Arcadia Care On The Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Illinois.
- Location
- 555 West Carpenter, Springfield, Illinois 62702
- CMS Provider Number
- 145160
- Inspections on file
- 46
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 30 (2 serious)
Citation history
Health deficiencies cited at Arcadia Care On The Hill during CMS and state inspections, most recent first.
A resident with a history of neurogenic bladder and multiple comorbidities did not have urinalysis and urine culture results sent promptly to the urologist, resulting in delayed treatment for a UTI. The resident experienced pain, was transferred to the ER, and developed sepsis requiring intensive interventions. Additionally, two residents were not properly assessed or documented during changes in condition, with missing current vital signs and incomplete evaluations prior to hospital transfers. Facility staff did not follow policies for timely communication of lab results and thorough documentation during changes in condition.
A resident with a history of multiple vertebral fractures and recent falls was admitted without documented fall prevention interventions in the care plan or admission assessment. The resident experienced two unwitnessed falls, resulting in skin tears and a hospital transfer for IV fluids and pain management. Facility staff did not document or implement interventions to prevent future falls, despite established fall prevention protocols.
A nurse failed to properly respond to a diabetic emergency by not administering the ordered Baqsimi (Glucagon) for hypoglycemia, instead incorrectly assembling and nasally administering epinephrine using a Narcan nasal spray cap. The error was discovered when EMS arrived to find the resident unresponsive, requiring IV glucose. The incident revealed a lack of competency in medication administration and failure to follow physician orders.
A resident with diabetes and other chronic conditions experienced a hypoglycemic crisis and did not receive the prescribed Glucagon due to a medication error by an RN, who instead administered epinephrine nasally after assembling it incorrectly with a nasal spray cap. The error was facilitated by another nurse who provided the wrong medications from the emergency kit. The resident's blood sugar dropped further, requiring emergency medical intervention and ICU admission. The incident involved failure to follow physician orders and standard medication administration protocols.
A resident with hemiplegia, reduced mobility, and a documented fall risk was left unattended on the toilet by a CNA, who stepped out to provide privacy and relied on the family to alert staff when assistance was needed. The resident subsequently fell, despite facility policy requiring staff to remain with residents needing assistance during toileting.
A resident with a known history of wandering and elopement risk, who was cognitively intact, was able to remove his wander guard and leave the facility without staff awareness. The resident obtained alcohol and was later found by police and transported to the hospital. Staff interviews and documentation revealed that monitoring practices and interventions in place were insufficient to prevent the resident's unsupervised exit.
A facility failed to notify a resident's POA of a change in condition when the resident was treated for pneumonia with antibiotics. The POA was only informed when the resident was sent to the hospital. The facility's policy requires notifying the legal representative of significant health changes, which was not adhered to in this case.
The facility failed to properly store, label, and date food items, including raw poultry, and did not adequately sanitize dishware due to a malfunctioning dishwashing machine. Thawed chicken was improperly stored, and undated food items were found in refrigerators. The dishwashing machine was not dispensing chlorine, and the facility lacked a manual dishwashing policy.
The facility failed to follow its water management policy, risking waterborne illnesses by not documenting monthly pipe flushing in unoccupied rooms. Additionally, two CNAs did not adhere to Enhanced Barrier Precautions (EBP) by providing care to a resident with severe cognitive impairment without wearing required PPE, despite clear signage. The facility's policies require weekly maintenance documentation and PPE use during high-contact care activities, which were not followed, potentially affecting all 109 residents.
The facility failed to accommodate the smoking needs of four cognitively intact residents, who expressed dissatisfaction with the current policy allowing only one cigarette per break and a six-minute limit. One resident, with a nicotine addiction, was unable to smoke due to a broken wheelchair, while others felt restricted by the policy. The administrator acknowledged the policy but cited practical and financial limitations.
The facility failed to provide adequate incontinent care for several residents, including those with cognitive impairments and mobility issues. Observations revealed that staff did not change gloves or perform hand hygiene between tasks, leading to contamination and incomplete cleaning. Residents were left in soiled briefs for extended periods, and staff did not follow facility policies for thorough cleaning and drying, increasing the risk of infection.
A resident with multiple medical conditions, including dysphagia and gastrostomy, received tube feeding that was not properly labeled, and the feeding rate was incorrect. Additionally, during peri-care, the resident's head of bed was lowered without stopping the tube feeding, contrary to facility policy. This resulted in a deficiency in the care provided, as staff failed to adhere to established protocols for tube feeding management.
