Benton Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Benton, Illinois.
- Location
- 1409 North Main Street, Benton, Illinois 62812
- CMS Provider Number
- 146121
- Inspections on file
- 30
- Latest survey
- September 30, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Benton Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
Several residents with respiratory and other chronic conditions underwent pulmonary function tests (PFTs) without documented physician orders. Staff interviews confirmed that an outside respiratory therapist performed the tests at the facility's request, and that physician authorization was not obtained or documented. The DON and other staff acknowledged that orders should have been in place, but could not account for their absence. The physician declined to sign orders for subsequent tests, and the facility administrator stated the tests were done as a screening measure, despite the lack of proper authorization.
During a meal service, several residents on altered textured diets were served incorrect portion sizes of turkey, with only 2 ounces provided instead of the required 3 to 3.75 ounces as specified in the facility's menu and recipes. This error was confirmed through observation, record review, and staff interview, affecting multiple individuals who required either pureed or mechanical soft diets.
Staff did not consistently assist two residents with significant physical and cognitive impairments during meals in a dignified manner, as required by facility policy. Instead of sitting beside each resident and feeding them one at a time, staff were observed standing while feeding and assisting more than one resident simultaneously.
A resident with multiple complex medical conditions experienced a significant weight loss of over 11% in one month. Despite facility policy requiring notification, neither the physician nor the POA was informed of this change. Interviews confirmed that the responsible parties were unaware of the weight loss, and documentation of notification was absent.
A resident with hemiplegia and moderate cognitive impairment had a dresser in disrepair, with a missing drawer front and a bottom drawer that frequently fell out. The issue persisted over several days and was not reported in the facility's maintenance logs. The Maintenance Director was unaware of the problem, as repairs rely on staff reporting and no routine room checks were conducted, contrary to facility policy requiring regular upkeep.
A resident with psychiatric diagnoses and prescribed antipsychotic medication did not receive an accurate AIMS assessment. The resident experienced and reported involuntary right arm movements, which were also observed by staff, but the RN completing the assessment marked 'none' for upper extremity movement. The DON confirmed the assessment was inaccurate, and the facility lacked a policy for AIMS assessments.
A resident with a seizure disorder and history of falls was not consistently supervised or provided with effective interventions to prevent falls, particularly after smoking. Staff were largely unaware of specific fall prevention measures related to the resident's seizure risk, and interventions such as encouraging the resident to sit or lie down after smoking were not reliably implemented.
A resident with COPD and heart failure was observed with oxygen tubing dragging on the floor and using a humidification bottle that was not dated. Facility protocol required weekly changes and dating of oxygen tubing, but records did not document when or if these changes occurred, resulting in a deficiency in respiratory care.
A resident with moderate cognitive impairment and a history of chronic conditions experienced ongoing dental pain and was prescribed Oragel, which was never administered. Despite a dental referral recommending extractions, there was no evidence of follow-up or interventions in the care plan or progress notes. The resident reported frequent toothaches and was told by staff that dental care was not covered by insurance, leading to a lack of timely dental services and appropriate documentation.
Two residents who had provided consent for influenza and pneumococcal vaccinations did not receive the immunizations as ordered and documented. One resident with multiple health conditions had a signed consent for the flu vaccine but was not vaccinated due to insurance denial, with no clear facility policy for such situations. Another resident had consented to pneumococcal vaccination, and the vaccine was available in the medication room, but it was not administered, and staff reported no specific policy for this vaccine.
Surveyors found that two rooms housing multiple residents did not meet the required 80 square feet of living space per resident, with actual measurements showing less space per bed. The rooms were waivered and Medicaid certified, and while most residents expressed satisfaction with their accommodations, one noted a desire for more space. No concerns were reported by residents, families, or in Resident Council meeting minutes.
The facility failed to maintain a clean and sanitary shower room on the South Hall, affecting 23 residents. An unknown black substance was found in the corner behind the toilet in shower room B, which could not be removed by housekeeping. Residents expressed concerns about the cleanliness of the bathrooms. The facility's policy requires routine and deep cleaning, but the buildup suggests a lapse in adherence to these guidelines.
A former BOM misappropriated funds from resident trust accounts and individual checking accounts, affecting 50 residents. Checks were written for cash without proper documentation, and residents reported not receiving ordered items. The BOM had a disqualifying criminal offense that was not identified due to a lack of a background check. The facility failed to monitor the handling of resident funds, leading to significant unaccounted amounts.
A facility failed to manage and safeguard resident trust funds, leading to a significant financial discrepancy. The Business Office Manager was involved in writing checks from resident accounts without proper documentation, resulting in unaccounted funds. An investigation revealed that the facility's policies for managing resident funds were not followed, leading to the misappropriation of funds.
The facility failed to maintain accurate records for residents' trust funds, affecting 50 residents. An investigation revealed that the Business Office Manager mishandled funds, leading to discrepancies in the resident trust petty cash box and bank account. Checks were written to cash without proper documentation, and a resident's account showed large withdrawals with no receipts. The facility's policies requiring dual signatures and receipts were not followed, resulting in misappropriation of funds.
