Carlyle Healthcare & Sr Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlyle, Illinois.
- Location
- 501 Clinton Street, Carlyle, Illinois 62231
- CMS Provider Number
- 145729
- Inspections on file
- 24
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Carlyle Healthcare & Sr Living during CMS and state inspections, most recent first.
Two cognitively intact residents with stroke histories and mobility impairments, one on anticoagulant therapy and one with a care plan for aggressive behavior, became involved in an unwitnessed altercation after a dispute over snacks. One resident reported that the other attempted to hit him, that he grabbed the other’s shirt, and that the other fell and then kicked him in the lower legs. Staff later observed the residents arguing, with one resident balling his fists and yelling profanities at the other and at staff. Documentation and interviews confirmed a large, tender bruise on one resident’s lower leg and a torn shirt on the other, indicating physical contact. Surveyors determined the facility failed to ensure a resident remained free from abuse during this resident-to-resident incident.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was found with a bruise/skin tear, and an agency nurse suspected possible abuse by a CNA. The DON was informed and began an investigation, but the administrator and State Survey Agency were not notified as required by policy. The facility's procedures mandate immediate reporting of such allegations, but this did not occur.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was found with a bruise/skin tear, and an agency nurse suspected an agency CNA was responsible. The DON began an investigation but did not immediately remove the CNA from resident care, instead reassigning her to a different hall and allowing her to finish her shift, which was not in accordance with facility policy.
The facility experienced staffing shortages in the dietary department, leading to delayed meal service for several residents. One resident with heart failure and diabetes reported receiving her dinner late, while another with Alzheimer's disease received her lunch over an hour late. The delays were due to three dietary employees calling off work, leaving insufficient staff to serve meals on time.
A resident with major depressive disorder and anxiety was mentally abused when a CNA slept in her bed and threatened her not to report it, causing the resident to feel upset and fearful of being kicked out of the facility. The incident was not immediately reported by staff who discovered the CNA sleeping, and the resident later confided in her daughter, leading to an investigation.
The facility failed to store, prepare, and serve food safely, risking foodborne illness for 79 residents. Observations included improper storage of hand sanitizer and insect traps near food, undated and unlabeled food items, and unsafe food temperatures. The Dietary Manager acknowledged these issues, which violated the facility's policies on safe food handling and storage.
The facility failed to implement an effective antibiotic stewardship program, resulting in inappropriate antibiotic use for four residents. Antibiotics were continued without proper justification, as the Infection Control Log lacked causative pathogens for urinary tract infections. The facility's policy was not followed, leading to antibiotics being administered based on symptoms or incomplete documentation.
The facility failed to ensure resident safety in smoking activities and fall prevention. Three residents were observed smoking without required supervision or safety measures, contrary to the facility's smoking policy. Additionally, a high fall-risk resident was left unattended on the toilet, resulting in a fall and fractured ankle. These incidents reflect a lack of adherence to safety protocols, as outlined in the facility's policies.
The facility failed to provide adequate incontinent care for four residents, leading to deficiencies in hygiene and infection prevention. CNAs did not perform hand hygiene or follow proper cleansing procedures, neglecting to clean necessary areas and improperly handling soiled linens. These actions were inconsistent with the facility's Perineal Care Policy, resulting in observed deficiencies.
A facility failed to store medications properly and did not date an open multidose vial, affecting 21 residents in the dementia unit. Ice buildup in the medication refrigerator led to water saturation of medication boxes, and an opened tuberculin vial lacked a date. The RN noted the refrigerator needed defrosting, and both the Administrator and DON expected proper dating and storage of medications.
CNAs in a facility failed to follow proper infection control protocols, including hand hygiene and glove use, during incontinence care for several residents with cognitive impairments. Despite the facility's policy emphasizing hand hygiene, CNAs were observed not washing hands before or after glove use, and improperly handling soiled linens, indicating a systemic issue with infection control practices.
