Arthur Home, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Arthur, Illinois.
- Location
- 423 Eberhardt Drive, Arthur, Illinois 61911
- CMS Provider Number
- 146023
- Inspections on file
- 21
- Latest survey
- March 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Arthur Home, The during CMS and state inspections, most recent first.
The facility failed to provide oral care for two residents, one with respiratory and cognitive impairments and another with severe cognitive impairment and dry mouth. CNAs did not clean dentures or provide oral hygiene for one resident, while an LPN failed to ensure medication was taken and oral care was given to another, resulting in discomfort and unswallowed medication.
A resident with severe cognitive impairment and a history of skin issues returned from the hospital with worsening Moisture Associated Skin Dermatitis (MASD). The facility failed to update the care plan and conduct weekly skin audits, leading to a deterioration in the resident's condition. Staff observations noted dark red lines and a beefy red appearance on the resident's skin, which were not addressed in a timely manner.
A resident with a history of anxiety and stroke was verbally abused by a CNA who shouted at the resident to stop using the call light and forcibly removed it from their reach. The incident was witnessed by other staff members, leading to the CNA's termination for founded abuse.
A facility failed to supervise a cognitively impaired resident, resulting in the resident exiting unnoticed and being exposed to cold temperatures and chemicals. The resident's care plan lacked interventions for wandering, and exit doors were unmonitored. Another resident fell in the bathroom due to lack of supervision, despite being a high fall risk. Both incidents highlight deficiencies in supervision and care planning.
The facility failed to employ a full-time Certified Dietary Manager (CDM), affecting all 33 residents. The previous CDM left in mid-October, and an uncertified interim manager, who is not present in the kitchen, was appointed. Staff reported struggles due to the lack of oversight, and the administrator confirmed ongoing interviews to fill the position.
The facility did not ensure that all dietary staff completed the required Food Handlers training, potentially affecting all 33 residents. Dietary Aides were observed serving meals and assisting residents without the necessary training. The Interim Dietary Manager was unaware of the training requirement for staff other than cooks and was inexperienced in managing a dietary department in LTC. The Administrator acknowledged the issue and was working on enrolling staff in the required training.
The facility failed to document temperature logs for kitchen coolers, freezers, and food, with significant gaps in logging for November. The walk-in cooler had a loose seal and leaking fan, creating unsanitary conditions. Staff were not properly trained to prevent cross-contamination, and facility policies on sanitation and food safety were not followed, compromising food safety for residents.
A facility failed to prevent cross-contamination in the dishwashing area after an employee defecated in the kitchen drain, leading to unsanitary conditions. Despite efforts to clean the area, the kitchen continued to operate, serving meals to residents. Additionally, the dishwashing system was not maintained properly, with inadequate sanitization due to a lack of litmus strips and low temperatures, posing a potential risk to all 33 residents.
The facility failed to provide required Dementia training for all staff, affecting 33 residents. Despite a policy mandating competencies for caring for residents with mental disorders, several staff members, including CNAs and a Dietary Aide, lacked documented training. The Administrator and DON acknowledged the lapse, with plans to arrange training. The Social Service Director noted limited training provided, emphasizing the need for comprehensive Dementia management skills.
The facility failed to maintain resident dignity during meal service when a dietary aide and three CNAs engaged in a loud argument over a resident's meal preference. The incident, witnessed by other residents, involved serving eggs to a resident who disliked them, causing distress and disruption in the dining room.
A resident with severe cognitive impairment experienced an unwitnessed fall and was found outside in cold temperatures with chemical exposure. The LPN failed to report these critical details to the physician, who was only informed of the fall without injuries. The DON was also unaware of the full circumstances, highlighting a deficiency in the facility's incident reporting.
A resident with CHF was hospitalized after the facility failed to adhere to a physician-ordered fluid restriction. Despite a daily limit of 1200 ml, the resident was consistently provided with excessive fluids by both dietary and nursing staff. The resident, who was cognitively intact, expressed frustration over the lack of communication and coordination among staff. Incorrect visual aids for fluid amounts contributed to the issue, leading to the resident's worsening condition and eventual hospitalization.
The facility failed to assist three residents with their ADLs, specifically in transferring out of bed. One resident was left in bed for breakfast despite needing assistance, while another's spouse had to call for help to get her out of bed. A third resident was left waiting for assistance with her breakfast out of reach. Staff were either unaware of or did not follow the residents' preferences and care plans.