The facility failed to conduct a pre-employment background check on the Business Office Manager, who was later found to have a disqualifying criminal offense. This oversight allowed the manager to misappropriate funds from resident trust accounts, affecting fifty current and former residents. The issue was discovered during an investigation into an allegation of misappropriation of resident property.
Staff failed to promptly report and investigate allegations of misappropriation of funds by a former Business Office Manager. Concerns were initially raised by a housekeeper and a transportation staff member about missing cash and irregular financial transactions involving residents. The Administrator dismissed these concerns, delaying the investigation until it was escalated to corporate management.
The facility failed to promptly investigate allegations of staff misappropriating resident funds, affecting all residents. A housekeeper delayed reporting suspicions due to uncertainty, and a transportation staff member's concerns about financial irregularities were initially dismissed by the administrator. The facility's abuse prevention policy was not followed, delaying the investigation until corporate intervention.
The facility failed to provide RN coverage for 8 consecutive hours per day, 7 days a week, affecting all 30 residents. The DON confirmed only one RN on staff, with another RN having resigned. The facility is working on hiring more RNs and using an outside agency for coverage. Multiple dates from October 2023 to April 2024 had no RN coverage.
The facility failed to follow infection control protocols for seven residents, including improper use of PPE, lack of hand hygiene, and non-compliance with Enhanced Barrier Precautions, leading to multiple instances of non-compliance with infection control standards.
The facility failed to provide the required Advanced Beneficiary Notice of Non-Coverage (SNFABN - CMS10055) for two residents discharged from Medicare Part A services prior to the exhaustion of their benefit day allotment. Both residents did not receive the necessary forms to inform them of their potential liability for non-covered services and their right to appeal the decision.
The facility failed to obtain the PASRR document for a resident with multiple diagnoses, including moderate cognitive impairment and significant dependence on assistance for daily activities. The PASRR screening was only completed after surveyor intervention, and the facility lacked a policy on conducting PASRR screenings.
A resident with severe cognitive impairment and high dependency on staff developed a pressure ulcer due to the facility's failure to consistently implement preventative measures such as regular repositioning and heel floating. Despite the care plan's requirements, the resident was observed in the same position for extended periods, and the nursing staff admitted to neglecting repositioning duties. The Director of Nursing emphasized the importance of these measures, but the facility's policy was not adequately followed.
The facility failed to provide physician-ordered nutritional supplements to two residents, resulting in a deficiency. One resident with severe cognitive impairment and another with multiple chronic conditions did not receive their prescribed nutritional shakes during lunch service on two consecutive days. The Dietary Manager confirmed the absence of the shakes and the lack of alternative supplements.
The facility failed to ensure proper G-tube placement checks and use of PPE for a resident with multiple medical conditions. The LPN did not check the G-tube placement before administering flush and feeding, and the DON confirmed that placement checks should be done prior to feedings. The facility's policy required placement confirmation before any flush or feeding, which was not followed.
A resident with multiple medical conditions and a moderate cognitive deficit was not provided with meals that met his nutritional needs, specifically his protein requirements, due to the facility's lack of a proper vegetarian menu and inadequate dietary management.
A resident with multiple medical conditions did not receive meals according to their prescribed dietary orders, including double protein servings and avoidance of certain foods. The facility's dietary manager acknowledged the deviation from the menu due to a special event, and the regional consultant confirmed the dietary orders were not followed.
The facility failed to provide at least 80 square feet of living space per resident in multiple rooms, affecting five residents. Despite residents not voicing concerns, the rooms measured only 75.74 square feet per bed, falling short of regulatory requirements.
Pulmonary Function Tests Performed Without Physician Orders
Penalty
Summary
The facility failed to obtain physician orders prior to performing pulmonary function tests (PFTs) on four residents who were reviewed for physician orders. The residents had various diagnoses, including chronic respiratory failure, heart failure, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and dementia. Medical records and care plans for these residents did not contain documentation of physician orders authorizing the PFTs performed on or around the date in question. Interviews with the residents revealed that some did not recall having the tests, while others confirmed the tests had been performed without expressing concerns. Staff interviews indicated that PFTs had been conducted in the past without physician orders, and that an outside company sent a respiratory therapist to the facility to perform these tests. The MDS Coordinator and a Registered Nurse confirmed that the tests were performed on multiple occasions and that there were no physician orders in place. The Director of Nurses acknowledged that physician orders should have been obtained prior to the tests, but could not explain why they were missing from the records. The facility administrator stated that the tests were intended to screen for COPD and that the practice was considered a standard of care according to corporate guidance, but also confirmed that the physician had refused to sign orders for the tests during a recent visit. The respiratory therapist who performed the tests reported being told by the facility that physician orders were in place, but did not see the actual orders. The physician involved did not recall authorizing the tests. The administrator also noted that the facility was under different ownership at the time the tests were performed and that no relevant policy was available for review. No documentation was found to support that physician orders were obtained prior to the administration of PFTs for the residents in question.