Failure to Prevent Resident-to-Resident Abuse Resulting in Bruising
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse during a resident-to-resident altercation. One resident (R1), who was cognitively intact and used a walker and wheelchair, had diagnoses including cerebral infarction, hypertensive heart disease with heart failure, asthma, chronic pain, major depressive disorder, gastric ulcer with hemorrhage, and was on anticoagulant therapy with a care plan noting increased risk of bruising and bleeding. Another cognitively intact resident (R2), who used a wheelchair, had diagnoses including cerebral infarction, major depressive disorder, type 2 diabetes with chronic kidney disease, chronic pain, anxiety disorder, and had a care plan focus area for aggressive behavior, including cussing and yelling profanities, with interventions to manage such behavior. On the day of the incident, R1 reported that R2 had been eating his snacks without permission. According to R1’s progress note, when R1 confronted R2, R2 got out of his wheelchair and attempted to hit him. R1 stated he grabbed R2 by the shirt because R2 was attempting to hit him, and R2 then fell to the floor and began kicking R1 in the lower legs. When nursing staff entered the room, they observed the two residents verbally arguing, with R2 balling up his fists and yelling profanities. R2’s progress note documented that he was found sitting on his bottom with his back against the wall and that he stated he had stood up and lost his balance, causing him to fall, while also balling up his fist in a threatening manner and yelling profanities at R1 and staff. Subsequent documentation and interviews confirmed that R1 sustained a large blue/purple bruise around the left lower extremity calf area that was very tender, and that R1 reported being kicked by R2. A CNA (V3) stated the incident was unwitnessed, that R2’s shirt was torn, and that R1 later had a bruise on his leg, noting R1 was on blood thinners and bruised easily. The administrator (V1) stated the altercation occurred less than 24 hours after R2 was moved into R1’s room and that both residents had prior stroke-related weakness, with R1 also having visual impairment and being on a blood thinner and anemic. The facility had a policy on resident-to-resident altercations requiring investigation and identification of what led to aggressive conduct, and the survey finding concluded the facility failed to ensure residents remained free from abuse for one resident reviewed for abuse.
Failure to Timely Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported immediately to the facility administrator and the State Survey Agency, as required by policy and federal regulations. The incident involved a resident with diagnoses including dementia, paranoid schizophrenia, and anxiety disorder, who was severely cognitively impaired and required substantial assistance with bed mobility. An agency nurse observed a bruise/skin tear on the resident and expressed suspicion that an agency CNA may have caused the injury. The nurse communicated this suspicion to the Director of Nursing (DON) by phone, who then began an investigation and assessed the resident, noting the injury but no signs of emotional distress or verbalization of harm from the resident. Despite the suspicion of abuse, there was no documentation that the administrator or the State Survey Agency was notified of the allegation as required. The DON instructed the agency nurse to contact the administrator and write a statement, but this was not done. The facility's policies clearly state that all allegations of abuse, including injuries of unknown origin, must be reported immediately to the administrator and appropriate authorities, with "immediately" defined as within two hours for abuse allegations. Interviews confirmed that the administrator was not made aware of the incident in a timely manner and that the required notifications were not completed.
Failure to Immediately Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from potential further abuse after an allegation was made. A resident with severe cognitive impairment, dementia, paranoid schizophrenia, and anxiety disorder was found with a bruise/skin tear. An agency nurse reported a suspicion that an agency CNA was responsible for the injury. The Director of Nursing (DON) was notified and began an investigation, but the CNA in question was not immediately removed from resident care. Instead, the CNA was reassigned to a different hall and allowed to complete her shift before being removed from the facility until the investigation was completed. Facility policy requires that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete. However, the DON did not follow this policy, as the CNA continued to have resident contact during the shift following the allegation. The facility's own documentation and staff interviews confirmed that the accused CNA was not immediately removed from resident care, contrary to established procedures.
