Arcadia Care Peoria Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Peoria Heights, Illinois.
- Location
- 1629 East Gardner Lane, Peoria Heights, Illinois 61616
- CMS Provider Number
- 145811
- Inspections on file
- 58
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Arcadia Care Peoria Heights during CMS and state inspections, most recent first.
A resident reported that his room was not cleaned regularly and that a shared toilet had not been cleaned for several days, with visible fecal smears on the seat. Surveyors observed debris and dirty spots on the floor, buildup in the toilet bowl, and dried brown smears in and on the shared toilet between two residents’ rooms. The Administrator acknowledged the room and toilet did not appear to have been cleaned recently, and the Housekeeping Supervisor stated that, due to short staffing, rooms were only receiving light cleaning and scheduled deep-cleaning had not been done consistently, despite housekeeping duties requiring thorough cleaning and sanitizing of fixtures and floors.
A resident with multiple comorbidities and an at-risk Braden score developed a facility-acquired Stage 3 pressure ulcer on the left buttock. Despite physician orders and the care plan requiring daily cleansing, application of silver sulfadiazine, and a gauze dressing, as well as regular repositioning and incontinence care, CNAs were observed transferring the resident with a soiled brief, providing no peri-care, and leaving the wound undressed before returning the resident to a wheelchair. The bed lacked a pressure-redistribution mattress, and staff confirmed the absence of a dressing, contrary to facility policy that required daily dressing checks, documentation of treatments, and care plan updates for skin breakdown.
A medication cart was left unlocked and unattended in a hallway where multiple residents reside, contrary to facility policies requiring all medication storage areas to be locked when not in use by authorized personnel. An RN left the cart unlocked while entering a room to check a resident’s blood sugar and later retrieve insulin, leaving medications accessible to residents, staff, and visitors. When questioned, the RN initially claimed the cart had been locked but then admitted to making a mistake, and the DON confirmed that carts must always be locked and free of accessible medications, needles, or keys when unattended.
Two cognitively intact residents became involved in a physical altercation after a dispute over loud music in one resident’s room. Staff, including LPNs and a CNA, heard yelling and a commotion and, upon entering the room, found both residents in wheelchairs hitting or punching each other. The residents were separated and assessed with no injuries identified. One resident reported that he turned off the other’s loud music after a request to lower the volume was ignored and was then struck in the face twice, while the other resident only stated that the first had been disrespectful. Staff confirmed the residents lived on the same hallway but were not roommates and that they only became aware of the incident after hearing the disturbance, reflecting a failure to prevent resident-to-resident abuse.
A resident with hemiplegia, hemiparesis, and documented one-sided upper and lower extremity ROM limitations was not placed on a Restorative Nursing Program despite facility policy requiring screening and individualized restorative plans. The resident’s care plan lacked any documentation or interventions for a contracted hand, and restorative observation records showed no PROM or AROM services were being provided. The resident reported minimal movement in the affected hand and that no interventions were being done, and the Administrator confirmed there was no documentation of restorative rehab efforts for this resident.
A resident receiving hospice services had multiple terminal diagnoses and had elected hospice benefits, but the facility failed to coordinate hospice communication and maintain required hospice documentation. The care plan only noted that hospice services were in place and did not specify hospice responsibilities or interventions, and the medical record lacked a hospice plan of care, election forms, physician certification of terminal illness, and hospice clinical notes. An LPN and CNA reported they did not know hospice visit frequency, disciplines, or specific care instructions, and the hospice binder at the nurse’s station contained no hospice documents or communication notes. The hospice RN, who was the primary hospice nurse, had not participated in care plan meetings and confirmed that hospice staff did not document in the binder and that an updated POLST form remained unresolved.
Staff failed to follow infection control policies requiring hand hygiene between glove changes and use of Enhanced Barrier Precautions. During wound care for a resident with multiple complex conditions, a nurse changed gloves several times without performing hand hygiene in between. For a resident with a feeding tube on EBP, an RN disconnected enteral feeding and flushed the G-tube wearing gloves but no gown, despite policy requiring both gown and gloves for device care. In another case, an RN performing a blood glucose check for a diabetic resident removed soiled gloves and donned clean gloves at the med cart without hand hygiene between glove changes, contrary to facility policy.
Multiple incidents occurred in which residents engaged in physical altercations, resulting in injuries and staff intervention, while a staff member verbally abused a resident using profane and derogatory language. These events indicate a failure to prevent both resident-to-resident physical abuse and staff-to-resident verbal abuse, as confirmed by witness statements and facility records.
A resident physically struck another resident after a verbal altercation involving inappropriate language toward CNAs. Both residents were cognitively intact, and the incident was confirmed through interviews and record review, indicating a failure to prevent abuse as required by facility policy.
A resident in an LTC facility was subjected to repeated verbal abuse by another resident, who made derogatory comments about their appearance and hygiene. Both residents were cognitively intact, and the incidents were documented by staff, including an LPN and the Social Service Director. Despite the reports, the facility failed to prevent or address the verbal abuse, resulting in a deficiency in resident protection.
The facility failed to report resident-to-resident verbal abuse incidents to the State Surveying Agency as required by their Abuse Prevention and Reporting policy. Two residents were involved in verbal altercations, one of which led to a police call. Despite these incidents, there was no evidence of reporting to the state agency, as confirmed by the facility's administrator.
The facility did not investigate two incidents of resident-to-resident verbal abuse, despite its policy requiring such investigations. An LPN witnessed one resident making rude comments, leading the other to call the police. Another incident involved cussing in the dining room. The facility's records lacked evidence of any investigation, as confirmed by the administrator.
A facility failed to report an incident involving a verbal altercation between a resident and a housekeeping staff member to the state surveying agency. The incident began when the resident requested hot water, which the staff member refused to provide, leading to an exchange of offensive language. The facility's policy requires such incidents to be reported, but the administrator confirmed it was not reported, resulting in a deficiency.
