Belvidere Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Belvidere, Illinois.
- Location
- 1701 5th Avenue, Belvidere, Illinois 61008
- CMS Provider Number
- 146071
- Inspections on file
- 22
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Belvidere Health And Rehab during CMS and state inspections, most recent first.
Several residents with contractures and hemiparesis did not receive regular restorative assessments or consistent range of motion (ROM) services as required. One resident with a history of stroke and right-sided hemiplegia was observed with a contracted hand and no splint, and family members raised concerns about lack of therapy. Staff confirmed that restorative assessments and services were not provided as per facility policy, and documentation showed missed or insufficient restorative care for multiple residents.
A resident with multiple cardiac and chronic conditions experienced a decline, including refusal of meals, shortness of breath, and low oxygen saturation. Staff delayed full assessment and documentation, and communication with the NP was not properly recorded. The resident was eventually sent to the ER and admitted for a non-STEMI, but the facility did not follow its change of condition policy for timely identification and documentation.
A resident was given an antibiotic for a presumed UTI despite the facility not obtaining a urine analysis or laboratory confirmation of infection. The antibiotic was started based on symptoms of decreased energy, and both the NP and DON were aware that no urine specimen had been processed, yet the medication was administered for several days.
A resident was prescribed an antibiotic for a presumed UTI without laboratory confirmation, as the urine specimen was not picked up and no SBAR form or urinalysis was documented. Despite facility policies requiring antibiotic use protocols and monitoring, these steps were not followed, resulting in the resident remaining on antibiotics without confirmed indication.
A resident with a history of mental health issues and aggression physically assaulted another resident during a bingo event, resulting in a bleeding and bruised lip. The altercation was witnessed by a nurse, and the facility's abuse prevention policy was not effectively implemented to prevent the incident.
The facility experienced CNA staffing shortages on evening shifts from October to December 2023, affecting all residents. Despite a plan of correction, the facility struggled with retention and call-offs, leading to insufficient staffing levels. Administrative staff, including the DON and other CNAs, covered shifts when needed. The facility's policy required staffing based on resident needs, supplemented by outside agencies.
The facility failed to date multi-dose insulin pens upon opening and did not dispose of expired medications for several residents. Insulin pens were found without opening dates, making it impossible to determine their expiration. A multi-dose vial of insulin was also found expired in the medication cart. The facility's policies require recording the date opened and disposing of outdated medications, but these were not adhered to, leading to the deficiency.
A facility failed to document advance directives for a resident with multiple health conditions, including dementia and chronic kidney disease. The resident's Facesheet, Physician Order Sheets, and EMR lacked necessary advance directive information, and the care plan did not address this until after a surveyor's interview. Staff acknowledged the oversight, which was contrary to the facility's policy requiring documentation of advance directives upon admission.
A resident with a cast on his left arm was found restrained by a side rail, which he could not remove himself. The facility lacked a physician's order, Side Rail Assessment, and Restraint Assessment for the use of the side rail, which was acknowledged by staff as potentially being a restraint. The resident was a high fall risk, but the facility did not have a care plan addressing the use of side rails or restraints.
A resident with COPD and other health conditions was using oxygen without documented physician orders or care interventions. The facility's policy requires such orders, but none were found in the resident's records. Staff confirmed the absence of necessary documentation, highlighting a deficiency in ensuring safe and appropriate respiratory care.
A facility failed to ensure proper monitoring and care planning for a resident requiring dialysis. The resident's care plan lacked details related to dialysis treatment, and there was no documentation of site monitoring. Staff interviews revealed poor communication with the dialysis center and uncertainty about the resident's dialysis access and monitoring procedures. The facility's policy on hemodialysis was not followed, leading to deficiencies in care.
A facility failed to document and reconcile the administration of Tramadol for a resident, resulting in a discrepancy in the narcotic count. The resident's electronic medical record showed three doses were given, but the paper count sheet only documented two. The shift change sign-out report was blank for several shifts, indicating a failure to properly reconcile the narcotic count as per facility policy.
