Bella Terra Wheeling
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheeling, Illinois.
- Location
- 730 West Hintz Road, Wheeling, Illinois 60090
- CMS Provider Number
- 145835
- Inspections on file
- 39
- Latest survey
- June 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bella Terra Wheeling during CMS and state inspections, most recent first.
Two cognitively impaired residents, both assessed as high risk for abuse, were involved in an incident where one physically injured the other, resulting in facial lacerations and swelling. Despite policies requiring an abuse-free environment, the altercation occurred in a shared room, and the injured resident was non-verbal and fully dependent on staff.
A resident with multiple health issues experienced a fall and subsequent shoulder pain, which was not adequately assessed or documented by the nursing staff. Despite complaints of increased pain, the staff failed to recognize the change in condition, leading to a delay in hospitalization and treatment for a shoulder fracture. The facility's policies on documentation and communication were not followed, resulting in a deficiency.
A resident with spastic quadriplegic cerebral palsy reported being roughly transferred and allegedly fondled by a male CNA during a mechanical lift transfer. Despite expressing distress, the involved CNAs did not report the incident immediately, as required by the facility's abuse policy. The resident reported the incident the following day, highlighting a deficiency in the facility's adherence to its abuse reporting procedures.
Two cognitively impaired residents, both at high risk for falls, were unsupervised and not using their walkers when one resident fell, causing the other to sustain a nasal fracture. Despite care plans indicating the need for supervision and assistive devices, staff failed to monitor the residents, leading to the incident. Interviews with facility staff confirmed the lack of supervision, and the facility's policies on fall prevention were not adequately followed.
The facility failed to administer medications as scheduled for three residents, with delays ranging from one to two hours. The Director of Nursing acknowledged that medications should be given within one hour of the scheduled time and that physicians should be notified of significant delays, but no such notifications were documented.
A resident with heart failure had a low potassium level and was started on Potassium Chloride, but the POA was not notified. The RN admitted to not informing the POA, and the NP confirmed that the medication change was not discussed with the POA. The facility's policy mandates notification of such changes, which was not adhered to in this case.
A resident in a long-term care facility was involved in an altercation with a CNA, resulting in bruising and lacerations on the resident's arm. The resident reported being verbally and physically assaulted by the CNA, while the CNA claimed self-defense. An LPN observed the resident's injuries but did not see any on the CNA. The facility's investigation deemed the abuse allegation unsubstantiated, despite inconsistencies in the accounts.
A resident with severe cognitive impairment and high fall risk suffered a hip fracture after a CNA attempted to dress her by sitting her on the edge of the bed, contrary to her care plan requiring maximum assistance and mechanical lift transfers. The facility's fall prevention protocols were not adequately followed, and the injury was not discovered until hours later, highlighting a deficiency in the facility's care practices.
A resident reported feeling disrespected by a CNA who allegedly used inappropriate language during care. The resident, with a complex medical history, expressed discomfort and reported the incident to the facility. The CNA denied the allegations and was suspended during the investigation. The facility's policy emphasizes the importance of providing safety and good care.
The facility failed to follow its intravenous therapy policy and accurately monitor a resident's condition, leading to a delay in care and the spread of MRSA. The resident, with a history of severe heart conditions, developed symptoms such as chills and elevated white blood cell count, which were not promptly addressed. The resident was eventually diagnosed with a MRSA infection in the PICC line, spreading to the knee and lungs, resulting in MRSA pneumonia.
The facility failed to ensure food containers were stored off the floor and that staff employed hygienic practices during food handling. Six cans of fruit cocktail were found on the floor in the dry storage room, and a dietary aide was observed touching her eyeglasses with gloved hands and then continuing to prepare food without changing gloves or performing hand hygiene.