A facility failed to thoroughly investigate a reported incident of potential mistreatment involving a resident and a housekeeping/laundry staff member. The incident involved a verbal altercation, and the facility's policy requires a comprehensive investigation. However, the administrator did not conduct additional interviews with other staff or residents, dismissing the incident as a bad day for the staff member, leading to a deficiency in the facility's handling of the report.
A resident on anticoagulants fell in the dining room, reportedly hitting his head, but was not sent for emergency evaluation as required by facility protocol. The resident's bruising and skin tear were not documented until days later, and no neurological checks were performed. The Medical Director confirmed the need for evaluation, highlighting a failure in care and documentation by the facility's staff.
The facility failed to label or date refrigerated foods and maintain a clean kitchen, as required by their policies. Unlabeled food items were found in the refrigerator, and the kitchen stove and grill were observed to be unclean over two days, despite a daily cleaning schedule. The Regional Dietary Manager confirmed these deficiencies.
The facility failed to maintain comfortable temperature levels, with residents frequently wearing heavy jackets due to cold conditions in the dining room and hallways. Room temperatures were documented below the comfortable range, and a gap in the dining room doors allowed cold air to enter. The Environmental Services Director and Administrator confirmed the low temperatures, indicating a failure to provide a homelike environment.
The facility failed to implement necessary precautions for two residents and did not follow hand hygiene protocols during catheter care for another resident. One resident suspected of having c-diff did not have contact precautions initiated, and another with a dialysis fistula lacked enhanced barrier precautions. Additionally, a CNA did not change gloves or perform hand hygiene after catheter care, as required by facility policy.
A facility failed to accurately document a resident's upper extremity fracture and range of motion impairment in the MDS. The resident had documented fractures of the clavicle and humerus, confirmed by X-rays and medical notes, but these were not reflected in the MDS. The DON acknowledged the inaccuracy, noting the absence of an onsite MDS Coordinator.
The facility failed to notify the state mental health authority after significant changes in the conditions of two residents with mental disorders, as required by their PASARR policy. One resident, initially diagnosed with various mental health conditions, was admitted to hospice without a subsequent PASARR review. Another resident, newly diagnosed with Schizophrenia, did not receive a PASARR II review despite the change in diagnosis and treatment. Staff were unsure of the PASARR process, leading to non-compliance with the policy.
The facility failed to implement personalized care plans for two residents, resulting in unaddressed medical needs. One resident with Non-Alzheimer's Dementia and PTSD lacked documented care plan goals or interventions for these conditions. Another resident experienced significant weight loss, yet their care plan did not identify this as a problem or include interventions. These deficiencies were confirmed by facility staff.
A resident experienced significant weight loss, but the facility failed to monitor and address it. The care plan did not document weight loss as a problem, and the dietician's recommendations were not communicated to the physician. The MDS inaccurately showed no weight loss, and the resident was not listed on the Significant Weight Loss list. The facility's administrator acknowledged these oversights.
A severely cognitively impaired resident, identified as an elopement risk, left the facility unsupervised, following staff out and taking a public bus. The resident wandered the city for over three hours before being found by family. The care plan required frequent checks and interventions to prevent wandering, but these were not adequately implemented. Staff interviews revealed a lack of awareness and insufficient security measures, contributing to the incident.
The facility failed to maintain a clean and homelike environment, with observations of unclean conditions in resident rooms and common areas. Residents reported infrequent laundry collection and unclean shower rooms, leading to dissatisfaction. The absence of a Housekeeping Supervisor contributed to the disorganization and lack of adherence to cleaning schedules, affecting all residents reviewed.
The facility failed to provide adequate personal hygiene care for four residents, including fingernail care, facial hair grooming, and scheduled showers. One resident had long facial hair and dirty fingernails, with no grooming documented in their records. Another resident expressed a desire for beard trimming, which was not provided. A third resident, dependent on staff for bathing, reported infrequent showers and poor hygiene care. The ADON acknowledged the need for regular grooming and shaving unless refused by the resident.
The facility failed to ensure call lights were within reach for three residents, compromising their ability to request assistance. One resident was found without a call light cord, another had their call light on the floor, and a third had it under the bed. These deficiencies occurred despite care plans indicating the need for assistance due to various health conditions.
A CNA failed to follow proper infection control practices during catheter and perineal care for a resident with an indwelling urinary catheter. The CNA did not change gloves or perform hand hygiene after cleansing the resident's perineal area and placed soiled washcloths on the bedside table. The resident, who had a history of UTIs, expressed concern about inadequate cleaning. The DON confirmed the CNA's actions were against facility policy.
A facility failed to date and store a resident's nebulizer mask and tubing in a bag between uses, contrary to its policy. The resident had a physician's order for Ipratropium-Albuterol Inhalation Solution four times a day. An LPN acknowledged that the facility does not bag the equipment between uses, and the ADON confirmed that the equipment should be dated weekly and bagged after each use.
A facility failed to follow its Enhanced Barrier Precaution policy for a resident with a gastrostomy tube, who required enhanced barrier precautions to prevent MDRO transmission. An LPN was observed disconnecting the resident's feeding tube and administering a water flush without wearing a gown, and two CNAs changed the resident's incontinence brief with only gloves on. The Assistant Director of Nursing confirmed the non-compliance with the precautionary measures.
The facility failed to keep the survey book accessible to residents, potentially affecting all 90 residents. The survey book was not found in the community areas and was eventually located in a drawer behind the receptionist's desk. The administrator confirmed that residents should have access to the survey book.
The facility did not adequately explain the arbitration agreement to residents or their representatives, affecting all 90 residents. The Business Office Manager, who did not fully understand the agreement, relied on a video for explanation and failed to inform that signing would waive legal rights. Interviews revealed residents and representatives were unaware of the agreement, with some overwhelmed by admission paperwork. The administrator acknowledged the complexity of the agreement and the need for staff training.
The facility failed to notify a physician about a resident's medication allergy and the unavailability of ordered medications. The resident's After Visit Summary indicated an allergy to Clonidine HCL, but the Progress Notes lacked documentation of notifying the physician or clarifying the admission orders. The DON confirmed the oversight.
