Carlinville Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlinville, Illinois.
- Location
- 751 North Oak Street, Carlinville, Illinois 62626
- CMS Provider Number
- 145454
- Inspections on file
- 41
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Carlinville Rehab & Hcc during CMS and state inspections, most recent first.
A resident with multiple health conditions reported verbal abuse by two CNAs, but the facility failed to properly identify the staff involved during its investigation, initially suspending the wrong CNA and later expressing confusion about the incident's details. The resident experienced fear of retaliation and inconsistent responses from facility leadership, with the investigation process not aligning with the facility's abuse prevention policy.
A resident with multiple complex conditions was admitted with an order for a specialized IV antibiotic that the facility was unable to provide due to pharmacy limitations. The medication was repeatedly held, and there was a delay in contacting the prescribing physician. Attempts to transport the resident for continued treatment were unsuccessful due to bariatric transport challenges, resulting in an interruption of therapy and the need for additional hospital care.
Several residents did not receive their physician-ordered medications as prescribed, including pain medications, anti-seizure drugs, Parkinson's therapy, and hormone replacement, due to delays in obtaining prescriptions, pharmacy refills, and communication issues among staff, pharmacy, and prescribers. Missed doses were documented, and residents reported experiencing pain and discomfort as a result.
A resident's debit card was misused by a CNA, who saved the card information on her phone and made unauthorized transactions. The resident, who is cognitively intact, reported the issue to her bank, leading to an investigation that identified the CNA as the unauthorized user. The resident did not consent to these transactions and felt unsafe and targeted.
A resident experienced severe pain that was not promptly assessed or treated by the facility staff. Despite reporting significant pain, the resident waited 44 minutes before receiving any pain management, which was limited to medication for mild pain. The facility lacked a comprehensive pain management policy, contributing to the deficiency.
A resident with morbid obesity and panniculitis did not receive physician-ordered InterDry sheets for abdominal folds, leading to redness and irritation. Despite documentation indicating treatment was given, observations confirmed the absence of the sheets. The ADON acknowledged the discrepancy, and the facility's wound assessment policy lacked guidance on following physician orders.
The facility failed to respond to call lights promptly for four residents, causing feelings of neglect and degradation. One resident reported waiting hours for assistance, while another experienced accidents due to long waits. The facility lacks a policy on call light response times, although the expectation is 3 to 5 minutes. Insufficient staffing, particularly on weekends and night shifts, contributed to the delays.
The facility failed to provide complete incontinent care for several residents, as observed during the survey. A CNA inadequately cleansed a resident's labia and inner thighs, while another CNA failed to change gloves between tasks, leading to incomplete cleaning of a resident's catheter tubing and groin area. Additional deficiencies included inadequate cleansing of buttocks and inner thighs for other residents, despite care plans specifying thorough cleaning. These observations highlight a pattern of incomplete and inconsistent incontinent care provided by the facility staff.
The facility failed to follow infection control protocols, including hand hygiene and PPE use, for several residents. A CNA and a wound nurse did not change gloves or perform hand hygiene while providing care to a resident with open wounds and a catheter. An RN administered IV medication without wearing a gown or performing hand hygiene, and an LPN was observed administering medications without hand hygiene. These actions violated the facility's infection prevention policies.
The facility failed to provide adequate nursing staff, resulting in significant delays in responding to residents' call lights. Several residents reported waiting hours for assistance, particularly at night and on weekends, due to insufficient staffing levels. The CNA scheduler confirmed that the night shift staffing is inadequate, contributing to the prolonged wait times for residents requiring care.
A facility failed to notify a resident or their representative of the bed hold policy upon hospital transfer. The resident, diagnosed with COPD and pneumonia, had no documentation of bed-hold notification in their records. Staff interviews indicated that while some documents are sent during transfers, the bed-hold policy was not documented. The administrator expects staff to adhere to the policy.