The facility failed to implement appropriate transmission-based precautions and provide necessary PPE supplies for three residents under isolation. A resident with COVID-19 had incorrect signage, and two residents with MRSA sacral wounds lacked necessary glove supplies in their PPE bins. Staff confirmed these deficiencies, which were against the facility's infection prevention policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in one resident sustaining physical injuries from another resident. Both residents involved had significant cognitive impairments and were assessed as high risk for abuse, with diagnoses including dementia, Alzheimer's disease, and delusional disorder. On the morning of the incident, a nurse found one resident standing next to the other's bed holding a pillow, with the injured resident displaying new lacerations to the forehead and swelling to the left eye. Staff interviews confirmed that the injured resident had no visible injuries earlier that morning, and the aggressor was observed to be confused and unable to explain his actions. The facility's policy requires an environment free from abuse, including physical harm inflicted by others. Despite both residents being identified as high risk for abuse, the incident occurred in a shared room without apparent preventive measures in place to separate or monitor them more closely. The injured resident was non-verbal and fully dependent on staff for care, further increasing vulnerability. The failure to prevent this altercation directly resulted in physical harm to the resident.
Failure to Address Acute Change in Condition
Penalty
Summary
The facility failed to provide adequate care for a resident, identified as R107, who experienced an acute change in condition. R107, a female with multiple diagnoses including a wedge compression fracture, dysphagia, and repeated falls, reported falling out of bed and subsequently experiencing pain in her right shoulder. Despite the resident's complaints of increased pain, the nursing staff did not perform a comprehensive assessment or document the change in condition, leading to a delay in the resident's hospitalization and treatment for a right shoulder fracture. Interviews with the nursing staff revealed that the resident's complaints of shoulder pain were not adequately assessed or documented. A registered nurse, V12, noted discoloration and swelling in the resident's shoulder during a shift but did not receive prior reports of the injury. Another nurse, V7, provided pain medication but did not document any assessment, assuming the pain was consistent with the resident's chronic pain history. The attending physician was only notified after the condition worsened, and an x-ray confirmed a fracture. The lack of documentation and failure to recognize the resident's pain as a change in condition contributed to the delay in appropriate medical intervention. The facility's policies require nurses to document assessments and notify physicians of significant changes in a resident's condition, which was not adhered to in this case. The deficiency highlights the need for thorough assessments and timely communication to ensure residents receive necessary care.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to adhere to its abuse policies and procedures by not immediately reporting an allegation of abuse involving a resident, identified as R86. R86, a 39-year-old resident with spastic quadriplegic cerebral palsy and other medical conditions, reported being roughly transferred and allegedly fondled by a male CNA, V8, during a mechanical lift transfer. Despite expressing discomfort and distress during the incident, R86's concerns were dismissed by the involved CNAs, V8 and V9, and were not reported to the administration immediately as required by the facility's policy. R86 reported the incident the following morning to an RN, V16, after feeling unsafe and distraught overnight. The RN confirmed that no staff had reported any concerns to her on the night of the incident. Both CNAs involved, V8 and V9, acknowledged the resident's complaints but failed to report them, with V8 believing there was no issue to report and V9 assuming V8 would handle it. The facility's administrator and director of nursing provided conflicting interpretations of the reporting requirements, suggesting a lack of clarity in the facility's abuse reporting policy. The facility's policy mandates immediate reporting of any allegations of abuse, including unwanted touching, to the administration. However, the staff involved did not follow this protocol, resulting in a delay in addressing the resident's allegations. The facility's documentation, including timecards and training records, confirmed the presence of the involved staff during the incident and their acknowledgment of the reporting requirements, yet the failure to act promptly led to a deficiency in the facility's handling of the situation.
