Bria Of Godfrey
Inspection history, citations, penalties and survey trends for this long-term care facility in Godfrey, Illinois.
- Location
- 1623 29 West Delmar, Godfrey, Illinois 62035
- CMS Provider Number
- 145656
- Inspections on file
- 43
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Bria Of Godfrey during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments experienced an unwitnessed fall that was not immediately reported to nursing staff. The resident was moved without a nursing assessment, and staff did not follow facility protocol for post-fall evaluation. As a result, the resident endured pain from undiagnosed rib and clavicle fractures for over a day before receiving appropriate medical attention.
The facility did not ensure that staff accused of abuse were immediately removed from resident access and failed to investigate all reported abuse allegations. In one case, a CNA remained in resident areas after an abuse allegation, and in another, a resident's repeated claims of verbal abuse by a nurse were not investigated or documented, contrary to facility policy.
A resident with diabetes and cognitive impairment received a double dose of Lantus insulin after two LPNs each administered the prescribed amount, due to confusion over resident assignments and inability to document in the MAR because of computer issues. The error was discovered after the resident's blood pressure was found to be elevated, leading to hospital evaluation.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, leading to increased risk of resident accidents.
A resident was provided with a makeshift closet area consisting of a PVC pipe and a portable metal rack, without any shelving or a proper wardrobe. The family had to add a curtain to make the space more homelike, as the facility did not meet its policy of providing sufficient individual closet space.
A nurse administered the wrong medication, Clozaril, to a resident who was not prescribed this drug after the resident requested his medication while the nurse was preparing medications for another individual. The resident, who has diabetes, became lethargic and was sent to the hospital, where he was admitted for hypoglycemia and accidental drug overdose. The error was recognized shortly after administration, and staff interviews confirmed that the nurse did not follow proper medication administration protocols.
Two residents did not receive their prescribed medications as ordered by their physicians due to the medications not being available on hand, resulting in multiple missed doses. One resident with multiple chronic conditions missed several daily medications, while another with GERD missed eight doses of calcium carbonate. Facility policy and the DON confirmed that medications are to be administered as ordered.
A resident with complex medical needs was discharged to a hospital without proper arrangements for housing, DME, and medications. The facility assumed the resident would be admitted to the hospital, but when this did not happen, they refused to accept the resident back, leaving him without a place to live and necessary medical support. The discharge process was inadequately managed, with incomplete documentation and lack of coordination, resulting in the resident being temporarily housed by a community social worker.
A long-term care facility failed to manage enteral feeding properly for three residents, leading to severe health complications. One resident was hospitalized with aspiration pneumonia due to incorrect feeding rates and lack of prescribed medication. Another resident received tube feedings while lying flat, and her stoma site was not properly cared for. The third resident's tube placement was not checked before feedings, and Enhanced Barrier Precautions were not followed. These deficiencies indicate a failure to adhere to medical orders and facility policies.
A resident with chronic pain conditions did not receive prescribed Oxycodone due to unavailability, leading to severe pain, incontinence, and aggressive behavior. The facility's staff failed to follow medication administration policies, resulting in missed doses and significant distress for the resident.
The facility failed to conduct suicide risk assessments for four residents upon admission, despite their histories and diagnoses indicating a need for such evaluations. This oversight involved residents with conditions like Major Depressive Disorder, Schizophrenia, and a history of suicidal ideation or self-harm, contrary to the facility's policy requiring such assessments.
The facility failed to administer medications on time for four residents, resulting in significant medication errors. Residents received medications two hours or more after scheduled times, affecting various medications for conditions like depression, dementia, and hypertension. Staffing issues contributed to the delays, and the facility's policy on timely administration was not followed.
The facility failed to implement fall interventions for two high-risk residents. One resident did not receive a required therapy evaluation after multiple falls, while another experienced falls due to improper transfer techniques and lack of prescribed safety measures like a floor mat and lowered bed. Staff were unaware of specific fall interventions, indicating a communication gap.
