Axiom Healthcare Of West Frankfort
Inspection history, citations, penalties and survey trends for this long-term care facility in West Frankfort, Illinois.
- Location
- 601 North Columbia, West Frankfort, Illinois 62896
- CMS Provider Number
- 145664
- Inspections on file
- 26
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Axiom Healthcare Of West Frankfort during CMS and state inspections, most recent first.
Multiple residents with intact or moderately impaired cognition, many with complex medical conditions such as fractures, severe protein-calorie malnutrition, COPD, diabetes with neuropathy, dementia, and chronic pain, reported that CNAs and dietary staff frequently displayed exasperated, snappy, or dismissive attitudes when they requested assistance or information. Residents described inadequate perineal cleaning after incontinence, delayed or unfulfilled responses to call lights, refusal or reluctance to provide drinks or ice, and visible irritation when residents asked about menus or meal substitutes, particularly on evening and night shifts. Some residents stated they had raised concerns about staff attitudes, roughness, and rushing of more fragile residents among themselves and at resident council, but recent council minutes did not reflect these complaints, and leadership reported being unaware of poor CNA attitudes, despite an existing Employee Standards of Conduct requiring professional and respectful treatment of residents.
Multiple residents reported that meals were frequently cold or barely warm, with butter or margarine not melting on vegetables or pancakes and visible solidified grease on entrees. Surveyors confirmed these concerns by measuring low food temperatures on resident trays and a test tray, including vegetables at 83°F and main dishes under typical hot-holding levels, despite a facility policy requiring proper holding temperatures and attractive presentation. Residents with conditions such as protein-calorie malnutrition, diabetes, anemia, GERD, and intellectual disabilities described the food as not good when cold and stated that this problem occurred often, whether they ate in their rooms or in the dining area, while facility leadership acknowledged that food should be hot when served but lacked clear implementation and documentation of food council activities.
A resident with a history of falls and diabetic neuropathy sustained significant arm lacerations after being bumped by another resident with impulsive behavior during a supervised smoking break. Multiple witnesses confirmed that the second resident frequently rushed and collided with others during smoke breaks. The supervising CNA was distracted while distributing cigarettes and did not ensure all residents were safely in the smoking area, leading to inadequate supervision and the resulting accident.
Staff were observed and reported discussing residents' health issues and care in common areas, such as the dining room and outside smoking areas, where other residents, families, and staff could overhear. These breaches of confidentiality included using resident names and making inappropriate comments, despite facility policies prohibiting such disclosures.
Residents reported ongoing issues with rude and dismissive behavior from some CNAs, which were discussed in resident council meetings but not formally documented or resolved. Multiple cognitively intact residents described staff responding with aggressive tones or reluctance to assist, and some staff acknowledged the problem. Despite the facility's grievance policy requiring prompt action, key staff and administration were unaware of the complaints, and no investigation or corrective measures were taken.
A nurse worked without a valid license for an extended period, administering medications and providing care to multiple residents with complex medical needs. The lapse was not identified by the DON until after the nurse had already performed nursing duties, after which she was reassigned as a CNA. This failure in licensure verification potentially affected all residents in the facility.
Multiple residents, including those with severe medical conditions and cognitive impairments, did not consistently receive water or other beverages as needed, despite being at risk for dehydration. Family members and staff reported that drinks were not regularly distributed, and some residents were left without access to water in their rooms. Staff acknowledged inconsistent drink distribution, and repeated complaints were documented in resident council minutes and concern forms.
Staff members repeatedly engaged in loud arguments, yelling, and use of inappropriate language in front of residents, creating a chaotic and undignified environment. A resident with mental health diagnoses reported increased agitation due to these incidents, and multiple staff confirmed ongoing conflicts and harassment among CNAs, which were audible throughout the facility. These actions violated the expectation of a respectful and professional environment as outlined in facility policy.
Multiple residents with significant medical and cognitive needs were found with their call lights out of reach, sometimes on the floor or placed intentionally by staff where they could not access them. Observations and interviews confirmed that this was a recurring issue, with some residents unable to summon help and staff not always responding to verbal requests. The facility's policy requires call lights to be accessible, but this was not consistently followed.
Several residents and staff reported witnessing staff members vaping inside the building, including hallways, resident rooms, and the break room. Despite facility policies and prior in-service training prohibiting vaping, staff continued to vape during various shifts, compromising the smoke- and vape-free environment expected for residents.
Multiple residents with nutritional risks and special dietary needs did not consistently receive meals as prescribed due to the facility running out of food, serving smaller portions, and providing inappropriate meal substitutions. Staff and residents reported frequent shortages, with some staff consuming resident food and leftovers being discarded, resulting in residents being unable to receive seconds or alternative options. These actions led to unmet nutritional needs for several residents.
Several residents reported not receiving adequate evening snacks, with options often limited to minimal items like saltine crackers and insufficient quantities for all. Staff, including CNAs and LPNs, confirmed frequent shortages and inconsistent distribution, sometimes leaving residents without snacks, especially those on special diets. Facility records and resident council minutes documented ongoing complaints about the lack of snacks and long periods without food between dinner and breakfast.
A resident with a history of depression and anxiety was subjected to mental abuse when a CNA compared the resident to a TV character in a derogatory manner, showing the character's image to other staff and laughing in the resident's presence. The incident was witnessed by multiple staff, and the resident reported feeling humiliated and mocked.
A resident with severe cognitive impairment and multiple health issues made allegations of staff abuse, including verbal threats and mistreatment during personal care. Staff failed to report these allegations to the state agency and the administrator as required by facility policy, and the incidents were not properly investigated or documented at the time they occurred.
A resident with severe cognitive impairment and multiple medical conditions alleged that staff made threatening and inappropriate comments during a breakfast incident. The facility did not thoroughly or promptly investigate the allegation, failed to obtain a statement from the resident at the time, and did not report the incident to the Department of Public Health as required by policy. The investigation was limited to staff interviews, and the required abuse protocol was not followed.
The facility did not ensure RN coverage for at least 8 hours per day, 7 days a week, as required. Facility schedules and staff confirmation showed that there were multiple days without an RN present, potentially affecting all 50 residents.
A resident with multiple diagnoses, including macular degeneration, was ordered Preservision AREDS 2 daily, but staff substituted Ocuvite without physician approval due to pharmacy and insurance issues. Staff continued to document that Preservision was administered, despite giving a different supplement, and the care plan did not address the resident's eye condition. The substitution persisted until the resident reported the issue to the state.
A resident with multiple psychiatric and medical diagnoses was not provided with the prescribed Preservision AREDS 2 supplement for an extended period, instead receiving Ocuvite without a physician's order to change the medication. Staff and pharmacy communication led to the substitution, and MARs inaccurately reflected administration of the ordered medication until the issue was brought to the attention of surveyors.