Lack of Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide appropriate assistive devices and staff supervision for two cognitively impaired, high-risk fall residents, resulting in an accident. Resident 1, who has severe cognitive impairment and a history of falls, was ambulating in the hallway without the use of a walker and without staff supervision. Resident 1 was holding hands with Resident 2, who also has severe cognitive impairment and is at high risk for falls. As Resident 2 began to fall, Resident 1 was pulled forward and bumped their nose on a hallway countertop, resulting in a nasal fracture. Resident 1's clinical records indicate a high risk for falls due to an unsteady gait, memory problems, and the need for assistance or an assistive device when walking. The care plan for Resident 1 included interventions such as cueing assistance and reminders to use a walker. Similarly, Resident 2's records show a high risk for falls, with a need for staff assistance and frequent reminders to use a walker. Despite these documented needs, both residents were unsupervised and not using their walkers at the time of the incident. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, confirmed that both residents require supervision and assistance when walking. The staff acknowledged that the residents were not being monitored at the time of the incident, and the Director of Nursing witnessed the event. The facility's policies on fall prevention and general care emphasize the importance of assessing fall risk and implementing appropriate interventions, which were not adequately followed in this case.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure medications were administered as scheduled per physician orders for three residents. Resident 3 reported receiving their 9:00 AM medications two hours late, close to lunchtime. Resident 4 received their 9:00 AM medications late, with insulin injections and other medications administered more than two hours past the scheduled time. Resident 5's medications were also administered late, more than one hour past the scheduled time. The facility did not document any notification to the physician regarding these late administrations. The Director of Nursing stated that medication administration should occur within one hour before or after the scheduled time, and if medications are given late, the physician must be notified, especially for significant medications like insulin and anticoagulants. However, the facility's records did not show any such notifications. The facility's policy requires that all medications be administered according to physician orders, and any deviations should be documented and communicated to the physician, which was not done in these cases.
Failure to Notify POA of Abnormal Lab Result and Medication Change
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) about an abnormal laboratory result and a change in medication. The resident, who has heart failure, had a low potassium level of 2.2 and was started on Potassium Chloride 40 meq tablet. Despite the significance of this change, the POA was not informed. The Registered Nurse responsible for the resident's care acknowledged not notifying the POA and stated that such notification would have been documented if it had occurred. The Nurse Practitioner also confirmed that discussions with the POA did not include the resident's new potassium medication. The facility's policy requires notification of any change in a resident's status, including abnormal lab results and new medication orders, but this was not followed in this instance.
Resident Assaulted by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical harm and mental abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who has a history of dementia, anxiety disorder, and other medical conditions, was involved in an altercation with the CNA. The resident reported that the CNA verbally and physically assaulted her, resulting in bruising and lacerations on her right forearm. The incident occurred after the resident requested assistance from the CNA, which led to a confrontation where the CNA allegedly slapped and grabbed the resident's arm. The CNA provided a different account of the incident, claiming that the resident was the aggressor, scratching and attempting to hit her. The CNA stated that she held the resident's arm in self-defense and then left the room. A Licensed Practical Nurse (LPN) who responded to the commotion observed scratches on the resident's arm and noted that the resident was asking the CNA to leave the room. The LPN did not observe any injuries on the CNA and did not witness the resident chasing or attempting to hit the CNA. The facility's investigation concluded that the allegation of physical abuse was unsubstantiated, citing the resident's own admission of reaching out towards the CNA. However, the surveyor noted inconsistencies in the accounts provided by the staff and the resident. The facility's policy on abuse and neglect emphasizes the importance of providing care in an environment free from abuse, yet the incident highlights a failure to ensure the resident's safety and well-being during the altercation.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to prevent an accident involving a severely cognitively impaired resident, identified as R2, who was at high risk for falls. R2, a female resident with multiple diagnoses including a displaced intertrochanteric fracture of the right femur, epilepsy, and severe cognitive impairment, was admitted to the facility with a history of falls. On the day of the incident, a Certified Nursing Assistant (CNA) attempted to dress R2 by sitting her on the edge of the bed, despite R2's need for maximum assistance with activities of daily living (ADLs) and a requirement for mechanical lift transfers. During this process, R2 began to lean forward and fell to the floor, resulting in a comminuted displaced fracture of the right femur. Interviews with facility staff revealed that the CNA was accustomed to sitting R2 on the edge of the bed to dress her, although this was not consistent with R2's care plan, which indicated the need for maximum assistance and mechanical lift for transfers. The CNA and other staff members did not recognize the risk associated with this practice, and the facility's fall prevention protocols were not adequately followed. The Director of Nursing and other staff members acknowledged that R2 required significant assistance and that interventions such as bed alarms and floor mats were in place, but these measures were insufficient to prevent the fall. The facility's incident report and subsequent interviews highlighted a lack of appropriate assessment and intervention following the fall. Although R2 was initially assessed for injuries and appeared to be at her baseline, her hip fracture was not discovered until several hours later when she exhibited signs of pain and a change in leg appearance. The facility's fall occurrence policy emphasized the need for reassessment and revision of interventions for high-risk residents, but this was not effectively implemented in R2's case, leading to the deficiency identified by the surveyors.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, a female with a complex medical history including anxiety, autoimmune hemolytic anemia, and other conditions, reported that the CNA used inappropriate language while providing care. The resident expressed discomfort and felt disrespected by the CNA's behavior. The incident was reported to the facility by both the resident and her family member. The CNA involved in the incident denied using inappropriate language and stated that they were suspended during the investigation. The Director of Nursing noted that the resident is alert and oriented but forgetful, and suggested that the resident might be seeking attention from her family member. The facility's policy on residents' rights emphasizes the importance of providing safety and good care, which was not upheld in this instance.