The facility did not follow its oxygen administration policy by failing to date oxygen tubing, nebulizer tubing, and humidification bottles for two residents. The policy requires weekly changes and labeling of equipment. Observations revealed undated equipment, and residents were unaware of when their tubing was last changed. The DON confirmed the policy of weekly changes on Tuesday nights.
The facility failed to provide palatable hot food to two residents, as observed during a survey. One resident received meals that were cold upon delivery, with breakfast items significantly below the required temperature. The Dietary Manager confirmed the timing of meal delivery, indicating the food would be cold if left uneaten for an hour. Another resident also reported receiving cold breakfast. The facility's policy requires hot foods to be held at 135 degrees Fahrenheit or greater, which was not met.
A facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter, as required by their policy. The resident's care plan indicated the need for such precautions, but observations showed that PPE was not available outside the room, and a CNA performed catheter care without proper protective equipment. The DON confirmed the requirement for Enhanced Barrier Precautions for residents with urinary catheters.
Two residents in an LTC facility were affected by the misappropriation of narcotic medications. A nurse from a private staffing agency, with a history of drug diversion, was involved in discrepancies between medication administration records and narcotic log removals. One resident reported not receiving Hydrocodone, while another did not receive Tylenol #3 as documented. The facility's investigation confirmed these discrepancies, violating the residents' rights to be free from misappropriation.
A facility failed to secure medications by leaving the medication room door open and the medication cart unlocked, allowing three residents to access the area unsupervised. The residents, who were somewhat confused and known to wander, were found near the open door, and a RN later confirmed that the narcotic lock box was not double locked as required by policy. The DON acknowledged the breach, which violated the facility's medication storage policy.
The facility failed to ensure a call light was within reach for a resident, as required by policy and the resident's care plan. The administrator observed the call light on the bed while the resident was in a chair, and the resident confirmed it was not given to him after breakfast. A grievance had been filed earlier by a family member about the same issue.
The facility failed to provide scheduled showers for two residents. One resident did not receive a shower since admission, and another missed multiple scheduled showers. Both residents and staff confirmed the lapses.
A resident sustained a bruise above the left eyebrow when a CNA performed a mechanical lift transfer alone, contrary to facility policy requiring two CNAs. The incident was documented, and the facility's policy mandates two CNAs for such transfers.
Failure to Provide Oral Care for Residents
Penalty
Summary
The facility failed to provide adequate oral care for two residents, R1 and R2, as observed and documented by surveyors. R2, who has medical diagnoses including Acute and Chronic Respiratory Failure, COPD, and Dementia, was noted to require supervision with oral hygiene. However, R2's medical record did not document any oral care being provided. On a specific day, CNAs V10 and V11 assisted R2 after lunch but did not provide oral care, leaving food particles in R2's dentures. V10 admitted to not cleansing R2's dentures or providing oral care during morning routines. Similarly, R1, who is severely cognitively impaired and has medical conditions such as Xerosis Cutis and Dysphagia, was found with a very dry and cracked mouth, tongue, and lips. R1 expressed discomfort due to the lack of oral care, stating that staff never brushed her teeth. An LPN, V9, acknowledged not providing oral care or ensuring R1 took her medication properly, which resulted in unswallowed medications in R1's mouth. The facility administrator noted that the black substance on R1's mouth was due to medications given with chocolate ice cream and milk, and confirmed that oral care was not provided as it should have been.
Failure to Update Care Plan and Conduct Skin Audits
Penalty
Summary
The facility failed to identify the worsening of a skin condition, update the care plan, and conduct weekly skin audits for a resident with Moisture Associated Skin Dermatitis (MASD). The resident, who has a medical history including Xerosis Cutis, Diastolic Congestive Heart Failure, and severe cognitive impairment, returned from a hospital stay with redness on the buttocks. However, the care plan was not updated to reflect the MASD on the perineal, buttocks, and sacral areas. Observations revealed that the resident's skin condition had worsened, with dark red lines on the inner groin area and a dark, beefy red appearance on the perineal, buttocks, and sacral areas. The Wound Nurse/LPN and Director of Nurses acknowledged the worsening condition and the lack of appropriate updates to the care plan and skin evaluations. The Wound Nurse noted that the resident's condition had deteriorated since returning from the hospital, and the Director of Nurses admitted that staff should have alerted them to update the care plan and initiate weekly skin evaluations. The facility is in the process of changing its culture, but the incident highlights ongoing training needs.