Incorrect Portion Sizes Served for Altered Textured Diets
Penalty
Summary
The facility failed to provide the correct portion size of meat for residents on altered textured diets, as observed during a lunch service. Specifically, the cook served a #16 scoop (2 ounces) of pureed and mechanical soft turkey to multiple residents, instead of the required 3 ounces for mechanical soft diets and 3.75 ounces (#8 scoop) for pureed diets, as documented in the facility's menu and recipes. This discrepancy was confirmed by review of the facility's dietary documentation and by interview with the Dietary Manager, who acknowledged that the incorrect portion sizes were served and could not explain why the error occurred. The affected residents were those identified as receiving either pureed or mechanical soft diets according to facility records. The deficiency was identified through interviews, observation of meal service, and review of dietary records, which showed that the prescribed menu and recipes were not followed for nine residents requiring altered textured diets.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
Staff failed to assist two residents during meals in a manner that promoted dignity, as required by facility policy and resident rights. One resident with hemiplegia, dementia, and memory problems required partial or moderate assistance with eating, while another resident with profound intellectual disability and dysphagia was totally dependent for eating. Both residents' care plans specified the need for supervision or total assistance during meals. Observations revealed that staff members, including a regional consultant and a CNA, fed these residents while standing beside them rather than sitting, as required by facility policy. In one instance, a staff member was feeding two residents at the same time, alternating between standing and sitting, due to a lack of available chairs and the need to assist multiple residents simultaneously. The Director of Nursing confirmed that staff are expected to sit while assisting residents with meals, and the facility's policy states that residents should be fed one at a time with staff seated next to them.
Failure to Notify Physician and POA of Significant Weight Loss
Penalty
Summary
The facility failed to notify both the physician and the resident's Power of Attorney (POA) of a significant change in condition for one resident. The resident, who had diagnoses including stage 4 pressure ulcer, severe protein-calorie malnutrition, type 2 diabetes, adult failure to thrive, dementia, cognitive communication deficit, and dysphagia, experienced a documented weight loss of 22.2 pounds (an 11.62% decrease) within one month. This weight loss was identified through the facility's weights/vitals records, and the Dietary Manager confirmed the significant loss after requesting and receiving two reweighs that confirmed the same result. Despite the facility's policies requiring notification of significant weight loss (defined as greater than 5% in 30 days) to both the physician and the resident's representative, there was no documentation that either party had been informed. Interviews with the resident's POA, physician, and nurse practitioner confirmed that none had been notified of the weight loss. The Director of Nursing also acknowledged that such notification should have occurred according to facility policy.
Failure to Maintain Resident's Dresser in Good Repair
Penalty
Summary
A deficiency was identified when a resident's dresser was found to be in disrepair, with the bottom drawer hanging out and not on track, and the middle drawer missing its front part. The resident, who has a history of hemiplegia and hemiparesis following a cerebral infarction, as well as other paralytic syndromes, reported that the dresser had been in this condition for some time. The resident, who is moderately cognitively impaired according to a BIMS score of 12, stated that the middle drawer had been missing for a while and the bottom drawer frequently fell out. Observations confirmed the ongoing issues with the dresser over multiple days, and the resident indicated limited use of the dresser due to its condition. A review of the facility's maintenance tracking logs for several months showed no documentation regarding the need for repair of the resident's dresser. The Maintenance Director was unaware of the issue and stated that repairs are typically reported by floor staff via a maintenance repair form, and that routine room checks are not conducted due to time constraints. The facility's policy requires routine upkeep and timely repairs to ensure a safe and comfortable environment, but there was no evidence that the broken dresser had been reported or addressed prior to the survey.
Failure to Accurately Complete AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident with multiple psychiatric diagnoses, including schizophrenia and dementia, did not receive an accurate Abnormal Involuntary Movement Scale (AIMS) assessment. The resident was prescribed Risperidone, an antipsychotic medication, and had a care plan in place to monitor for psychotropic drug-related complications, including movement disorders. Despite this, the AIMS assessment completed by a registered nurse documented 'none' for involuntary movements in the resident's upper extremities, even though the resident reported and was observed to have irregular, bothersome shaking and jerking of the right arm, particularly during eating. The nurse later admitted to being in a hurry and not marking the correct level of involuntary movement on the assessment. Further interviews with the Director of Nursing confirmed that the resident did have moderate involuntary movement in the right arm and that the AIMS assessment was completed incorrectly. The administrator also stated that the facility did not have a policy regarding AIMS assessments. These actions and omissions resulted in the resident not receiving an accurate assessment as required.
