Aviston Countryside Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Aviston, Illinois.
- Location
- 450 West 1st Street, Aviston, Illinois 62216
- CMS Provider Number
- 145601
- Inspections on file
- 27
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Aviston Countryside Manor during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition was mistakenly given Keppra 750 mg and Metoprolol 100 mg by an LPN during a shared med pass, even though there were no orders for these drugs for that resident. Progress notes documented the error and monitoring, but the DON and ADON reported being unaware of any medication errors, and no medication error reports were on file despite facility policy requiring incident reporting and notification of nursing administration and the consultant pharmacist. The administrator also stated he was not informed of the event until questioned by surveyors.
Multiple residents with cognitive impairment and significant medical and psychiatric conditions were subjected to verbally and mentally abusive interactions by an LPN, including loudly telling a resident repeatedly asking for her mother that her mother was dead, yelling at a resident to get out of bed and not allowing her to call her son when she was crying, and forcing another resident who feared mechanical lifts and usually received bed baths to get up for a shower while she cried and screamed. Staff witnesses described the LPN as rude and verbally mean to residents, observed residents crying and emotionally distressed, and in several cases did not report these incidents to leadership despite care plans and facility policy requiring prompt reporting of suspected abuse.
Staff failed to recognize and immediately report suspected verbal abuse by an LPN toward three cognitively impaired residents. One resident with severe cognitive impairment and a care plan identifying abuse risk was reportedly yelled at and told her mother was dead, causing her to cry, but the witnessing therapy director did not report the incident. Another severely cognitively impaired resident was described by nursing staff as being yelled at to get out of bed and being denied timely access to call her son, yet these concerns were not reported due to fear of retaliation. A third resident with physical disabilities, vascular dementia, and fear of mechanical lifts was made to get up for a shower despite her refusals, with multiple staff describing the LPN loudly insisting on a shower while the resident cried and screamed; these events were also not reported to facility leadership. These actions and omissions violated the facility’s abuse prevention policy requiring immediate internal reporting of any suspected abuse.
Two residents experienced falls related to the facility’s failure to follow its own safety policies for wheelchair use and gait belt application. A resident with severe cognitive impairment and a history of falls, who required substantial assistance and cueing, was pushed in a manual wheelchair without footrests in place; the resident put her feet down, a foot became caught in the wheel, and she fell forward to the floor, reopening a prior forehead laceration and injuring an elbow. Another resident with multiple medical conditions, known balance issues, and a need for partial/moderate assistance was assisted by a CNA from a recliner to the bathroom with a walker but without a gait belt, contrary to facility policy; the resident became off balance, was guided to the floor, and later was found to have a left shoulder separation. Staff interviews and documentation confirmed that required wheelchair footrest positioning and gait belt use were not implemented at the time of these events.
A resident with significant mobility impairments and a history of falls was left unattended by a CNA during post-shower care, despite requiring two staff for safe repositioning. The CNA, working alone and without placing a blanket on the low air mattress as required, attempted to turn the wet resident to apply lotion, resulting in the resident slipping off the bed and sustaining an abrasion. The DON confirmed that proper procedures were not followed.
A resident with orthostatic hypotension fell while using a bedside commode unsupervised, resulting in facial bruising and a hematoma. Despite being on blood thinners and requiring substantial assistance for transfers, the resident was left alone after requesting privacy. The care plan did not adequately address her condition, and staff interviews indicated a lack of adherence to fall prevention protocols.
Failure to Administer Medications as Ordered and to Report Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and to properly recognize and manage a medication error for one cognitively intact resident. The resident was admitted with multiple diagnoses including a left pubis fracture, UTI, heart failure, atrial fibrillation, hypertension, chronic kidney disease, and hyperkalemia, and had a BIMS score of 15. Progress notes show that on one shift the resident was given Keppra 750 mg and Metoprolol 100 mg in error, despite having no physician orders for either medication in the order history covering the relevant period. Nursing documentation states that the error was recognized, the on‑call nurse practitioner was notified, vital signs were monitored, and no adverse reactions were noted, with a subsequent note indicating no adverse side effects from the medication error on the following shift. However, the facility’s leadership and systems did not identify or track this medication error as required. The DON initially stated there had been no medication errors and that the facility had no medication error reports. One LPN reported that a night‑shift nurse had given the wrong medications to the wrong resident and that this had been reported to the DON, but the DON and the ADON both stated they were not aware of any medication errors. The LPN who made the error later described helping another nurse with a med pass, pulling medications from the med cart for a resident in one room but administering them to a different resident in another room, and stated she reported the incident and documented it. The DON subsequently acknowledged only learning of the event days later during surveyor questioning and had to review charts to determine which resident was involved. The administrator also stated he was not made aware of the medication error until the survey, despite facility policy requiring documentation of the error and forwarding incident reports to nursing administration and the consultant pharmacist.