A resident with end stage renal disease and a physician order for regular dialysis missed multiple dialysis treatments because the facility's transportation van was out of service and no alternative transportation could be arranged. This led to missed appointments, hospital admissions, and documented complications, despite the facility's policy requiring assistance with transportation for essential medical services.
The facility failed to ensure RN coverage for 8 consecutive hours daily, 7 days a week, as required. Interviews and record reviews revealed no RN on shift for specific dates in November and December 2024. The absence of RN coverage was confirmed by an LPN, the DON, and the Regional Director of Operations. The facility lacked a specific policy on RN coverage, relying on general staffing regulations, potentially affecting all 40 residents.
The facility failed to maintain the required water temperature for dishwashing, with the dish machine's water at 80°F instead of the recommended 120°F. Additionally, improper food handling was observed, as a cook used the same gloves for multiple tasks, risking cross-contamination. These issues could affect all 40 residents.
The facility failed to document quarterly QAPI meetings, as required by their policy, potentially affecting the quality of care for all 40 residents. The Regional Director of Operations confirmed the meetings occurred but could not provide records after February 2024.
The facility failed to provide dietary supplements as ordered to four residents, impacting their nutritional status. Due to a late delivery, the dietary manager reported that mighty shakes were not provided at breakfast or lunch, affecting residents with specific dietary orders for weight management and nutritional needs.
A facility failed to notify law enforcement in an abuse investigation involving a resident who reported verbal abuse and theft by night shift CNAs. Despite the facility's policy requiring notification of authorities in such cases, the Regional Director of Operations confirmed that the police were not informed. The incident highlights a deficiency in the facility's adherence to its abuse prevention and reporting procedures.
A resident with multiple mental health diagnoses expressed suicidal ideations, but the LTC facility failed to provide timely interventions and documentation. The staff did not notify the physician immediately or conduct a suicide assessment promptly, contrary to the facility's policy. The resident's care plan included monitoring for depression and suicidal thoughts, but these were not effectively implemented, leading to a deficiency in care.
The facility failed to safeguard medical records for three residents due to water damage in the records room, resulting in missing documentation prior to the transition to electronic records. Staff confirmed the loss of paper records and the lack of a backup system to retrieve the missing information.
A resident was administered Chlorpromazine twice without consent or a physician's order, leading to an emergency room visit for possible allergic reaction. The LPN did not verify medication orders or document the administration, and the medication had been discontinued months prior.
A facility failed to remove discontinued Chlorpromazine from stock, leading to its unauthorized administration to a resident with multiple diagnoses. The medication, intended for psychosis, was discontinued by the pharmacy but remained on the cart. An LPN mistakenly prepared it, and another LPN administered it during an incident of aggressive behavior, unaware of its discontinuation.
The facility failed to protect two residents from physical and verbal abuse by a CNA, resulting in mental anguish and fear for the residents. The abuse was confirmed through interviews and observations, and the CNA was terminated after the investigation.
The facility failed to promptly and thoroughly investigate multiple allegations of staff-to-resident abuse, allowing the alleged perpetrator to continue working and providing care to residents. This led to multiple instances of verbal and physical abuse, causing distress and feelings of unsafety among the residents involved.
The facility administration failed to report and investigate abuse allegations, suspend staff pending investigations, and accurately document resident assessments. Incidents involved physical and verbal abuse, delayed reporting, and improper handling of care plans, affecting three residents and potentially all 47 residents in the facility.
The facility failed to honor the resident's right to share a room with their spouse and to visit other residents. Two residents expressed their desire to be in the same room, but their requests were not addressed promptly, and the facility lacked proper documentation and follow-up on their rooming preferences.
The facility failed to report allegations of verbal and physical abuse involving three residents to the Administrator and the Illinois Department of Public Health (IDPH). Despite residents and staff reporting incidents involving a CNA, the Administrator did not report the incidents to IDPH, and the CNA continued to work without being interviewed or suspended.
Failure to Ensure Resident Dignity and Respect in Daily Care and Staff Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect and that their input was valued, particularly in relation to staff attitudes, responsiveness, and thoroughness of care. Multiple residents with intact or moderately impaired cognition reported that CNAs, especially on the night shift, displayed “nasty” or exasperated attitudes when residents requested assistance. One resident with multiple medical conditions, including muscle wasting, lymphedema, venous insufficiency, and spinal stenosis, stated that a night CNA did not clean him adequately after incontinence episodes, wiping only the front and not further down despite his explanation that urine runs down due to gravity. Another resident with fractures, an artificial hip joint, and severe protein-calorie malnutrition reported that a male night CNA acted exasperated when she requested care, sometimes wiped her with a used brief, and did not adequately clean her when she had stool related to medication side effects. Several other residents with diagnoses such as anxiety, depression, COPD, diabetes with neuropathy, osteoporosis, epilepsy, dementia, and chronic pain described CNAs as snappy, short, rushed, or not always nice, with particular emphasis on evening and night shifts. Residents reported that call lights could take a long time to be answered, sometimes 45 minutes to an hour at night, and that staff would say they would return but often did not. One cognitively impaired resident, alert to situation at the time of interview, stated that some staff were not nice or gentle and that they did not return after saying they would, and that a recent request for ice was denied with the explanation that they were out. Another resident stated that staff were often too busy on their phones to pay attention and specifically identified a CNA who lacked patience with certain residents, noting that some residents “have nothing else” and need staff to be patient. Residents also reported issues with dietary and ancillary staff interactions that affected their sense of dignity and respect. One resident’s written concern described drinks not being made available until late in the afternoon despite repeated requests, leading residents to feel they were “making them mad” by knocking on the door. Another resident’s written complaint stated that the menu was posted late and too high to read, and that a kitchen worker became angry when asked for ice and told the resident to obtain it from a locked break room, causing the resident to stop asking for drinks due to staff reactions. Additional residents reported that kitchen staff were unhappy when residents knocked to request substitutes, that they sometimes had to knock multiple times because staff would not answer, and that night staff would not provide items such as milk. Multiple residents stated that concerns about staff attitudes, roughness, and rushing of more fragile residents had been discussed among residents and, at times, in resident council, although recent council minutes did not reflect these concerns. Facility leadership and some staff reported being unaware of poor staff attitudes, and resident council minutes documented few or no complaints about nursing, despite residents’ statements that they had raised these issues previously. The facility’s own Employee Standards of Conduct document, dated 07/2024, states that the company expects each employee’s conduct and performance to conform with the highest standards of professionalism in the treatment of residents, visitors, and families, and to comply with applicable laws and regulations. However, the resident interviews and written complaints describe repeated instances where staff behavior—such as exasperated responses, refusal or reluctance to provide requested care or beverages, inadequate cleaning after incontinence, delayed call light response, and visible irritation when residents requested information or substitutes—did not align with these standards. The DON stated she was not aware of poor CNA attitudes, and a CNA reported not having seen staff display attitudes with residents, which contrasts with the multiple resident accounts of disrespectful or dismissive interactions. These findings collectively demonstrate that the facility did not consistently maintain residents’ rights to dignity, respect, and self-determination in daily care and communication.
