnosed with Schizoaffective Disorder. The Business Office Manager confirmed that no PASARR screenings or notifications were made, despite the facility's policy requiring such actions.
A resident with wounds on the right inner thigh and left inner ankle did not receive timely wound care as per facility policy and physician's orders. The resident's right thigh wound was left exposed without a dressing, and the left ankle dressing was improperly adhered. Despite notifying staff, the resident experienced delays in receiving appropriate wound care, which was eventually addressed by an LPN after multiple reminders.
A resident with dementia was prescribed Fluphenazine for psychosis without appropriate indication, as required by the facility's policy. Despite no observed behaviors justifying the medication, the facility did not adjust the prescription. Staff noted the resident was calm and had no aggressive behaviors, and the DON acknowledged the diagnosis was inappropriate for the medication use.
A resident experienced a medication administration deficiency with a 23.53% error rate due to late administration of morning medications, including insulin, which was refused as it was too close to lunchtime. The LPN acknowledged the delay, and the DON confirmed the medications were not administered as per the physician's orders.
The facility failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) policies, leading to infection control deficiencies. Staff did not perform hand hygiene after glove changes during care for a resident with a catheter and feeding tube. Additionally, a resident with an indwelling catheter did not have appropriate EBP signage or PPE available, and another resident received catheter care without the staff wearing a protective gown.
The facility failed to notify in writing, and maintain a copy in the medical record, notification to the Ombudsman and resident/resident representatives of residents before transfers. The Director of Nursing could not provide documentation of such notifications, and the Social Services Director admitted to not notifying the Ombudsman or resident/resident representative in writing of hospital transfers, unaware of the requirement. This affects all 70 residents in the facility.
The facility failed to notify residents or their representatives in writing about the bed-hold policy during transfers and did not maintain a copy of this notification in the medical records. The DON and an RN confirmed that the required documentation was not completed, affecting all 70 residents.
The facility failed to implement enhanced barrier precautions (EBP) as required, affecting all 70 residents. Despite a policy mandating gown and glove use for residents with wounds, indwelling medical devices, or infections, staff were observed using only gloves. Interviews revealed a lack of awareness and delayed implementation of EBP, as acknowledged by the Director of Nursing.
The facility failed to ensure residents knew the Grievance Officer, did not provide a private area for Resident Council meetings, and did not respond to Resident Council concerns. Residents reported loud noise during meetings and lack of responses to their grievances. Observations confirmed inadequate postings and lack of follow-up on complaints.
The facility failed to accurately code a resident's visual status in their MDS assessments. Despite signs and verbal confirmation of the resident's legal blindness, the MDS documentation was inconsistent, listing the resident's vision as both highly impaired and adequate. Staff verified the resident's visual impairment but did not ensure accurate MDS documentation.
The facility failed to document a vision care plan for a legally blind resident, despite staff actions and signs indicating the resident's impairment. Both an LPN and the Social Services Director confirmed the oversight.
The facility failed to revise the Comprehensive Care Plans for two residents, resulting in discrepancies between documented care and actual care provided. One resident's care plan incorrectly indicated continuous oxygen use, and another's inaccurately documented a tracheostomy despite decannulation months prior.
The facility failed to provide necessary shower and nail care for a resident, as required by their policies. The resident had overgrown fingernails and reported not receiving a shower since admission. Documentation was inconsistent, and staff interviews confirmed that care was not provided as needed.
The facility failed to have orders for indwelling catheter care and to record catheter output for two residents. Observations showed catheters draining urine, but there were no orders or documentation for catheter care or output. An RN confirmed the lack of orders and documentation, and CNA charting for catheter care was missing.
The facility failed to post required State and Federal postings for resident use, with only the Ombudsman office information displayed. The Administrator confirmed the absence of other required postings, and the Activity Director noted that the postings were removed during remodeling and could not be found. New postings were eventually printed and displayed.
An incident of physical abuse occurred when one resident with Paranoid Schizophrenia and Major Depressive Disorder, exhibiting severe cognitive impairment (BIMS score 4/15), assaulted another resident diagnosed with Dementia. The aggressor physically hit the victim multiple times, causing an orbital fracture and injuries to the face and hands. The victim, who primarily speaks Vietnamese and has communication barriers, was unable to defend herself. The facility's Abuse Prevention and Reporting policy, which emphasizes residents' right to be free from abuse, was not effectively implemented, leading to an Immediate Jeopardy situation. The incident was captured on video and witnessed by staff members.
Failure to Maintain a Full-Time RN Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) who is a Registered Nurse (RN), as required by regulation and the facility’s own job description. The facility assessment tool dated 1/6/26 identified an individual (V9) as the DON and stated that a DON would provide resources needed to support competent care for the resident population every day and during emergencies, and that the Administrator’s team members included the DON. The resident census roster dated 3/6/26 showed 78 residents residing in the facility. Review of V9’s employee file showed a start date of 12/22/25 and a termination date of 1/26/26, and the facility’s DON job description dated 7/2023 required that the DON be an RN with a current, unencumbered state license and direct the overall operation of the nursing department in accordance with state and federal standards. On 3/8/26, during surveyor review, the Administrator (V1) was unable to provide a DON license and stated that the facility required a full-time DON but had not had one since V9’s termination on 1/26/26. V1 further stated that there was no RN serving as DON and that the Assistant Director of Nursing (V2), who was functioning as the acting DON, was only an LPN. Verification of V2’s professional license on 3/8/26 confirmed that V2 held an active LPN license, not an RN license. As a result, the facility did not have a full-time RN serving as DON for the period following 1/26/26, despite having 78 residents in care.