A facility failed to ensure timely availability of physician-ordered medications for a resident. The resident's Clonidine patch was delayed from 3/25/24 to 4/7/24, Lacosamide was unavailable from 4/2/24 to 4/7/24, and Pregabalin was unavailable from 4/4/24 to 4/9/24. The DON confirmed the delay.
The facility failed to maintain functional bathing facilities, leaving residents without access to showers for up to two weeks. One shower room had been non-functional for eight months, and the other was out of order for two weeks, with no system in place for maintenance work orders.
The facility failed to ensure residents received showers as preferred due to plumbing issues that rendered both shower rooms unavailable. Residents were given bed baths or had to go to another facility for showers, leading to dissatisfaction among cognitively intact residents who preferred showers.
The facility failed to ensure that CNA staff were licensed and trained to perform haircuts, leading to a CNA cutting multiple residents' hair without proper licensure or training. Residents confirmed the absence of a licensed beautician, and the facility administrator acknowledged the lack of compliance with state regulations.
Failure to Maintain Clean and Sanitary Resident Room and Shared Bathroom
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment in resident rooms and shared bathroom areas, as evidenced by unsanitary conditions in the room currently occupied by R2 and the shared toilet between R2 and R3. R2, who was admitted on an unspecified date and now resides in the room previously occupied by R1, reported that his room was not cleaned very often and that the toilet had not been cleaned for five days, with feces smears on the seat. On observation the same day, surveyors noted obvious debris on the floor and near the baseboards, numerous dirty spots on the floor, a dark grey substance clinging to a large area in the toilet bowl, and three dried smears of dark brown substance in and on the shared toilet between R2 and R3’s rooms. The Administrator acknowledged that the condition of R2’s room and the shared toilet needed cleaning and did not appear to have been cleaned recently. The Housekeeping Supervisor stated that, due to short staffing, resident rooms were only receiving very light cleaning, the shared toilet between R2 and R3’s rooms probably had not been cleaned, and that regularly scheduled deep-cleaning of resident rooms, normally done on Fridays, had not been performed consistently, despite the housekeeper job description requiring cleaning and sanitizing of fixtures and floors. R1 had voluntarily discharged home with a family member prior to these observations and no longer resided in the facility at the time of the survey, but R2 was occupying R1’s former room when the unsanitary conditions were identified.
Failure to Provide Ordered Care for Facility-Acquired Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care for a facility-acquired Stage 3 pressure ulcer on a resident’s left buttock. The resident had multiple diagnoses, including paranoid schizophrenia, type 2 diabetes, hypertension, muscle wasting/atrophy, and unsteadiness on feet, and had Braden scores indicating they were at risk for pressure injury. The care plan documented the need for repositioning/ambulation at least every two hours, substantial/maximal staff assistance with ADLs, incontinence care after each episode, and minimizing pressure over bony prominences with treatment as ordered. Physician orders and the TAR directed that the left buttock wound be cleansed with wound cleanser, treated with silver sulfadiazine, and covered with a gauze dressing daily and as needed. The facility’s wound report and wound evaluation summaries documented that the Stage 3 pressure ulcer was facility-acquired and provided measurements and characteristics of the wound, including moderate serous drainage and significant slough. On observation, CNAs transferred the resident with a mechanical lift and found the incontinence brief soiled with urine, but they did not perform perineal care, did not apply a dressing to the left buttock wound, and instead placed a clean brief and pulled up the resident’s pants before returning the resident to the wheelchair without the ordered dressing. The resident’s bed did not have a pressure-redistribution mattress, despite the resident spending increased time in a wheelchair and having a facility-acquired Stage 3 pressure ulcer. Staff confirmed during interviews that the resident did not have a dressing on the left buttock at the time of observation, and the wound physician and administrator acknowledged that the pressure ulcer was acquired in the facility. The facility’s own skin condition and pressure injury policy required that dressings be dated by the licensed nurse, checked daily for placement and cleanliness, that care plans be revised to reflect skin alterations and approaches, and that physician-ordered treatments be recorded after each administration, but these requirements were not followed for this resident’s pressure ulcer care.
Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were securely stored and medication carts were locked in accordance with facility policy and professional standards. The facility’s Medication Storage policy, last approved in December 2025, requires all medications and biologicals, including treatment items, to be securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. The Medication Administration Policy, last approved in October 2024, further specifies that medication storage areas, including medication carts, must be locked when not in use by authorized personnel, and that any other individual needing access must be supervised by an authorized person. On the date of the survey, an RN left a medication cart unlocked in the hallway across from a resident room on a hall where 23 residents reside. The RN left the cart to check a resident’s blood sugar, leaving medications accessible to residents, staff, and visitors. When questioned, the RN initially stated the cart had been locked and that they always lock the medication cart, but when asked why keys were not used to reopen the cart upon returning to obtain insulin for the resident, the RN became flustered and acknowledged making a mistake regarding the cart being unlocked. The DON confirmed that medication carts should always be locked when the nurse leaves the cart and that nothing, including medications, needles, or keys, should be accessible on top of the cart.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to prevent resident-to-resident abuse when two cognitively intact residents engaged in a physical altercation in one resident’s room. On 12/25/25 at 5:55 PM, two LPNs and a CNA heard yelling coming from the room of one resident and, upon entering, observed both residents in their wheelchairs hitting or punching each other. The residents were separated and assessed, and no injuries were identified. One resident later reported that the other had his music playing loudly, and after a request to turn it down was ignored, he turned the music off himself, at which point he stated the other resident hit him in the face twice, though without causing injury. The other resident reported that the first resident had been disrespectful but would not provide further detail. Staff interviews confirmed that the residents were not roommates but lived on the same hallway and that staff heard a commotion and then found both residents in their wheelchairs physically striking each other in the room, with one LPN stating she did not hear loud music prior to the incident. This sequence of events, including the escalation of a dispute over loud music into physical contact between two cognitively intact residents, and staff only becoming aware once yelling and commotion were heard, demonstrates a failure by the facility to protect each resident from abuse, specifically resident-to-resident physical abuse, as required by its abuse prevention responsibilities.