Resident Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a staff member. The incident involved a resident with a care plan that included diagnoses of Chronic Vulvitis, Vulvar Cancer, Anxiety Disorder, and a history of stroke with right hemiplegia/hemiparesis. On the morning of December 26, 2024, the Social Service Director and the Dietary Manager overheard an argument between the resident and a staff member, identified as a Certified Nurse's Aide (CNA), in which the CNA shouted at the resident to stop pushing the call light. The resident responded by telling the CNA to stop yelling and threatened to report the behavior. The Dietary Manager witnessed the CNA forcibly remove the call light from the resident's hand and place it out of reach, which was corroborated by another CNA present in the room. The second CNA confirmed that the first CNA raised her voice and shouted at the resident multiple times, expressing frustration. The incident concluded with the first CNA leaving the room after realizing her behavior. The facility administrator later verified that the CNA involved in the incident was terminated for founded abuse.
Inadequate Supervision Leads to Resident Elopement and Fall
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident known to wander, resulting in the resident exiting the facility unnoticed and unsupervised. The resident, who had medical diagnoses including dementia with agitation and Alzheimer's disease, was found outside in 21-degree Fahrenheit temperatures and later in the facility's mechanical room with a chemical spill on her. The resident's care plan did not include interventions for her known wandering behavior, and her elopement risk assessment was outdated. Additionally, the facility's exit doors were not monitored, and the resident's personal alarm was not in place at the time of the incident. The facility also failed to provide supervision during toileting for another resident, resulting in a fall. This resident, who was moderately cognitively impaired and dependent on staff for toileting, was left unattended in the bathroom by an agency RN. The resident attempted to stand up on her own, fell, and sustained minor injuries. The resident's care plan included the use of a personal alarm, and she was identified as a high fall risk prior to the incident. Both incidents highlight deficiencies in the facility's supervision and monitoring of residents, particularly those at risk for elopement and falls. The lack of timely assessments, inadequate care planning, and failure to ensure the proper functioning of personal alarms contributed to these events. The facility's policies on elopement and fall prevention were not effectively implemented, leading to these deficiencies.
Removal Plan
- R8 was placed on 15 minute visual checks, increased sensory alarm checks, and a departure alert band was placed on R8's wheelchair, and the staff assignment sheet and careplan were updated by V2 DON.
- V3 Minimum Data Set (MDS) Coordinator/MDS Careplan Coordinator(CPC)/Licensed Practical Nurse (LPN) updated R8's elopement risk assessment.
- All current residents' elopement risks were reviewed by V2 and V3. Any resident identified to be at risk has interventions in place to keep residents safe and unable to wander away without staff knowledge.
- V3 reviewed and updated all resident care plans of residents identified as at risk for elopement.
- V38 Licensed Social Worker contractor was contacted by V1 Administrator to schedule Dementia training.
- V3 updated the elopement book. A check off list was placed in the staff/new staff/agency binder to address steps to be taken during an elopement. Implemented by V2.
- V2 reviewed the facility's last quarter of falls to ensure interventions were appropriate and careplans updated with each fall. V2 will review falls with the Interdisciplinary Team (IDT) to ensure fall interventions are implemented, and careplans are reviewed and updated as needed by V3.
- The facility fire doors at the North end of skilled unit were alarmed, a keyed lock was placed on the mechanical room door, an alarm audible to staff was placed on the employee dietary east entrance/exit door, a lock was placed on the door separating the kitchen from the dining rooms, with all resident areas remaining open.
- All new admissions/readmissions or those residents with a change in condition, will have an elopement assessment completed and residents at risk of elopement will be added to the elopement book and 15 minute checks will be initiated. Initiated and will be ongoing per V2.
- All staff were educated on the elopement policy by V1 Administrator and V2.
- Random elopement drills will be conducted by V1 Administrator or designee, to assess staff understanding of the policy including the codes/locks for doors and new doors/alarms. The first elopement drill was completed.
- V2 and V26 Assistant Director of Nurses educated staff on the Fall Prevention Program Policy to include assessment of the resident by a Licensed Nurse and the alarm policy.