A resident with intracerebral bleed, Alzheimer's, and atrial fibrillation was administered an incorrect dosage of Seroquel at bedtime over several days, receiving 37.5mg instead of the prescribed 25mg. This error was identified by the Assistant Director of Nursing during a review, and confirmed by the DON, indicating a failure to follow the facility's medication administration policy.
A resident with an indwelling catheter experienced a delay in UTI treatment due to poor communication and follow-up by the facility staff. Despite the urologist's orders for better catheter care, the facility failed to act promptly on urinalysis results, leading to the resident's hospitalization for septic shock.
A resident with a left knee prosthesis infection did not receive physician-ordered Oxycodone-Acetaminophen for several days due to a lapse in prescription refills and delayed pharmacy delivery. The resident reported severe pain, and alternative pain management was inadequate.
Failure to Communicate Lab Results and Assess Changes in Condition Leads to Delayed Treatment and Hospitalization
Penalty
Summary
The facility failed to provide timely communication of urinalysis and urine culture results to a resident's urologist, which resulted in a significant delay in treatment for a urinary tract infection (UTI). The resident, who was nonverbal and had a complex medical history including hemiplegia, stroke, neurogenic bladder, and prostate cancer, had a physician's order for increased fluid intake and monitoring for UTI symptoms. However, there was no documentation that the order was followed or reflected in the care plan, and the urinalysis and urine culture results were not promptly sent to the urologist as required. The urologist did not receive the results until ten days after they were available, which led to a lack of timely antibiotic treatment and escalation of the resident's condition. The resident subsequently experienced a decline, including pain, discomfort, and ultimately required transfer to the emergency room, where he was diagnosed with a UTI and sepsis. He received IV hydration, antibiotics, and underwent invasive procedures such as a PICC line insertion and intubation. Documentation revealed that staff failed to reassess the resident for warning signs of sepsis after readmission and did not complete change in condition documentation, including current vital signs and assessments, on multiple occasions prior to the resident's deterioration. The lack of timely and thorough assessment and communication contributed to the resident's progression to septic shock and cardiac arrest, necessitating emergent CPR. A second resident was also identified as not having proper assessment or documentation during a change in condition, specifically lacking current vital signs and respiratory assessment prior to hospital transfer for pneumonia. Facility policies required prompt reporting of diagnostic results and thorough documentation during changes in condition, but these were not followed. Interviews with facility staff, including the DON and NP, confirmed expectations for timely communication and documentation, which were not met in these cases.
Failure to Implement and Document Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement and document fall prevention interventions for a newly admitted resident with a documented history of multiple vertebral fractures and recent falls. Upon admission, the resident's hospital discharge plan and baseline care plan both indicated a significant risk for falls, including recent compression and burst fractures, low back pain, abnormal gait, muscle wasting, and lack of coordination. Despite these risk factors, no specific goals or interventions to prevent falls were documented in the resident's baseline care plan or admission assessment. Following admission, the resident experienced two unwitnessed falls within the facility. The first fall resulted in a skin tear to the left elbow, and the second fall led to a skin tear on the right elbow and post-fall lethargy, requiring transfer to the emergency department. The resident received IV fluids and narcotic pain medication at the hospital. Nursing notes and fall reports for both incidents did not document any interventions implemented to prevent future falls, nor were any changes made to the care plan after these events. Interviews with facility staff, including the Director of Nursing, confirmed that interventions should have been documented for residents with a history of falls. The facility's Fall Prevention Program requires individualized assessment and implementation of appropriate interventions at admission and after any fall, but these measures were not followed for this resident. The lack of documented interventions and failure to update the care plan after repeated falls constituted the deficiency.