Failure to Implement Restorative ROM Interventions for Resident With Contracted Hand
Penalty
Summary
The deficiency involves the facility’s failure to implement restorative therapies and interventions to maintain or improve range of motion (ROM) and prevent contracture for a resident with known functional limitations. The facility’s Restorative Nursing Program policy requires that each resident be screened for restorative nursing upon admission, annually, quarterly, and with any significant change in function, and that appropriate residents have individualized restorative programs with goals, measurable objectives, and documented interventions and responses. The resident in question was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, COPD, seizures, and heart failure. A Minimum Data Set (MDS) assessment documented intact cognition, functional limitation in ROM to upper and lower extremities on one side, dependence in dressing, hygiene, and transfers, and that the resident was not in a Restorative Nursing Program. Despite these identified ROM limitations, the resident’s current care plan contained no documentation regarding her contracted left hand and no interventions to prevent further decrease in ROM. A Restorative Observation assessment documented that the resident was not receiving restorative programs for PROM (passive ROM) or AROM (active ROM). During observation, the resident was seen lying in bed with a contracted left hand, and in interview she stated she had minimal movement in her left hand and that nothing was being done for it. The Administrator confirmed there was no documentation of any restorative rehabilitation attempts for this resident and acknowledged that, although the resident frequently refused care, there was no documentation related to restorative care and that no restorative tasks had been implemented for her until very recently.
Failure to Coordinate Hospice Communication and Maintain Required Hospice Documentation
Penalty
Summary
The deficiency involves the facility’s failure to coordinate hospice communication and maintain required hospice documentation for a resident who had elected hospice benefits. Facility policy and the hospice service agreement required that hospice assessments and a hospice plan of care be integrated into the resident’s overall care plan, that hospice progress notes and communication be available in the medical record or hospice binder, and that hospice staff participate in care planning. The resident, admitted with terminal diagnoses including dementia, congestive heart failure, protein malnutrition, paranoid schizophrenia, and traumatic brain injury, elected hospice benefits, but the resident’s care plan only noted that hospice services were being received and lacked specific hospice responsibilities and interventions. The medical record did not contain a hospice plan of care, hospice election forms, physician certification of terminal illness, or hospice clinical notes. Staff interviews confirmed that hospice visit frequency, disciplines involved, and care instructions were not documented or known by facility staff. An LPN stated there was no documentation in the electronic record regarding hospice visit frequency, disciplines, or care instructions, and that the hospice binder contained no hospice documents or communication notes. A CNA reported that hospice aides provided care but was unaware of the days, times, or frequency of visits. The hospice RN stated that the hospice binder at the nurse’s station was empty and that hospice staff did not document in it after visits, and also reported not having attended or participated in any care plan meetings with the facility despite being the resident’s primary hospice nurse. The hospice RN further noted an issue with an updated POLST form that had been sent back to the facility for correction and had not yet been received back by hospice. The administrator acknowledged that the facility failed to ensure hospice communication was coordinated and that required documents were available and accessible to staff.
Failure to Perform Hand Hygiene Between Glove Changes and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices, specifically related to hand hygiene between glove changes and adherence to Enhanced Barrier Precautions (EBP). For one resident with osteomyelitis, quadriplegia, dysphagia, pressure ulcers, neuromuscular bladder dysfunction, a suprapubic catheter, and a colostomy, the Infection Preventionist/Wound Nurse changed gloves multiple times during a wound care procedure but did not perform hand hygiene between glove changes, contrary to the facility’s Glove Use and Hand Hygiene policies that require hand hygiene after glove removal and before new glove placement. The Administrator later agreed that hand hygiene should have been conducted between glove changes. The facility also failed to follow its EBP policy requiring gown and gloves for residents with indwelling medical devices during high-contact care. A resident with a feeding tube, care planned for EBP due to the tube, was observed receiving an enteral feeding disconnection and water flush from an RN who performed hand hygiene and donned gloves but did not wear a gown during the procedure; the RN acknowledged a gown should have been worn, and the Infection Preventionist confirmed that gown and gloves are required for any care involving a G-tube. In another instance, an RN performing a medication pass for a resident with cerebral palsy and type 2 diabetes, who required QID blood glucose checks and insulin, removed soiled gloves after performing a blood sugar check and then donned clean gloves at the medication cart without performing hand hygiene in between, despite facility policy and the DON’s confirmation that hand hygiene is required between glove changes.