- A Performance Improvement Tool was initiated by V2 to review residents that are at risk of elopement.
- A Performance Improvement Tool was initiated to review fall reports, appropriate interventions and follow through on interventions by V2. Audits will continue five times weekly for two weeks, three times weekly for two weeks, weekly for two weeks, monthly for three months and then quarterly for three quarters.
- A Performance Tool was initiated by V2 and V26 to randomly review door locks/alarms. The audits will take place seven times per week for four weeks, five times per week for four weeks, three times per week for four weeks, weekly for four weeks, monthly for four months and then quarterly for four quarters.
- The facility Quality Assurance Committee will review the Performance Improvement Tools and make additional recommendations based on the outcome of the tools.
Absence of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) full-time, which has the potential to affect all 33 residents residing in the facility. The facility's assessment indicated that a Dietician or other clinically qualified nutrition professional should serve as the director of food and nutrition services. However, during the survey conducted from 11/27/24 to 12/9/24, there was no CDM onsite. Interviews with staff revealed that the previous Dietary Manager left in mid-October 2024, and an interim Dietary Manager, who is not certified, was appointed. This interim manager is primarily occupied with another full-time job and is not present in the kitchen, leading to struggles among the kitchen staff. The facility administrator confirmed the absence of a CDM and acknowledged ongoing interviews to fill the position, while also being aware of the existing problems in the kitchen.
Failure to Ensure Dietary Staff Completed Food Handlers Training
Penalty
Summary
The facility failed to ensure that all dietary staff completed the required Food Handlers training, which has the potential to affect all 33 residents residing in the facility. On a specific date, a staff member was observed giving instructions to Dietary Aides on serving and assisting in the dietary department. Later, several Dietary Aides were seen serving meals, providing drinks, and assisting residents in the dining room. The Interim Dietary Manager admitted to being unaware that anyone other than the cooks needed training and acknowledged a lack of experience as a Dietary Manager in a long-term care facility. The manager was in the process of making a list of dietary employees to enroll them in a Safe Food Handlers course. The facility's Administrator confirmed awareness of the training requirement and stated that efforts were underway to register employees for the necessary training.
Deficiencies in Kitchen Sanitation and Temperature Documentation
Penalty
Summary
The facility failed to maintain proper documentation and sanitation standards in its kitchen, which could potentially affect all 33 residents. The facility did not document temperature logs for kitchen coolers, freezers, and food being served or kept on warmers. This lack of documentation was observed for the entire month of November, with significant gaps in temperature logging for both day and evening shifts. Additionally, the facility's food temperature sheets for October and November showed numerous instances where food temperatures were not recorded for entire meals. The facility's walk-in cooler had a loose seal, and the fan was leaking water, which dripped onto the food, walls, and floor, creating unsanitary conditions. The thermometer in the cooler read 42 degrees Fahrenheit, indicating improper temperature maintenance. Large empty trays were placed on the top shelves to catch some of the leaking water, but this was not entirely effective, as water continued to drip onto the food. The local County Health Department's inspection report also noted poor cleanliness of non-food contact surfaces and required corrections, some of which remained unaddressed. Interviews with facility staff revealed that the kitchen staff had not been properly trained to prevent cross-contamination and were not consistently obtaining or documenting temperatures as required. The facility's policies on sanitation and food safety were not being followed, as evidenced by the lack of daily sanitation inspections and failure to maintain safe refrigerated storage practices. These deficiencies in documentation, training, and equipment maintenance contributed to the potential for cross-contamination and compromised food safety for the residents.
Inadequate Sanitation in Dishwashing Area
Penalty
Summary
The facility failed to prevent cross-contamination in the dishwashing area due to an incident involving a dishwasher employee, identified as V6, who defecated in the kitchen drain area. This incident was reported by the Dietary Manager, V5, who upon returning from an errand, noticed a foul smell emanating from the dishroom. V6 was instructed to leave the premises, and efforts were made by the Maintenance Director, V19, and the Head of Housekeeping, V18, to sanitize the area. However, the malodorous stench persisted, and the kitchen continued to operate, serving meals to residents despite the unsanitary conditions. The facility's dishwashing system was not maintained in a sanitary manner, as evidenced by the County Health Department's inspection report, which rated the kitchen's non-food contact surfaces and food contact surfaces as out of compliance. The Dish Machine Part Per Million (PPM) Record Log indicated consistent readings of 100 PPM, but it was later discovered that the facility lacked litmus strips to verify these readings. The dishwasher's sanitize cycle temperatures were recorded below the required 120 degrees Fahrenheit, and the sanitizer was not being properly dispensed due to a weak hose, compromising the sanitization process. Interviews with staff, including the Maintenance Director and a service technician, revealed that the facility had been without litmus strips for months, preventing accurate monitoring of the dishwashing machine's sanitization levels. The service technician confirmed that the dishwasher was a low-temperature style, requiring either a minimum temperature of 120 degrees Fahrenheit or effective sanitizer levels to ensure proper sanitization. The facility's failure to maintain the dishwashing system in a sanitary manner posed a potential risk to all 33 residents residing in the facility.