Failure to Use Enhanced Barrier Precautions and Maintain Sanitary Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), during indwelling urinary catheter care for one resident and to maintain a sanitary, homelike environment for two residents. The facility’s Infection Surveillance, Tracking and QA policy dated 12/2025 requires monitoring adherence to infection control practices, including proper use of PPE and ensuring proper precautions are initiated. The resident census roster shows multiple residents residing on the A Wing hallway. One resident (R7) had diagnoses including urogenital implants, benign prostatic hyperplasia with lower urinary tract symptom impairments, and urinary retention, and the care plan specified EBP related to an indwelling urinary catheter, including gown and glove use during high-contact care such as hygiene and device care. On 3/9/26 at 9:48 a.m., an LPN (V12) performed suprapubic catheter care for R7 without wearing a gown or mask, despite being assigned to the entire A Wing hallway and acknowledging not using this PPE. The Administrator (V1) later stated that nurses should always wear a gown, gloves, and mask when providing catheter care and that EBP is required. The deficiency also includes failure to maintain a clean and safe environment in a resident room shared by two residents (R11 and R12). The Administrator job description requires ensuring the facility is maintained in a clean and safe manner, and the housekeeper job description requires following cleaning schedules, coordinating with nursing, cleaning resident living areas and floors, and discarding waste in proper containers. On 3/7/26 at 10:32 a.m., surveyors observed a soiled wet incontinence brief, a white bath towel with an approximately eight-inch area of brown matter, wet maroon sweatpants, a wet brown sweatshirt, and yellow non-skid socks on the floor in front of the commode in R11 and R12’s room. At 1:09 p.m. the same day, the same soiled items remained on the floor in front of the commode. On 3/8/26 at 8:15 a.m., a clear bag containing the soiled maroon sweatpants, brown sweatshirt, and yellow non-skid socks was observed on the floor in front of the sink in the same room. The Administrator stated that it was unacceptable for the soiled clothing, towel, and dirty incontinence brief to remain on the bathroom floor for that length of time.
Failure to Provide Timely Showers and Incontinence Care, Leaving Residents Soiled for Extended Periods
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences for hygiene and incontinence care, resulting in residents going without weekly showers and remaining in urine and feces for extended periods. Facility policies state that residents have rights to exercise autonomy and choice in daily life and care, and that CNAs are responsible for bathing, grooming, answering call lights promptly, and washing and drying incontinent residents. The Incontinent Care policy requires incontinent residents to be checked approximately every two hours and provided perineal and genital care after each episode. Despite these policies, Resident Council minutes and concern/compliment forms over several months document repeated complaints that showers were a persistent concern on all shifts, that residents had to ask multiple times to receive showers, and that some residents received bed baths instead of preferred showers. One cognitively intact resident who required partial/moderate assistance with toileting reported going to the bathroom, removing a wet disposable brief, and activating the bathroom call light for a replacement. After waiting 35 minutes without staff response, the resident put the wet brief back on and returned to the room to activate the room call light. The resident estimated wearing the wet brief from about 8:45 a.m. until 10:30 a.m., describing discomfort, burning, and feelings of helplessness and anger due to not being properly cared for. Another cognitively intact resident, dependent for toileting and rolling, reported that after receiving a laxative and having a bowel movement, staff did not respond promptly to the call light, resulting in remaining soiled for more than 90 minutes, and that bed linens were not changed afterward. This resident stated feeling degraded and that dignity was compromised, and also reported being given a quick bed bath instead of a requested shower because use of a mechanical lift required two staff. The same resident described waiting two and a half hours to be changed when an agency CNA said she had a hernia and could not lift, requiring the resident to wait for the next shift. Another resident with moderate cognitive impairment and partial/moderate assistance needs for toileting and transfers was reported by a roommate to have been left wet in urine for over 40 minutes after a call light was activated at 6:14 a.m. and not answered until 6:56 a.m. A cognitively intact resident who was always incontinent of urine and had an ostomy, and who was dependent for toileting and showers, stated that a family member typically visited daily to assist with showers, disposable brief changes, and ostomy care, and that staff relied on this family member to perform these tasks. When the family member did not visit, staff attempted to provide bed baths instead of showers, and the resident had to repeatedly request the scheduled shower. Another cognitively intact resident, dependent on toileting care and requiring substantial/maximal assistance for rolling, reported waiting all morning and afternoon for help changing a soiled and wet disposable brief. A staff member began to assist but left, stating there were no clean sheets and did not return, leaving the resident with soiled brief and linens. The resident became visibly upset, tearful, and angry, questioning whether life would continue with such mistreatment. A CNA who worked on the day the last resident described the incident stated that it was after 3:00 p.m. when the resident reported having asked all day to be changed, and that the resident was covered in urine from back to neck and down to the feet, with a saturated brief, strong urine odor, and reddened skin everywhere urine had touched. Another CNA stated that all staff were having to choose which resident cares to complete and that agency staff often arrived hours late, slowing resident care. A different CNA reported that staffing was becoming an issue, that the facility had not evaluated resident load compared to staff, and that CNAs were required to perform dietary tasks such as serving and picking up room trays, serving in the dining room, and feeding residents while also trying to chart and provide resident care, resulting in residents suffering because CNAs could not care for them properly. The Administrator acknowledged being unaware that residents were sitting in urine and feces for long periods, confirmed CNAs were required to help with dietary tasks, and agreed staff were overworked. The Ombudsman reported receiving a call from a very upset resident who said she had sat in feces for 90 minutes with the call light on and no staff response, and also noted numerous complaints from residents about call lights not being answered or being turned off by staff who said they would return but did not.