Failure to Provide Restorative Services and Assessments for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate care and restorative services to maintain or improve range of motion (ROM) and mobility for several residents with physical limitations. One resident with a history of cerebral infarction and right-sided hemiplegia was observed with a contracted right arm and tightly closed fist, without any splint or device in place. Staff interviews confirmed that the resident was admitted with a contracted hand and had not been provided with a splint until occupational therapy was recently initiated, despite the last restorative assessment being over a year prior. The resident's family expressed concerns about the lack of exercises or therapy and the resident being in bed most of the time. The facility did not have a formal restorative program, and assessments were only conducted through the MDS process. Additionally, three other residents with documented hemiparesis and contractures were observed without evidence of regular restorative assessments or consistent provision of restorative services. Staff interviews indicated that restorative assessments should be completed quarterly and that services such as passive ROM should be provided every shift. However, records showed gaps in restorative minutes provided and missing assessments for the year. The facility's own policy stated that all residents would receive maintenance nursing services, but this was not consistently implemented for residents with physical limitations.
Failure to Timely Identify and Document Change in Condition
Penalty
Summary
The facility failed to identify and respond to a resident's change in condition in a timely manner. A female resident with a history of peripheral vascular disease, chronic heart failure, NSTEMI, atrial fibrillation, chronic kidney disease stage 3, hypertension, and muscle weakness was noted to have refused breakfast and lunch, consumed minimal fluids, and complained of not feeling well. She also reported shortness of breath, and her oxygen saturation was recorded at 89% on room air. Oxygen was applied, and Tylenol was administered for a mild fever. Two hours later, two nurses reassessed her and observed abdominal breathing and an irregular heart rate, prompting a call to the nurse practitioner and a decision to send her to the emergency room, where she was later admitted for a non-STEMI heart attack. Interview and record review revealed that the nurse did not document all assessments or communications with the nurse practitioner regarding the resident's condition. The nurse acknowledged that documentation was limited to a single progress note and that she should have documented more. The facility's policy requires prompt notification and documentation of significant changes in a resident's condition, including consultation with the physician and notification of the resident's representative, but this process was not fully followed in this case.
Antibiotic Administered Without Laboratory Confirmation
Penalty
Summary
A resident was prescribed and administered an antibiotic, Cefuroxime Axetil, for a presumed urinary tract infection (UTI) without laboratory confirmation of the infection. The resident exhibited decreased energy and was not acting like herself, prompting the facility to order a urine analysis (UA). However, due to repeated issues with the laboratory not picking up the urine specimen, no urinalysis results were obtained. Despite the absence of diagnostic confirmation, the resident was started on the antibiotic and received eight doses over several days. Progress notes and interviews confirm that both the nurse practitioner and the director of nursing were aware that the urine specimen had not been collected or processed, yet the antibiotic regimen was initiated and continued. The facility's policy requires that medications be administered only with adequate clinical indications, which was not met in this case as there was no documented evidence of a UTI or laboratory results to support the use of antibiotics.
Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to follow its antibiotic stewardship program, resulting in a resident being prescribed an antibiotic for a presumed urinary tract infection (UTI) without confirmation of the infection. The resident's electronic medical record indicated that an antibiotic was started, and although a urine specimen was collected for analysis, it was never picked up by the laboratory. Despite the lack of laboratory confirmation, the resident continued to receive the antibiotic. During an interview, the DON stated that nurses use McGeer's criteria and an SBAR form to determine the need for antibiotics and that residents on antibiotics are monitored as part of the stewardship program. However, the resident's record did not contain a completed SBAR form or documentation of a urinalysis. Facility policies require the implementation of antibiotic use protocols and monitoring as part of the infection prevention and control program, but these protocols were not followed in this instance.