Failure to Provide Dementia Training for Staff
Penalty
Summary
The facility failed to provide required Dementia training for all staff, which has the potential to affect all 33 residents residing in the facility. The facility's policy on Behavior Health Services, revised in April 2023, mandates that staff have the appropriate competencies and skill sets to care for residents with mental and psychosocial disorders, including Dementia. However, the facility's staff education logs for 2024 show that several staff members, including CNAs and a Dietary Aide, have not received any documented Dementia training. The Social Service Director had only one hour of training. The facility assessment also indicated the need for Dementia management training, but this was not implemented for new hires post-April 2023. Interviews with the facility's Administrator and Director of Nurses revealed that the facility has not kept their staff current with Dementia training since April 2023. The Administrator acknowledged the lapse and mentioned plans to arrange training. The Director of Nurses emphasized the importance of such training, given the number of residents with Dementia in the facility. The Social Service Director noted that the facility provided a two-day online training, which included only one hour of Dementia training, and highlighted the benefits of staff being trained in managing and deescalating behaviors associated with Dementia.
Disruptive Staff Behavior During Meal Service
Penalty
Summary
The facility failed to ensure the dignity of four residents during meal service, as observed through inappropriate staff behavior. The incident involved a dietary aide, V16, and three CNAs, V11, V14, and V15, who engaged in a loud and disruptive argument in the dining room. This occurred when V16 served eggs to a resident, R5, who was known by the staff to dislike eggs, although this preference was not documented in the resident's records. The argument took place in front of other residents, causing distress and disrupting their meal experience. R5, who is moderately cognitively impaired and requires assistance with meals, was served eggs despite not having an allergy or documented dislike for them. The CNAs, V11, V14, and V15, loudly reprimanded V16 for serving eggs to R5, using a 'hateful and mean' tone, according to V16. This behavior was witnessed by other residents, including R6, who expressed a preference to eat meals in their room to avoid such drama, and R4, who was upset by the staff's lack of manners. The incident was further complicated by the fact that the dining room sections were combined due to maintenance, leading to a larger audience for the argument. The interim dietary manager, V20, acknowledged the incident but was unaware of its potential classification as abuse. The facility's policy on dignity and privacy emphasizes the importance of residents living with dignity, privacy, independence, and choice, which was not upheld in this situation.
Failure to Accurately Report Unwitnessed Fall and Exposure
Penalty
Summary
The facility failed to accurately report the circumstances of an unwitnessed fall involving a resident who was severely cognitively impaired. The resident was found on the floor in the kitchen by an outside door, with the wheelchair alarm not in place. The post-fall evaluation indicated that the resident should have a wander-guard applied when near exit doors and that the wheelchair alarm should be checked when the resident self-transfers. However, the Licensed Practical Nurse (LPN) who reported the incident to the physician did not include critical details such as the resident being outside in 20-degree Fahrenheit temperatures, exposure to chemicals, and the lack of a nurse assessment before moving the resident. The Director of Nurses (DON) confirmed that these details were not reported to them either, acknowledging the severity of the oversight. The physician stated that had they been informed of the full circumstances, they would have sent the resident to the emergency room due to the exposure to frigid temperatures and chemicals. The physician emphasized the importance of notifying emergency services in such extreme cases before contacting the physician and family. The failure to report these significant details represents a deficiency in the facility's handling of the incident.