Failure to Prevent Resident-to-Resident Physical Abuse and Staff-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to prevent both resident-to-resident physical abuse and staff-to-resident verbal abuse involving four residents. In one incident, two residents with a history of anxiety disorder, major depression, and chronic pain engaged in a physical altercation in the smoking area and dining room. One resident sustained a hematoma above the right eye after a verbal disagreement escalated to physical contact, including chest bumping and pushing. Witness statements from staff and residents confirmed the sequence of events, with both parties acknowledging their involvement in the altercation. In a separate incident, two other residents argued over a borrowed phone, which led to one resident throwing a plate and physically striking the other. Staff present during the altercation intervened to separate the residents, and the missing phone was later found in the possession of the resident who initiated the physical contact. Additionally, the facility failed to prevent staff-to-resident verbal abuse. A staff member (receptionist) was reported to have yelled at a resident, used profane language, and made derogatory comments about the resident's mother after the resident returned from an outing. Another staff member witnessed the verbal abuse and intervened, confirming that inappropriate language was used and reporting the incident to nursing staff. These events demonstrate that the facility did not effectively implement its abuse prevention and reporting policy, resulting in multiple instances of abuse and failure to protect residents from harm.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent abuse when one resident physically struck another resident. According to the facility's incident report and subsequent investigation, a resident (R1) admitted to slapping another resident (R2) on the left side of the head. This action occurred after R2 was reportedly calling certified nurse aides inappropriate names. Both residents were found to be cognitively intact, as indicated by their BIMS scores of 15. The incident was reported to the nurse on duty and subsequently to the state surveying agency. The facility's Abuse Prevention and Reporting policy prohibits abuse, neglect, and mistreatment of residents, and affirms the right of residents to be free from such actions. Despite this policy, the incident occurred when R1 confronted R2 in another resident's room and made physical contact in response to R2's verbal behavior toward staff. The facility's investigation confirmed the physical altercation and the circumstances leading up to it, demonstrating a failure to protect residents from abuse as required by facility policy.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, which constitutes a deficiency in ensuring a safe environment free from abuse. The incident involved two residents, both of whom were cognitively intact. One resident, identified as R3, reported feeling threatened and harassed by another resident, R4, who made derogatory and offensive comments. R3's care plan noted verbal aggression, and R4's care plan indicated a potential for verbal aggression due to ineffective coping skills and poor impulse control. The verbal abuse incidents were documented in nursing and social service notes, with R4 admitting to making derogatory comments about R3's appearance and hygiene. R3 reported feeling distressed and harassed by R4's repeated verbal attacks, which included being called offensive names. Staff members, including an LPN and the Social Service Director, confirmed the occurrences of verbal abuse, with R4 consistently using offensive language towards R3. Despite these reports, the facility did not effectively prevent or address the verbal abuse, leading to a deficiency in protecting residents from abuse.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its Abuse Prevention and Reporting policy by not immediately reporting an allegation of resident-to-resident abuse to the State Surveying Agency. The policy mandates that any allegation of abuse or incident resulting in serious bodily injury must be reported immediately, but not more than two hours after the allegation. In this case, two residents were involved in verbal altercations on two separate occasions. The first incident occurred when a resident felt threatened by another resident's rude comments and called the police. The second incident involved a resident cussing out another resident in the dining room. Despite these events, there was no evidence that the facility reported these incidents to the State Surveying Agency as required. The deficiency was identified through interviews and record reviews, which revealed that the facility's Abuse Investigations and the residents' Electronic Medical Records did not document the reporting of these verbal abuse incidents. The facility's administrator confirmed that the incidents were not reported to the state surveying agency. This failure to report is a direct violation of the facility's own policy and the regulatory requirements for reporting abuse allegations, highlighting a significant lapse in the facility's abuse prevention and reporting procedures.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention and Reporting policy by not thoroughly investigating allegations of resident-to-resident verbal abuse involving two residents. The policy mandates that any incident or allegation involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property must be investigated. However, the facility did not investigate two separate incidents of verbal altercations between the residents, which were documented in nursing and social service notes. The first incident occurred when a Licensed Practical Nurse (LPN) witnessed one resident making rude comments to another, prompting the latter to feel threatened and call the police. The second incident involved one resident cussing out the other in the dining room. Despite these documented altercations, the facility's records did not show any evidence of an investigation into these incidents, as confirmed by the facility's administrator.
Failure to Report Alleged Mistreatment Incident
Penalty
Summary
The facility failed to report an allegation of potential mistreatment involving a resident and a staff member to the state surveying agency. The incident involved a resident, identified as R4, and a staff member from housekeeping/laundry, identified as V9. According to a handwritten letter by an LPN, V8, the incident occurred when R4 requested hot water from V9, who refused to bring it to him. This led to a verbal altercation where R4 used offensive language towards V9, who responded by running down the hall and confronting R4 with similar language. V8, who witnessed the incident, described V9's demeanor as sassy and inappropriate, although V9 did not threaten R4. The facility's policy on abuse prevention and reporting requires that any allegations of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property be reported to the resident's representative and the state surveying agency's regional office. Despite this policy, the administrator, V1, confirmed that the incident was not reported to the state surveying agency. The failure to report this incident constitutes a deficiency in the facility's adherence to its abuse prevention and reporting policy.
Inadequate Investigation of Resident Mistreatment Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following a report of potential mistreatment involving a resident and a staff member. The incident involved a verbal altercation between a resident and a housekeeping/laundry staff member, where inappropriate language was exchanged. The facility's policy requires immediate reporting and a comprehensive investigation of any allegations of abuse, neglect, or mistreatment. However, the investigation conducted by the administrator was insufficient, as it did not include interviews with other staff members or residents who may have had interactions with the accused staff member. The administrator acknowledged that no additional interviews were conducted beyond the initial report, and the incident was dismissed as the staff member having a bad day. This lack of a thorough investigation is a violation of the facility's abuse prevention and reporting policy, which mandates that all potential abuse incidents be fully investigated to ensure the safety and well-being of residents. The failure to follow these procedures resulted in a deficiency in the facility's handling of the reported incident.
Failure to Provide Competent Care After Resident Fall
Penalty
Summary
The facility failed to ensure competent nursing care for a resident who sustained a fall with a head injury. The resident, who was on anticoagulant medication, experienced a fall in the dining room and reportedly hit his head, resulting in bruising on his left ear and arm. Despite the facility's standing orders requiring residents on anticoagulants to be transported to the emergency room for evaluation after any head trauma, this protocol was not followed. The resident's fall was initially documented as not involving a head injury, and no neurological checks were performed. The resident's bruising and skin tear were not documented until several days later, despite being visible and reported by the resident and his Power of Attorney. The facility's staff, including the LPN and CNA involved, failed to accurately assess and document the resident's condition following the fall. The Medical Director confirmed that the resident should have been sent for evaluation due to the anticoagulant use and the presence of a bruise, which was indicative of a head injury. The Director of Nursing acknowledged the failure to perform necessary neurological checks and the lack of documentation regarding the resident's injuries, which were only addressed after being brought to attention days later.