Failure to Ensure Nursing Competency in Emergency Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to demonstrate competency in responding to a resident experiencing severe hypoglycemia. The resident, who had a history of diabetes mellitus, end-stage renal disease, and other chronic conditions, was found lethargic with a blood glucose level of 49, which later dropped to 33. Instead of following the physician's order to administer Baqsimi (Glucagon) nasal spray for low blood sugar, the RN incorrectly assembled and administered an epinephrine auto-injector with a nasal spray cap, intended for Narcan, and delivered it nasally to the resident. The RN did not verify the medication before administration and was unfamiliar with the emergency medications in the facility's E-Kit. The incident was witnessed by another nurse, who assisted in retrieving the emergency kit and observed the incorrect assembly and administration of the medication. The RN initially misrepresented the events but later admitted to not checking the medications and being unfamiliar with their use. Documentation and interviews confirmed that the resident did not receive the ordered Glucagon, and the error was only discovered after emergency medical services arrived and found the epinephrine pen with the nasal spray cap in the resident's bed. The resident was unresponsive when EMS arrived and required intravenous glucose administration to stabilize blood sugar levels. The physician and medical director were not initially informed of the medication error, only of the hypoglycemic episode and hospital transfer. The facility's investigation and staff interviews revealed a lack of competency in medication administration and failure to follow professional standards and physician orders, resulting in a significant medication error affecting the resident's care.
Removal Plan
- All nurses were educated on the use of Emergency Medications by DON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- DON, LPN, and RN, ADON reviewed the incident.
- 100% Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyperglycemia by DON and RN, ADON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- NP was notified of the change in condition and MD notified of the resident being hypoglycemia and being sent to ER.
- V6 and V27 educated on ensuring right medication and dose prior to medication administration by DON.
- The monthly refresher will begin at our all-staff meeting.
- All nursing staff educated on the 5R's of medication administration by DON.
- V6 and V27 were educated and completed competent in medication administration on Narcan, Epinephrine, and Baqsiumi.
- 100% of nursing staff was educated on medication administration.
- DON or Designees will audit medication administration 2 times a week for 3 months.
- DON or Designee will audit 3 residents 2 times weekly to ensure blood sugar are within normal limit per MD orders for 3 months.
- DON or designee will perform an audit to ensure all emergency was handled correctly. This will be ongoing for 3 months and reviewed in our QA meeting.
- The emergency kits and the cart will be audit weekly to ensure educational material is in place. This will be ongoing for 3 months and review in our QA meeting. This will be monitored by ADON or designee.
- ADHOC QA completed with IDT regarding Policy and procedure.
- QA to review policy and procedure as part of Quality Assurance Process.
- This will be ongoing for 3 months.
Failure to Administer Correct Emergency Medication During Hypoglycemic Crisis
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) failed to administer the correct medication to a resident experiencing a hypoglycemic crisis. The resident, who had a history of diabetes mellitus, end-stage renal disease, and other chronic conditions, was found to have a critically low blood glucose level. Despite having a physician's order for Baqsimi (Glucagon) nasal powder to be administered in such situations, the RN did not provide the prescribed medication. Instead, the RN mistakenly assembled and administered an epinephrine auto-injector with a nasal spray cap, believing it to be Glucagon, and delivered it nasally to the resident. This error was compounded by the involvement of another nurse who assisted in retrieving the emergency kit and handing the incorrect medications to the RN. The resident did not receive the ordered Glucagon, and his blood sugar continued to drop, necessitating emergency medical intervention and subsequent transfer to the hospital, where he was admitted to the intensive care unit. Interviews and documentation revealed that the RN was unfamiliar with the emergency medications and did not verify the medication before administration. The incident was further complicated by initial inaccurate reporting by the RN regarding the medications given. The facility's medication administration policy and the standard nursing practice of verifying the five rights of medication administration were not followed, resulting in the resident not receiving the appropriate treatment for hypoglycemia.
Removal Plan
- All nurses were educated on the use of Emergency Medications by DON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyperglycemia by DON and ADON.
- Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
- NP was notified of the change in condition and MD notified of the resident being hypoglycemic and being sent to ER.
- V6 and V27 educated on ensuring right medication and dose prior to medication administration by DON.
- All nursing staff educated on the 5R's of medication administration by DON.
- V6 and V27 were educated and completed competency in medication administration on Narcan, Epinephrine, and Baqsimi.
- Nursing staff was educated on medication administration.
- DON or Designees will audit medication administration 2 times a week for 3 months.
- DON or Designee will audit 3 residents 2 times weekly to ensure blood sugars are within normal limit per MD orders for 3 months.
- The emergency kits and the cart will be audited weekly to ensure educational material is in place. This will be ongoing for 3 months and reviewed in our QA meeting. This will be monitored by ADON or designee.