Failure to Provide Palatable, Hot Meals to Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and drink were provided in a palatable, attractive manner and at safe and appetizing temperatures for 14 of 15 residents reviewed. Multiple residents with intact or moderately impaired cognition reported that their meals were frequently cold or barely warm, with specific complaints that butter or margarine would not melt on hot items and that food appeared unappetizing. One resident with diagnoses including muscle wasting, anemia, and vitamin deficiencies stated that food quality, temperature, and insufficient meat portions had been raised several times with staff and in Resident Council, and that his food arrived cold and “gross,” which he attributed to his room being far from the kitchen. Surveyors directly observed and measured food temperatures that corroborated resident complaints. One resident received a lunch tray with peas that she refused to eat because they were cold; the peas were measured at 83°F using a calibrated thermometer, and the resident pointed out visible solidified grease on the beef stew. Another resident demonstrated that margarine placed on peas did not melt at all, and surveyors observed solid margarine spread over the peas with no signs of melting. A test tray obtained from the kitchen on another day showed tuna noodle casserole at 98°F and carrots at 103°F, temperatures that the acting dietary manager acknowledged should have been hotter and sufficient to melt margarine at least somewhat. Additional residents with diagnoses such as protein-calorie malnutrition, diabetes, GERD, anemia, and intellectual disabilities consistently reported that food was often cold, barely warm, or not good when cold, whether eaten in their rooms or in the dining room. One resident stated that food is one of the only things residents have to look forward to and expressed disappointment that it was generally not warm. Another resident reported being told that food would be hotter if she ate in the dining room, but she believed she should receive hot food in her room as well. Resident Council minutes over several months documented dietary complaints about specific menu items and service issues, though they did not specifically record temperature concerns. The acting dietary manager, who was also the Activities Director, stated she was unaware of any food council minutes and acknowledged that food should be hot regardless of where residents eat, while the Administrator stated he expected food to be hot when residents receive it, even though he was unsure of exact temperature standards. The facility’s policy on handling, serving, and transporting foods required proper holding temperatures and attractive presentation according to the menu, but the observed practices and resident reports showed that food was not consistently served hot or palatable. The facility’s failure to maintain appropriate food temperatures and palatability affected residents across multiple units and with varying cognitive and medical conditions. Residents repeatedly raised concerns in interviews and in Resident Council about cold food and poor quality, and surveyor observations of solid margarine on hot items and substandard temperatures on both resident trays and a test tray supported these complaints. Despite a written policy requiring proper holding temperatures and attractive presentation, the facility did not ensure that meals were consistently served hot and appetizing to residents in their rooms or in the dining area.
Failure to Provide Adequate Supervision During Smoking Breaks Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision during a designated smoking break, resulting in a resident with a history of falls and diabetic neuropathy sustaining significant injuries. The resident, who was cognitively intact and required supervision and touching assistance for ambulation, was attempting to navigate a ramp to the smoking area using a rolling walker. During this time, another resident with moderately impaired cognition and a history of impulsive behavior during smoke breaks was also present. The second resident, known for being impatient and having previously bumped into others with his walker, collided with the first resident, causing her to fall and sustain large skin tears and lacerations to both forearms, necessitating emergency medical care and wound specialist intervention. Multiple interviews with residents and staff confirmed that the second resident frequently rushed during smoke breaks, often bumping into others with his walker. Witnesses described the incident as the injured resident trying to move out of the way to avoid being run over, ultimately losing her balance and falling. Several other residents reported similar experiences of being bumped by the same individual during smoking breaks, with at least one other resident sustaining a skin tear as a result. Staff statements indicated that supervision during the incident was insufficient, as the supervising CNA was occupied distributing cigarettes and did not ensure all residents were safely in the smoking area before doing so. The facility's policies required supervision during smoking and interventions to address individual fall risks, but these were not effectively implemented. The care plan for the resident who fell included interventions for fall prevention, but did not address the specific risk posed by the other resident's impulsive behavior during smoke breaks. Additionally, the care plan for the resident with impulsive behavior had previously removed a focus area on his rushing during smoke breaks, despite ongoing incidents. The lack of adequate supervision and failure to implement appropriate interventions directly contributed to the accident and resulting injuries.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
Staff at the facility failed to maintain the privacy and confidentiality of residents' personal and medical information. Multiple residents, both cognitively intact and moderately impaired, reported overhearing staff discussing other residents' health issues, care, and personal backgrounds in common areas such as the dining room, outside smoking areas, and even in residents' rooms. Some residents also stated that staff would make fun of other residents during these conversations. These discussions were reportedly held in the presence of other residents, families, and staff, with specific instances of staff using residents' names while talking about their care. Interviews with staff members, including CNAs and the Activities Director, confirmed that conversations about resident care occurred in common areas where they could be overheard by others. The facility's confidentiality agreement explicitly prohibits the sharing of resident information except as required for care or by authorized personnel. Despite this policy, the practice of discussing resident information in public areas was observed and reported, affecting the privacy rights of all 52 residents in the facility.
Failure to Address and Resolve Resident Grievances Regarding Staff Attitudes
Penalty
Summary
The facility failed to address and resolve concerns raised by residents regarding the rude and disrespectful attitudes of some Certified Nurse Assistants (CNAs), as documented in resident council meeting minutes. Despite the issue being discussed and recorded in the resident council, there was no evidence that a grievance or concern form was completed, nor was there any documentation of investigation or resolution. Multiple residents, all cognitively intact as indicated by their BIMS scores, reported ongoing issues with staff rudeness, including dismissive or aggressive responses when requesting assistance. Staff interviews confirmed awareness of the problem, with some CNAs and the Activities Director acknowledging that certain staff members had been rude to residents. However, key personnel such as the Social Service Director, Administrator, and Director of Nursing were unaware of the complaints, and no in-service training or corrective action was documented. The facility's grievance policy requires prompt documentation, investigation, and resolution of all grievances, including those discussed in resident council meetings. However, the policy was not followed in this instance, as the concern about staff attitudes was neither formally documented nor addressed. The lack of communication and follow-through among staff and administration resulted in the residents' grievances remaining unresolved, affecting all 52 residents in the facility.