Two residents in the facility did not receive adequate pressure ulcer care as per physician orders. One resident, who is severely cognitively impaired, was found without pressure-relieving boots, leading to red heels. Another resident with multiple sclerosis had a pressure ulcer without a dressing, and CNAs failed to inform the nurse, leaving the ulcer exposed. The Director of Nursing was unaware of these lapses in care.
A resident with a history of falls and multiple medical conditions experienced several falls and injuries due to inadequate supervision and ineffective fall prevention strategies. Despite being identified as high risk, the facility failed to implement and monitor appropriate interventions, leading to repeated falls and a head laceration. The facility also lacked timely fall risk assessments and documentation of enhanced supervision.
A resident with multiple health conditions, including an above-the-knee amputation and severe malnutrition, was admitted to the facility and identified as high risk for pressure ulcers. The facility failed to provide timely wound care and follow the care plan, resulting in severe pressure wounds and infection, necessitating hospitalization.
The facility failed to perform catheter care for three residents with indwelling catheters, as documented in their care plans and treatment administration records. The residents experienced delays in catheter care documentation and treatment, leading to issues such as contaminated catheters and bladder infections.
The facility failed to complete wound treatments as ordered for a resident with a stage 4 pressure ulcer on the left buttock. The Treatment Administration Record showed multiple instances of undocumented wound care over several months. The DON acknowledged the issue, particularly with agency staff, and the resident confirmed delays in dressing changes.
The facility failed to provide adequate CNA coverage, particularly during the evening and night shifts, as reported by multiple residents and staff members. The DON and Administrator confirmed staffing shortages, exacerbated by high call-offs and staff leaving for higher-paying jobs. A review of Daily Staffing Sheets revealed multiple instances where the facility did not meet its own staffing grid requirements.
The facility failed to provide proper perineal and catheter care, leading to UTIs in two residents. One resident with acute cystitis and Alzheimer's disease received inadequate perineal care, while another resident with an indwelling urinary catheter received improper catheter care. Staff interviews revealed a lack of awareness and concern regarding the high incidence of UTIs.
A resident with chronic pain did not receive Hydrocodone/Acetaminophen as ordered by the physician due to delays in obtaining the medication from the pharmacy and the need for a hard prescription. The resident experienced significant distress, and the medication was eventually administered from the emergency kit.
The facility failed to provide quality and good tasting food to three residents, who reported issues with food palatability, portion sizes, and overall quality. Staff confirmed frequent complaints, and the facility lacked a policy for Food Palatability.
The facility failed to adhere to infection control practices for two residents, leading to deficiencies in infection prevention and control. Improper hand hygiene and perineal care techniques were observed, likely contributing to recurrent UTIs in the affected residents. Staff acknowledged the presence of UTIs but did not express significant concern or awareness of the potential link to improper practices.
Failure to Timely Assess and Report Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with a complex medical history, including Parkinson's disease, chronic respiratory failure, severe malnutrition, and cognitive impairment, experienced a fall in the dining room that was not witnessed by nursing staff. The resident was dependent on staff for mobility and required substantial assistance for activities of daily living. After the fall, the resident was found on the floor by a CNA, but the incident was not immediately reported to nursing staff, and the resident was moved without a nursing assessment. The fall was only brought to the attention of nursing staff the following day, at which point a range of motion and skin assessment was performed, and the resident was noted to be in pain and resistant to having her arm touched. Subsequent evaluation by hospice and hospital staff revealed that the resident had sustained multiple rib fractures and a fractured clavicle, as well as a urinary tract infection. The delay in notifying nursing staff and the lack of immediate assessment resulted in the resident enduring pain for over a day before appropriate medical intervention was initiated. Interviews with facility staff confirmed that the expected protocol was for staff to notify nursing immediately and not to move a resident after a fall until assessed by a nurse, but this protocol was not followed in this instance. Facility policy required that all falls be promptly evaluated for injury, with the physician and emergency contact notified, and an incident report completed. However, in this case, the failure to follow these procedures led to a significant delay in the identification and treatment of the resident's injuries. The deficiency centers on the lack of timely assessment and communication following the resident's fall, contrary to facility policy and standard care expectations.