Failure to Prevent and Report Verbal and Mental Abuse by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from verbal and mental abuse by a staff nurse and the failure of other staff to report witnessed or suspected abuse, resulting in emotional harm and distress. One resident with malignant neoplasm of the left breast, depression, generalized anxiety, unspecified mood disorder, mild cognitive impairment, and a BIMS score of 5 (severely cognitively impaired) repeatedly asked for her mother. The Director of Physical Therapy (V15) stated that an LPN (V11) turned to this resident and loudly told her that her mother was dead, which V15 characterized as hateful, verbally, and mentally abusive. V15 reported that the resident became very upset and cried after this statement. Although V15 believed the interaction was abusive, she did not report this incident to administration or the DON at the time it occurred, despite the resident’s care plan identifying her as at risk for abuse/neglect and directing staff to address complaints promptly and report suspected abuse immediately. Another resident with Alzheimer’s disease, unspecified dementia, major depressive disorder, insomnia, and a BIMS score of 5 (severely cognitively impaired) was also involved in alleged verbal abuse. Nursing staff (V3 and V4) reported that the same LPN (V11) was verbally mean and not nice to residents, and specifically that she yelled at this resident, who liked to sleep in, from the hallway telling her she needed to get out of bed and that she was getting up. V3 stated she did not report this behavior because she felt it would put a target on her back. V4 reported that on one occasion this resident was crying and asking to call her son, and V11 would not call him; V4 eventually called the son herself, which calmed the resident. V4 also described an incident where the resident was sitting near the nurse’s station and V11 was yelling at her in a very loud and rude manner, which upset the resident. The resident herself reported poor memory and uncertainty about whether staff had yelled at her, but did recall being very upset and mad when she was not allowed to use the phone to call her son. Her care plan, like that of the first resident, identified risk for abuse/neglect and directed staff to address complaints and report suspected abuse immediately. A third resident with cerebral palsy, paraplegia, vascular dementia, bipolar disorder, major depressive disorder, anxiety disorder, unspecified intellectual disabilities, and a BIMS score of 11 (moderately impaired) reported being forced to get out of bed for a shower when she normally received bed baths. She stated that the LPN (V11) told her in a loud voice that she had to get up and take a shower, despite her back and spine problems and her fear of the mechanical lift due to a prior fall from a lift sling at another facility. The resident reported that staff, at V11’s direction, got her up with the mechanical lift for the shower, and she was crying, very upset, and stated she was unhappy at the facility because they made her do things she did not want to do and raised their voices at her. Another LPN (V4) corroborated that V11 instructed staff to get this resident up for a “real shower” despite the resident’s refusals and fear of the lift, and that the resident was crying and screaming, very upset during the process. A CNA (V9) confirmed that she gave the resident a shower at V11’s direction despite the resident’s refusal to get out of bed, and another CNA (V21) reported hearing the resident yelling and screaming during the shower, noting it was the first time she had seen the resident get up out of bed for a shower. The resident’s care plan did not include a focus area for abuse, and staff who witnessed or were aware of these events did not report them to the administrator or DON at the time. Multiple staff interviews further described a pattern of verbally rude or mean behavior by the LPN (V11) toward residents, including telling another resident who was yelling out to stop because no one needed to hear that. The DON (V2) acknowledged that she had previously spoken to V11 about being rude to a resident but had not received additional reports until the surveyor’s inquiry, and stated that if the resident who feared the lift did not want a shower, V11 should not have made her get one, and that no staff should yell at any resident or prevent a resident such as the second resident from calling her son. The facility’s Abuse Prevention Program policy states the facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident-sensitive and resident-secure environment. Despite this, the reported incidents show residents being subjected to loud, rude, or coercive interactions by an LPN, residents becoming upset, crying, or emotionally distressed, and staff failing to promptly report suspected abuse as required by resident care plans and facility policy.