Failure to Provide Adequate Supervision and Fall Prevention for Resident with Seizure Disorder
Penalty
Summary
A deficiency was identified when the facility failed to provide adequate supervision and implement effective interventions to prevent falls for a resident with a known seizure disorder. The resident, who had a history of seizures and multiple medical diagnoses including epilepsy, experienced several falls while in the facility. Despite being alert and oriented, the resident was dependent on staff for supervision or assistance with ambulation and had a documented history of falls, many of which were associated with seizure activity or occurred after smoking. The care plan for the resident included interventions such as reviewing the smoking policy, encouraging the use of non-skid shoes, and having the resident sit or lie down after smoking. However, these interventions were not consistently implemented or communicated to staff. Multiple staff members, including CNAs and an RN, were unaware of specific interventions to prevent injury prior to falls, particularly those related to seizures. Observations confirmed that the resident was not assisted or encouraged to sit or lie down after smoking, despite this being an identified intervention. Interviews with staff revealed a lack of awareness and understanding of the resident's fall and seizure risk interventions. Staff responses indicated that their knowledge was limited to general safety measures, such as keeping the environment free of clutter and monitoring the resident, rather than specific actions to prevent falls related to seizures. The facility's failure to ensure staff were informed and interventions were consistently applied contributed to the ongoing risk of falls and injury for the resident.
Failure to Properly Date, Secure, and Document Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic combined systolic and diastolic heart failure, COPD, and panlobular emphysema who was receiving oxygen therapy. Observations revealed that the resident's oxygen tubing was dragging on the floor while the resident was propelling himself in a wheelchair, and the tubing was not changed or dated according to facility protocol. The humidification bottle attached to the oxygen concentrator was also undated during multiple observations. Interviews with the Director of Nursing confirmed that oxygen tubing is supposed to be changed weekly and dated, and that this should be documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). However, review of the resident's records showed no documentation of when or how often the oxygen tubing was changed, nor any evidence that the tubing had been changed as required. The lack of proper dating, securing, and documentation of oxygen equipment led to the identified deficiency.
Failure to Provide Timely Dental Services for Resident with Ongoing Dental Pain
Penalty
Summary
A deficiency occurred when the facility failed to offer and provide necessary dental services to a resident with a history of dysarthria following cerebral infarction, anxiety disorder, chronic pain, major depressive disorder, and alcohol abuse. The resident had a moderate cognitive impairment and had been prescribed Oragel for oral pain, but the medication was never administered. Despite a dental referral recommending evaluation and extraction of specific teeth, there was no evidence in the medical record or care plan of follow-up or interventions for dental pain, and the resident's complaints were not documented in progress notes. The resident reported experiencing a toothache for an extended period, indicating that the pain was present on average three days a week and that some teeth needed to be pulled. The resident stated that he routinely requested Tylenol for the pain and was told by staff that he could not see a dentist due to insurance coverage issues. Staff interviews revealed inconsistent awareness of the resident's dental pain, with some staff recalling complaints and others not, and there was confusion regarding the process for dental referrals and follow-up. Although the facility's dental policy required routine and emergency dental care to be available, including for acute dental pain, the resident did not receive timely dental services or appropriate follow-up after the initial referral. The lack of documentation, follow-up, and provision of dental care led to the deficiency identified during the survey.
Failure to Administer Consented Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to administer influenza and pneumococcal vaccinations to two residents who had previously provided consent for these immunizations. One resident, admitted with multiple diagnoses including protein calorie malnutrition, major depressive disorder, and anxiety disorder, had a signed consent form for the influenza vaccine completed by a family member. Despite a physician's order for annual influenza vaccination and documentation of consent, the resident did not receive the vaccine. The resident confirmed never having received the influenza vaccine during their stay, and the immunization record showed the status as pending. The administrator stated the vaccine was not given due to insurance denial and was unsure of the facility's policy in such cases. Another resident, admitted with diagnoses such as osteomyelitis of the vertebra, severe protein calorie malnutrition, and dementia, had signed consent forms for multiple pneumococcal vaccines. The vaccine was present in the medication room, but there was no documentation that it had been administered. The administrator and the DON both confirmed the resident had not received the vaccine, and the DON stated there was no specific policy for pneumococcal vaccinations, only that CDC guidelines were followed. Facility policy for influenza vaccination was available, but there was no documented policy for pneumococcal vaccination.
Failure to Meet Minimum Room Size Requirements for Multiple Residents
Penalty
Summary
The facility failed to provide the required minimum living space of 80 square feet per resident in multiple occupancy rooms for four residents. During the survey, maintenance staff and the surveyor measured two rooms, each housing two residents, and found that the available space per resident was 75.57 and 73.19 square feet, respectively. The measurements did not include the area of inset dressers. Both rooms contained two beds, two nightstands, and dressers. The residents occupying these rooms were alert and oriented, and most expressed satisfaction with their room size, with only one resident stating they could use more room but were otherwise content. The facility administrator confirmed that several rooms, including those observed, were waivered and did not meet the 80 square feet per resident requirement, yet were Medicaid certified. Review of the facility's census report confirmed the residents' occupancy in the measured rooms. Additionally, inquiries with residents and families, as well as a review of six months of Resident Council meeting minutes, revealed no concerns or complaints regarding the size of the waivered rooms.