Failure to Protect Resident from Abuse During Bingo Event
Penalty
Summary
The facility failed to protect a resident, identified as R2, from abuse by another resident, R1. R1, who has a history of altered mental status, psychosis, and adjustment disorder, exhibited physical aggression towards R2 during a community bingo event. R1's care plan noted behavioral distress and aggression, including physical and verbal aggression, which were triggered by poor impulse control and mood instability. R2, who has delusional disorders and a history of mental health problems, was verbally aggressive and had a history of making inappropriate comments towards staff. During the bingo event, R1 struck R2 multiple times in the face following a verbal altercation, resulting in R2 sustaining a bleeding and bruised lip. The incident was witnessed by a registered nurse who intervened to separate the residents. The Director of Nursing confirmed the altercation and noted that R1's actions were willful and intentional. The facility's policy on abuse prevention emphasizes the protection of residents from abuse, including physical injury inflicted deliberately. Despite this policy, the facility did not prevent the altercation, which resulted in physical harm to R2. The report highlights the failure of the facility to protect R2 from abuse by another resident, as required by their abuse prevention program.
CNA Staffing Shortages in Evening Shifts
Penalty
Summary
The facility failed to ensure sufficient Certified Nursing Assistant (CNA) staffing from October through December 2023, which had the potential to affect all residents residing in the facility. The facility's assessment indicated that the evening shift required four CNAs, but the schedules showed that on multiple occasions during these months, only 2 to 2.5 CNAs were scheduled. This staffing shortage was acknowledged by the Director of Nursing (DON), who mentioned that the facility had a plan of correction in place and that administrative staff, including the Activity Director, Receptionist, and Dietary Manager, who are also CNAs, would cover shifts if needed. The Administrator confirmed that the facility struggled with maintaining staff for the evening shift, particularly at the end of 2023, due to call-offs and retention issues. Despite hiring efforts, only one new hire remained. The Administrator also noted that if administrative staff covered the floor, it was reported in the system, indicating that any staffing triggers were due to actual shortages. The facility's policy stated that staffing should be based on resident needs and supplemented by outside agencies if necessary.
Failure to Date Insulin Pens and Dispose of Expired Medications
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens were dated when opened and did not dispose of expired medication for several residents. During an observation, five insulin pens belonging to different residents were found in a medication cart without the required date indicating when they were opened. The pens were labeled with a sticker stating they should be discarded after 28 days, but without the opening date, it was impossible to determine their expiration. A registered nurse acknowledged that the pens should have been dated upon opening, as they are only effective for 28 days. Additionally, a multi-dose vial of Fiasp insulin was found in the medication cart with an open date that indicated it was expired. The Director of Nurses confirmed that expired medications should be disposed of to prevent accidental use, as they may lose potency and effectiveness. The facility's policies require that the date opened be recorded on multi-dose vials and that no outdated medications be available for use, but these procedures were not followed, leading to the deficiency.
Failure to Document Advance Directives for Resident
Penalty
Summary
The facility failed to ensure that a resident had an order or care plan for advance directives. This deficiency was identified for one resident who was admitted with multiple diagnoses, including a left arm fracture, atrial fibrillation, stage 4 chronic kidney disease, diabetes, dementia, congestive heart failure, dysphagia, and depression. Upon review, it was found that the resident's Facesheet, which should have contained information about advance directives, was blank. Additionally, the resident's Physician Order Sheets and Electronic Medical Record (EMR) did not contain an order for advance directives or a scanned POLST form. The care plan also did not address advance directives until after the surveyor's interview with the Social Services Director. During interviews, a Registered Nurse and the Social Services Director both acknowledged the absence of advance directive information in the resident's records. The Registered Nurse explained that the facility's process involves entering advance directive orders into the EMR upon a resident's admission from the hospital, but this was not done for the resident in question. The Social Services Director admitted responsibility for the care plan and acknowledged that the necessary information was missing from the resident's chart. The facility's Advance Directives Policy requires that residents be informed of their rights to accept or refuse treatment and to formulate an advance directive, but this was not adhered to in this case.