Two residents in a facility had non-occlusive dressings on their PICC lines, which were not changed as required. A nurse administered IV medication without addressing the issue, and records failed to document necessary dressing changes. Facility policy on maintaining infusion equipment was not followed.
A resident with depression did not receive her prescribed Effexor due to the facility's failure to reorder the medication in a timely manner. The resident missed doses over two days, leading to withdrawal symptoms. The ADON was aware of the shortage but did not ensure the medication was available until later. The facility's pharmacy procedures for urgent medication needs were not effectively followed.
The facility failed to properly label and store medications for three residents. An outdated Cephalexin suspension was not discarded, a Humalog Kwik Pen lacked an open date, and two medications were missing pharmacy labels. Staff acknowledged these oversights, which contravened facility policies.
A resident with a mental disorder was verbally abused by two LPNs during a shift change. The resident, who was confused and repeatedly expressed a desire to leave the facility, was told to 'shut up' by the LPNs. Multiple staff members witnessed the incident, but there was a delay in reporting it to the Administrator. The facility's policy on abuse prevention was not followed, leading to the substantiation of the abuse.
The facility failed to properly implement its abuse prevention policies, leading to incidents where a resident was verbally abused by staff. Despite reports from other residents and staff, the facility did not immediately suspend the alleged perpetrators or protect the residents during the investigation. The facility's policy requires immediate reporting and removal of staff involved in abuse allegations, which was not followed in these cases.
The facility failed to report allegations of abuse involving two residents in a timely manner. A CNA was accused of making inappropriate comments to a resident, and two LPNs were reported for verbally mistreating another resident. Both incidents were not immediately reported to the appropriate authorities, violating the facility's policy.
The facility failed to protect residents and conduct thorough abuse investigations. In one case, a CNA allegedly verbally abused a resident, but was not suspended during the investigation. In another case, two LPNs were reported to have verbally abused a resident, with a delay in reporting and removal from the floor. The investigation process was flawed, contributing to the deficiency.
The facility failed to identify, assess, and treat pressure ulcers for two residents. One resident had untreated pressure sores on both heels, contrary to physician orders, while another had an undocumented pressure ulcer on the left gluteal fold. The facility's policy required daily skin observations and treatment to prevent and heal pressure ulcers, which was not followed.
A facility failed to change nebulizer therapy tubing weekly for a resident with COPD and sleep apnea. The resident's nebulizer tubing was observed to be dated several weeks prior, despite the resident's statement that it used to be changed weekly. The facility's MDS coordinator confirmed the absence of a specific policy for nebulization tubing, although it should be changed weekly like oxygen tubing.
A resident with Type 2 Diabetes Mellitus was hospitalized with uncontrolled diabetes due to the facility's failure to monitor blood glucose levels and notify the physician of critical lab results. Despite having a care plan, the resident's blood glucose was not routinely checked, and an A1C level of 9.4 was not communicated to the physician. The resident's condition deteriorated, leading to hospitalization with a blood glucose level of 614.
A resident's medications, Morphine Sulfate and Lorazepam, were misappropriated in an LTC facility. Discrepancies were found during audits, revealing tampering with the Morphine's color and substitution of Lorazepam with an OTC medication. Despite investigations and staff interviews, the responsible party was not identified. The LPN involved was suspended and later terminated.