Unlicensed Nurse Provided Care and Administered Medications
Penalty
Summary
The facility failed to ensure that all nursing staff maintained appropriate and current licensure while working, resulting in an unlicensed individual performing duties as a nurse. Specifically, an LPN's license expired, and she continued to work as a nurse for a period of time without a valid license. The Director of Nursing (DON) and other staff confirmed that the lapse in licensure was not identified until after the LPN had already worked several shifts in the nursing role. The DON admitted that the LPN was a transfer from another facility and her license status was not checked upon transfer. Once the expired license was discovered, the LPN was removed from nursing duties and reassigned as a CNA while she worked to renew her license. During the period when the LPN's license was expired, she administered medications and provided nursing care to multiple residents with complex medical conditions, including Alzheimer's disease, bipolar disorder, chronic kidney disease, and various mental health disorders. Medication administration records confirmed that the unlicensed LPN dispensed a range of medications to several residents during this time. The facility census indicated that 52 residents could have been affected by this lapse in licensure oversight.
Failure to Consistently Provide Beverages to Residents
Penalty
Summary
The facility failed to consistently provide beverages to residents in accordance with their needs and preferences, resulting in multiple instances where residents did not have access to water or other drinks. Several residents, including those with significant medical conditions such as acute kidney failure, urinary tract infections, epilepsy, and cirrhosis of the liver, were identified as being at risk for dehydration and required assistance with personal care. Despite care plans indicating a risk for dehydration, residents and their family members reported that water and ice were not regularly passed out, and at times, residents were left without any drinks in their rooms. Observations confirmed that some residents did not have water or cups within reach, and staff interviews corroborated that the distribution of drinks was inconsistent. Multiple staff members, including CNAs and an agency LPN, acknowledged that water and ice were not always provided, citing staffing issues as a contributing factor. Resident council minutes and concern forms documented repeated complaints about the lack of drink distribution, with some residents stating they had to request water from night staff or that staff became upset when asked for drinks other than water. The facility had previously conducted an in-service on passing water and snacks, but there was no evidence of follow-up to ensure compliance. The deficiency had the potential to affect all 52 residents residing in the facility.
Staff Conflicts and Disruptive Behavior Compromise Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to maintain an environment that promotes the maintenance and enhancement of residents' quality of life, as evidenced by multiple incidents of staff members engaging in loud arguments, yelling, and using inappropriate language in the presence of residents. Interviews and record reviews revealed that staff conflicts, particularly among CNAs on the evening shift, were frequent and disruptive, with staff members yelling and cursing at each other in hallways and near the nurses' station. These altercations were witnessed by residents and other staff, and were described as ongoing and creating a chaotic atmosphere within the facility. One resident, who was cognitively intact and had a history of mental health diagnoses including bipolar disorder, schizophrenia, and anxiety, reported that staff frequently got loud and fought in front of residents, which contributed to agitation and restlessness. Staff interviews corroborated these accounts, with one CNA describing being harassed and verbally abused by coworkers to the point of feeling unsafe and needing to leave work early. Other staff, including an activity director and agency LPNs, confirmed that yelling and drama among staff were common occurrences, and that these behaviors were audible throughout the north and south halls where a large number of residents resided. Documentation showed that the facility's own policy required staff to treat residents, family members, coworkers, and visitors with respect, kindness, and professionalism at all times. Despite this, the environment described by both residents and staff was one of frequent conflict and lack of professionalism, directly impacting the residents' right to a dignified existence and a quality living environment.
Failure to Ensure Call Lights Are Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were consistently within reach for multiple residents who required assistance, as observed through direct observation, interviews, and record review. Several residents with significant medical conditions and varying levels of cognitive impairment were found with their call lights placed out of reach, sometimes on the floor, on bedside tables several feet away, or wrapped around bed lights. In some cases, residents were unable to summon help due to the inaccessibility of their call lights, and staff did not always respond to verbal requests for assistance. Specific examples include a resident with chronic respiratory failure and moderate cognitive impairment whose call light was repeatedly found three feet away while she was in bed, and another resident with vascular dementia and a history of falls whose call light was similarly out of reach. One resident, dependent for transfers and at risk for falls, was observed with her call light on the floor, and the cord was not long enough to reach her recliner. Residents and staff reported that call lights were sometimes intentionally placed out of reach, with one resident stating that staff would hide her call light or put it where she could not access it, and a CNA confirming that it was common practice to take away call lights from certain residents. The facility's own policy requires that call lights be available and easily accessible to all residents capable of using them, and that maintenance be notified if the call light cord is not long enough. Despite this, multiple observations and interviews confirmed that call lights were not consistently kept within reach, and some residents had to rely on others to turn on their call lights or resorted to yelling for help when they could not access them. Family members and staff corroborated that this was a recurring issue affecting several residents.
Staff Vaping Inside Facility Violates Smoke-Free Environment Policy
Penalty
Summary
Multiple residents who were alert and oriented reported observing staff members vaping inside the facility, including in hallways, resident rooms, and the break room. These observations were corroborated by several staff members, including CNAs and the Activities Director, who stated they had witnessed staff vaping in various areas of the building. One resident specifically identified a CNA vaping while pushing a resident in a wheelchair. The reports indicated that vaping occurred on both day and evening shifts and involved several staff members, some of whom were not named. Facility documentation, including an in-service form and the Employee Standards of Conduct, clearly stated that vaping is not permitted within the building and that violations of the non-smoking policy could result in corrective action or termination. Despite these policies and prior in-service training on vaping, staff continued to vape inside the facility, compromising the expectation of a smoke- and vape-free environment for residents.
Failure to Follow Menus and Provide Adequate Portions Leads to Food Shortages
Penalty
Summary
The facility failed to follow the prescribed menus and provide adequate portion sizes as directed, resulting in multiple instances where residents did not receive meals that met their nutritional needs. Several residents, including those with diagnoses such as protein-calorie malnutrition, diabetes, and vitamin deficiencies, reported that the facility frequently ran out of food or essential meal components. In some cases, residents received smaller portions or were given inappropriate food items, such as a diabetic resident being served two cinnamon rolls and a bowl of cereal due to a lack of suitable alternatives. Staff interviews corroborated these accounts, with multiple CNAs and dietary staff acknowledging that food shortages led to reduced portion sizes and an inability to provide seconds or alternative options when requested. Residents described situations where staff and sometimes other employees consumed food intended for residents, further contributing to shortages. There were also reports of the kitchen discarding leftover food after serving the main meal, leaving nothing available for residents who requested additional servings. The issue was not isolated to a single meal or day, as both residents and staff recounted repeated occurrences of running out of food, including breakfast meats and eggs, and lacking basic supplies like sugar and condiments. These deficiencies were documented through resident interviews, staff statements, and concern forms submitted by residents requesting larger portions and more snacks, especially during long intervals between dinner and breakfast. Care plans and medical records reviewed for affected residents indicated that many were at risk for malnutrition or had specific dietary needs that were not consistently met due to these failures. The facility's inability to ensure that menus were followed, meals were prepared in advance, and adequate food was available for all residents directly led to the deficiency. The administrator and dietary staff acknowledged awareness of the problem, with the administrator stating efforts were being made to address menu compliance, but the deficiency persisted at the time of the survey.