Failure to Maintain Cleanliness in Shower Room
Penalty
Summary
The facility failed to maintain the shower room on the South Hall in a clean and sanitary condition, which has the potential to affect 23 residents residing in that area. During an observation on December 2, 2024, a significant buildup of an unknown black substance was found in the corner behind the toilet in shower room B. Multiple residents, who were alert to person, place, and time, expressed concerns about the cleanliness of the shower rooms and bathrooms, describing them as often dirty and damp. A housekeeping staff member attempted to clean the buildup with a damp rag and cleaner, but it did not come off, indicating that some of it was under a layer of clear sealant. The facility's administrator was unaware of the issue, assuming that housekeeping would have addressed it. The facility's policy requires routine and daily cleaning, as well as monthly deep cleaning schedules for shower rooms. However, the presence of the buildup suggests a lapse in adherence to these guidelines. The shower room B is used by all 23 residents on the South Hall, as confirmed by a CNA, highlighting the importance of maintaining a clean and sanitary environment in shared spaces.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
The facility failed to prevent the misappropriation of resident trust funds and private checking accounts by a former Business Office Manager (BOM), identified as V3, affecting 50 out of 50 residents reviewed for theft. This misappropriation involved checks written for cash from pooled resident trust accounts totaling $5,515.19 and checks from an individual resident's account totaling $10,650. The issue was first identified when a housekeeper reported concerns about V3's handling of the resident trust fund, leading to an investigation. Interviews and record reviews revealed that V3 was unable to provide receipts or explanations for the missing funds. Residents reported that they had requested items to be ordered, which were never received, and checks were written for cash without proper documentation. One resident, R1, was taken to the bank by a staff member to cash checks, with the remaining cash handed over to V3, who claimed it was for room and board payments, which were not made. The facility's records showed discrepancies in the resident trust account and individual accounts, with significant amounts unaccounted for. The investigation also uncovered that V3 had a disqualifying criminal offense on her record, which was not identified at the time of her hiring due to a lack of a background check. The facility's failure to conduct a proper background check and monitor the handling of resident funds led to the misappropriation. The facility was unable to account for the missing funds, and the issue was reported to the local police department for further investigation.
Mismanagement of Resident Trust Funds
Penalty
Summary
The facility failed to manage, safeguard, and accurately account for the residents' trust funds and personal checking accounts for 50 residents. This deficiency was identified through interviews and record reviews, revealing that the Business Office Manager (BOM), identified as V3, was involved in the misappropriation of resident property. A housekeeper, V6, reported concerns about V3's handling of the resident trust fund, leading to an investigation. V3 was unable to provide receipts or answer specific questions related to checks written from the resident accounts and the resident trust account. Additionally, a resident, R2, reported that items ordered through V3 were never received, although they were later ordered by the facility. The investigation revealed that V3 had been writing checks from the resident trust account and the pooled resident trust account without proper documentation or receipts. The facility was unable to account for $2,728.59 from the resident trust petty cash box and $5,515.19 from the pooled resident trust account. V3 was also found to have written checks to cash from a resident's account, R1, who owed a significant amount for room and board. The checks were cashed, and the remaining cash was allegedly given to V3, but there was no documentation of how the cash was used. V3 denied any wrongdoing but was unable to provide evidence to support her claims. The facility's policies and procedures for managing resident funds were not followed, as evidenced by the lack of dual signatures on transactions, missing receipts, and unbalanced accounts. The facility's failure to safeguard resident funds and maintain accurate records led to the misappropriation of funds and a significant financial discrepancy. The investigation was turned over to the local police department, and V3 was terminated from her position.
Mismanagement of Resident Trust Funds
Penalty
Summary
The facility failed to maintain accurate records for residents' trust funds and personal checking accounts, affecting 50 residents. The issue was identified following an allegation of misappropriation of resident property involving the Business Office Manager (BOM), who was suspected of mishandling the resident trust fund. The BOM was unable to provide receipts or answer specific questions related to checks written from the resident accounts, leading to a discrepancy of $2,728.59 in the resident trust petty cash box and $5,515.19 in the actual resident trust bank account. The facility replaced these amounts, but the investigation revealed that the BOM had been writing checks to cash from the resident trust account without proper documentation or receipts. The investigation further uncovered that a resident had checks written to cash from her account totaling $10,650, with no documentation of how the cash was used. The resident's room and board invoices were unpaid, amounting to $9,857. The BOM denied any wrongdoing but was unable to provide a clear explanation for the discrepancies. The facility's policy required dual signatures on all banking transactions and receipts for all purchases made from residents' personal monies, but these procedures were not followed, leading to the mismanagement of funds. Interviews with staff revealed that the BOM had been writing large checks to cash for a resident, who would then return the cash to the BOM without receiving a receipt. The facility's records showed that the BOM had stopped balancing the accounts in November 2023, and the previous corporation managing the facility had not provided any resident trust documentation to the current receivership corporation. This lack of oversight and failure to adhere to established procedures resulted in the misappropriation of funds and the inability to account for significant amounts of money from the resident trust accounts.