Failure to Properly Investigate Alleged Abuse and Identify Involved Staff
Penalty
Summary
The facility failed to follow its own policy for conducting a thorough investigation of alleged abuse, specifically by not properly identifying the staff involved in an incident reported by a resident. The resident, who had multiple diagnoses including major depressive disorder, morbid obesity, and chronic obstructive pulmonary disease, reported that two CNAs entered his room and one made a derogatory and abusive remark. Initial investigation led to the suspension of the wrong CNA due to misidentification, and only after further interviews and review of schedules were the correct staff members identified. The confusion over which staff were involved was compounded by inconsistent statements and uncertainty from both the resident and facility leadership. The resident described feeling fearful of retaliation from one of the CNAs involved, particularly after observing her continue to work on his hall and walk past his room, sometimes laughing. The resident reported that after the incident, he was left without assistance to use the bathroom for an extended period and that the staff involved did not respond to his needs. Interviews with other staff and residents revealed varying accounts, with some staff denying knowledge of the incident and others reporting that the resident had used inappropriate language toward the CNAs. The administrator admitted to confusion and panic during the investigation process, acknowledging that the wrong CNA may have been suspended initially and that the timeline of the incident was unclear. The facility's own abuse prevention and investigation policy required immediate reporting and a thorough investigation of alleged violations of residents' rights. However, the investigation was hampered by misidentification of staff, inconsistent documentation, and uncertainty about the sequence of events. The resident did not have a care plan addressing abuse, and the administrator expressed uncertainty about the details of the incident and the actions taken. This failure to properly identify the alleged staff involved and to conduct a clear, thorough investigation resulted in the resident experiencing ongoing fear of retaliation.
Failure to Administer Ordered IV Antibiotic and Ensure Timely Physician Communication
Penalty
Summary
A deficiency occurred when the facility failed to administer an ordered intravenous (IV) antibiotic to a resident as prescribed, did not ensure timely transport for continued treatment, and did not promptly contact the prescribing physician. The resident was admitted with multiple complex diagnoses, including Fournier Gangrene, chronic kidney disease, urinary tract infection, and a colostomy. Upon admission, the resident had an order for Ceftazidime-Avibactam IV antibiotic to be administered twice daily. However, the facility's pharmacy was unable to supply the medication due to its instability, high cost, and the need for immediate use, and this information was not communicated prior to the resident's admission. The medication administration records show that the IV antibiotic doses were repeatedly marked as "Hold" over several days. Progress notes indicate that the facility staff attempted to contact the prescribing infectious disease physician and the hospital, but there was a delay in communication and obtaining alternative orders. The nurse practitioner at the facility gave an order to hold the antibiotic until the prescribing physician could be reached, but the physician was not notified of the issue until several days later. During this period, the resident remained stable and continued on oral antibiotics, but the prescribed IV antibiotic therapy was interrupted. Efforts to transport the resident back to the hospital for the required IV antibiotic were unsuccessful for several days due to the resident's bariatric status and the inability to secure appropriate ambulance services. The resident ultimately required readmission to the hospital and an additional six days of IV antibiotic therapy due to the interruption in treatment. Interviews with facility staff and the pharmacist confirmed that the facility was not equipped to provide the ordered medication and that there was a breakdown in communication regarding the resident's needs and the facility's capabilities.
Failure to Administer Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to administer physician-ordered medications as prescribed for four residents, resulting in multiple missed doses of critical medications. For one resident with diagnoses including end-stage renal disease, COPD, and diabetic neuropathy, there were several days where a prescribed pain medication (Pregabalin) was not administered due to delays in obtaining a new prescription and pharmacy refill. Documentation showed that both nursing staff and the pharmacy attempted to contact the physician for a new script, but the medication was not available for several days, during which the resident reported experiencing pain. Another resident with a history of diabetes, obesity, and neuropathy also experienced repeated interruptions in receiving Pregabalin, with missed doses documented and the resident reporting frequent shortages of the medication. The DON acknowledged ongoing issues with the medication ordering system, particularly for controlled substances, and noted that the facility was transitioning to a new medical director and system, which contributed to the delays. Nursing staff were sometimes unaware of the missed doses, and the facility's policy required timely reordering of medications before supplies were exhausted, which was not consistently followed. Additional residents were affected by similar issues. One resident with Parkinson's disease missed several doses of Gocovri (amantadine), with progress notes indicating the medication was on order or awaiting delivery from the pharmacy. Another resident missed multiple doses of prescribed estrogen cream, with no documentation in the progress notes explaining the missed doses. Interviews with staff and family confirmed that medication administration was inconsistent due to delays in obtaining medications and communication issues between the facility, pharmacy, and prescribers.