Staffing Shortages Lead to Delayed Meal Service
Penalty
Summary
The facility failed to adequately staff the dietary department, resulting in delayed meal service for several residents. One resident, who was admitted with heart failure and diabetes, reported receiving her dinner late and not as ordered. She expressed that meal service often started later than scheduled. Another resident, with Alzheimer's disease and blindness, received her lunch meal over an hour after it was scheduled to begin. A third resident, with type 2 diabetes and pressure ulcers, also experienced a delay in receiving her lunch meal, which was delivered one hour and twenty-six minutes after the scheduled time. A fourth resident, with chronic kidney disease and type 2 diabetes, received her lunch meal one hour and thirty-five minutes late. The delays in meal service were attributed to staffing shortages in the dietary department. On the day of the survey, three dietary employees called off work, leaving the Environmental Services and Dietary Supervisor to handle much of the work alone. The facility's weekly schedule indicated that five dietary staff were originally scheduled to be present during the lunch hour, but the call-offs led to insufficient staffing. The facility's policy requires meals to be served at scheduled times, but the staffing issues resulted in significant delays, impacting the residents' meal service.
Failure to Prevent Mental Abuse of Resident
Penalty
Summary
The facility failed to prevent mental abuse for a resident, identified as R2, who was found to be tearful and expressed feelings of being upset and fearful of being kicked out of the facility. R2, who is alert, oriented, and cognitively intact, was admitted with diagnoses of major depressive disorder and anxiety. The incident involved a CNA, V6, who was found sleeping in R2's bed. R2 reported that V6 threatened her not to tell anyone about the incident, stating that if she did, V6 would be fired and R2 would be kicked out of the facility. This threat caused R2 significant emotional distress, as she was afraid of losing her place in the facility. The incident occurred when V6 entered R2's room early in the morning, claiming to be cold and tired, and subsequently fell asleep in R2's bed. R2, who usually sleeps in her recliner, was awake and witnessed the event. Staff members, including V8 and V7, later found V6 sleeping in R2's bed and woke her up. Despite being aware of the situation, V8 and V7 did not report the incident to management immediately. R2 did not initially report the incident due to fear of repercussions, but later confided in her daughter, V5, who then reported it to the facility's administration. The facility's investigation revealed that R2 was tearful and upset during interviews with staff and her family member, V5. The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised in April 2021, states that residents have the right to be free from abuse, including mental abuse. Despite this policy, the failure to prevent and address the mental abuse experienced by R2 highlights a deficiency in the facility's handling of the situation, as R2 was left feeling unsafe and emotionally distressed.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness, potentially affecting all 79 residents. Observations revealed several issues in the large dry storage room, including hand sanitizer stored next to food items like sugar, and insect bait traps placed near food products such as hot sauce and poppy seed dressing. Mouse droppings were found on the top of the storage rack. In the kitchen, grease and burnt matter were observed on the stovetop and ovens, and the walk-in refrigerator contained undated sweet potatoes and cream cheese removed from original packaging without expiration dates. The walk-in freezer had unlabeled pie crusts, and the standing refrigerator had an opened jar of bouillon without a date of opening. Additional issues were noted in the small dry storage closet, where large tubs of oatmeal, sugar, flour, and thickener were labeled but not dated. The staff and resident refrigerator contained various unlabeled and undated food items, including moldy and expired products. Food temperatures in the second-floor dining room were below safe levels, with green beans at 113°F and salads at 69°F and 56°F, which are within the danger zone as per the facility's policy. The Dietary Manager acknowledged the issues with food storage and temperature management. The facility's policies require food to be stored and handled safely, with specific guidelines for labeling, dating, and maintaining appropriate temperatures, which were not followed in these instances.