Deficiency in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to its own policies regarding food storage and kitchen cleanliness, as observed during a survey. Specifically, the facility did not label or date refrigerated open and stored foods, which is a requirement according to their Food & Supplies: Storage policy. This policy mandates that all prepared foods stored in the refrigerator must be covered, labeled, and dated with an expiration date. During an inspection, metal containers with various food items such as ground ham, chicken nuggets, raw sausage links, and sliced turkey were found in the walk-in refrigerator without any labels or dates. This was confirmed by the Dietary Cook, who acknowledged that the foods should have been labeled and dated. Additionally, the facility's kitchen was found to be unclean, with the stove's backsplash and back burners caked with dried food particles and the adjacent grill covered with a black sticky substance. The top shelf of the stove was also dusty and littered with dark-colored crumbly material. Despite the facility's Daily Cleaning Schedule, which includes tasks such as cleaning the stovetop and grill, these areas remained unclean over two consecutive days. The Regional Dietary Manager confirmed that the stove and grill are supposed to be cleaned daily by the dietary staff, as documented on the cleaning schedule, but acknowledged the presence of debris on the kitchen stove and grill.
Facility Fails to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels for several residents, compromising their right to a homelike environment. Observations and interviews revealed that residents frequently wore heavy jackets in the dining room due to cold temperatures. The facility's logbook documented room temperatures ranging from 64.8 to 69.6 degrees Fahrenheit, which are below the comfortable range for residents. A significant gap in the dining room's double doors allowed cold air to enter, exacerbating the issue. The outside temperature was recorded at 32 degrees Fahrenheit, contributing to the cold conditions inside. Residents expressed discomfort, stating that the dining room and certain hallways were consistently cold. The Environmental Services Director confirmed the low temperatures, with readings between 66 and 70 degrees Fahrenheit in the dining room. The facility administrator also verified the low temperatures in various areas of the building. These findings indicate a failure to provide a safe and comfortable environment for the residents, as required by the federal Nursing Home Reform Law.
Failure to Implement Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement transmission-based precautions and Enhanced Barrier Precautions as per their policy for two residents. One resident, suspected of having Clostridium difficile (c-diff), did not have contact precautions initiated despite a physician's order for treatment and a stool specimen collected for testing. The Director of Nursing confirmed that contact precautions should have been initiated when c-diff was suspected. Another resident with a dialysis fistula did not have enhanced barrier precautions in place, despite the potential for bleeding at the fistula site, as verified by the Infection Preventionist. Additionally, the facility did not adhere to hand hygiene protocols during indwelling urinary catheter care for a resident. A Certified Nursing Assistant performed catheter care without changing gloves or performing hand hygiene before touching other items and the resident's clothing. This was acknowledged by the CNA, who confirmed that gloves should have been changed and hand hygiene performed immediately following catheter care.
Inaccurate MDS Documentation of Resident's Fractures
Penalty
Summary
The facility failed to accurately document a resident's upper extremity fracture and range of motion impairment in the Minimum Data Set (MDS). The resident, identified as R82, had a documented acute fracture of the distal clavicle and a comminuted supracondylar fracture of the left humerus. These injuries were confirmed by X-ray reports and medical notes from radiology and orthopedic physicians. Despite these documented injuries, the MDS completed on 11/07/24 did not reflect the resident's left arm and clavicle fractures, cast placement, and impairment of her upper extremity. The deficiency was identified through observation, interview, and record review. On 12/01/24, the resident was observed in a wheelchair with a pink fiberglass cast and sling on her left arm, self-propelling using her feet and right arm only. The Director of Nurses (DON) acknowledged on 12/03/24 that the MDS was inaccurate and should have included the resident's fractures and impairments. It was also noted that the facility lacked an onsite MDS Coordinator, with the Corporate Regional MDS Coordinator temporarily filling the role.
Failure to Notify State Authorities of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the state mental health authority following significant changes in the physical condition of two residents with mental disorders, as required by their Preadmission Screening and Annual Resident Review (PASARR) policy. Resident R19, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Disorganized Schizophrenia, and Major Depressive Disorder, experienced a significant change in condition and was admitted to hospice care. Despite this change, the facility did not conduct an annual PASARR review or notify the state mental health authority, as confirmed by the Business Office Manager and Social Service Director, who were unsure of the exact process for significant change PASARR reviews. Similarly, Resident R59, who was initially documented as not having a serious mental illness, was later diagnosed with Schizophrenia and prescribed Quetiapine Fumarate. Despite this new diagnosis and the administration of medication for Schizophrenia, the facility did not conduct a subsequent PASARR review or notify the state mental health authority. The Assisting Director of Nursing and the Administrator confirmed that a PASARR II was not conducted following the significant change in R59's condition, indicating a failure to adhere to the facility's PASARR policy.
Failure to Implement Personalized Care Plans
Penalty
Summary
The facility failed to implement personalized care plans for two residents, leading to deficiencies in addressing their specific medical needs. One resident, diagnosed with Non-Alzheimer's Dementia and Post Traumatic Stress Disorder, did not have documented goals or interventions in their care plan to address these conditions. This was confirmed by the facility administrator. Another resident experienced significant weight loss over a six-month period, with a 10.92% decrease in weight, and a 7.58% loss over three months. Despite this, the resident's care plan did not identify weight loss as a problem or include any goals or interventions to address it. This oversight was acknowledged by both the administrator and the regional dietary manager.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to monitor and prevent weight loss for a resident, identified as R77, who was admitted with diagnoses including cerebral vascular accident, partial paralysis, a speech disorder, and difficulty swallowing. Despite a significant weight loss of 10.92% over six months and 7.58% over two months, the care plan did not document weight loss as an identified problem or include interventions related to weight loss. The facility's policies required dietician recommendations to be communicated to the medical provider and for nutritional assessments to be completed according to specific criteria, but these were not followed. The resident's Minimum Data Set (MDS) inaccurately documented no weight loss, and the dietician's assessment recommending supplements was not acted upon. The physician's progress notes did not reflect any assessment or notification of the resident's weight loss, nor were any interventions ordered for weight loss management. The facility's administrator acknowledged that the resident's weight loss was not monitored by the dieticians, the physician was not notified, and there were no specific interventions in the care plan. Additionally, the Mini Nutritional Assessment inaccurately indicated normal nutrition with no weight loss, and the resident was not listed on the Significant Weight Loss list in November 2024, despite previous documentation of significant weight loss.