Unauthorized Use of Resident's Debit Card by Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically involving the unauthorized use of the resident's debit card by a staff member. The incident involved a cognitively intact resident, who noticed inconsistencies in her bank account and reported them to her bank. The bank's investigation revealed that two staff members had made unauthorized transactions using the resident's mobile payment application, leading to the involvement of the local police department. The investigation found that a Certified Nursing Assistant (CNA) had saved the resident's debit card information on her phone to order pizza, but subsequently used the card for personal transactions, including transferring money to herself and another former employee. The resident did not give permission for these transactions and felt unsafe and targeted as a result. The CNA admitted to using the resident's money but claimed she was unaware she was doing so until later. The police report confirmed the unauthorized transactions and identified the CNA as the unauthorized user. The facility's policy prohibits misappropriation of resident property, and the incident was determined to be substantiated abuse due to the evidence provided. The resident expressed feelings of sadness and betrayal, highlighting the emotional impact of the incident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident, identified as R129, who was experiencing significant pain. On the morning of June 24, 2024, R129 reported stomach pain to the Assistant Director of Nursing, who promised to inform the nurse but did not follow up. Despite continued complaints of severe pain, including groaning and expressing a desire to die, the resident was not assessed or treated for 44 minutes. A Certified Nursing Assistant (CNA) informed the Registered Nurse (RN) about the resident's pain, but the RN continued with medication rounds without addressing the issue immediately. The resident's pain was eventually assessed as a 10 on a scale of 1-10, indicating the worst possible pain, yet the RN did not contact the doctor or provide immediate relief. The resident's care plan indicated a risk for pain related to depression and required monitoring and reporting of pain complaints. However, the facility did not have a pain policy in place, and the Medication Administration Record (MAR) only included orders for mild pain management, with no provisions for severe pain. The resident was eventually given acetaminophen for mild pain, which was not appropriate for the level of pain reported. The lack of a comprehensive pain management policy and the failure to assess and address the resident's pain in a timely manner contributed to the deficiency identified by the surveyors.
Failure to Administer Physician-Ordered Wound Treatment
Penalty
Summary
The facility failed to provide the physician-prescribed skin and wound treatments for a resident diagnosed with morbid obesity and panniculitis. The resident, who is cognitively intact, reported that he often experiences cellulitis in his abdomen and used to receive InterDry moisture-wicking sheets for his abdominal folds, but had not received them for some time. During an observation, the resident's abdominal fold was found to be red and irritated, and no InterDry sheet was present, despite physician orders specifying its use. The Assistant Director of Nurses confirmed that the InterDry sheets should have been applied as per the physician's orders and acknowledged that documentation falsely indicated the treatment was being administered. The Treatment Administration Record inaccurately documented that the resident received the treatment on specific dates. The facility's policy on wound assessment did not include instructions to follow physician orders for treatment, contributing to the oversight.
Delayed Call Light Response Leads to Resident Distress
Penalty
Summary
The facility failed to answer call lights in a timely manner for four residents, leading to feelings of neglect and degradation among the residents. Resident 38 reported that it sometimes takes hours for staff to respond to call lights, making her feel abandoned. She is cognitively intact and dependent on staff for toileting and bed mobility. Resident 22 also expressed that at night, the response time can exceed an hour, resulting in accidents and feelings of worthlessness. She is cognitively intact, uses a wheelchair, and requires assistance for toileting and hygiene. Resident 50 mentioned that on weekends, the staff response can take hours due to insufficient staffing, leading to feelings of neglect. She is cognitively intact, uses a wheelchair, and is frequently incontinent. Resident 5 reported waiting for over an hour on a bedside commode due to inadequate staffing, with one aide refusing to work due to pregnancy. He is cognitively intact, uses a wheelchair, and requires assistance for toileting and transfers. The facility lacks a policy on call light response times, although the expectation is 3 to 5 minutes. The Resident Council meeting minutes and the Illinois Long Term Care Ombudsman also documented issues with delayed call light responses.