Failure to Remove Accused Staff and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure that staff members accused of abuse were immediately removed from resident access and that all abuse allegations were properly investigated. In one instance, a resident with significant physical impairments and cognitive intactness reported a verbal altercation with a certified nursing assistant (CNA). The CNA was not immediately removed from the premises and remained in areas accessible to residents, including the nurse's station, after being told to leave. Statements from staff and the CNA confirm that she was present in the facility and in proximity to residents after the allegation was made, contrary to facility policy requiring immediate suspension and removal of accused staff pending investigation. Additionally, the facility did not investigate all reported abuse allegations. Another resident with a history of traumatic brain injury and behavioral issues made repeated allegations that a nurse made inappropriate comments about his body. The resident's family also reported these concerns. Despite these reports, there was no documentation of any investigation into the allegations, and the administrator confirmed that no investigation was conducted. The administrator attributed this failure to the absence and inaction of the previous Director of Nursing (DON), who did not initiate or document any inquiry into the matter. The facility's own abuse policy requires immediate protection of residents and prompt, thorough investigation of all abuse allegations. However, in both cases, the facility did not follow its policy: the alleged perpetrator was not immediately removed from resident areas, and one resident's abuse allegation was not investigated at all. These failures were confirmed through interviews, record reviews, and the absence of required documentation.
Double Dosing of Insulin Due to Medication Administration Error
Penalty
Summary
A resident with diagnoses including Type 2 Diabetes Mellitus, Alzheimer's Disease, Dementia, and Anxiety Disorder was admitted to the facility and prescribed 27 units of Lantus insulin to be administered subcutaneously at bedtime. On the night in question, two LPNs each administered a full dose of Lantus insulin to the same resident, resulting in a double dose. The first LPN administered the insulin and was unable to immediately document the administration in the Medication Administration Record (MAR) due to computer and internet issues. Subsequently, the second LPN, confused about her assigned residents and not seeing the prior administration on the MAR, also gave the resident the prescribed dose of insulin. Following the double administration, the resident's blood sugar and blood pressure were monitored, with the blood pressure found to be elevated. The on-call physician was notified, and the resident was given glucose gel and snacks as a precaution. The resident was then transferred to a local hospital for evaluation of hypertension, which was reported to be related to the double dose of insulin. Documentation from the hospital confirmed the double dosing incident and the resident's subsequent evaluation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Adequate Closet Space and Shelving
Penalty
Summary
The facility failed to provide adequate closet space with shelving for one resident. According to a family member, the resident's room was located at the end of the hall and did not contain an actual closet or a portable wardrobe. Instead, the facility had installed a PVC pipe from the ceiling, forming a box-like structure intended for hanging clothes, but there were no shelves available. The family had to purchase a curtain and tension rod to make the space more homelike, as the original setup was not considered homelike. Observation of the room confirmed the absence of a built-in wardrobe or closet. The only available storage was a portable metal clothes rack and the PVC pipe structure, with no shelving present. The facility administrator acknowledged that the wardrobe had been removed from the room and that maintenance had installed the PVC pipe, but no shelves were provided. The facility's own policy requires sufficient individual closet space for each resident, which was not met in this case.
Significant Medication Error: Wrong Medication Administered to Resident
Penalty
Summary
A significant medication error occurred when a nurse administered the wrong medication to a resident. The nurse was preparing medications for another resident when the affected resident approached and requested his medication. The nurse mistakenly gave the resident another individual's medication, specifically Clozaril (Clozapine) 150 mg, which was not prescribed for him. The error was recognized by the nurse approximately 15-20 minutes after administration, at which point the resident exhibited lethargy. The resident, who has a history of diabetes and is described as a severe brittle diabetic with rapidly fluctuating blood sugars, was sent to the emergency room for evaluation. Upon arrival at the hospital, the resident was found to be hypoglycemic and was admitted for observation due to accidental drug overdose and altered mental status. The emergency department records indicate that critical care was necessary to manage the resident's hypoglycemia and acute ingestion of the medication. The resident remained hospitalized for several days before returning to the facility. Review of the resident's physician orders confirmed there was no order for Clozaril for this individual, while another resident did have an active order for the medication. Interviews with facility staff confirmed the sequence of events, with the nurse acknowledging the error and the DON stating that the nurse did not follow the rights of medication administration, which include verifying the right medication and right resident prior to administration.