Failure to Supervise Elopement Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident identified as an elopement risk. The resident, who had a documented history of elopement risk and required supervision when accessing the community, managed to leave the facility unsupervised. This incident occurred when the resident followed ancillary staff out of the building, boarded a public bus, and wandered the city for over three hours before being located by a family member. The resident's care plan indicated the need for 15-minute checks and specific interventions to prevent wandering, such as offering diversions and redirecting the resident away from exits. However, on the day of the incident, the resident was last seen during the morning medication pass and was not located until a family member reported finding them in the community. The facility lacked special interventions for residents assessed as elopement risks, and there was no receptionist at the desk to monitor exits. Interviews with staff revealed that checks on the resident were not conducted as required, and there was a lack of awareness regarding the interventions in place for elopement risks. The facility's security measures were insufficient, as evidenced by the resident's ability to leave the premises without being stopped. The absence of a receptionist and the failure of staff to monitor the resident contributed to the incident.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations of unclean conditions in resident rooms and common areas. The report highlights that the floors, blinds, and a shower room toilet were not kept clean and free of debris. Specific instances include a resident's tube feeding splattered and dried on blinds, dirty baseboards, and sticky floors with debris. Additionally, the shower room toilet was observed with smeared, dried feces, and the floor was dirty with debris against the wall. Interviews with residents revealed dissatisfaction with the frequency of laundry collection and cleaning services. Residents reported that laundry was only picked up once a week, resulting in dirty clothes overflowing onto the floor, creating unpleasant odors. Concerns were also raised about the cleanliness of the shower room, with residents having to clean it themselves before use. The lack of a Housekeeping Supervisor was noted as a contributing factor to the disorganization and lack of adherence to cleaning schedules. The facility's housekeeping guidelines and cleaning schedule policies were not effectively implemented, as confirmed by staff interviews. The Housekeeping Manager's job description emphasized maintaining a clean and safe environment, but the absence of a supervisor led to confusion among housekeeping staff about their responsibilities. The administrator acknowledged the need for daily cleaning of shower rooms and blinds, but the lack of oversight resulted in these tasks being neglected. The report indicates that the facility's failure to ensure a clean environment affected all 39 residents reviewed in the sample.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care, including fingernail care, facial hair grooming, and scheduled showers, for four residents. Resident R43 was observed with long facial hair and dirty, jagged fingernails, and their electronic medical record showed no evidence of grooming in the months of May and June 2024. R43's Power of Attorney expressed concerns about the resident's lack of cleanliness and grooming. Similarly, R45 was found with long, dirty fingernails, and their records also lacked documentation of nail care during the same period. Resident R50 expressed a desire for beard and mustache trimming, which had not been provided, and their records showed no evidence of grooming. R83, who is cognitively intact and dependent on staff for bathing, was found with greasy hair, unkempt facial hair, and dirty fingernails. R83 reported infrequent showers and expressed a desire for better personal hygiene care. The Assistant Director of Nursing acknowledged that residents' fingernails should be cleaned and clipped at least twice a week on shower days, and residents should be shaved unless they refuse or request otherwise.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, R43, R45, and R83, as observed during a survey. R45 was found lying in bed without a call light cord attached to the call light panel, making it inaccessible. This issue persisted over two consecutive days, despite R45's care plan indicating a need for assistance with activities of daily living due to encephalopathy. Similarly, R43's call light was found on the floor, out of reach, and the resident expressed concern about not being able to reach it when needed. R43's care plan highlighted a dependency on assistance for bed mobility and transfers due to conditions such as respiratory failure and encephalopathy. In another instance, R83's call light was found under the bed, out of reach, after a Licensed Practical Nurse left the room without ensuring it was accessible. R83 demonstrated limited mobility by attempting to reposition himself in bed, further emphasizing the need for the call light to be within reach. A Certified Nurse Assistant later verified the call light's inaccessibility. These observations indicate a failure to adhere to the facility's call light policy, which mandates that call lights be accessible to residents at all times.
Inadequate Infection Control During Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the provision of indwelling urinary catheter and perineal care for a resident. The facility's policies on urinary catheter care and hand hygiene were not followed by a Certified Nursing Assistant (CNA), identified as V6, who was observed performing care on a resident with an indwelling urinary catheter. The CNA did not change gloves or perform hand hygiene after cleansing the resident's perineal area and before touching the resident's bare skin to assist with turning. Additionally, the CNA placed soiled washcloths on the resident's bedside table instead of disposing of them properly. The resident involved, identified as R5, had a history of urinary tract infections and expressed concern that inadequate cleaning might have contributed to their condition. The Director of Nursing confirmed that the CNA should have changed gloves, performed hand hygiene, and prepared the area with a plastic bag for soiled linens. These actions and inactions led to a deficiency in providing appropriate care to prevent urinary tract infections and maintain infection control standards.
Failure to Properly Store and Date Nebulizer Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident by not dating and storing a nebulizer mask and tubing in a bag between uses. The facility's policy, dated 1/7/19, requires that handheld nebulizers and masks be changed weekly and as needed, with each setup marked with the date of change and stored in a clean plastic bag. However, during an observation, it was found that the nebulizer mask and tubing for a resident, who had a physician's order for Ipratropium-Albuterol Inhalation Solution four times a day, were left undated and unbagged on the bedside table. A Licensed Practical Nurse admitted that the facility does not bag the nebulizer mask and tubing between uses, although they should have been dated. The Assistant Director of Nursing confirmed the deficiency, stating that the nebulizer masks and tubing should be dated weekly and bagged after every use.
Failure to Follow Enhanced Barrier Precautions for Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precaution policy, which is designed to reduce the transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact resident care activities. This deficiency was observed in the care of a resident with a gastrostomy tube, who was identified as requiring enhanced barrier precautions. The resident's care plan specifically required the use of gowns and gloves during high-contact activities, such as device care and incontinence care. During an observation, a Licensed Practical Nurse (LPN) was seen disconnecting the resident's gastrostomy tube feeding and administering a water flush without wearing a gown, despite being aware of the enhanced barrier precautions. Additionally, two Certified Nursing Assistants (CNAs) were observed changing the resident's incontinence brief with only gloves on, and no gown, while the Assistant Director of Nursing confirmed the lack of compliance with the precautionary measures. These actions demonstrate a failure to follow the facility's infection control guidelines for residents at higher risk of MDRO transmission.