Failure to Adhere to Fluid Restriction Leads to Resident Hospitalization
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a resident with Congestive Heart Failure (CHF), leading to the resident's hospitalization. The resident, who was cognitively intact, had a medical history including Chronic Respiratory Failure, Cerebral Infarction, Chronic Diastolic CHF, Atrial Fibrillation, and Chronic Pulmonary Edema. The physician's order specified a daily fluid restriction of 1200 milliliters, with 800 ml to be provided by dietary and 400 ml by nursing, documented each shift. However, the resident was consistently provided with more fluids than prescribed, both by dietary and nursing staff, over several days. Observations and interviews revealed that the resident was served and consumed more fluids than allowed, with dietary providing between 1060 ml and 1100 ml on multiple days, and nursing providing between 420 ml and 480 ml on others. The resident expressed frustration, stating that staff did not communicate effectively about the fluid restriction and continued to provide excessive fluids, despite the resident's attempts to comply. The resident's condition, including shiny, red, and swollen lower legs, indicated worsening edema, which was corroborated by the resident's statements about recent hospitalization for CHF. Further investigation showed that the facility's visual aids for staff to determine fluid amounts were incorrect, leading to the provision of excessive fluids. The Director of Nurses acknowledged the issue, stating that the staff's actions in providing extra fluids were a facility problem. The resident was eventually sent to the emergency room due to weight gain, shortness of breath, and severe edema, requiring intensive care and intravenous diuretics. The Medical Director confirmed that the staff's failure to adhere to the fluid restriction contributed to the resident's re-hospitalization, although the resident's multiple comorbidities also played a role.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to assist three residents with their activities of daily living (ADLs), specifically in transferring out of bed. One resident, identified as R236, was observed lying in bed on two consecutive days, expressing a desire to get up for breakfast but was not assisted by staff. The resident's admission assessment indicated a need for one-person assistance for transfers, ambulation, and dressing. However, the CNAs were either unaware of the resident's usual routine or did not inquire about the resident's preferences, leading to the resident having breakfast in bed against his wishes. Another resident, R28, was found in a wheelchair with a finished breakfast tray after her spouse had to call for assistance to get her out of bed. The resident expressed a preference to get up earlier, as documented in her routine questionnaire, but was not assisted in a timely manner. Similarly, R25 was left in bed with her breakfast out of reach, waiting for assistance to get up and dressed. Her care plan indicated she needed assistance in all ADL areas except eating, yet the staff did not provide the necessary help when her breakfast was delivered.
Failure to Date Oxygen and Nebulizer Equipment
Penalty
Summary
The facility failed to adhere to its oxygen administration policy by not dating the oxygen tubing, nebulizer tubing, and humidification bottles for two residents. The policy, revised on 10/2/24, requires that oxygen tubing and mask/cannula be changed weekly and labeled with the date and initials. During a facility tour, one resident was observed using a nasal cannula with an oxygen concentrator, where the humidifier bottle was labeled with a date of 9/19/24, but the oxygen tubing was not labeled. The resident was unaware of when the tubing was last changed. Another resident was observed with oxygen tubing and a humidifier bottle that were not dated, and nebulizer tubing and a medication mouthpiece that were also not dated. This resident stated that none of his tubing, except for his IV tubing, had been changed. The Director of Nursing confirmed that all oxygen, nebulizer, and CPAP equipment should be changed weekly on Tuesday nights during the night shift.