Failure to Recognize and Report Suspected Verbal Abuse Toward Cognitively Impaired Residents
Penalty
Summary
Facility staff failed to identify and immediately report staff-to-resident verbal abuse involving three residents with cognitive impairments. One resident with malignant neoplasm of the left breast, cerebral infarction, depression, generalized anxiety, unspecified mood disorder, and mild cognitive impairment had a BIMS score of 5, indicating severe cognitive impairment, and adequate hearing. Her care plan identified risk for abuse/neglect with an intervention to report any suspected abuse/neglect to the administrator immediately. The Director of Physical Therapy stated she witnessed an LPN turn to this resident, who was repeatedly asking for her mother, and yell that her mother was dead, after which the resident became very upset and cried. The Director of Physical Therapy described the LPN’s behavior as verbally and mentally abusive but did not report this incident to the administrator or DON, despite facility policy requiring immediate internal reporting of suspected abuse. Another resident with Alzheimer’s disease, unspecified dementia, major depressive disorder, and insomnia also had a BIMS score of 5 and adequate hearing, and a care plan identifying risk for abuse/neglect with instructions to promptly address complaints and report suspected abuse to the administrator. A RN reported that a newer LPN was verbally mean to most residents and had yelled at this resident, who liked to sleep in, from the hallway, telling her she needed to get out of bed and that she was getting up, which the RN considered verbal and mental abuse. The RN admitted she did not report this behavior because she felt it would “put a target on your back.” Another LPN reported that on a weekend the same LPN yelled very loudly and rudely at this resident while she sat near the nurse’s station, upsetting her, and that on another occasion the resident cried when she was not allowed to call her son. This LPN also did not report these incidents to the administrator or DON. A third resident with cerebral palsy, paraplegia, vascular dementia, bipolar disorder, major depressive disorder, anxiety disorder, and unspecified intellectual disabilities had a BIMS score of 11, indicating moderately impaired cognition, and adequate hearing. Her care plan did not include a focus area for abuse. She reported that an LPN told her in a loud voice that she had to get up and take a shower, despite her usual practice of receiving bed baths due to back and spine problems and fear of mechanical lifts after a prior fall from a lift sling at another facility. She stated that staff, at the LPN’s direction, got her up with a mechanical lift for a shower, during which she cried and was very upset. Another LPN corroborated that the LPN insisted staff get this resident up for a “real shower” despite her refusals and fear of the lift, and that the resident was crying and screaming, but this was never reported to the administrator or DON. A CNA confirmed she gave the resident a shower at the LPN’s direction despite the resident’s refusal to get out of bed, and another CNA reported hearing the resident yelling and screaming during the shower, noting it was the first time she had seen the resident get up for a shower. These events, along with staff statements that they did not report the LPN’s conduct, demonstrate a failure to recognize, internally report, and escalate suspected verbal abuse as required by the facility’s Abuse Prevention Program policy. The facility’s Abuse Prevention Program policy requires employees to immediately report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect to the administrator, with specified time frames for reporting based on seriousness, and directs that employees immediately inform the administrator of all such reports so that an investigation can be initiated. Multiple staff, including the Director of Physical Therapy, a RN, and an LPN, acknowledged witnessing or being aware of verbally abusive or coercive interactions by the LPN toward these residents but did not report these concerns to the administrator or DON at the time they occurred. The failure of these staff members to follow the internal reporting requirements resulted in suspected verbal and mental abuse not being promptly identified or reported to facility leadership as required by policy.