Survey Book Accessibility Deficiency
Penalty
Summary
The facility failed to keep the survey book in a location accessible to residents, which has the potential to affect all 90 residents in the nursing facility. During an observation, the survey book was not found in the resident community areas. A transport driver, who was interviewed, stated that they had never seen the survey book but eventually located it in a drawer behind the receptionist's desk. The administrator confirmed that residents should have access to the survey book, indicating a lapse in ensuring the book's availability to residents.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to residents or their representatives in a manner they could understand, potentially affecting all 90 residents. The arbitration agreement, which is a binding legal document, was not clearly communicated by the Business Office Manager (V8), who admitted to not fully understanding the agreement herself. V8 relied on a video to explain the agreement and did not inform residents or their representatives that signing the agreement would waive their right to take legal action against the facility. Furthermore, V8 was unaware of any time limit for residents to change their minds about signing the agreement. Interviews with residents and their representatives revealed a lack of understanding and awareness of the arbitration agreement. For instance, R85's Power of Attorney (V9) did not recall any discussion about the agreement and was overwhelmed by the amount of paperwork during admission. Similarly, R21, who has moderate cognitive impairment, did not understand the agreement and was not involved in the decision-making process, as confirmed by her Power of Attorney (V16). The facility's administrator acknowledged that the agreement is complex and requires proper explanation, highlighting the need for additional training for V8.
Failure to Notify Physician of Medication Allergy and Unavailability
Penalty
Summary
The facility failed to notify the physician of medications not available for one resident. The facility's policy requires informing the resident, consulting with the resident's physician, and notifying the resident's legal representative or an interested family member when there is a need to alter treatment significantly. The resident's After Visit Summary documented the need to apply a Clonidine transdermal patch weekly, starting on a specific date. The resident had an allergy to Clonidine HCL, which was noted in the After Visit Summary. However, the Progress Notes from the specified period showed no documentation that the resident's primary care physician was notified of the allergy or to clarify the admission orders. The Director of Nursing verified that there was no documentation of the allergy clarification on admission and that the physician was not notified of the resident not receiving the ordered medications.
Failure to Provide Timely Medications
Penalty
Summary
The facility failed to ensure that physician-ordered medications were available for a resident. According to the facility's Pharmacy policy, medications should be received from the pharmacy in a timely manner, and accurate records of medication orders and receipts should be maintained. However, the resident's After Visit Summary indicated that a Clonidine 0.2mg/24-hour transdermal patch was to be applied weekly starting on 3/25/24, but the Medication Administration Record (MAR) showed that the patch was not available until 4/7/24. Additionally, the MAR documented that the resident's Lacosamide 50mg was not available from 4/2/24 to 4/7/24, and Pregabalin 75mg was not available from 4/4/24 to 4/9/24. The Director of Nursing confirmed that the medications were ordered but did not arrive in a timely manner.
Failure to Maintain Functional Bathing Facilities
Penalty
Summary
The facility failed to ensure it was equipped with functional bathing facilities/shower rooms, affecting all 90 residents. The facility's preventive maintenance policy emphasizes the importance of maintaining fixtures and equipment in good working order. However, during a tour, it was observed that one of the two designated shower rooms was taped off and marked as out of order, while the other was operational. No resident rooms had individual bathing facilities. Multiple residents reported that the shower rooms were non-functional for varying periods, with some stating they had no access to a shower for up to two weeks. The Ombudsman confirmed that one shower room had been non-functional for at least eight months, and the other had been out of order for around two weeks, leaving residents without a place to shower for ten days. The facility administrator, who had been in the position since May 1, 2024, confirmed that both shower rooms were unavailable due to plumbing issues from April 24, 2024, through May 3, 2024. The administrator also noted that there was no system in place for maintenance work orders. This lack of functional bathing facilities and the absence of a maintenance system led to significant inconvenience and potential hygiene issues for the residents.
Failure to Provide Preferred Shower Facilities
Penalty
Summary
The facility failed to ensure residents received showers as preferred instead of bed baths for five of six residents reviewed. The facility's policy stated that showers, tub baths, or bed/sponge baths would be offered according to residents' preferences. However, due to plumbing issues, both shower rooms were unavailable from 4-24-24 through 5-3-24. As a result, residents were given bed baths or had to go to another facility to get a shower. This situation affected residents who were cognitively intact and preferred showers over bed baths, leading to dissatisfaction and a feeling of not being as clean as they would have been with showers. During a tour of the facility, it was observed that one shower room was operational while the other was taped off and marked as out of order. Interviews with residents revealed that they were unhappy with the bed baths and preferred showers. The administrator confirmed that the shower rooms were unavailable due to plumbing issues, and no alternative shower facilities were provided within the facility during that period. This failure to accommodate residents' preferences for showers resulted in a deficiency in the quality of care provided.
Unlicensed CNA Performing Haircuts
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff were licensed and trained to perform resident haircuts. This deficiency was identified through observation, interview, and record review, revealing that a CNA was using electric hair trimmers to shave a resident's hair without the necessary licensure. The Illinois Barber, Cosmetology, Esthetics, Hair Braiding, and Nail Technology Act of 1985 mandates that only licensed individuals can perform such services, and the facility's CNA job description also requires adherence to all federal, state, and local requirements. Despite these regulations, the facility had not employed a licensed beautician or barber for over four years, and the CNA admitted to cutting multiple residents' hair without proper training or licensure. Residents expressed that there was no licensed beautician available, leading them to rely on staff for haircuts. One resident confirmed that the CNA had been cutting their hair, and the CNA acknowledged performing haircuts for several residents without formal training or a license. The facility administrator confirmed the absence of a licensed beautician or barber, highlighting a significant lapse in compliance with state regulations and professional standards. This failure had the potential to affect all residents reviewed for staff competency in the sample of 16.
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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