Failure to Provide Palatable Hot Food
Penalty
Summary
The facility failed to provide palatable hot food to two residents, R25 and R28, as observed during a survey. On multiple occasions, R25 received meals that were cold upon delivery to her room. Specifically, on one occasion, R25's breakfast, consisting of a biscuit with white gravy, sausage, and eggs, was found to have temperatures significantly below the facility's policy requirement of 135 degrees Fahrenheit, with the biscuit at 74 degrees, sausage at 80 degrees, and eggs at 79.4 degrees. The Dietary Manager confirmed that R25's breakfast tray was delivered at 8:05 AM, and if it sat for an hour, it would indeed be cold. Similarly, R28 reported that her breakfast was cold when delivered to her room. The facility's policy mandates that hot foods be held at 135 degrees Fahrenheit or greater, which was not adhered to in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter, as required by their policy. The policy mandates that an order for Enhanced Barrier Precautions be obtained for residents with indwelling medical devices, such as urinary catheters, and that personal protective equipment (PPE) like gowns and gloves be made available near or outside the resident's room. The resident's care plan, updated in April 2024, indicated the need for an indwelling urinary catheter, and the resident had a history of urinary tract infections. However, during observations in October 2023, it was noted that the entrance to the resident's room did not indicate Enhanced Barrier Precautions, and PPE was not available outside the room. Additionally, a CNA performed catheter care without wearing a gown or mask, further indicating a failure to adhere to the required precautions. The Director of Nurses confirmed that residents with urinary catheters should be placed under Enhanced Barrier Precautions.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of narcotic medication, affecting two residents, R1 and R2. R1's medical records indicated a prescription for Hydrocodone-Acetaminophen for pain management, which was not administered as documented. The discrepancy was noted when R1 requested Tylenol and was informed by an LPN that Hydrocodone had already been administered, which R1 denied receiving. The investigation revealed that the medication was signed out by a nurse from a private staffing agency, V5, who had a history of drug diversion. R2's records showed prescriptions for Tramadol and Tylenol #3 for pain management. On the same day as R1's incident, R2's records indicated that Tramadol and Tylenol #3 were removed from the narcotic lock box by V5, but the administration records did not match the removal times. R2, who was cognitively intact, reported not receiving the Tylenol #3, corroborating the discrepancies found in the records. The facility's investigation into the misappropriation of narcotic medications involved reviewing the narcotic logs and interviewing staff. The Director of Nursing confirmed the discrepancies and reported the findings to the local police department. The facility's policy on abuse, neglect, and exploitation emphasizes the residents' right to be free from misappropriation of property, which was violated in this case.
Medication Security Breach in Facility
Penalty
Summary
The facility failed to secure medications, including controlled substances, by leaving the medication room door open and the medication cart unlocked. This incident was observed when three residents, who were independently propelling their wheelchairs, were found outside the medication room. The door was propped open with an exercise barbell, and the medication cart was within reach of the residents. There was no staff present in the medication room or nearby halls, leaving the medications accessible to the residents for a total of nine minutes. A Registered Nurse later confirmed the situation, acknowledging that the narcotic medication lock box was not double locked as required by the facility's policy. The residents involved were somewhat confused at times and known to wander the halls. One resident expressed a need for pain medication and requested assistance from the surveyor, who was mistaken for a staff member. The Director of Nursing later acknowledged the breach in protocol, confirming that the narcotic controlled medications were not secured under double lock as per the facility's medication storage policy. The facility's policies on controlled substance administration and medication storage emphasize the importance of double-locking controlled substances and ensuring medication security, which were not adhered to in this instance.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident reviewed for accommodation of needs. The facility's policy requires staff to ensure the call light is within reach with each interaction in the resident's room or bathroom. The resident's care plan also specified that the call light should be kept in reach at all times. On the specified date, the administrator observed that the resident's call light was on the bed and not within reach while the resident was sitting in a chair. The resident confirmed that the call light was not given to him after returning from breakfast. A grievance had been filed earlier by a family member, noting that the resident was left without the call light after being assisted to bed. The administrator acknowledged that the call light should have been within reach and confirmed previous complaints regarding this issue.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to assist with showers as scheduled for two residents. According to the facility's undated Resident Showers policy, residents are to be provided showers as per request or facility schedule protocols. The facility's Shower List indicated that one resident was to receive showers on Wednesdays and Saturdays, but there was no documentation that the resident received a shower on the specified Saturday. A family member confirmed that the resident had not been showered since admission. Additionally, another resident, also scheduled for showers on Wednesdays and Saturdays, did not have shower sheets for multiple Saturdays. This resident confirmed that they did not always receive their scheduled showers and expressed a preference for them. The Director of Nursing acknowledged that residents should be showered on their designated days.
Failure to Provide Safe Transfer Using Mechanical Lift
Penalty
Summary
The facility failed to provide a safe transfer for one resident (R2) of three reviewed for transfers. On 5/22/24, R2 was observed with a three-inch bruise above the left eyebrow, which R2 stated was caused by the mechanical lift arm hitting her in the eye during a transfer. R2 reported that the Certified Nurse's Assistant (CNA), V25, was assisting her alone at the time of the incident. V25 confirmed that she performed the transfer by herself, despite facility policy requiring two CNAs to be present during mechanical lift transfers. The event report dated 5/19/24 documented the incident and the resulting bruise. The facility's mechanical lift policy mandates that two CNAs must be present, with one operating the controls and the other guiding the lift, which was not followed in this case.
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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