Insufficient Food Supply and Delayed Call Light Response Compromise Resident Rights
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to a dignified existence, self-determination, and timely communication by not providing sufficient food to follow the posted menu and not answering call lights in a timely manner. Facility policies required that resident rights be promoted, that call lights be answered promptly by all staff, and that dietary staff prepare and serve meals according to planned menus and standardized recipes. Despite these policies, surveyors observed that on a day when the lunch menu listed beef and bean chili, cornbread, and Snickerdoodle Blonde Bars, residents were served chocolate pudding instead of the listed dessert because the facility was out of eggs. Multiple CNAs and a prior dietary manager reported that running out of food, including main menu items and desserts, had been an ongoing issue, with residents sometimes receiving only toast when eggs or sausage were unavailable, or peanut butter and jelly sandwiches when portions were small. Staff also reported that residents who ate in their rooms, particularly those in certain room ranges, often did not receive the menu items because there was not enough food for all residents. Several residents with intact or mildly impaired cognition described not receiving the food listed on the menu and having to supplement with personal food supplies. One resident with a BIMS score indicating intact cognition stated that the kitchen runs out of food and that she does not get served what other residents are having, regardless of what the menu says. Another cognitively intact resident reported that the facility does not serve enough food during meals and kept a basket of various food items at the bedside to avoid going hungry. A different resident with intact cognition stated that she never receives a menu and that even when menus were posted, they were not followed; she kept a three-shelf storage unit in her room stocked with items such as beef stew, tamales, and soda. CNAs corroborated that several residents purchased their own cereal and other food because the facility frequently ran out of items like juice, eggs, and sausage, and that residents in specific rooms often did not receive the planned menu items. The deficiency also includes repeated failures to answer call lights in a timely manner, affecting multiple residents. One cognitively intact resident reported turning on the bathroom call light after removing a wet disposable brief and waiting 35 minutes without response, ultimately putting the wet brief back on and returning to bed, where she waited with the room call light on until staff eventually arrived and took her to the shower; she stated she is supposed to have help with toileting but often goes alone because there is not enough staff. Another resident with intact cognition stated that call light response times ranged from two minutes to two hours, especially on evening shifts. A resident with mild cognitive impairment had a roommate report that a call light activated at 6:14 a.m. for incontinence care was not answered until 6:56 a.m., during which time the resident remained soiled in urine. Additional residents with intact cognition reported long call light wait times and reliance on family members to assist with showers, changing disposable briefs, and ostomy care because staff said they were short-staffed. Family members and staff further described the impact of delayed call light responses. A family member of a severely cognitively impaired resident stated that staff were often short, that he routinely toileted the resident himself because staff did not answer call lights quickly, and that staff would delay responding because they knew he helped. CNAs reported that staffing was always short, that daily staffing sheets were inaccurate, and that they did not have time to complete all resident care because they were also required to assist dietary by delivering trays and serving meals and drinks. Resident council minutes and concern/compliment forms documented repeated complaints over several months about call lights not being answered timely and concerns about the dietary menu, including late trays, missing milk for cereal, and dissatisfaction with peanut butter and jelly or grilled cheese as meal alternatives. The ombudsman reported numerous complaints from residents that call lights were not answered or that staff would turn off the light and state they would return but did not. The administrator acknowledged that residents should not have to wait more than 10–15 minutes for call lights to be answered and that the kitchen should have the ingredients needed to follow the menu and provide the same meal to all residents, while the registered dietitian and regional dietary manager indicated they had not been fully informed of the extent of menu noncompliance and food shortages.