Failure to Provide Adequate Evening Snacks to All Residents
Penalty
Summary
The facility failed to provide sufficient evening snacks to ensure that every resident had access to a snack, as required by their needs and preferences. Multiple residents, including those with diagnoses such as protein-calorie malnutrition and those at risk for malnutrition, reported that evening snacks were inadequate, often limited to only two saltine crackers or other minimal options. Residents also noted that snacks were sometimes only available to certain groups, such as smokers, and that there was a lack of variety and quantity, with some residents suggesting that additions like peanut butter would make the snacks more suitable, especially for those with diabetes. Staff interviews consistently confirmed that the facility frequently ran out of snacks in the evening, with CNAs and LPNs stating that there were not enough snacks to serve all residents. Staff described situations where ambulatory residents would take preferred snacks, leaving little or nothing for others, and noted that mechanically altered diets were not always accommodated. Dietary staff reported assembling snack baskets with a limited number of items, estimating that the total number of snacks was often insufficient for the resident population, and that they did not count or track the distribution to ensure all residents received a snack. Documentation and resident council minutes further supported these findings, with written complaints about the lack of snacks and long intervals between dinner and breakfast without adequate nourishment. The facility's own policy required snacks to be provided as requested and at bedtime, but observations and interviews indicated that this was not consistently implemented. The deficiency was substantiated by direct resident statements, staff admissions, and review of facility records and snack basket contents.
Mental Abuse of Resident by Staff Through Derogatory Comparison
Penalty
Summary
A resident with multiple diagnoses, including COPD, depression, and anxiety disorder, was admitted with a care plan identifying a risk for abuse or neglect. The care plan included interventions such as assessing for abuse risk, educating the resident to report uncomfortable situations, and observing the resident during care and in the company of peers. Despite these measures, an incident occurred in which a Certified Nursing Assistant (CNA) showed other staff members a picture of a TV character on her cell phone, making a comparison to the resident's appearance and intelligence. The resident witnessed the CNA pointing at him and laughing, which caused him to feel humiliated. Multiple staff members confirmed that the CNA showed the image and made the comparison in the dining room, and some acknowledged that the comparison could be perceived as offensive. The resident reported feeling mocked and mortified by the incident, and a family member stated that the resident was upset and did not want to return to the facility. Written statements from staff corroborated the resident's account, with one CNA confirming that the comparison was made and the image was shown to others. The facility's policy affirms residents' rights to be free from abuse, neglect, and mistreatment, but the actions of the CNA constituted mental abuse, as determined by the facility's investigation.
Failure to Report Allegations of Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to report allegations of staff-to-resident abuse to the state agency and the facility administrator as required by policy. One resident with severe cognitive impairment and multiple medical conditions, including major depressive disorder and a need for assistance with personal care, made allegations that a staff member threatened her and that another staff member allowed shampoo to run into her eyes during a shower, causing her distress. The resident's care plan included interventions for behavior management and abuse risk, with instructions to investigate allegations per facility protocol and notify the abuse care coordinator immediately. Despite these protocols, the incident where the resident accused a staff member of threatening her was not reported to the Illinois Department of Public Health (IDPH), and the administrator did not obtain a statement from the resident at the time of the allegation. Staff interviews revealed that the resident had reported being mistreated during a shower, with one CNA witnessing the resident in distress and reporting it to a nurse. However, the nurse did not escalate the report to the administrator, and the administrator was not made aware of the incident until it was brought to her attention by IDPH. The facility's policy required immediate reporting of any incident, allegation, or suspicion of abuse, neglect, or exploitation to the administrator and, in cases of abuse, to the Department of Public Health within specified timeframes. In these cases, the required notifications and investigations were not completed as outlined in the policy, resulting in a failure to follow internal and regulatory reporting requirements for suspected abuse.
Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly and timely investigate an allegation of staff-to-resident abuse involving a resident with severe cognitive impairment and multiple medical conditions, including major depressive disorder, overactive bladder, and a history of cancer. The resident, who was dependent on staff for toileting, alleged that staff made threatening and inappropriate comments during a breakfast incident. The care plan for the resident included interventions for behavior management and a specific protocol for investigating abuse allegations, including checking for physical marks, interviewing assigned staff, and notifying the abuse care coordinator immediately. On the date of the incident, the resident accused staff of making a threatening statement, which was reported to the nurse by the Activity Director. The nurse notified the Administrator and DON, and statements were taken from several staff members present. However, the Administrator did not obtain a statement from the resident at the time of the incident and did not report the allegation to the Department of Public Health as required. The investigation was limited to staff interviews, and the staff members involved were not suspended during the investigation. The Director of Nursing was not aware of the allegation until much later, and there was confusion among staff regarding the resident's toileting schedule and care plan interventions. Documentation shows that the facility's abuse prevention and reporting policy required a thorough investigation of all allegations, including interviews with the person reporting the incident, the resident if interviewable, and review of all relevant documentation. Despite this, the facility did not follow its own protocol, as the investigation was incomplete and not timely, and the required notifications were not made. The failure to properly investigate and report the abuse allegation constituted a deficiency in the facility's response to alleged violations.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 hours per day, 7 days a week, as required. Record review and staff interviews confirmed that there was no RN coverage on several specific dates, and the Director of Nurses acknowledged the absence of RN staff on those days. Facility schedules for July and August documented the lack of RN coverage on multiple occasions, and the Director of Nurses confirmed via email that no RN was present during those times. This deficiency had the potential to affect all 50 residents currently residing in the facility. No information was provided regarding the specific medical history or condition of any individual resident at the time of the deficiency.
Failure to Administer Medications as Ordered Due to Unapproved Substitution
Penalty
Summary
The facility failed to administer medications as ordered for a resident with diagnoses including bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability. The resident had a physician's order for Preservision AREDS 2 Soft gel to be given once daily, which was documented on the Medication Administration Records (MAR) as being administered. However, interviews and observations revealed that the facility was actually administering Ocuvite instead of Preservision for an extended period. Staff, including LPNs and the DON, acknowledged that due to pharmacy and insurance issues, they substituted Ocuvite for Preservision without a physician's order to do so, and continued to document that Preservision was given. The pharmacist confirmed that Preservision and Ocuvite have different formulas and that no refills for Preservision had been provided since late April. The resident reported the issue to multiple staff members and administration, but the substitution continued until the resident contacted the State Survey Agency. The care plan did not address the resident's diagnosis of macular degeneration, and staff were unclear about how long the incorrect medication had been administered. The facility's policy requires medications to be administered as ordered by the physician, but this was not followed in this case, as staff substituted a different supplement and documented administration of the original ordered medication.