Failure to Administer Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to administer medications as ordered by physicians for two of four residents reviewed for pharmacy services. One resident, who had multiple diagnoses including a three-part fracture of the left humerus, COPD, neuropathy, major depressive disorder, CHF, cardiac pacemaker and defibrillator, history of falling, arthropathy, gout, hypertension, low back pain, and chronic atrial fibrillation, did not receive several prescribed medications on two consecutive days. Documentation in the Medication Administration Record (MAR) and progress notes indicated that these medications were not administered because they were not available on hand. Another resident, diagnosed with GERD, reported not receiving her prescribed calcium carbonate tablets after meals for several days, resulting in a total of eight missed doses. The MAR confirmed these omissions, and the resident's care plan specifically included the intervention to administer medications as ordered. The facility's policy requires all medications to be administered safely and appropriately, and the Director of Nurses confirmed that medications are to be given as ordered by the physician.
Incomplete Discharge Process for Resident
Penalty
Summary
The facility failed to ensure a complete discharge process for a resident, identified as R2, who was transferred to a hospital due to behavioral issues. R2, who had a complex medical history including spinal stenosis, diabetes, and bipolar disorder, was discharged to the hospital without proper arrangements for housing, Durable Medical Equipment (DME), and medications. The facility assumed R2 would be admitted to the hospital, but when the hospital did not admit R2, the facility refused to accept him back, leaving R2 without a place to live and without necessary medical equipment and medications. The discharge process was inadequately managed, as evidenced by incomplete documentation and lack of coordination between the facility and external parties. R2's discharge plan assessment and instructions were left blank, and there was confusion regarding the ordering and approval of DME. The facility's Social Service Director and Administrator were not fully aware of the readiness of R2's apartment, and the facility did not hold a bed for R2's potential return. This lack of communication and preparation resulted in R2 being temporarily housed in a Bed and Breakfast by his community social worker until his apartment was ready. The facility's actions were based on the assumption that R2 would be admitted to the hospital for a psychiatric evaluation, but this did not occur. The facility's Administrator and staff did not verify R2's admission status before proceeding with the discharge, leading to a situation where R2 was left without adequate support. The facility's discharge policy was not followed, as evidenced by the lack of a completed discharge instruction form and the failure to ensure R2 had access to his medications and necessary equipment upon discharge.