Failure to Provide Daily Room Cleaning and Trash Removal
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring that resident rooms were cleaned and trash removed on a daily basis. The facility’s own housekeeper job description requires adherence to cleaning schedules, including cleaning and sanitizing resident rooms and discarding trash into proper containers. Resident council minutes documented grievances about soiled items in rooms and reports that rooms were not cleaned when housekeepers were off work. Review of the housekeeping/laundry schedule showed limited staffing, including days with only one staff member on days and no staff scheduled for evening shifts, and other days with no housekeeper assigned to one side of the building. Multiple cognitively intact residents reported that their rooms were not cleaned daily and that trash was not removed unless they specifically requested it. One resident stated his room was not cleaned on specific days and that when a particular housekeeper was off, his room did not get cleaned, despite the housekeeping manager being expected to cover. Another resident reported her room had not been cleaned for several days, that she had to mash down garbage in an overfull wastebasket, and that she used a t‑shirt to mop water off the bathroom floor; surveyors observed a strong urine odor, full trash cans, and soiled disposable briefs in her room and bathroom. A roommate reported that no one had cleaned the shared room, where surveyors observed a large dried brown sticky stain on the floor and unswept, unmopped floors. A third resident stated she was “lucky” if housekeeping came to sweep and mop and that her room and trash were not addressed daily. Staff interviews confirmed that when the primary housekeeper was off, daily cleaning did not occur in all rooms, that rooms on one hall were not cleaned on a specific date, and that there was no housekeeper for one side of the building on another date. The administrator confirmed that resident rooms and floors should be cleaned daily and trash removed daily or when full.
Chronic Understaffing Leads to Delayed Care, Missed Showers, and Inadequate Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and accurately reported nursing and direct care staffing to meet residents’ needs for timely call light response, showers, incontinence care, room cleaning, and fall prevention. The facility’s own Facility Assessment Tool for 08/2025–08/2026 documented expected CNA staffing levels (seven CNAs on days and evenings for 87–92 residents and three CNAs on nights for a census under 86), but the Administrator later stated the assessment had not been updated and did not reflect the actual number of CNAs needed. Daily staffing calculator reports for multiple dates in December 2025 showed CNA hours worked were below the calculated hours needed on numerous days. Staff schedules and interviews confirmed that on some shifts there were significantly fewer CNAs present than planned, including reports that at 6:00 AM on at least one day there were only two CNAs in the building when there should have been seven or eight. The facility also failed to accurately document staffing on its Daily Staffing Calculator reports. On two randomly selected dates, the calculator overstated therapy and activity staff hours compared to the actual treatment and direct engagement hours documented by the Therapy Director and Activity Director. The Administrator acknowledged relying on reported numbers from these department heads and was unaware they were inaccurate. Additionally, daily assignment sheets showed that the Administrator, the MDS Coordinator (RN), and the previous DON were working the floor for portions of shifts to cover staffing gaps, while the Laundry and Housekeeping schedule showed limited housekeeping/laundry coverage on certain evenings, with no staff scheduled 4:00 PM–12:00 AM on some dates. Resident and family interviews, Resident Council minutes, and grievance/concern forms documented repeated complaints of long call light response times, missed or delayed showers, and inadequate room cleaning. Residents reported waiting from an hour to several hours for call lights to be answered, including one resident who stated she remained in feces for approximately 90 minutes after receiving a laxative and that her bed linens were not changed afterward. Another resident reported having only one shower since admission and needing to ask multiple times for showers, while others stated they were given bed baths instead of preferred showers and had to “nag” staff. A family member reported having to toilet a resident himself due to call lights not being answered. Residents and staff also reported that staff were too busy or too few to get residents up as ordered, to provide showers as scheduled, or to remain present in the assisted dining room as required. Staff interviews further described chronic understaffing, particularly on evening and night shifts, frequent reliance on agency CNAs and nurses, and agency staff not completing all required care or answering call lights consistently. CNAs reported that staffing on some mornings started with only two CNAs in the building, that they often had to cover large halls and also assist in the assisted dining room, and that daily staffing sheets did not match the actual staff present. The Ombudsman reported receiving multiple complaints about call lights not being answered or being turned off without staff returning, including a call from a resident who said she sat in feces for 90 minutes with her call light on. The incident/accident log and Regional Nurse Consultant interview documented multiple unwitnessed falls for one resident in the assisted dining room and at the nurses’ station, including a fall on one date that was not documented on the log, while a CNA stated she believed residents were having falls because there was not enough staff. Resident Council minutes over several months consistently recorded concerns about call lights, showers, soiled items in rooms, and lack of room cleaning when housekeepers were off work. Overall, the observations, records, and interviews show that the facility did not maintain sufficient numbers of CNAs and licensed nurses on each shift to meet residents’ needs for timely assistance, personal hygiene, toileting, and environmental cleanliness, and did not maintain accurate staffing records or an updated facility assessment reflecting actual staffing needs for its census of approximately 83–91 residents.