Inadequate Incontinent Care Provided to Residents
Penalty
Summary
The facility failed to provide complete incontinent care for several residents, as observed during the survey. In one instance, a CNA provided care to a resident with a saturated brief but did not adequately cleanse the labia and inner thighs. This resident was documented as severely cognitively impaired and required substantial assistance with personal hygiene. The facility lacked a specific incontinent care policy, relying instead on staff to follow general standards of practice. Another resident, who was cognitively intact and had a catheter, reported needing incontinent care. A CNA provided care without proper gowning and failed to change gloves between tasks, leading to inadequate cleaning of the resident's catheter tubing and groin area. The wound nurse later found feces remaining in the resident's gluteal fold, indicating incomplete care. Additional deficiencies were noted with other residents. One resident received care where the CNA did not cleanse the buttocks or inner thighs adequately, despite the care plan specifying thorough washing, rinsing, and drying of the perineum. Another resident, who was incontinent and had impaired mobility, did not receive proper cleaning of the scrotum or peri area during care. The care plan for this resident also required thorough cleaning after incontinent episodes. These observations highlight a pattern of incomplete and inconsistent incontinent care provided by the facility staff.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, particularly in hand hygiene and the use of Personal Protective Equipment (PPE), for several residents. One resident, who was cognitively intact and required contact isolation due to open wounds and a urinary catheter, did not have appropriate signage or PPE available at her door. A Certified Nursing Assistant (CNA) provided incontinent care without donning a gown and failed to change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. Similarly, a wound nurse did not use a gown and neglected hand hygiene between glove changes while treating the resident's wounds. Another incident involved a Registered Nurse (RN) who entered a resident's room, which had an enhanced barrier precaution sign, without wearing a gown or performing hand hygiene. The RN administered intravenous medication through a PICC line without following proper protocols. Additionally, a Licensed Practical Nurse (LPN) was observed administering medications without performing hand hygiene. These actions were contrary to the facility's infection prevention and control policies, which require enhanced barrier precautions, including the use of gowns and gloves, during high-contact resident care activities.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed response times to call lights. Resident 38 reported that it sometimes takes hours for staff to respond, attributing the delay to staff being backed up. Resident 22 also experienced significant delays, particularly at night, with call light responses taking over an hour. Both residents are cognitively intact and require assistance with toileting and mobility, highlighting the critical need for timely staff support. Resident 50 noted that on weekends, the response time can be hours due to insufficient staffing. Similarly, Resident 5 experienced a delay of over an hour while on a bedside commode, with only two CNAs available for two halls, one of whom was unwilling to work due to pregnancy. The CNA scheduler confirmed that the night shift staffing levels are inadequate, with only three CNAs available, which is insufficient to meet the needs of the residents, especially those requiring one-to-one supervision. This staffing shortage has led to prolonged wait times for residents needing assistance.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a notice of bed hold policy to a resident and/or their representative upon transfer to a hospital. This deficiency was identified for one resident, who was readmitted from the hospital with diagnoses of COPD and pneumonia. The resident's records did not document any bed-hold notification provided to the resident or their Power of Attorney. Interviews with facility staff, including an LPN and a social worker, revealed that while certain documents are sent with residents during hospital transfers, the bed-hold policy was not documented as being provided. The facility administrator stated that staff should follow the policy regarding documentation and transfer paperwork.