Inadequate Enteral Feeding Management and Care in LTC Facility
Penalty
Summary
The facility failed to provide appropriate enteral feeding management for three residents, leading to significant health complications. Resident R2, who was admitted with severe cognitive impairment and multiple medical conditions, was returned from the hospital with specific discharge orders for tube feeding. However, the facility did not follow these orders, starting the feeding at a higher rate than recommended, which likely contributed to R2's aspiration pneumonia and subsequent hospitalization. Additionally, the facility failed to provide the prescribed Scopolamine patch for nausea and secretions, and no alternative medication was sought. Resident R1, also severely cognitively impaired, reported that nurses sometimes administered tube feedings while she was lying flat, contrary to her care plan that required the head of the bed to be elevated. During an observation, a nurse provided a tube feeding bolus without checking for residuals or tube placement, and the stoma site was not properly cleaned or assessed for infection, despite signs of tenderness and redness. The dressing on the stoma site was not changed as required, indicating a lack of adherence to care protocols. Resident R3, with a history of severe malnutrition and cerebral palsy, did not receive proper care for her gastrostomy tube. The facility staff failed to check the tube placement before administering feedings and did not maintain a dressing on the stoma site as expected. Additionally, staff did not follow Enhanced Barrier Precautions during care, which is crucial for preventing the transmission of infections. These deficiencies highlight a pattern of inadequate care and failure to follow medical orders and facility policies, putting residents at risk for serious health issues.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide physician-prescribed narcotic pain medication for a resident, resulting in severe pain and distress. The resident, who had a history of spinal stenosis, chronic pain syndrome, and other related conditions, was admitted with a care plan that included administering pain medication and assessing its effectiveness. However, the facility did not have the prescribed Oxycodone available for the resident on multiple occasions, leading to missed doses and significant pain. During the period when the medication was unavailable, the resident experienced severe pain, became incontinent of bowel and bladder, and exhibited aggressive behaviors. The resident was documented as being in a fetal position, experiencing loose stools, and expressing extreme distress due to the lack of pain management. Staff interviews confirmed that the resident was usually continent and mobile but was significantly affected by the absence of the medication. The Director of Nursing and other staff members were unaware of the missed doses until the resident's behavior escalated, prompting a call to the police. The facility's medication administration policy required documentation and notification of the healthcare provider if medication was not given as ordered, but these steps were not followed. The delay in obtaining the medication from the pharmacy and the lack of immediate access to the emergency medication kit contributed to the resident's prolonged suffering.
Failure to Conduct Suicide Risk Assessments
Penalty
Summary
The facility failed to assess four residents for risks of self-harm upon their admission, which is a necessary component of behavioral health care and services. Resident 2 was admitted with diagnoses including Major Depressive Disorder and Vascular Dementia, and had a history of threatening suicide when upset, as reported by family members. Despite these indicators, there was no documentation of a suicide risk assessment upon admission. Similarly, Resident 3, with a history of Suicidal Ideation and diagnoses such as Schizophrenia and Major Depressive Disorder, also lacked a documented suicide risk assessment upon admission. Resident 11, admitted with multiple diagnoses including Major Depressive Disorder and a history of Suicidal Ideations, did not have a suicide risk assessment documented in her records. Resident 12, who had a diagnosis of Non-Suicidal Self-Harm and Major Depressive Disorder, was also not assessed for suicide risk upon admission. The facility's policy requires a suicide assessment for residents with a history or diagnosis of suicidal ideation, but this was not followed for these residents, as confirmed by the facility administrator.
Significant Medication Errors Due to Delayed Administration
Penalty
Summary
The facility failed to administer medications as prescribed and according to its policy and procedures for four residents, resulting in significant medication errors. Residents received their medications two hours or more after the scheduled times. This issue was identified through interviews and record reviews, highlighting a pattern of delayed medication administration. Resident 2, who has a history of major depressive disorder, vascular dementia, and other conditions, received multiple medications late, including Aricept, Seroquel, Depakote, Synthroid, Xarelto, Metoprolol, Paroxetine, Losartan, and Hydroxyzine. The delays ranged from 3 to 19 doses being administered more than two hours late. The resident's niece confirmed that medications were not given on time, and the facility's administrator acknowledged the issue, citing staffing challenges as a contributing factor. Similarly, Resident 3, with diagnoses including schizophrenia, PTSD, and hypertension, experienced delays in receiving medications such as Lidoderm Patch, Acetaminophen, Aspirin, Metoprolol, Bupropion, Clozapine, Fluoxetine, Lisinopril, Amlodipine, Vraylar, Olanzapine, and Donepezil. The delays affected a significant number of doses, with some medications consistently administered late. Resident 5 and Resident 13 also faced similar issues, with medications like Norco, Morphine, Lyrica, Gabapentin, Lasix, Duloxetine, Lopressor, Mirtazapine, Prozac, Hydroxyzine, Metoprolol, Metformin, Trulicity, and Lisinopril being administered late. The facility's policy requires timely medication administration, and the failure to adhere to this policy was not communicated to the nurse practitioner, potentially impacting medication management decisions.