- ADHOC QA completed with IDT regarding Policy and procedure.
- QA to review policy and procedure as part of Quality Assurance Process.
- This will be ongoing for 3 months.
Failure to Provide Adequate Supervision During Toileting Results in Resident Fall
Penalty
Summary
A resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, lack of coordination, and reduced mobility was identified as being at risk for falls and dependent for toileting. The resident's care plan and fall risk assessment documented these risks and the need for staff assistance. On the date of the incident, the resident was being assisted with toileting by a CNA, who stepped out of the room to provide privacy while the resident was on the toilet, leaving the resident unattended. The resident's family was present in the room at the time. The resident subsequently fell off the toilet and was found lying on the bathroom floor by staff after being alerted by the family. The facility's Fall Prevention Program Policy states that residents requiring staff assistance should not be left alone after being assisted to bathe, shower, or toilet. Despite this policy, the CNA left the resident unattended, resulting in a fall. Interviews with facility staff confirmed that the CNA left the room and relied on the family to notify staff when the resident was finished, contrary to facility policy.
Failure to Prevent Elopement and Provide Adequate Supervision for At-Risk Resident
Penalty
Summary
A deficiency occurred when a cognitively intact resident, identified as an elopement risk, left the facility unsupervised, obtained alcohol, and was subsequently found by police and transported to the hospital. The resident was known to have a history of wandering and exit-seeking behaviors, as documented in multiple risk assessments and care plans. Despite these known risks, the resident was able to remove his wander guard device and exit the facility without staff knowledge. Staff interviews revealed that the resident was last seen in the building around 1 PM, and the facility did not become aware of his absence until contacted by police several hours later. The facility's policy required frequent monitoring and the use of electronic alert systems for residents at high risk of elopement. However, staff reported that rounds were made every two hours, and there was no formal policy on the frequency of these rounds. The resident's care plan included interventions such as a wander guard, door alarms, and structured routines, but these measures were not effective in preventing the resident from leaving. Staff also noted that the resident had previously removed his wander guard and had a pattern of wandering and exit-seeking, yet he was able to leave undetected. Documentation showed that the resident was alert and oriented at the time of the incident, and his medical records indicated a history of alcohol use and elopement risk. The facility's elopement policy focused primarily on cognitively impaired residents and did not clearly address procedures for cognitively intact individuals with elopement risk. The lack of effective supervision and monitoring allowed the resident to leave the facility, obtain alcohol, and require emergency medical evaluation.
Failure to Notify POA of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) of a change in condition for one resident who was being treated for pneumonia. The POA was not informed that the resident was placed on an antibiotic until the resident was being sent to the hospital. This lack of communication was confirmed by the POA and the facility's administrator, who acknowledged that the registered nurse did not notify the POA of the change in the resident's condition. The resident's medical records indicated a positive chest x-ray for pneumonia and a new order for Doxycycline, but there was no documentation of the POA being notified. The facility's policy requires that the resident's legal representative or family be informed of significant changes in the resident's health status. This policy was not followed, leading to the deficiency noted in the report.
Improper Food Storage and Dish Sanitization
Penalty
Summary
The facility failed to properly store, label, and date raw poultry and other food items, as well as failed to properly sanitize dishware, cups, and silverware. During an inspection, a zip lock bag with thawed chicken was found on the top shelf of a refrigerator, with cups of juice underneath, and a sandwich dated from ten days prior. Another refrigerator contained undated fruit bowls and cups of a red, jelled substance. The dishwashing machine was found to be malfunctioning, with a chlorine test strip reading zero, indicating no sanitization was occurring. The machine was also leaking water, and its temperature gauge was broken. The dietary consultant, V15, acknowledged the issues with the food storage and the dishwashing machine, stating that the chlorine was not being dispensed properly. The administrator, V1, confirmed that the thawed chicken should have been dated and stored correctly. The facility's policies require all food to be labeled and dated, and for raw animal foods to be stored separately from ready-to-eat foods. The dishwashing machine should not be used if it is not functioning properly, and manual dishwashing procedures should be followed if necessary. However, the facility did not have a policy for manual dishwashing at the time of the inspection.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its water management policy, which is designed to prevent potential waterborne illnesses such as Legionella. The Maintenance Director, identified as V20, admitted to flushing the pipes in unoccupied rooms on the 1st and 4th floors only once a month without documenting the procedure. This is contrary to the facility's policy, which requires weekly verification and documentation of preventative maintenance activities, including flushing eyewash stations and ensuring water temperatures are within specified ranges. The Administrator, V1, acknowledged the ongoing construction on the 4th floor and the need for a log to document these procedures. Additionally, the facility did not follow its Enhanced Barrier Precautions (EBP) policy, which is intended to reduce the transmission of multidrug-resistant organisms. A resident, identified as R58, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was not provided care in accordance with EBP. Two Certified Nursing Assistants (CNAs), V25 and V26, entered R58's room and performed peri-care without wearing the required personal protective equipment (PPE), despite a sign on the door indicating the need for EBP. The CNAs admitted to forgetting to wear gowns, and the Licensed Practical Nurse (LPN), V28, was unaware of the CNAs' actions. The facility's policy on Enhanced Barrier Precautions mandates the use of gloves and gowns during high-contact resident care activities, especially for residents with indwelling medical devices such as feeding tubes. The Administrator, V1, confirmed the expectation that all staff should wear appropriate PPE when entering a resident's room under EBP. The failure to comply with these infection control measures has the potential to affect all 109 residents residing in the facility.