Failure to Maintain Occlusive PICC Line Dressings
Penalty
Summary
The facility failed to maintain an occlusive dressing for a Peripherally Inserted Central Catheter (PICC) for two residents receiving intravenous therapy. For one resident, a registered nurse observed that the dressing on the PICC line was not adhered to the skin at the bottom and right side, yet proceeded to hang an IV medication without changing the dressing. The dressing was dated five days prior, and the nurse later admitted to not changing it until after the IV was finished. The resident's medication administration record did not document a weekly or as-needed dressing change, as required. Similarly, another resident was observed with a PICC line dressing that was not attached at the bottom or right side, with the dressing dated thirteen days prior. This resident received daily IV medication, but the treatment administration record did not document a dressing change on the day shift. A health status note later indicated that the dressing was changed, and the area appeared intact with no signs of infection. The facility's policy on IV therapy care, which includes maintaining infusion equipment and catheters, was not adhered to in these instances.
Failure to Provide Timely Medication Refill for Resident
Penalty
Summary
The facility failed to ensure that physician-ordered medication was readily available for a resident, leading to a deficiency in pharmaceutical services. A resident, who is cognitively intact and diagnosed with depression, reported that she had run out of her prescribed antidepressant, Effexor, and missed doses on two consecutive days. The resident expressed experiencing withdrawal symptoms due to the missed doses, which were not administered as prescribed. The resident's care plan and physician's orders documented the need for the medication to be administered twice daily, but the medication administration record indicated missed doses with a note to see the progress note. The Assistant Director of Nursing (ADON) acknowledged awareness of the situation and stated that the medication should have been reordered when the medication card indicated a low supply. Despite the resident informing the ADON about the shortage, the medication was not available until after lunch on the day it was reordered. The facility's pharmacy procedures outlined the process for obtaining medications that cannot wait for the next scheduled delivery, but this process was not effectively utilized. Additionally, there was no entry in the resident's progress notes on the day the medication was missed, and subsequent notes indicated the medication was not available.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols for three residents. During an inspection, it was found that a resident's Cephalexin oral suspension was not discarded after the recommended 14 days, as confirmed by the Assistant Director of Nursing. Additionally, a Humalog Kwik Pen used by another resident was not dated upon opening, which is against the facility's policy that requires medications to be dated after opening. The LPN acknowledged the oversight and decided to replace the pen due to the lack of an open date. Further deficiencies were observed with the labeling of medications. A resident's fluticasone propionate nasal spray was found in the medication cart without a pharmacy label, contrary to the facility's policy that requires all medications to be properly labeled. Similarly, a tube of wound debridement ointment used for another resident was missing a pharmacy label, with only the resident's name handwritten on it. The wound nurse was unable to explain the absence of the original labeled box, acknowledging that the medication should have had a pharmacy label.
Verbal Abuse of Resident by LPNs
Penalty
Summary
The facility failed to prevent verbal abuse of a resident by two Licensed Practical Nurses (LPNs), which was substantiated through interviews and records. The incident involved a resident with a mental disorder and altered mental status, who repeatedly expressed a desire to leave the facility to see her son. During a shift change, the resident was at the nurses' station, and two LPNs, identified as V13 and V14, were reported to have told the resident to 'shut up' in response to her repetitive statements. This interaction was witnessed by multiple staff members, including a Registered Nurse (RN) and a Medical Records staff member, who corroborated the verbal abuse. The incident occurred in the early morning, and the facility's Administrator was notified about an hour later. The LPNs involved were suspended following the report of the incident. Witnesses reported that the LPNs used inappropriate language and tone, with one LPN wheeling the resident into the dining room while continuing to use abusive language. Despite the presence of other staff members, the incident was not immediately reported to the Administrator, indicating a delay in addressing the abuse. The facility's policy on abuse prevention and prohibition clearly states that residents must not be subjected to abuse by anyone, including facility staff. However, in this case, the policy was not adhered to, as evidenced by the verbal mistreatment of the resident. The failure to immediately report the incident by some staff members further contributed to the deficiency, highlighting a lapse in the facility's adherence to its own abuse prevention protocols.