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement progressive fall interventions for two residents identified as high risk for falls. The first resident, admitted with conditions such as bipolar disorder and unsteadiness, had multiple falls documented over several months. Despite a fall intervention requiring a therapy evaluation after a fall in February, the evaluation was never completed. This oversight indicates a lack of follow-through on planned interventions to mitigate fall risks for this resident. The second resident, with severe cognitive impairment and dependent for transfers, experienced falls due to improper transfer techniques and self-transferring. The root cause analysis identified that a mechanical lift should have been used for transfers, but this was not consistently implemented. Additionally, the resident's care plan included interventions such as keeping the bed in the lowest position and using a floor mat, but these were not in place during an observation. Staff members were unaware of the specific fall interventions, highlighting a communication gap and failure to adhere to the care plan designed to prevent falls.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for two residents, R3 and R35, as observed during the survey. R3, who is severely cognitively impaired and requires substantial assistance, was found without the physician-ordered pressure-relieving boots on multiple occasions, resulting in red heels. Despite having a care plan intervention to protect her heels, the boots were not utilized as required, and the Director of Nursing acknowledged the oversight. R35, diagnosed with multiple sclerosis and pressure ulcers, was admitted with skin complications. Despite having a care plan and physician orders for wound treatment, R35's pressure ulcer on the left ischium was found without a dressing during incontinent care. The CNAs did not inform the nurse about the missing dressing, and the Director of Nursing was unaware if the treatment was applied after the resident was changed. The wound nurse later applied the necessary treatment, but the deficiency in care was evident as the pressure ulcer was exposed without protection.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to implement appropriate fall interventions and supervision for a resident, resulting in multiple falls and injuries. The resident, who was admitted with a history of falls and several medical conditions including hemiplegia, diabetes, and a recent hip fracture, was identified as being at high risk for falls. Despite this, the facility did not ensure adequate supervision or implement effective fall prevention strategies, leading to the resident experiencing multiple falls, including one where she sustained a head laceration. The resident's care plan and fall risk assessments documented her high risk for falls and outlined interventions such as keeping the call light within reach and providing a clutter-free environment. However, these interventions were not effectively implemented or monitored. The resident reported that staff were slow to respond to her call light, and she attempted to transfer herself to the bathroom, resulting in falls. The facility also failed to conduct timely fall risk assessments and root cause analyses following each fall, as required by their policy. Additionally, the facility did not maintain adequate documentation of the resident's enhanced supervision, which was supposed to include 15-minute checks. The lack of documentation and failure to update the care plan with new interventions after each fall further contributed to the resident's repeated falls and injuries. The facility's inaction and inadequate supervision directly led to the resident's multiple falls and injuries, highlighting a significant deficiency in their fall prevention and management practices.
Failure to Assess and Treat Pressure Wounds
Penalty
Summary
The facility failed to assess and treat pressure wounds for a resident (R2) who was admitted with multiple health conditions, including severe protein calorie malnutrition, type 2 diabetes mellitus, and an above-the-knee amputation. Upon admission, R2 was identified as high risk for pressure ulcers and required assistance with turning and repositioning. Despite this, there was no documentation of wound care from the time of admission until several days later, and the resident's care plan was not followed. The resident's treatment administration record (TAR) showed gaps in wound care documentation, and there was no record of indwelling catheter care. When R2 was transferred to the emergency room, the resident was found to have severe pressure wounds, including stage 3/4 ulcers, and an infection at the surgical site. The ER staff noted that the resident's catheter appeared filthy and had not been properly cared for. The facility's policy on skin management and pressure injury treatment was not adhered to, as evidenced by the lack of timely wound care and documentation. The failure to follow the care plan and provide necessary treatments led to the resident's condition worsening, requiring hospitalization and further medical intervention.