Failure to Accommodate Residents' Smoking Needs
Penalty
Summary
The facility failed to accommodate the smoking needs of four residents, all of whom were cognitively intact and expressed dissatisfaction with the current smoking arrangements. Resident R14, who has a physical and psychological addiction to nicotine, was unable to smoke due to a broken wheelchair that limited his mobility, forcing him to stay in bed all day. This resident typically receives three smoke breaks a day, each lasting six minutes, which he feels is insufficient. The care plan for R14, initiated in 2020, acknowledges the potential for physical and psychosocial disturbances due to disruptions in his smoking routine. Other residents, R47, R61, and R97, also reported dissatisfaction with the smoking policy, which allows only one cigarette per break and limits the time to six minutes. These residents expressed feelings of being restricted and desired more time or additional cigarettes during their breaks. Observations confirmed that residents were given one cigarette and were taken back inside after six minutes, despite their requests for more. The facility's smoking schedule indicates designated times for smoking breaks, but the administrator acknowledged that residents are allowed more than one cigarette, although practical limitations and financial considerations were cited as reasons for the current policy.
Inadequate Incontinent Care and Hygiene Practices
Penalty
Summary
The facility failed to provide timely and complete incontinent care for several residents, as observed during the survey. Resident R25, who has multiple diagnoses including Multiple Sclerosis and is frequently incontinent, reported waiting extended periods before being cleaned after incontinence episodes. Observations revealed that staff did not change gloves or perform hand hygiene between tasks, and contaminated clean water by using soiled gloves. This resulted in inadequate cleaning and potential risk of infection. Resident R58, who is severely cognitively impaired and always incontinent, also received inadequate care. Staff were observed using the same gloves throughout the cleaning process, contaminating clean water, and failing to thoroughly clean the peri area. This incomplete cleaning process was not in line with the facility's policies, which require thorough cleaning and drying of the resident's skin. Similar deficiencies were noted with residents R4 and R97. Staff failed to cleanse and dry all necessary areas during incontinent care, leaving soap suds on the skin and not addressing all soiled areas. These actions were contrary to the facility's policies, which emphasize the importance of thorough cleaning and drying to prevent skin breakdown and infection.
Deficiency in Tube Feeding Protocols
Penalty
Summary
The facility failed to adhere to its policy regarding tube feeding for a resident, identified as R58, who was admitted with multiple medical conditions including cerebral infarction with monoplegia, dysphagia, and gastrostomy. The care plan for R58 required specific interventions such as checking tube placement, maintaining the head of the bed (HOB) at a 45-degree angle during and after feeding, and proper labeling of feeding bottles. However, observations revealed that the tube feeding bottles were not consistently labeled with the resident's name, date, and time, and the feeding rate was incorrect on one occasion. During the survey, it was observed that an unlabeled bottle was used for R58's tube feeding, which was not in compliance with the facility's policy. The bottle was spiked and hung without proper labeling, and it was used for feeding despite the lack of identification. Additionally, the feeding rate on the unlabeled bottle was noted to be 65 ML/hour, which was not in accordance with the physician's order of 55 ML/hour. This discrepancy in labeling and feeding rate was not addressed by the staff, leading to a deficiency in the care provided to R58. Furthermore, during peri-care, the CNAs lowered R58's HOB without stopping the tube feeding, contrary to the facility's policy that required the feeding to be paused during such care. The CNAs were unaware of the need to inform the nursing staff to stop the feeding, and the LPN was not informed of the care being provided. This lack of communication and adherence to protocol contributed to the deficiency in the resident's care, as the tube feeding continued while the resident's position was altered, potentially compromising their safety.