Failure to Investigate, Document, and Intervene After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Prevention Program and Incident/Accident policies for a resident with severe cognitive impairment and total dependence for ADLs and transfers. The resident, who had athetoid cerebral palsy, anxiety, and a developmental speech and language disorder, was care planned as being at risk for falls related to immobilization and decreased cognition. Despite this, the resident experienced multiple falls in a short period, including falls at the nurses’ station and in the Assisted Dining Room (ADR), while dependent on staff for safety and supervision. On one occasion, therapy staff observed the resident lean forward in a wheelchair and fall, striking her head on a sharps container and nurses’ cart. On another documented fall at the nurses’ station, the resident was noted as alert but disoriented at baseline. The facility’s own policies required completion of incident/accident reports for all accidents, assessment and documentation of injuries and vital signs, physician and family/legal representative notification, and care plan updates with appropriate interventions after each fall. However, for a fall that occurred in the ADR on 12/3, staff statements show the resident was found on the floor tipped back in her wheelchair, but no incident report was completed, no nursing note was entered, no notifications were made to the physician or the resident’s representative, and no new interventions were implemented. Additional documentation and interviews show that the resident had further falls in the ADR on subsequent dates, and that at least one of these later falls also did not result in new interventions being put in place. The incident/accident log omitted the 12/3 ADR fall entirely, despite staff and a resident witness describing that the resident fell backwards in her wheelchair in the ADR while no staff were present, and that another resident had to yell repeatedly for help. The resident’s representative reported being informed of only three falls and stated she would have wanted to know about other falls. Overall, the facility failed to prevent falls, failed to investigate at least one fall, failed to notify the physician and resident representative of two falls, and failed to implement fall-related interventions after two of the resident’s falls, contrary to its written policies and fall prevention program.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Catheter Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of catheter care and adherence to Enhanced Barrier Precautions (EBP) and hand hygiene requirements for one resident with an indwelling urinary catheter. Facility policy on urinary catheter care required disposable one-time-use gloves when emptying urinary drainage bags and performing perineal care, and hand hygiene before and after touching any part of the urinary catheter drainage system. The EBP policy required gown and gloves for high-contact resident care activities, including medical device care and incontinent care, and specified that standard precautions must be followed with all care. The CNA job description required adherence to infection control and standard precaution practices when performing nursing procedures. The resident involved was an older adult with dementia, cognitive communication deficit, urinary retention, obstructive and reflux uropathy, and a history of UTI, with physician orders and a care plan in place for EBP related to an indwelling urinary catheter and for infection risk related to poor oral intake, dehydration, and weakened immune function. During an observation of catheter care, a CNA entered the resident’s room, applied gloves without performing hand hygiene, and did not don a gown despite the resident being on EBP for an indwelling catheter. Another CNA entered the room, assisted with repositioning the resident in bed, and did not wear gloves or a gown. The first CNA filled a washbasin with water and multiple washcloths, then used one washcloth to clean the resident’s penis, another to clean the scrotum, and another to clean the catheter tubing and catheter bag, all from the same basin. The CNA then changed gloves for the first time after completing this sequence of care but again did not perform hand hygiene, and proceeded to adjust the resident’s pants. When questioned, the CNA stated that a gown was not required for catheter care, which conflicted with the facility’s EBP policy and the resident’s orders and care plan for EBP and infection prevention measures.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple documented instances of delayed responses to call lights and toileting assistance. The facility's own Call Light policy requires timely responses, especially for bathroom lights, which are to be treated as emergencies. However, interviews with staff, including LPNs and CNAs, revealed that frequent staff call-ins and understaffing led to longer wait times for residents. Residents reported waiting extended periods, sometimes up to three hours, for assistance with toileting and call lights, resulting in residents remaining in soiled briefs for prolonged periods. The Activity Director confirmed that concerns about delayed call light responses were raised in resident council meetings but were not documented in the minutes as instructed by previous administration. Review of facility records, including Daily Assignment Sheets and the Facility Assessment, showed that the facility was consistently short of the required nursing hours on several days, with shortages ranging from 33 to 47.1 hours per day based on their own staffing calculations. The Regional Director of Operations confirmed these staffing shortages. Resident complaints documented in concern forms and interviews further corroborated the impact of insufficient staffing, with reports of residents being told to wait for assistance and experiencing significant delays in care.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Food Palatability and Presentation Deficiency
Penalty
Summary
The facility failed to serve food that was visually appealing and palatable to residents, potentially affecting 78 residents who are prescribed oral intake. During an observation, the lunch meal of beef stroganoff, steamed zucchini, and chilled pears was served with the zucchini not properly drained, resulting in a watery and unappetizing appearance. Several residents did not eat the served lunch and requested an alternative meal. Multiple residents expressed dissatisfaction with the food, citing issues such as it not being warm, not pleasing to taste, and being too salty. The Ombudsman confirmed that food palatability is a recurring issue raised at resident council meetings and is often not addressed by staff. The Director of Nursing verified that two residents do not eat and take nothing by mouth.
Improper Trash Disposal and Pest Control
Penalty
Summary
The facility failed to ensure that two large trash dumpsters were secured from pests and rodents, as the lids of the dumpsters were not closed. This deficiency was observed during a follow-up tour with the Regional Dietary Manager, where it was noted that one of the dumpsters was overfilled with facility trash. The facility's policy on trash disposal requires that the dietary department dispose of trash appropriately and maintain the dumpster area to prevent the spread of infection and deter pests and rodents. The policy specifically states that dumpster lids should be closed and no trash should be on the ground surrounding the dumpster. The Regional Dietary Manager confirmed that the lids should have been closed, indicating a lapse in adherence to the facility's trash disposal policy.