Failure to Ensure Wheelchair Safety and Proper Gait Belt Use Resulting in Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents, both in relation to wheelchair safety and transfer/ambulation assistance. One resident with severe cognitive impairment, dementia, bipolar disorder with psychotic features, schizoaffective disorder, seizure history, and prior falls used a manual wheelchair and required substantial to maximal assistance for wheeling 50–150 feet, along with maximum verbal and tactile cues due to low comprehension and confusion. The resident’s care plan identified risk for falls and injuries related to weakness, dementia, and poor safety awareness, with interventions including use of proper assistive devices and cueing/redirection as needed. The facility’s wheelchair safety policy required staff to ensure proper foot placement on footrests and safe use and supervision of wheelchairs. On one occasion, a CNA was asked to return this resident from a hallway where the resident was known to go in an attempt to get into other residents’ beds. The CNA began pushing the resident in the wheelchair back toward the nurse’s station without foot pedals in place. Multiple staff, including the CNA, LPN, and DON, reported that the resident’s feet were not on footrests and that the resident put her feet down while being pushed, causing a foot to become caught in the wheelchair wheel. This resulted in the resident falling forward out of the wheelchair and striking her head on the floor, reopening a previous forehead laceration and causing additional injury to the elbow. The facility’s event report documented that the resident’s foot became caught in the front wheel while being pushed in the hallway, leading to the forward fall. The second resident had diagnoses including cerebral infarction, COPD, asthma, hypertension, seizure disorder, depression, anxiety, and osteoarthritis, and was cognitively intact with a BIMS score of 14. The MDS and therapy staff documented that this resident required partial/moderate assistance with self-care and mobility and had episodes of being unbalanced and falling backward when ambulating. The resident’s care plan identified a need for assistance with ADLs due to weakness and a risk for falls and injuries, with an intervention to observe for safety. The facility’s gait belt policy required use of gait belts when transferring weight-bearing residents or assisting them with walking. Despite this, a CNA responded to the resident’s call light for toileting assistance and helped the resident ambulate with a walker from a recliner to the bathroom without using a gait belt. During ambulation, the resident became off balance, which the CNA stated happens at times, and the CNA grabbed the resident’s shirt and pants on the left side to guide the resident to the floor. The resident ended up sitting on the bathroom floor with her back against the door and was then assisted by two CNAs to the toilet and back to the recliner. Both the CNA and the resident later confirmed that no gait belt was used during the transfer or ambulation. Several days later, an LPN noted the resident’s complaints of left shoulder pain, bruising, and limited movement, and imaging ordered by the practitioner showed a left shoulder separation and arthritis. The DON and Administrator stated that facility policy and their expectations required use of a gait belt during transfers and ambulation, and the fall management policy defined such an event, including a loss of balance that would have resulted in a fall without staff intervention, as a fall.
Failure to Provide Safe Repositioning Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide safe turning and repositioning care for a resident with significant physical impairments and a history of falls. The resident, who was cognitively intact but had one-sided weakness and required substantial assistance with activities of daily living, was at high risk for falls due to conditions including Parkinson's disease and a previous hip dislocation. After receiving a shower, the resident was returned to bed, which was equipped with a low air mattress. Only one certified nursing assistant (CNA) was present, despite facility protocol requiring two staff members for such care. The CNA attempted to turn the resident alone to apply lotion, without placing a blanket underneath as expected for residents on low air mattresses, and the resident subsequently slid off the bed and fell to the floor. Interviews and documentation confirmed that the resident was wet from the shower, making the surface slippery, and that the CNA was aware of the requirement for a second staff member but proceeded alone due to being busy. The Director of Nursing acknowledged that staff are expected to use a blanket to prevent slipping on air mattresses, which was not done in this instance. The facility's fall policy emphasizes the need to recognize and address high fall risk, but these procedures were not followed, resulting in the resident sustaining an abrasion and requiring hospital evaluation.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident diagnosed with orthostatic hypotension. The resident, who requires substantial assistance for transfers, was found with bruises on her face and neck after attempting to use the bedside commode independently. Despite being on blood thinners, which increased her risk of injury from falls, the resident was left unattended on the commode after requesting privacy. This lack of supervision led to her becoming dizzy and falling, resulting in a hematoma to her left eye. The resident's care plan documented her risk for falls due to weakness and included interventions such as a comprehensive medication review and individualized toileting interventions. However, the care plan did not specifically address her orthostatic hypotension or provide clear guidance for staff on how to manage this condition. The resident's fall risk assessment identified her as a moderate risk for falls, yet the facility's fall prevention program did not adequately mitigate this risk. Interviews with facility staff revealed that the resident was known to have orthostatic hypotension, yet staff did not remain with her during toileting despite her condition. The facility's policy aimed to decrease falls by recognizing high-risk residents, but the implementation of this policy was insufficient in this case. The resident's electronic health record did not document a refusal to attend a cardiology appointment, which was necessary for managing her condition.
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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