Failure to Ensure Resident is Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as R156, was free from the use of physical restraints. During observations on multiple occasions, R156 was found in bed with a side rail pulled up, which he could not remove himself due to his physical limitations. R156 had a blue cast on his left arm, rendering him unable to use it to grab the side rail, and he was observed making attempts to move in bed but was unable to sit up or reposition himself. The side rail was positioned in such a way that it could only be adjusted by someone outside the bed, effectively restraining R156. Interviews with facility staff, including CNAs and an RN, revealed that there was no physician's order for the use of side rails as restraints, nor was there a completed Side Rail Assessment or Restraint Assessment in R156's electronic medical record. Staff acknowledged that the side rail could be considered a restraint since R156 was unable to get out of bed on his own. The facility's policies required assessments and consent for restraint use, but these were not completed for R156. R156 was admitted to the facility with a history of falls and a broken arm, and he was identified as a high fall risk. Despite this, the facility did not have a care plan addressing the use of side rails or restraints for R156. The lack of proper assessments and documentation, as well as the absence of a care plan, contributed to the deficiency in ensuring R156 was free from unnecessary restraints.
Lack of Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to ensure that physician orders and interventions were in place for the administration of oxygen to a resident diagnosed with chronic obstructive pulmonary disease (COPD), atrial fibrillation, congestive heart failure, and the presence of a cardiac pacemaker. The resident, who was observed using oxygen at 1.5 liters per minute via a nasal cannula, did not have any documented physician orders or care interventions related to oxygen use in their medical records. The resident reported using oxygen at night and occasionally during the day while napping, but there was no formal documentation or care plan to guide this practice. A registered nurse and the Director of Nurses confirmed the absence of necessary physician orders and care interventions for the resident's oxygen use. The facility's policy on oxygen administration requires obtaining or reviewing a physician's order, which should include the flow rate and method of administration, as well as monitoring and documenting the resident's response to oxygen. The lack of these orders and interventions was identified as a deficiency, as oxygen is considered a medication that requires a physician's order to ensure safe and appropriate use.
Inadequate Dialysis Care and Monitoring for Resident
Penalty
Summary
The facility failed to provide adequate monitoring and care planning for a resident requiring dialysis treatment. The resident, who has a history of anoxic brain damage, chronic kidney disease, end-stage renal disease, hyperkalemia, acute kidney failure, and Type 2 Diabetes, was observed without a care plan related to her dialysis treatment. The facility's records lacked essential information, such as the name and contact details of the dialysis treatment center, and there was no documentation of monitoring the dialysis site in the electronic Treatment Administration Record (eTAR). Interviews with facility staff revealed a lack of communication and coordination with the dialysis center. The RN and DON admitted to not performing pre and post-treatment weights and not having emergency equipment at the resident's bedside. The staff also demonstrated uncertainty about the type of dialysis access the resident had and the necessary monitoring procedures. The facility's policy on hemodialysis was not followed, as it required the development and implementation of a care plan, assessment and documentation of the fistula or graft site, and obtaining post-dialysis weights, none of which were adequately addressed for the resident.
Failure to Document and Reconcile Narcotic Administration
Penalty
Summary
The facility failed to properly document and reconcile the administration of a narcotic medication for a resident, leading to a discrepancy in the narcotic count. The resident had an order for Tramadol HCl 50 mg to be administered every six hours for pain. During a review of the medication cart, it was found that the Tramadol card had 19 tablets remaining, while the count sheet indicated 20 tablets. The discrepancy was identified by a registered nurse during a shift change count, revealing that three doses had not been signed out on the previous shifts. The electronic medical record confirmed that the three doses were administered, with one dose given by an LPN during the PM shift and two doses given by a registered nurse during the night shift. However, the paper count sheet only reflected the two doses given by the night shift nurse, with no documentation for the dose given by the LPN. Additionally, the shift change sign-out report was blank for several shift changes, indicating a failure to properly reconcile the narcotic count. The facility's narcotic policy requires two nurses to count narcotics at the beginning and end of each shift, and any discrepancies should be reported immediately to the Director of Nurses.
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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