Failure to Conduct PASARR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to obtain Pre-Admission Screening and Resident Review (PASARR) and/or Level II Resident Reviews for three residents diagnosed with mental illness. Resident 17, diagnosed with Schizoaffective Disorder, did not have a PASARR screening in her electronic medical records, and there was no evidence that a PASARR was initiated at the time of her diagnosis. Similarly, Resident 60, diagnosed with Other Schizoaffective Disorder, lacked a PASARR screening in his records, and no evidence was found that a PASARR was initiated at the time of his diagnosis. The Business Office Manager confirmed that the necessary screenings were not conducted for these residents, despite the facility's procedure requiring psychiatric evaluations and agency notifications for significant changes or new diagnoses. Resident 32, who was admitted with a diagnosis of Schizophreniform Disorder, also did not have a PASARR Level II screening following the diagnosis. The Administrator confirmed the absence of a PASARR Level II for this resident. The facility's policy mandates annual PASARR Level I screenings and reporting of any changes to the state mental health or intellectual disability authority, which was not adhered to in these cases. The lack of PASARR screenings for these residents indicates a failure to comply with regulatory requirements for residents with mental health diagnoses.
Failure to Notify Authorities of Significant Changes in Mental Health Conditions
Penalty
Summary
The facility failed to notify the appropriate state mental health and intellectual disability authorities regarding significant changes in the mental health conditions of two residents. Resident 17 was diagnosed with Schizoaffective Disorder on February 4, 2023, and Resident 60 was diagnosed with Other Schizoaffective Disorder on October 2, 2023. Despite these new diagnoses, the facility did not initiate the required Preadmission Screening and Annual Resident Review (PASARR) screenings or notify the relevant authorities as mandated by their policy. The Business Office Manager, who was responsible for coordinating PASARR screenings with the Social Services Director, confirmed that no screenings or notifications were made for the new diagnoses of these residents. The manager, who began employment at the facility in October 2024, acknowledged that the procedure for handling significant changes in diagnoses was not followed, as no agency notifications were made for the residents' significant changes in condition.
Failure to Maintain Proper Wound Care for Resident
Penalty
Summary
The facility failed to maintain proper wound care for a resident, identified as R12, who had wounds on the right inner thigh and left inner ankle. The facility's policy requires that wound dressings be checked daily for placement, cleanliness, and signs of infection, and that a licensed nurse observe the condition of the wound daily or with dressing changes as ordered. However, observations revealed that R12's right inner thigh wound was exposed without a dressing, and the left inner ankle dressing was not properly adhered and lacked a date and signature. R12 reported notifying staff about the issue, but the dressings were not promptly changed, leaving the wounds exposed to potential contamination. The facility's records indicated that R12's right thigh wound was due to trauma, while the left ankle wound was diabetic in nature. Despite having a physician's treatment order for specific wound care procedures, the facility did not adhere to these orders. R12 expressed frustration over the delay in receiving wound care, stating that the nurse eventually changed the dressings after multiple reminders. The Licensed Practical Agency Nurse, identified as V5, acknowledged the delay in changing the dressings, indicating a lapse in timely wound care management.
Inappropriate Use of Antipsychotic Medication for Resident with Dementia
Penalty
Summary
The facility failed to provide an appropriate indication for the use of antipsychotic medication for a resident diagnosed with dementia. The resident, admitted to the facility with a diagnosis of dementia and other related conditions, was prescribed Fluphenazine, an antipsychotic medication, for psychosis. However, the facility's policy requires that psychotropic drugs are only given when necessary to treat a specific or suspected condition, and at the lowest therapeutic dose. Despite this, the resident's behavior monitoring records from January 22 to February 20 documented no observed behaviors that would justify the continued use of the antipsychotic medication. Observations and interviews conducted during the survey revealed that the resident appeared calm and well-kempt, with no aggressive or other concerning behaviors noted by staff. The Director of Nursing acknowledged that the behaviors associated with dementia are not an appropriate diagnosis for the use of Fluphenazine. Despite this understanding, the facility had not received orders to change the diagnosis or adjust the medication, indicating a lack of appropriate action to ensure compliance with the facility's policy on psychotropic medication use.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 23.53%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed in the case of one resident, R12, during a medication pass. The facility's Medication Administration Policy requires that medications be administered in accordance with a physician's order and documented on the Medication Administration Record. However, R12's medications, which were scheduled for 8:00 am, were administered late, between 10:38 am and 11:02 am. This delay in administration led to R12 refusing their insulin dose, as it was too close to lunchtime, potentially affecting their diabetic management. R12, a diabetic resident, expressed concern about the timing of their medication administration, stating that they had already eaten breakfast and had not received their morning medications, which include insulin and other diabetic medications. The Licensed Practical Agency Nurse, V5, acknowledged the delay in medication administration, admitting to being late in passing the morning medications. The Director of Nursing, V2, confirmed that the medications were administered later than the scheduled time, which was not in accordance with the physician's orders. This failure to adhere to the prescribed medication schedule highlights a significant lapse in the facility's medication administration process.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to adhere to its hand hygiene and Enhanced Barrier Precautions (EBP) policies, resulting in deficiencies in infection control practices. During an observation, the Director of Nursing (DON) and a Wound Nurse were seen performing care for a resident with an indwelling urinary suprapubic catheter and a feeding tube. The DON dropped a glove on the floor, picked it up, disposed of it, and then donned a new glove without performing hand hygiene. Similarly, the Wound Nurse changed gloves without performing hand hygiene after completing catheter care and before proceeding with feeding tube care. This lack of hand hygiene was verified by the facility's Administrator. Additionally, the facility did not follow its EBP policy for residents with indwelling medical devices. A Licensed Practical Nurse (LPN) provided catheter care to a resident with an indwelling urinary catheter without wearing a protective gown, contrary to the facility's expectations. Another resident, who had an indwelling catheter, was found to have no EBP sign or personal protective equipment (PPE) available in their room after being moved. The LPN acknowledged the absence of the EBP sign and PPE, indicating a lapse in maintaining infection control measures for residents with medical devices.