Failure to Perform Catheter Care for Residents
Penalty
Summary
The facility failed to perform catheter care for three residents who required the use of indwelling catheters. Resident 2 (R2) was severely cognitively impaired and had an indwelling catheter due to obstructive uropathy and urinary retention. R2's care plan did not include instructions for cleaning the catheter, and the treatment administration records (TAR) for March, April, and May did not document any catheter care until late May. R2 was noted to have a contaminated catheter by a local hospital, which led to a catheter change on May 18, 2024. Resident 3 (R3) was moderately cognitively impaired and required an indwelling catheter due to neurogenic bladder and obstructive uropathy. R3's TAR for March, April, and May also lacked documentation of catheter care until May 22, 2024. R3 was placed on isolation for a multidrug-resistant organism in the urine and had multiple instances of bladder infections requiring antibiotic treatment. Resident 4 (R4) had a diagnosis of obstructive and reflex neuropathy and was moderately cognitively impaired. R4's care plan did not address catheter cleaning, and the TAR for March, April, and May did not document catheter care until May 22, 2024. Multiple CNAs confirmed that catheter care was not performed until late May, despite the facility's policy requiring daily and as-needed catheter care.
Failure to Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to complete wound treatments as ordered by the physician for a resident with multiple diagnoses, including Multiple Sclerosis, Paraplegia, and a stage 4 pressure ulcer on the left buttock. The resident's Treatment Administration Record (TAR) showed multiple instances where the wound care was not documented as completed over several months. Specifically, the TAR for February, March, and April 2024 showed that the wound care was not documented 4, 17, and 5 times, respectively. The Director of Nurses (DON) acknowledged that the treatments might not have been done or were not signed off, particularly by agency staff, and attempts were made to contact them to ensure treatments were completed as ordered. The resident confirmed that there were instances where the dressing was not changed for up to three days, although the wound was not worsening, it was also not improving. The resident's care plan included an intervention to provide treatment as ordered for the left buttock wound, but the facility failed to adhere to this plan. The facility's policy on Skin Management: Pressure Injury Treatment/General Wound Treatment required documentation of routine and PRN treatments in the treatment administration record of the Electronic Health Record (EHR) and significant observations in the Nursing Progress Note. The failure to consistently document and possibly perform the wound care treatments as ordered led to the deficiency noted in the report.
Inadequate CNA Coverage During Evening and Night Shifts
Penalty
Summary
The facility failed to provide adequate CNA coverage for residents, particularly during the evening and night shifts. Multiple residents and staff members reported that the facility often had only one nurse and one CNA working during these times. The Director of Nurses (DON) confirmed that the staffing levels were lower than required, especially in the evenings and nights, and that they were relying on agency staff and recruitment efforts to fill the gaps. The Administrator also acknowledged the staffing issues and mentioned that they had experienced a high number of call-offs recently, which exacerbated the problem. The Social Services Director noted that many staff members had left for higher-paying jobs at other facilities, further contributing to the staffing shortages. A review of the Daily Staffing Sheets from 4/1/24 to 4/25/24 revealed multiple instances where the facility did not meet its own staffing grid requirements. For example, on 4/14/24, the day shift had only 1 LPN, 1 RN, and 2 CNAs, while the evening shift had 1 LPN, 1 RN, 1 nurse in training, and 2 CNAs. Similar deficiencies were noted on other dates as well. The facility's staffing policy, dated 6/2015, mandates that appropriate numbers of staff be available to meet the needs of the residents, a standard that was not met according to the documented staffing levels and the Midnight Census Report, which showed 45 residents residing in the facility on 4/25/24.