Failure to Administer Ordered Medication Due to Unapproved Substitution
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for a resident with diagnoses including bipolar disorder, delusional disorder, insomnia, and moderate intellectual disability. The resident had a physician's order for Preservision AREDS 2 Softgel to be given once daily, which was documented on the Medication Administration Records (MAR) as being administered. However, the resident reported that she was receiving Ocuvite instead of Preservision for her macular degeneration, despite informing nursing staff, administration, the DON, and the ADON. Upon inspection, it was confirmed that Preservision was only obtained after the resident contacted the State Survey Agency, and the medication bottle was dated the same day as the surveyor's visit. Interviews with staff revealed that the pharmacy stopped sending Preservision, and staff substituted Ocuvite based on information from the pharmacy and direction from the DON, without a physician's order to change the medication. The pharmacist confirmed that Preservision and Ocuvite have different formulas and that Preservision had not been refilled since the initial supply. Staff were unsure how long the resident had been receiving the incorrect medication, and the MARs continued to indicate that Preservision was administered, despite the substitution. The facility's policy requires medications to be administered according to physician orders and regulations, which was not followed in this case.
Failure to Provide Timely Dialysis Due to Transportation Breakdown
Penalty
Summary
A deficiency occurred when a facility failed to ensure that a resident dependent on dialysis received scheduled dialysis treatments. The resident, who had diagnoses including end stage renal disease, chronic diastolic heart failure, and dependence on renal dialysis, was admitted with a care plan specifying the need for regular dialysis to avoid complications. Despite this, the resident missed multiple dialysis appointments due to the facility's transportation van being out of service and the inability to secure alternative transportation. Documentation and interviews revealed that the resident missed dialysis sessions on several occasions, resulting in at least one hospital admission for dialysis and pulmonary venous congestion. The facility's progress notes and staff interviews confirmed that the transportation van was broken for approximately one and a half weeks, during which time the resident was unable to attend scheduled dialysis treatments. Attempts to arrange alternative transportation were unsuccessful, as local companies either did not operate early enough or did not service the area. The resident was sent to the hospital twice; on one occasion, dialysis was not provided, and on another, the resident was admitted overnight to receive dialysis. The dialysis center and hospital staff confirmed that the resident had not received dialysis for an extended period due to transportation issues. The facility's own policy required assistance in obtaining transportation for necessary medical services, but this was not achieved, resulting in missed life-sustaining treatments. The resident expressed awareness of the missed treatments and the importance of dialysis, and laboratory findings indicated a need for ongoing dialysis.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, which is a requirement for long-term care facilities. This deficiency was identified through interviews and record reviews, revealing that there was no RN on shift for specific dates in November and December 2024. The facility's agency nursing time reports documented the absence of RN coverage on 11/10/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/7/2024, 12/8/2024, and 12/21/2024. Interviews with a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Regional Director of Operations confirmed the lack of RN coverage on these dates. The facility did not have a specific policy on RN coverage, instead relying on general staffing regulations. This failure had the potential to affect all 40 residents living in the facility.
Deficiencies in Dishwashing Temperature and Food Handling Practices
Penalty
Summary
The facility failed to maintain the hot water source at the required minimum temperature for dishwashing, which could potentially affect all 40 residents. During an observation, the dish machine's water temperature was recorded at 80 degrees Fahrenheit, below the manufacturer's recommended minimum of 120 degrees Fahrenheit for proper dish cleansing and sanitization. The Dietary Manager acknowledged the issue, noting that the facility's two 40-gallon water heaters were insufficient when both the three-compartment sink and the dish machine were in use simultaneously. The Maintenance staff suggested a temporary procedure to avoid simultaneous use until a long-term solution is found. Additionally, improper food handling practices were observed in the kitchen. A cook was seen using the same pair of gloves to handle various tasks, including taking food temperatures and touching food directly, which could lead to cross-contamination. The Dietary Manager recognized the need to address this behavior, as it violated the facility's policy on proper hand washing and glove use, which requires changing gloves whenever hand washing is necessary or when gloves become contaminated.
Lack of Documentation for QAPI Meetings
Penalty
Summary
The facility failed to maintain documentation of quarterly Quality Assurance and Performance Improvement (QAPI) meetings, which is a requirement for ensuring ongoing quality assessment and improvement processes. During the investigation, no evidence of meeting attendance or information was found for any QAPI meetings held after February 16, 2024. This lack of documentation was confirmed by the Regional Director of Operations, who acknowledged that while the facility has been conducting these meetings, they were unable to produce any records to substantiate this claim. The facility's policy, last revised on October 24, 2022, outlines the purpose and guidelines for the QAPI program, emphasizing the need for an organized and systematic approach to quality improvement. The policy specifies that the QAPI Committee should identify issues, assess quality assurance activities, and develop action plans to address performance variations. However, the absence of documented evidence of these meetings suggests a failure to adhere to the policy, potentially affecting the quality of care for all 40 residents residing in the facility.
Failure to Provide Dietary Supplements as Ordered
Penalty
Summary
The facility failed to provide dietary supplements as ordered to four residents, leading to a deficiency in maintaining their nutritional status. Resident 4, diagnosed with dementia and vitamin deficiencies, was ordered a regular diet with mighty shakes twice a day due to a low BMI. Resident 13, with bipolar disorder and muscle wasting, was ordered mighty shakes with meals for significant weight loss. Resident 19, with dementia and Alzheimer's, was ordered mighty shakes with three meals to address weight loss. Resident 20, diagnosed with Alzheimer's and muscle wasting, was ordered mighty shakes at meals to encourage increased intake due to weight loss. Each resident's care plan included interventions to provide the diet as ordered to maintain adequate nutritional status. On the day of the survey, the dietary manager, V5, reported that the delivery truck arrived late, and the mighty shakes were frozen upon delivery. As a result, the residents did not receive their supplements for breakfast or lunch. V5 confirmed that residents who were supposed to receive supplements twice a day did not receive them at breakfast and lunch, and those ordered supplements three times a day did not receive them with each meal. This failure to provide the dietary supplements as ordered contributed to the deficiency in maintaining the residents' nutritional status.
Failure to Notify Law Enforcement in Abuse Investigation
Penalty
Summary
The facility failed to notify the proper authorities in an abuse investigation involving a resident, identified as R14, who was admitted with multiple diagnoses including peripheral vascular disease, heart failure, Type 2 Diabetes Mellitus, and chronic pressure ulcers. R14, who was cognitively intact with a BIMS score of 15, reported to a dayshift CNA that night shift CNAs were rude and took his laptop away. The facility's initial report to the IDPH Regional Office documented the allegation of verbal abuse and noted that the CNAs in question were suspended, and the physician and Power of Attorney were notified. However, there was no documentation indicating that the local police were notified, which was confirmed by the Regional Director of Operations. The facility's policy on Abuse Prevention and Reporting requires informing local law enforcement in certain situations, including when there is a reasonable suspicion that a crime has been committed. Despite this policy, the facility did not contact law enforcement regarding the incident involving R14. The final report submitted to the IDPH also lacked information on whether law enforcement was notified, highlighting a deficiency in the facility's adherence to its own abuse prevention and reporting procedures.