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to operationalize their abuse policies and procedures, resulting in a deficiency related to the handling of abuse allegations. Specifically, the facility did not conduct a thorough investigation of allegations of abuse, failed to protect residents during the investigation, and did not report allegations to the administrator immediately. This was evident in the cases of two residents, R5 and R41, who were involved in incidents where staff members allegedly verbally abused R41. R5 reported that a CNA, V11, got in R41's face and made inappropriate comments, which R5 perceived as mental abuse. Despite R5's report to the Social Service Director and the Administrator, the response was inadequate, as V11 was not suspended during the investigation and continued to work on the floor. In another incident, two nurses, V13 and V14, were reported to have verbally abused R41 by telling her to shut up during a shift change. Multiple staff members, including a Registered Nurse and a Medical Records staff, witnessed the incident but did not report it immediately. The delay in reporting and the failure to remove the alleged perpetrators from resident contact during the investigation were significant lapses in the facility's abuse prevention and response protocols. The facility's policy mandates immediate reporting and removal of staff involved in abuse allegations, which was not adhered to in this case. The facility's final investigation confirmed the inappropriate verbal interaction between the nurses and R41, leading to the suspension and eventual termination of the involved staff. However, the initial handling of the situation, including the delay in reporting and the failure to protect residents from potential further abuse, highlights deficiencies in the facility's implementation of its abuse prevention and prohibition policy. The facility's policy clearly outlines the steps to be taken in such situations, but these were not followed, resulting in a failure to protect the residents and ensure a safe environment.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents. One resident reported that a Certified Nurse Aide (CNA) got in the face of another resident and made inappropriate comments about her son being in prison. This incident was reported to the Social Service Director and the Administrator, who decided that the CNA needed retraining. However, there was no documentation that this allegation was reported to the Illinois Department of Public Health (IDPH). Another incident involved two Licensed Practical Nurses (LPNs) who were reported to have verbally mistreated a resident by telling her to shut up during a shift change. This incident was initially reported to the Business Office Manager, who then informed the Administrator. There was a delay in reporting the incident, as it occurred at 6:15 AM, but the Administrator was not notified until 7:30 AM. Despite the report, one of the LPNs continued to work on the floor until the Director of Nursing arrived. The facility's policy requires immediate reporting of abuse allegations to the Administrator or a designated representative and to the mandated state agency. However, in both cases, there was a failure to report the allegations in a timely manner, and the incidents were not immediately communicated to the appropriate authorities as required by the facility's policy.
Failure to Protect Residents and Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to protect residents and prevent further potential abuse during abuse investigations and did not conduct thorough abuse investigations for two residents. One incident involved a Certified Nurse Aide (CNA) allegedly getting in the face of a resident, R41, and telling her she would never go home to see her son because he was in prison. This was reported by another resident, R5, to the Social Service Director and the Administrator, who decided that the CNA needed retraining. However, the CNA was not suspended during the investigation, and there was a lack of thorough interviews with other residents or staff about the incident. Another incident involved two Licensed Practical Nurses (LPNs) who were reported to have told a resident, R41, to shut up during a shift change. The incident was reported to the Administrator by the Business Office Manager after a delay. The LPNs were suspended after the investigation substantiated the abuse, and they were eventually terminated. However, there was a delay in removing one of the LPNs from the floor, and the incident was not reported immediately by a CNA who witnessed it. The facility's investigation process was flawed, as evidenced by the Administrator not reviewing collected interviews promptly and the CNA involved in the first incident being allowed to continue working without suspension. Additionally, there was a lack of immediate reporting and action taken in the second incident, which contributed to the deficiency in protecting residents from potential abuse.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly identify, assess, and treat pressure ulcers for two residents. One resident was observed with pressure sores on both heels without any dressings, contrary to the physician's orders which required specific treatments and dressings. The wound nurse confirmed that the treatments were not being administered as ordered, and the resident's care plan indicated multiple areas of potential skin integrity impairment. The facility's policy on pressure ulcer prevention required treatment to heal existing ulcers and prevent new ones, which was not adhered to in this case. Another resident was found to have a pressure ulcer on the left gluteal fold, which was not documented in the medical record. The resident and a CNA confirmed the presence of the ulcer, but the wound nurse was unaware of it until later. The facility's policy required daily skin observations by CNAs, but there was a lack of documentation, assessment, and notification to the doctor regarding the pressure ulcer. This oversight led to a delay in obtaining necessary treatment orders.