Failure to Notify Ombudsman and Resident Representatives of Transfers
Penalty
Summary
The facility failed to notify in writing, and maintain a copy in the medical record, notification to the Ombudsman and resident/resident representatives of residents that were reviewed for notices before transfers. This deficiency was identified based on interviews and record reviews. The facility's Bed Hold and Return to Facility policy, revised on 9/17/17, requires that residents and/or their representatives be notified of a transfer from the facility. However, on 4/11/24, the Director of Nursing was unable to provide any documentation that the Ombudsman or resident/resident representative was notified of resident transfers. Additionally, on 4/12/24, the Social Services Director admitted to not notifying the Ombudsman or resident/resident representative in writing of transfers to the hospital, stating they were unaware of the requirement. The facility has 70 residents, all of whom could potentially be affected by this failure.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives in writing about the bed-hold policy during transfers to a hospital or therapeutic leave, and did not maintain a copy of this notification in the medical records. This deficiency was identified through interviews and record reviews. The facility's policy, revised on 9/17/17, mandates that residents and/or their representatives be informed of the bed-hold policy upon admission and at the time of transfer. However, on 4/11/24, the Director of Nursing (DON) was unable to provide documentation that such notifications were given. Additionally, on 4/12/24, the DON admitted that although staff were instructed to send the bed-hold policy with residents at discharge and to make a copy for the resident's record, this procedure had not been followed. An RN also confirmed that they had not documented the bed-hold policy in the resident's chart during transfers. The facility houses 70 residents, all of whom could potentially be affected by this oversight.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required, which has the potential to affect all 70 residents. The facility's EBP policy, revised on 4/8/24, mandates the use of gowns and gloves during high-contact resident care activities for residents with wounds, indwelling medical devices, or infections. Despite this, observations during the survey from 4/9/24 to 4/12/24 revealed that no EBP signs were posted throughout the facility, and staff were not adhering to the required precautions. For instance, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) were observed performing treatments on residents with only gloves, and Certified Nurse Aides (CNAs) confirmed they were unaware of the need to wear gowns in addition to gloves for certain care activities. Interviews with staff further highlighted the lack of implementation and awareness of the EBP. A CNA stated she only learned about the gown requirement the day before the survey, and another CNA, responsible for showering residents, admitted to using only gloves. The Director of Nursing (DON) acknowledged that an email was sent on 4/8/24 to start EBP on 4/9/24, but the implementation was delayed due to the survey. The DON mentioned that signs had just arrived, and staff education was ongoing. The facility's failure to implement EBP as required by their policy and corporate directive resulted in a deficiency that could impact the health and safety of all residents.
Failure to Address Resident Council Concerns and Provide Privacy
Penalty
Summary
The facility failed to ensure residents were aware of the Grievance Officer, did not provide a private area for Resident Council meetings, and did not respond to Resident Council concerns. During a Resident Council meeting, residents reported that the meetings were always loud due to the lack of doors in the dining room where the meetings were held. The residents also stated they did not know who the Grievance Coordinator was, were unaware of the location of required postings, and did not receive responses to their concerns. The monthly Resident Council Minutes did not include follow-up on resident complaints or concerns from the prior month. Observations confirmed that the only required posting in the facility was for the Ombudsman office information. The Administrator acknowledged that resident grievances were completed with the individual who reported the grievance and not shared with all Resident Council members. The Administrator also confirmed the lack of a private area for Resident Council meetings and stated that the required postings and the name of the Grievance Officer would be made available to residents.
Failure to Accurately Code Visual Status in MDS
Penalty
Summary
The facility failed to accurately code the visual status of a resident (R12) in their Minimum Data Set (MDS) assessments. On 4/9/24, it was observed that a sign above R12's bed indicated the resident was legally blind, and R12 confirmed he could only see shadows but not details. However, R12's MDS dated [DATE] documented his vision as highly impaired, while a subsequent MDS dated [DATE] documented his vision as adequate. On 4/10/24, an LPN verified that R12 was visually impaired and required visitors to introduce themselves. On 4/12/24, the LPN Careplan Coordinator confirmed that R12's visual impairment should have been accurately documented in the MDS.