Failure to Implement Suicide Prevention Protocols
Penalty
Summary
The facility failed to provide necessary behavioral interventions and procedures for suicide observation and prevention for a resident with suicidal ideations. The resident, identified as R23, was admitted with multiple diagnoses including major depressive disorder, schizophrenia, and borderline personality disorder. Despite these conditions, the facility did not adequately monitor or document the resident's suicidal ideations as required by their policy. On a specific date, R23 expressed suicidal thoughts multiple times during a shift, but the staff did not document any follow-up actions or notify the physician immediately. The resident's care plan included interventions for monitoring signs of depression and suicidal thoughts, but these were not effectively implemented. The staff failed to complete a suicide checklist or assessment promptly, and there was no evidence of continuous monitoring or physician notification until days later. The facility's policy on suicide observation and prevention requires prompt notification of the physician and continuous monitoring of residents exhibiting suicidal tendencies. However, the staff did not adhere to these procedures, resulting in a lack of timely intervention and documentation. The Director of Nursing and Social Services Assistant were not informed of the situation until after the fact, and the necessary assessments and notifications were delayed, compromising the resident's safety and care.
Failure to Safeguard Medical Records Due to Water Damage
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. This deficiency was identified for three residents whose electronic health records (EHR) were missing critical documentation dated prior to the facility's transition to electronic records on January 29, 2025. The missing records included progress notes, behavior tracking, physician orders, and discharge summaries. The absence of these records was attributed to water damage in the medical records room caused by a burst pipe in the facility's sprinkler system, which rendered the paper records illegible. During interviews, facility staff confirmed the loss of paper records due to flooding and acknowledged the lack of a backup system to retrieve the missing information. The Regional Director of Operations and the Financial Coordinator both stated that the facility's electronic medical records system went live on January 29, 2025, and that the paper records prior to this date were destroyed and unreadable. This incident highlights the facility's failure to ensure the security and accessibility of medical records, resulting in a significant gap in the documentation of residents' medical histories.
Unauthorized Administration of Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as staff administered an injectable anti-psychotic medication, Chlorpromazine, twice within an 8-hour period without the resident's consent and without a physician's order. The resident, who had a history of Parkinsonism, Paranoid Schizophrenia, and other mental health disorders, was given the medication by an LPN without verifying the current medication orders. The medication had been discontinued in September 2023, and there was no valid order for its administration at the time of the incident. The LPN administered the first injection at 10:30 PM after the resident exhibited behaviors such as spitting and verbal aggression. The LPN did not inform the resident about the injection, and the resident expressed that the action was sneaky. A second injection was reportedly given at 5:30 AM, although this was not witnessed by the CNA who was monitoring the resident. The LPN admitted to not checking the medication orders or documenting the administration of the medication in the Medication Administration Record (MAR). As a result of the unauthorized administration of Chlorpromazine, the resident was sent to the emergency room with symptoms of lethargy, facial swelling, and a possible allergic reaction. The emergency room physician was not initially aware of the Chlorpromazine injections, which could have posed additional risks to the resident's health. The facility's failure to follow proper medication administration protocols and to attempt less restrictive alternatives before resorting to chemical restraints led to this deficiency.
Removal Plan
- Facility Restraint Policy was reviewed by Regional Director of Operations and was found to be in compliance with state and federal regulations.
- Facility Administrator initiated in-servicing, for all staff, on the use of non-pharmacological interventions for resident behaviors all other staff will be in-serviced before the beginning of the next shift.
- The Administrator will interview 3 staff members, 3 times weekly x4 weeks to ensure that staff understand using non-pharmacological interventions for resident behaviors.
- Director of Nursing in-serviced all nurses to obtain orders for the administration of an injectable anti-psychotic to be completed by the beginning of the next scheduled shift.
- Director of Nursing in-serviced all nurses on documenting all medication administration in the MAR to be completed by the beginning of the next scheduled shift.
- Social Service Director will interview 3 residents, 3 times weekly x4 weeks to ensure that residents are getting their medication as prescribed.
- IDT has assessed R1 and care plan updated to reflect non-pharmacological interventions for behaviors.
- IDT team reviewed all residents for the potential to not be free of abuse and care plans updated to reflect interventions to protect residents from abuse.
- IDT in-serviced by Regional Director of Operations to review any resident for changes in behaviors, increase in behaviors or new behaviors in order to investigate and identify any potential triggers prior to an incident, ensure that person centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff.
- Residents who trigger during this IDT review will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. Individualized intervention will be developed to decrease episodes of behaviors, in order to prevent situations that may cause abuse to a resident.
- The nurses in question were suspended pending investigation of the med error and ultimately terminated.
- ADON completed an audit of the medication carts and medication room to ensure there were no medications present that did not have orders from the physician.
Failure to Remove Discontinued Medication from Stock
Penalty
Summary
The facility failed to timely remove discontinued medication from the working stock for a resident diagnosed with multiple conditions including Parkinsonism, Paranoid Schizophrenia, and Heart Failure. The resident had a previous order for Chlorpromazine 100mg IM for psychosis, which was discontinued by the pharmacy after 14 days as per regulations. However, the medication remained on the medication cart, and staff were unaware of its discontinuation. A Licensed Practical Nurse (LPN) mistakenly pulled the medication, thinking it was Compazine, and prepared it for potential use without verifying the current orders. Another LPN later administered the medication during an incident involving the resident's aggressive behavior, unaware that the order had been discontinued. The medication remained on the cart in a box labeled with the resident's name, and it was not removed or destroyed as per the facility's policy on discontinued medications. The oversight was discovered when a charge nurse investigated the medication administration and found the box of Chlorpromazine with several ampules missing. The pharmacy confirmed that the order had been discontinued, and the facility's policy required discontinued medications to be removed and placed in a designated secure location. The failure to remove the discontinued medication led to its unauthorized administration to the resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from physical and verbal abuse, resulting in incidents involving two residents. One resident, R26, experienced mental and verbal abuse from a CNA, V34, who ripped the resident's clothing while transferring them to a wheelchair and verbally abused them. R26 reported feeling unsafe and experiencing mental anguish due to V34's actions. The abuse was substantiated by interviews with R26 and their roommate, who confirmed the rough handling and verbal aggression by V34. Another resident, R44, who had severe cognitive impairment, was also subjected to verbal abuse by V34. The CNA made threatening remarks about taking away the resident's call light if they continued to use it frequently. This behavior was witnessed by another CNA, V37, who acknowledged the verbal abuse but did not report it immediately. The facility's investigation confirmed the abuse allegations, and V34 was terminated. The facility's failure to protect these residents from abuse was further highlighted by inadequate documentation in the residents' care plans regarding their potential for abuse. Additionally, the facility's response to the abuse allegations was delayed, with the Regional Director of Operations forgetting about one of the allegations and the Administrator only interviewing a limited number of staff and residents. This lack of timely and thorough investigation contributed to the ongoing risk of abuse for the residents involved.