Failure to Conduct Background Check Leads to Misappropriation of Funds
Penalty
Summary
The facility failed to perform a pre-employment background check on the Business Office Manager (BOM), which led to the hiring of an individual with a disqualifying criminal offense. This oversight was discovered during an investigation into an allegation of misappropriation of resident property. The BOM, identified as V3, was hired on 4/22/21 without a background check, and it was later found that she had a forgery conviction for writing bad checks in her husband's name. The lack of a background check allowed V3 to manage resident trust accounts, which she allegedly misappropriated. The issue came to light when a housekeeper reported an allegation of misappropriation of resident property on 5/24/24. An audit of the resident trust fund petty cash revealed discrepancies, with checks written and signed by V3 indicating that the facility had more petty cash than necessary. The records, which were meticulously kept by V3, balanced correctly until November 2023, after which they stopped balancing. This misappropriation affected the pooled account of fifty current and former residents with trust accounts during the period from 11/1/23 to 6/1/24.
Failure to Report and Investigate Misappropriation of Resident Funds
Penalty
Summary
Facility staff failed to immediately report an allegation of potential misappropriation of funds involving a former Business Office Manager, V3. The issue came to light when V6, a housekeeper and Power of Attorney for a resident, R3, was informed by V7, the Housekeeping Supervisor, that cash was missing from Easter eggs intended for a community event. V7 expressed concerns about V3's financial integrity, suggesting that R3's trust account should be monitored closely. Despite these concerns, V6 delayed reporting the issue to the Administrator, V1, due to uncertainty about the allegations. Further suspicions arose when V10, a transportation staff member, noticed irregularities in financial transactions involving another resident, R1. V10 regularly accompanied R1 to the bank to withdraw cash, which was then partially handed over to V3 for room and board payments without receipts. V10 reported these concerns to V1, who dismissed them as business office matters and did not recognize the potential misappropriation. V10 then escalated the issue to V16, the Corporate Regional Director of Marketing, which eventually led to an investigation by V11, the Regional Director of Clinical Operations. The investigation revealed that V3 could not provide receipts for the missing funds, confirming the suspicions of financial misappropriation. The facility's failure to promptly report and investigate these allegations of misappropriation of resident funds highlights a significant lapse in adherence to the facility's Abuse Prevention Policy. This policy mandates immediate reporting of any suspected mistreatment or exploitation to the Administrator, which was not followed in this case.
Failure to Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to initiate an immediate investigation into an allegation of staff-to-resident misappropriation, potentially affecting all 46 residents. The issue came to light when a housekeeper, who is also the Power of Attorney for a resident, was informed by the housekeeping supervisor about missing cash from Easter eggs intended for a community event. The housekeeper delayed reporting the suspicion to the former administrator due to uncertainty about the accusation. When the housekeeper eventually reported the concern, the administrator dismissed it as staff drama and did not take immediate action. Another staff member, responsible for transportation, reported suspicious financial transactions involving a resident's funds to the former administrator. The transportation staff member was concerned about irregularities in the amounts of checks written for cash and the lack of receipts for money supposedly used for the resident's room and board. Despite expressing these concerns, the administrator did not recognize the report as a potential misappropriation issue and failed to act promptly. The facility's abuse prevention policy requires employees to report any suspicion of misappropriation immediately to a supervisor and the administrator, who should then initiate an investigation. However, the administrator did not follow this protocol, leading to a delay in addressing the allegations. The situation was only addressed after the corporate marketing director intervened, prompting an investigation by the regional director of clinical operations.
Failure to Provide RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day, 7 days a week, which has the potential to affect all 30 residents residing in the facility. On 4/10/2024, the Director of Nursing (DON) confirmed that there was only one RN on staff, and another RN had resigned the previous week. The DON does not work the floor, and the facility is working on hiring more RNs while utilizing an outside agency to maintain RN coverage. A review of the nursing schedules from October 1, 2023, through April 11, 2024, revealed multiple dates with no RN coverage. Observations on 4/08/2024, 4/09/2024, 4/10/2024, and 4/11/2024 showed the DON and agency RNs working in the facility. The Resident Census and Conditions of Residents, dated 4/08/2024, documented a current census of 30 residents.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to ensure the infection control program was followed using current standards of practice and per the facility policy for seven residents. Personal protective equipment (PPE) containers were noted outside several residents' doors without appropriate signage indicating the type of transmission-based precautions. The Director of Nursing (DON) and Regional Consultant were unaware of the reasons for the isolation precautions and admitted that staff were not trained on Enhanced Precautions. Additionally, staff were observed not following proper PPE protocols, such as not wearing gowns or performing hand hygiene between glove changes during resident care activities, including wound care and catheter care. One resident with a Stage 4 pressure ulcer was observed receiving wound care without the nurse donning the required PPE. The nurse did not perform hand hygiene after removing a dirty dressing and attempted to change gloves without proper technique, leading to potential contamination. Another resident with an indwelling catheter was observed receiving catheter care where the CNA placed dirty washcloths on a clean field and did not wear the required PPE. The DON confirmed that this was not standard practice and that staff should have been wearing gowns and gloves during these procedures. Several other residents on Enhanced Barrier Precautions were observed receiving care without staff donning the required PPE. For instance, a resident with a wound on the left lower leg was on contact isolation, but the nurse did not wear a gown or mask and improperly disposed of soiled dressings. Another resident with a G-tube and catheter was observed receiving care without staff wearing the required PPE. The facility's policies on hand hygiene and Enhanced Barrier Precautions were not followed, leading to multiple instances of non-compliance with infection control standards.