Failure to Provide Proper Perineal and Catheter Care
Penalty
Summary
The facility failed to provide proper perineal care and adhere to infection control practices, leading to urinary tract infections (UTIs) in two residents. One resident, diagnosed with acute cystitis and Alzheimer's disease, was observed receiving inadequate perineal care. The CNA did not perform hand hygiene or change gloves during the procedure, and the resident was left soiled with urine and feces. This resident was later admitted to the hospital with a UTI and readmitted to the facility with the same diagnosis. Another resident, with a diagnosis of obstructive and reflux uropathy and an indwelling urinary catheter, also received improper catheter and perineal care. The CNA did not maintain a clean/dirty field and failed to change gloves or perform hand hygiene during the procedure. This resident had multiple UTIs, as documented in their progress notes, and was treated with various antibiotics. Interviews with facility staff revealed a lack of awareness and concern regarding the high incidence of UTIs. The Director of Nursing denied any concerns, while an LPN acknowledged the frequent occurrence of UTIs but was unsure of the cause. The facility's policies on perineal and incontinence care were not followed, contributing to the deficiencies observed.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered by the physician for a resident diagnosed with chronic pain. The resident's physician had prescribed Hydrocodone/Acetaminophen 10/325mg to be given every 4 hours. However, the Medication Administration Record (MAR) showed that the medication was not administered as ordered. The resident, who was cognitively intact with a BIMS score of 15, reported not receiving any medications for a week upon admission and experienced delays in receiving pain medication due to issues with the pharmacy and the need for a hard prescription from the Nurse Practitioner or Medical Doctor. The resident's progress notes documented multiple instances where the pharmacy was contacted regarding the medication, and the resident expressed significant distress due to the delay. On one occasion, the resident was yelling and screaming in pain, and the nurse had to obtain the medication from the emergency kit to administer it. The Director of Nurses confirmed that nurses have access to the emergency medication kit and can obtain medications from there if needed. The facility's Medication Administration policy emphasizes the importance of administering medications safely and appropriately, but this was not adhered to in this case.
Failure to Provide Quality and Palatable Food
Penalty
Summary
The facility failed to provide quality and good tasting food to three residents, as evidenced by multiple complaints about the food's palatability, portion sizes, and overall quality. Resident R2 reported not receiving a full meal and described the food as horrible, particularly during the evening meal. R2 had previously filed a grievance regarding the unsatisfactory food, which was addressed by educating R2 on available menu items and substitutions. Resident R4 also complained about the food quality, stating it tasted bad and the portions were sometimes insufficient, leading to hunger at night. Resident R3 echoed similar sentiments, describing the food quality and taste as horrible. All three residents were cognitively intact, as indicated by their BIMS scores of 15, 13, and 14, respectively. The Resident Council Note documented issues with the quality and variety of food, including the lack of meat for breakfast and repetitive meals. Staff members, including an RN and an LPN, confirmed that residents frequently complained about the food's taste, quality, and portion sizes. The Administrator acknowledged that the menu options were not the greatest but mentioned a new menu with more hearty meals was forthcoming. The Dietary Manager claimed no complaints had been brought to her attention and stated that they followed the menu and production guide for portion sizes. The Social Services Director noted that food presentation and taste had been an ongoing issue for the past year. The facility was unable to provide a policy for Food Palatability when requested.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices for two residents, leading to deficiencies in infection prevention and control. Resident 1 (R1) had multiple diagnoses, including acute cystitis and Alzheimer's disease, and was dependent on assistance for toileting. During an observation of perineal care, a CNA did not perform hand hygiene or change gloves while providing care, and the resident was left soiled with urine and feces. This improper technique likely contributed to R1's recurrent urinary tract infections (UTIs), as documented in the resident's progress notes and hospital records. Resident 5 (R5) had a diagnosis of obstructive and reflux uropathy and required an indwelling urinary catheter. During an observation of catheter and perineal care, a CNA failed to maintain a clean/dirty field and did not change gloves or perform hand hygiene until the care was completed. R5 had a history of UTIs, as indicated by multiple progress notes and urine culture results showing the presence of Citrobacter freundii and vancomycin-resistant Enterococcus faecalis. The improper infection control practices observed during care likely contributed to R5's recurrent UTIs. The facility's hand hygiene and perineal care policies, dated June 2015, emphasize the importance of proper hand hygiene and perineal care to prevent infections. However, the observations and interviews with staff revealed a lack of adherence to these policies. The Director of Nursing (DON) and other staff members acknowledged the presence of UTIs but did not express significant concern or awareness of the potential link to improper infection control practices.
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.