Removal Plan
- IDT team has assessed R26 and care plan updated to reflect potential for abuse and interventions to protect R26 from abuse.
- V34 CNA had been suspended pending outcome of an investigation and was terminated.
- Facility Abuse Prevention Policy was reviewed and was found to be in compliance with state and federal regulations.
- V44 Regional Director in-serviced the Administrator (V1) on the Abuse Prevention Policy, which included identifying types of abuse, investigating and reporting all alleged abuse allegations and immediately suspending employee, accused.
- Facility Administrator (V1) initiated in-servicing, for all staff, on the Abuse Prevention Policy prior to their shift, all staff on shift and will inservice all other staff prior to their next shift.
- The Administrator (V1) will interview 3 staff members, 3 times weekly x 4 weeks to ensure that staff, understand the Abuse Prevention Policy, timely reporting of abuse, who to report abuse to, types of abuse and immediately separating residents or suspending a suspected staff member.
- Resident council meeting was conducted to review the Abuse Prevention Policy and how to report abuse or perceived mistreatment. Resident council president and IDT team members present.
- Social Service Director (V6) will interview 3 residents, 3 times weekly x 4 weeks to ensure understanding of abuse and reporting of any abuse or perceived mistreatment, by another residents or a staff member.
- IDT team reviewed all residents for the potential of abuse and care plans updated to reflect interventions to protect residents from abuse.
- IDT in-serviced to review any resident for changes in behaviors, increase in behaviors or new behaviors in order to investigate and identify any potential triggers prior to an incident, ensure that person centered interventions are developed to alleviate/decrease behaviors and to communicate identified triggers and interventions to staff.
- Residents who trigger during this IDT review will be discussed during morning meeting and a root cause analysis will be completed to determine potential triggers. Individualized intervention will be developed to decrease episodes of behaviors, in order to prevention situations that may cause abuse to a resident.
Failure to Investigate and Prevent Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly and timely investigate an allegation of staff-to-resident abuse and failed to prevent further abuse from occurring. This failure involved four residents who were reviewed for abuse. One resident, who was cognitively intact, reported being physically tackled by a CNA on the night of admission, which exacerbated his chronic back pain. Despite reporting the incident to multiple staff members, the investigation was delayed, and the alleged perpetrator continued to work and provide care to residents, including the complainant, for several days before being suspended. Another resident with moderate cognitive impairment reported being verbally and physically abused by the same CNA, who would roughly handle him and verbally demean him during night shifts. This resident expressed feelings of unsafety and distress due to the CNA's actions. The facility's investigation substantiated these allegations, but the CNA continued to work for several days before being terminated. A third resident with severe cognitive impairment was verbally threatened by the same CNA, who threatened to take away the resident's call light if he continued to use it frequently. This incident was witnessed by another staff member who did not report it immediately. The facility's investigation into this allegation was incomplete, with only one staff member being interviewed. A fourth resident, who was cognitively intact, reported being verbally abused by the same CNA over loud music. The resident felt unsafe and reported the incident to a housekeeper, who then informed a nurse. The facility's investigation did not substantiate the allegation, and only staff members were interviewed, not residents. The facility's failure to promptly and thoroughly investigate these allegations and to protect residents from further abuse led to multiple instances of abuse and a lack of safety for the residents involved.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility administration failed to report abuse allegations, investigate them thoroughly and timely, suspend staff pending investigations, and accurately document resident assessments. This failure involved three residents (R26, R46, and R300) and had the potential to affect all 47 residents in the facility. The incidents included physical abuse allegations, verbal abuse, and improper handling of residents' complaints and care plans. One incident involved R300, who reported an allegation of physical abuse to a Psychiatric Rehabilitation Service Counselor (PRSC) on 5/3/2024. The PRSC did not report the allegation to the Administrator until 5/6/2024. The alleged perpetrator, a CNA, was not suspended until 5/10/2024, despite working multiple shifts in the interim. The investigation was delayed, and the care plan for R300 was updated to reflect false allegations without proper substantiation. Another incident involved R26, who reported that a CNA had ripped his clothes and verbally abused him. The resident expressed feeling unsafe and mentioned that the abuse had occurred within the past week. The facility's investigation substantiated the allegations, but the CNA was not suspended immediately. A third incident involved R46, who reported verbal abuse by a CNA. The Administrator did not believe the resident's allegations and did not report them. The facility's investigation only included staff interviews and did not involve any residents.
Failure to Honor Resident Rooming Preferences
Penalty
Summary
The facility failed to honor the resident's right to share a room with their spouse and to visit other residents. Resident R300 reported that his wife, R301, was moved out of their shared room to accommodate another male resident, and he was told by a CNA that he could not visit her past the double doors. Both R300 and R301 expressed their desire to be in the same room, but their requests were not addressed promptly. R300's medical records indicated he was cognitively intact, and R301's records showed she had intact cognition as well. Despite their clear preferences, the facility did not document or follow up on their rooming preferences adequately. The Social Services Director (V6) stated she was unaware of any rule preventing R300 from visiting R301 and admitted to not following up on R301's happiness with the room change. V6 also provided conflicting information about R301's request to move, initially stating R301 wanted to move away from her husband but later documenting that R301 wanted to move back in with him. The facility's records lacked proper documentation of the residents' rooming preferences, and there was no policy in place for resident rights pertaining to romantic partners choosing to reside in the same room. Eventually, R300 and R301 were reunited in the same room, but the facility's handling of the situation demonstrated a failure to respect and act on the residents' rights and preferences in a timely manner.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to identify and report allegations of staff-to-resident verbal abuse immediately to the Administrator and failed to report an allegation of abuse to the Illinois Department of Public Health (IDPH) for three residents. One resident, who was cognitively intact, reported that a CNA had verbally abused him by cursing at him over loud music. Despite the resident's report and corroborating statements from other staff, the Administrator did not report the incident to IDPH, believing the allegation was unsubstantiated. Another resident, who had severe cognitive impairment, was verbally threatened by the same CNA, but the incident was not reported by the witnessing CNA, who wanted to give the perpetrator a chance to improve his behavior. The resident was unable to provide a coherent account due to cognitive issues, further complicating the situation. A third resident, who was cognitively intact, reported being physically abused by the same CNA on the night of his admission. The resident described being tackled and dragged to the ground, which exacerbated his pre-existing back pain. Despite reporting the incident to multiple staff members, the investigation was delayed, and the CNA continued to work without being interviewed or suspended. The facility's Abuse Prevention Program mandates immediate reporting of abuse allegations to the Administrator and external authorities, but this protocol was not followed in these cases.
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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