Failure to Provide Advanced Beneficiary Notice of Non-Coverage
Penalty
Summary
The facility failed to provide the required Advanced Beneficiary Notice of Non-Coverage (SNFABN - CMS10055) for two residents, R2 and R26, who were discharged from Medicare Part A services prior to the exhaustion of their benefit day allotment. R2, diagnosed with hypertension, hyperlipidemia, anxiety disorder, depression, and asthma, was discharged with a last covered day of Part A services on 12/15/23. The facility did not provide R2 with the necessary SNFABN form to inform her of her potential liability for non-covered services and her right to appeal the decision. The regional consultant confirmed the absence of the form, and R2 did not recall receiving any forms about her therapy days. Similarly, R26, diagnosed with a left hip fracture, duodenal ulcers, and atherosclerosis, was discharged with a last covered day of Part A services on 1/19/24. The facility also failed to provide R26 with the SNFABN form, which would have explained her potential liability and right to appeal. The regional consultant acknowledged the oversight, and R26 did not remember receiving any forms regarding her therapy days. Both instances indicate a failure to comply with the requirement to notify residents of their Medicare coverage status and potential financial responsibilities.
Failure to Obtain PASRR Screening for Resident
Penalty
Summary
The facility failed to obtain the Pre-Admission Screening and Resident Review (PASRR) document for one resident (R29) out of five reviewed for PASRR screening in a sample of 28. R29 was admitted with multiple diagnoses, including Cerebral Vascular Accident (CVA), depression, anxiety, and Post Traumatic Stress Syndrome. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and significant dependence on assistance for daily activities. Despite these conditions, the PASRR screening was not completed at the time of admission, as confirmed by the Business Office Manager (V22), who admitted to forgetting to submit the PASRR Level 1 screening for R29, who was admitted from out of state. The PASRR screening was only completed after the surveyor's intervention, documenting no need for a Level II review. Additionally, the facility lacked a policy on conducting PASRR screenings, as stated by the Regional Consultant (V3). This oversight indicates a systemic issue in the facility's admission process and compliance with regulatory requirements for PASRR screenings. The failure to complete the PASRR screening in a timely manner could have impacted the resident's care and placement decisions, highlighting a significant deficiency in the facility's procedures.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to implement interventions to prevent and treat a pressure ulcer for a resident with severe cognitive impairment and high dependency on staff for daily needs. The resident was admitted with diagnoses including mixed receptive-expressive language disorder and unspecified intellectual disability. The resident's care plan documented a high risk for pressure ulcers, requiring specific interventions such as skin checks, pressure-relieving devices, and regular repositioning. However, observations revealed that the resident was not consistently repositioned every two hours, and their heels were not floated as required, leading to the development of a small open area on the sacrum. On multiple occasions, the resident was observed lying in bed or sitting in a geri-chair for extended periods without being repositioned. The nursing staff admitted to being aware of the need for regular repositioning but failed to do so due to being busy or forgetting. The resident's sacral area, which frequently opens and heals, was found to have a small open area with redness but no signs of infection. The Licensed Practical Nurse (LPN) acknowledged the lack of a current treatment order for the open area and stated that she would contact the primary physician for a treatment order and a consult with the wound physician. The Director of Nursing (DON) stated that it is the facility's expectation for nursing staff to utilize preventative measures such as heel protectors and regular repositioning to prevent pressure ulcers. The DON also emphasized the importance of reporting and treating any open areas immediately. Despite these expectations, the facility's failure to consistently implement the care plan and preventative measures resulted in the resident developing a pressure ulcer. The facility's policy on decubitus care and pressure areas was not adequately followed, leading to the deficiency noted in the report.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered nutritional supplements to two residents, R1 and R4, as documented in their respective medical records. R1, who has a diagnosis of mixed receptive-expressive language disorder and unspecified intellectual disabilities, did not receive the prescribed nutritional shake during lunch service on two consecutive days. The Dietary Manager (V7) confirmed that the facility did not have the nutritional shakes on those days and stated that residents should have received an alternative supplement, which did not occur. R1's cognitive skills for decision-making are severely impaired, making it crucial for the facility to adhere to the physician's orders to maintain R1's nutritional health. Similarly, R4, who has multiple diagnoses including COPD, chronic kidney disease, and major depression, also did not receive the prescribed nutritional shake during lunch service on two consecutive days. R4's care plan includes a goal to prevent significant weight loss, and the physician's orders specified the provision of a nutritional shake twice a day. The Dietary Manager (V7) acknowledged the absence of nutritional shakes and mentioned that the supply truck arrived after the lunch service on the second day. Despite this, no alternative supplement was provided to R4. The Licensed Practical Nurse (V9) confirmed that R4 did not receive any nutritional supplement during the lunch meals on the specified days. This failure to provide the necessary nutritional supplements as ordered by the physician constitutes a deficiency in the facility's care for these residents.