Failure to Change Nebulizer Tubing Weekly
Penalty
Summary
The facility failed to change nebulizer therapy tubing on a weekly basis for a resident, identified as R65, who was reviewed for respiratory therapy. On June 26, 2024, it was observed that R65's nebulizer machine and tubing were on the nightstand beside the bed, with the tubing dated June 2, 2024. R65, who is cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15, stated that the oxygen and nebulizer tubing used to be changed weekly. R65's medical records indicate a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and sleep apnea, with a physician's order for Ipratropium-Albuterol Solution to be inhaled every six hours as needed for shortness of breath. The physician's order also specified that oxygen tubing should be changed weekly, every Sunday during the night shift. On July 1, 2024, the MDS coordinator confirmed that the facility does not have a specific policy for nebulization tubing but stated that it should be changed weekly, similar to the oxygen tubing.
Failure to Monitor and Treat Diabetes Leads to Hospitalization
Penalty
Summary
The facility failed to adequately monitor and treat a resident with Type 2 Diabetes Mellitus, leading to the resident's hospitalization with uncontrolled diabetes and acute on chronic renal failure. The resident, who was moderately cognitively impaired and dependent on staff for activities of daily living, had a history of insulin-dependent diabetes and was admitted to the hospital with a blood glucose level of 614. Despite having a care plan that included diabetes management, the plan did not address monitoring blood glucose levels or recognizing signs and symptoms of hyper or hypoglycemia. The resident's medical records revealed that there was no routine blood glucose monitoring order after the resident returned from a previous hospitalization. The resident's A1C level was recorded as 9.4, which is significantly higher than the target level for diabetics, but there was no documentation that the physician was notified of this abnormal result. Additionally, the resident's blood glucose level was recorded as 374 on a lab result, but no follow-up action was documented. The facility's failure to ensure routine blood glucose monitoring and to notify the physician of critical lab results contributed to the resident's deteriorating condition. Interviews with facility staff and the resident's primary care physician's office indicated a lack of communication and follow-up regarding the resident's diabetes management. The resident's nurse did not perform an accucheck despite observing a change in the resident's condition, and the physician's office did not receive notification of the resident's high A1C result. The hospitalist who treated the resident during the hospitalization stated that routine blood glucose monitoring could have prevented the resident's hospitalization and associated complications.
Misappropriation of Resident Medications
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their medications, specifically Morphine Sulfate and Lorazepam. The incident was identified during an audit conducted by a pharmacy representative on January 3, 2024, when a discrepancy was noted with the color of the Morphine Sulfate, which was supposed to be blue but appeared light green. This indicated potential tampering. The resident involved, who had a history of acute respiratory failure, pulmonary embolism, and cancer, was moderately cognitively impaired and on pain medication therapy related to cancer. Further investigation revealed another discrepancy on January 8, 2024, during a random audit of the medication carts. It was found that the Lorazepam 1 mg medication card for the same resident had been tampered with, as the pill slot contained an over-the-counter medication instead of the prescribed Lorazepam. The facility's Director of Nursing and Administrator conducted interviews with staff members who had access to the medication cart, but they were unable to identify the person responsible for the drug diversion. The facility reported the incidents to the local police department, the medical doctor, the ombudsman, and the responsible party. Despite the investigation and interviews conducted, the facility could not substantiate a perpetrator responsible for the medication diversion. The LPN involved was suspended pending the investigation's outcome and was eventually terminated for improperly handling narcotics. The facility continued to work with law enforcement to gather additional information related to the investigation.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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