Failure to Follow Intravenous Therapy Policy and Monitor Resident Condition
Penalty
Summary
The facility failed to follow its intravenous therapy policy and accurately assess and monitor a resident's signs, symptoms, and changes in condition, leading to a delay in care and the spread of MRSA. Specifically, the facility did not properly monitor and report significant changes in the resident's arm circumference and external catheter length, which are critical indicators of potential complications with a PICC line. The resident, who had a history of severe heart conditions and was admitted with a PICC line, developed symptoms such as chills, elevated white blood cell count, and malaise, which were not promptly addressed by the staff. The resident's medical records indicated fluctuating arm circumference measurements and multiple complaints of knee pain, which were not reported to the physician as required. Despite the resident's complaints and abnormal lab results, the staff failed to recognize and act on the signs of a potential infection. The resident was eventually transported to the hospital, where they were diagnosed with a MRSA infection in the PICC line, which had spread to the right knee and lungs, resulting in MRSA pneumonia. Interviews with the facility's staff revealed a lack of adherence to the PICC line protocol, including the failure to notify the physician of significant changes in the resident's condition. The nurse practitioner noted that the PICC line was likely infected due to improper aseptic technique during care. The facility's intravenous therapy policy mandates regular assessment and monitoring of intravenous access sites, which was not followed in this case, leading to severe health complications for the resident.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure food containers were stored off the floor and that staff employed hygienic practices during food handling in the dining room. During an initial tour, six cans of fruit cocktail were observed on the floor in the dry storage room. The cook acknowledged that the cans should not be on the floor, and the administrator confirmed that food should be stored on shelves. Additionally, a dietary aide was observed touching and adjusting her eyeglasses with gloved hands and then continuing to prepare food without performing hand hygiene and changing gloves. The dietary aide admitted that she should have changed gloves before continuing to prepare food. The assistant director of nursing and infection control confirmed that the dietary aide should have removed her gloves and performed hand hygiene after touching her eyeglasses before continuing her task.
Failure to Implement Appropriate Transmission-Based Precautions and Provide Necessary PPE
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions and provide necessary personal protective equipment (PPE) supplies for three residents under isolation. Specifically, a resident identified as COVID-19 positive was observed with only a Contact Precaution sign outside their room, while the correct precaution should have been both Contact and Droplet Precautions. This discrepancy was confirmed by multiple staff members, including the Licensed Practical Nurse (LPN), Director of Nursing (DON), and Assistant Director of Nursing/Infection Control. Additionally, two other residents on Contact Precaution for MRSA sacral wounds had PPE bins outside their rooms that lacked necessary glove supplies. This issue was acknowledged by a Registered Nurse (RN) who stated that the Central Supply Personnel were responsible for ensuring PPE availability. The Assistant Director of Nursing/Infection Control also confirmed that the isolation bins should have complete PPE supplies, including gloves. The facility's policy on Infection Prevention and Control, revised in October 2023, mandates that transmission-based precaution setups should include PPE like gowns and gloves and appropriate signage indicating the type of precaution required.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