Failure to Ensure Proper G-Tube Placement Checks and Use of PPE
Penalty
Summary
The facility failed to ensure proper placement checks of a G-tube before administering flush and feeding for a resident with multiple medical conditions, including cerebral vascular accident, diabetes mellitus type 2, and chronic obstructive pulmonary disease. The resident's care plan required Jevity feedings and specific flush orders, but the Licensed Practical Nurse (LPN) did not check the G-tube placement before administering the flush and feeding. Additionally, the LPN did not use the required personal protective equipment (PPE) other than gloves, despite the resident being under Enhanced Barrier Precautions. The Director of Nursing (DON) confirmed that G-tube placement should be checked prior to feedings and was unsure of the facility's policy on the frequency of these checks. The facility's policy on enteral feeding required placement confirmation via aspiration of residual or air instillation before any flush or feeding. The DON also acknowledged that staff should probably wear PPE while administering G-tube feedings but was not certain. The facility's failure to adhere to these protocols resulted in a deficiency in the care provided to the resident.
Failure to Meet Nutritional Needs of a Resident on a Vegetarian Diet
Penalty
Summary
The facility failed to provide a menu that met the nutritional needs of a resident (R16) who was on a Regular, Vegetarian diet. R16, who has a moderate cognitive deficit and various medical conditions including vitamin B and D deficiencies, atrial fibrillation, Alzheimer's disease, and congestive heart failure, was observed to have been served meals that did not meet his protein requirements. Despite R16's documented need for 86 grams of protein per day, the facility's dietary staff did not have a proper system in place to ensure this requirement was met. The dietary manager and staff were unable to provide documentation or accurate information on the protein content of the meals served to R16, leading to inconsistencies in his diet and potential nutritional deficiencies. On multiple occasions, R16 was served meals that did not align with his dietary preferences or protein needs. For instance, R16 requested a burger but was served two boiled eggs instead, and on another occasion, he was given a peanut butter and jelly sandwich with cooked broccoli, which he did not eat. The dietary manager admitted to not having a vegetarian menu and relied on a list of protein substitutes without proper documentation or verification of protein content. The registered dietitian also confirmed that there was no specific vegetarian spreadsheet and that the facility's approach was to match the protein content of the regular menu without ensuring the exact nutritional needs of R16 were met. The facility's policies on vegetarian diets and cycle menus were not effectively implemented, as evidenced by the lack of a proper vegetarian menu and the dietary staff's inability to ensure R16 received the recommended daily amount of protein. The dietary manager and cook were not adequately informed or trained on how to meet R16's nutritional needs, leading to a failure in providing appropriate meals. This deficiency highlights a significant gap in the facility's dietary management and oversight, resulting in inadequate nutritional care for R16.
Failure to Follow Prescribed Dietary Orders
Penalty
Summary
The facility failed to provide the diet as ordered for a resident (R25) who has multiple medical conditions including hemiplegia, end-stage renal disease, type 2 diabetes, and dysphagia. Despite having specific dietary orders documented by the physician, including a double protein serving and no tomato products, the resident received meals that did not comply with these orders. On one occasion, the resident was served a hamburger patty with tomato, potato salad, baked beans, and cheesecake, and on another occasion, the resident received scalloped potatoes and ham, broccoli, a roll with margarine, and a frosted cupcake. These meals did not adhere to the prescribed dietary restrictions and requirements for double protein servings and avoidance of certain foods like tomato products and baked potatoes. The dietary manager (V7) acknowledged that the menu was not followed on one of the days due to a special event (a cookout for the eclipse). The regional consultant (V3) confirmed that the resident should have received the double protein servings and should not have been given items restricted by the registered dietitian. The facility's policy on nutrition supplements and nourishments emphasizes the importance of providing adequate nutrients through regular meals and following dietary orders, which was not adhered to in this case. The resident's dietary assessments and notes further documented the specific dietary restrictions and the need for a consistent carbohydrate diet with fluid restrictions, which were not followed during the observed meal times.
Failure to Provide Adequate Room Size
Penalty
Summary
The facility failed to provide at least 80 square feet of living space per resident in multiple rooms, affecting five residents. During observations, it was noted that the rooms were smaller than required, with measurements indicating 75.74 square feet per bed. The rooms contained two beds, nightstands, and inset dressers, leaving limited space for movement. Despite the residents not voicing concerns about the room sizes, the facility did not meet the regulatory requirements for room size. The administrator confirmed that the rooms in question had a size waiver and were still certified for two residents, even though most rooms currently housed only one resident. The facility's room roster corroborated the residents' occupancy in the measured rooms. Additionally, a review of six months of Resident Council meeting minutes showed no concerns related to room size. However, the deficiency remains as the rooms do not meet the required square footage per resident.
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.