Medication Administration Error
Penalty
Summary
The facility failed to administer medications according to the physician's orders for a resident diagnosed with intracerebral bleed, Alzheimer's, and atrial fibrillation. The resident was prescribed Seroquel 25mg, with instructions to take half a tablet every day and a full tablet at bedtime. However, the facility's records indicated that the resident was administered both a half tablet and a full tablet of Seroquel at bedtime, resulting in a total of 37.5mg being given instead of the prescribed 25mg. This medication error occurred over several days, from the 6th to the 10th of July, before being identified by the Assistant Director of Nursing during a review of consents. The error was acknowledged by both the Assistant Director of Nursing and the Director of Nursing, who confirmed that the resident received an incorrect dosage of Seroquel at bedtime, which was not in accordance with the doctor's orders. The facility's policy on medication administration requires adherence to doctor's orders, which was not followed in this instance.
Failure to Timely Treat UTI Leads to Septic Shock
Penalty
Summary
The facility failed to timely treat a urinary tract infection (UTI) for a resident (R3) who had an indwelling catheter due to obstructive uropathy. Despite the care plan indicating the need to monitor and report signs and symptoms of a UTI, the facility did not act promptly on the urinalysis results. R3's urinalysis, collected on 4/7/2024, indicated a UTI, but there was a delay in communication and follow-up with the urologist's office, resulting in a delay in antibiotic therapy and catheter change. This delay contributed to R3's condition worsening, leading to septic shock and admission to the intensive care unit (ICU). The urologist had ordered Bactrim, monthly catheter changes, and bladder irrigations, but these orders were not promptly executed by the facility staff. R3's medical history included a right femoral head fracture, obstructive uropathy, and chronic Foley catheter use. The urologist's progress note from 3/27/2024 indicated that R3's bladder was loaded with debris and the catheter tubing was very dirty, suggesting poor care at the facility. Despite the urologist's orders for better catheter care, the facility failed to follow through in a timely manner. The urinalysis results were not promptly communicated to the urologist, and there were multiple attempts by the urologist's office to contact the facility without success. This lack of timely communication and follow-up led to a significant delay in R3 receiving the necessary antibiotic treatment and catheter care. On 4/23/2024, R3 was admitted to the local hospital's emergency room with symptoms of septic shock, including suprapubic pain, weakness, decreased oral intake, and abnormal lab results. The hospital's emergency room notes documented that R3 had a history of UTIs and was found to have acute kidney injury, severe anemia, lactic acidosis, and sepsis secondary to a UTI. The delay in antibiotic therapy and improper catheter care at the facility were significant factors contributing to R3's deteriorating condition and subsequent hospitalization.
Failure to Provide Physician-Ordered Pain Medication
Penalty
Summary
The facility failed to provide the physician-ordered pain medication for a resident (R3) who was admitted with an infection and inflammatory reaction due to an internal left knee prosthesis. Despite having a physician's order for Oxycodone-Acetaminophen to be administered every four hours as needed for chronic pain, R3 did not receive the medication from 3/23/24 to 3/25/24. The resident reported severe pain during this period, rating it as a 30 on a 0-10 pain scale. The delay in medication was due to the prescription running out of refills and the subsequent order not being delivered until 3/26/24, despite being placed as a STAT order on 3/25/24. The resident's pain was not adequately managed with alternative medications, as he refused Tylenol offered by the nursing staff. Interviews with the nursing staff and the Director of Nurses revealed that the issue was identified on 3/25/24, but the pharmacy's cut-off time delayed the delivery of the new prescription until the following day. The staff noted that the resident often complained of pain but did not exhibit obvious signs of distress. The Director of Nurses acknowledged the lapse in medication management and the failure to ensure timely delivery of the pain medication. The facility was unable to locate the pharmacy policy at the time of the survey, indicating a potential gap in procedural adherence and documentation.
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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