Failure to Develop Vision Care Plan for Legally Blind Resident
Penalty
Summary
The facility failed to develop a vision care plan for one resident (R12) who was legally blind. Despite the presence of a sign above R12's bed indicating the resident's visual impairment and staff actions such as introducing themselves and placing the call light in the resident's hand, R12's current care plan did not document this impairment. Observations included a tape player with headphones for books on tape in R12's room, and staff were seen identifying themselves and explaining the location of items to R12. Both a Licensed Practical Nurse (LPN) and the Social Services Director confirmed R12's visual impairment and acknowledged that it should have been included in the care plan.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise the Comprehensive Care Plan for two residents, leading to discrepancies between the documented care plans and the actual care being provided. For one resident, the care plan indicated continuous oxygen dependency, but there was no physician order for continuous oxygen, and the resident was observed multiple times without using oxygen. The MDS Coordinator confirmed that the resident had not been on oxygen since being taken off hospice care in April 2023, yet the care plan was only updated on the day of the surveyor's visit. For another resident, the care plan inaccurately documented the presence of a tracheostomy, despite the resident having been decannulated several months prior. Observations and staff interviews confirmed that the resident no longer had a tracheostomy, and the care plan should have reflected a history of tracheostomy instead. The Director of Nursing and the MDS Coordinator acknowledged that the care plan should have included information about the resident's open airway post-decannulation.
Failure to Provide Shower and Nail Care
Penalty
Summary
The facility failed to ensure that shower and nail care were performed for a resident (R125) who was unable to perform these activities of daily living independently. The facility's policies and procedures require CNAs to assist residents with personal hygiene, including showers and nail care, and to document these actions. However, observations and interviews revealed that R125 had overgrown and jagged fingernails, and the resident reported not having received a shower since admission. The EHR and Shower Sheets for R125 showed inconsistencies and lack of documentation regarding the provision of showers and nail care, with no reasons provided for the missed care. Interviews with the DON and CNAs confirmed that nail care should be done on shower days or as needed, but this was not consistently documented or performed for R125. The DON acknowledged the deficiency and personally attended to R125's nail care after the issue was identified. The lack of proper documentation and adherence to the facility's policies resulted in the failure to provide necessary hygiene care for R125, compromising the resident's health and dignity.
Failure to Document Catheter Care and Output
Penalty
Summary
The facility failed to have orders for indwelling catheter care and to record catheter output for two residents. One resident was observed multiple times with a catheter draining clear amber urine, but there were no orders for catheter care or documentation of catheter output in the resident's records. Similarly, another resident was observed with a catheter draining cloudy yellow urine, but there were no orders for catheter care or documentation of catheter output in the resident's records. The facility's Urinary Catheter Care policy requires routine hygiene and catheter drainage bag emptying each shift, but these were not documented for the residents in question. A Registered Nurse (RN) confirmed the lack of orders and documentation for catheter care and output for the two residents. The RN also mentioned difficulty in finding where Certified Nurse Aides (CNAs) chart catheter output, emphasizing the importance of knowing the output for residents with catheters. The CNA charting for catheter care was reviewed and found to be missing, further highlighting the deficiency in adhering to the facility's catheter care policy.
Failure to Post Required State and Federal Postings
Penalty
Summary
The facility failed to post required State and Federal postings for Long-Term Care Facility Resident use, which has the potential to affect all 70 residents residing in the facility. The only posting observed was for the Ombudsman office, with no other required postings noted. The facility's Resident and Family Handbook and Residents' Rights policy document the residents' rights to contact outside organizations and advocates, but these postings were not displayed. The Administrator confirmed the absence of required postings and mentioned that she had never put up the required postings in any of her facilities, only the Ombudsman's poster. The Activity Director stated that the postings were removed by the previous Housekeeping Supervisor before the start of remodeling in November of the previous year and could not be found. The Resident Council Minutes indicated that residents were reminded about the ongoing remodeling. The Activity Director eventually printed new postings and hung them on the glass window at the front of the facility. The Long-Term Care Facility Application for Medicare and Medicaid form documented that there are 70 residents currently residing in the facility.
Resident-to-Resident Physical Abuse Incident Resulting in Injury
Penalty
Summary
The report details a case of physical abuse involving a resident (R2) in a long-term care facility. The incident occurred when another resident (R1) physically assaulted R2, resulting in R2 sustaining an orbital fracture. R1 exhibited aggressive behavior towards R2, hitting her multiple times with a closed fist, causing injuries to R2's face and hands. R2, who primarily speaks Vietnamese and has communication barriers, was unable to effectively communicate or defend herself during the assault. The report highlights that R1 displayed a lack of remorse for his actions, stating that R2 deserved the assault. R1, the aggressor in this incident, has a documented history of Paranoid Schizophrenia and Major Depressive Disorder. R1's medical records indicate severe cognitive impairment, with a BIMS score of 4/15, suggesting significant mental health challenges. On the other hand, R2, the victim, has a diagnosis of Dementia and other medical conditions, including an orbital fracture that put her at risk of experiencing pain and discomfort. R2's language barrier and memory problems further compounded the challenges she faced in this abusive situation, as she was unable to effectively communicate or understand the events unfolding. The facility's Abuse Prevention and Reporting policy emphasizes the residents' right to be free from abuse and outlines various forms of abuse, including physical harm, pain, and mental anguish. The report underscores the failure of the facility to prevent abuse, resulting in an Immediate Jeopardy situation. The incident involving R1 and R2 was captured on video, providing clear evidence of the physical assault. The report details eyewitness accounts from staff members who witnessed the assault, highlighting the severity of the incident and the immediate actions taken to address R2's injuries and ensure her safety.
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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