Inadequate Antibiotic Stewardship in LTC Facility
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, particularly in antibiotic stewardship, for four residents. The Infection Control Log did not list causative pathogens for urinary tract infections in these residents, leading to inappropriate antibiotic use. For one resident, an antibiotic was continued despite a urine culture showing no microbial growth, based solely on symptoms. Another resident received an antibiotic without a culture to justify its use, and the facility struggled to obtain necessary documentation from the hospital. Similarly, two other residents were administered antibiotics without appropriate culture results to support their use, with one case relying on an elevated white blood cell count from a metabolic panel, which did not justify the antibiotic treatment. The facility's Antibiotic Stewardship Policy, revised in 2016, mandates that antibiotics be prescribed and administered under the guidance of the stewardship program. However, the facility did not adhere to this policy, as evidenced by the lack of proper documentation and justification for antibiotic use. The administrator acknowledged the expectation for staff to follow the policy and educate new hires, but the report highlights a significant gap in the implementation of the program, leading to the continuation of antibiotics without appropriate clinical justification.
Deficiencies in Smoking Safety and Fall Prevention
Penalty
Summary
The facility failed to ensure the safety of residents who engage in cigarette smoking activities by not developing and implementing personalized care plan interventions. Three residents were affected by this deficiency. One resident, who is cognitively intact, was observed smoking without wearing a smoking apron and keeping a lighter in his pocket, which resulted in a burn. Another resident, who is moderately cognitively impaired, was also observed smoking without supervision and not wearing a smoking apron, despite being on oxygen in his room. A third resident, who is cognitively intact, admitted to keeping a lighter in her purse and not wearing a smoking apron. The facility's smoking policy requires supervision and the use of safety measures, which were not adhered to in these cases. The facility also failed to provide adequate supervision to prevent falls for a resident at high risk for falls. This resident, who is severely cognitively impaired, was left unattended on the toilet by a CNA, resulting in an unwitnessed fall and a fractured ankle. The resident's care plan indicated the need for substantial assistance with transfers and the use of a sensor pad, which was not followed. The facility's policy on fall risk management emphasizes the need for supervision in the bathroom for high-risk residents, which was not implemented in this instance. The deficiencies highlight a lack of adherence to established safety protocols for both smoking and fall prevention. The facility's policies clearly outline the need for supervision and specific interventions to ensure resident safety, yet these were not consistently applied, leading to unsafe conditions and injuries for the residents involved.
Inadequate Incontinent Care and Hygiene Practices
Penalty
Summary
The facility failed to provide complete incontinent care for four residents, leading to deficiencies in maintaining hygiene and preventing infections. Resident R17, who is severely cognitively impaired and always incontinent of urine, was observed being transferred into bed by two CNAs who did not perform hand hygiene before or after the procedure. The CNAs used the same disposable cloth to cleanse different areas of R17's body without changing gloves or cloths, and they did not cleanse all necessary areas, such as the outer labia and inner thighs. After completing the care, the CNAs left the room without performing hand hygiene. Resident R3, who is moderately cognitively impaired and dependent on staff for toileting hygiene, was also subjected to inadequate care. The CNAs did not perform hand hygiene before or after handling R3, and they failed to cleanse the entire length of R3's penis, inner thighs, scrotum, and buttock. Additionally, they did not retract R3's uncircumcised penis to cleanse the area properly. Similar issues were observed with Resident R38, who is severely cognitively impaired. The CNAs did not use perineal cleanser or soap and failed to cleanse R38's frontal labia region after a bowel movement. Soiled linens were improperly handled, and hand hygiene was neglected. Resident R59, who requires substantial assistance with toileting, was also inadequately cared for. The CNAs did not cleanse R59's frontal region, including the inner labia and thighs, and failed to perform hand hygiene before and after the procedure. The facility's Perineal Care Policy outlines specific steps for maintaining cleanliness and preventing infections, but these were not followed, leading to the observed deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store medications in a sanitary manner and did not date an open multidose medication vial, which could potentially affect all 21 residents in the dementia unit. During an inspection of the dementia unit's medication storage room, a large block of ice buildup was observed in and around the freezer section of the medication refrigerator. This ice was dripping onto the bottom of the refrigerator, causing water saturation of a box containing a vial of abrysvo vaccine and another box containing bisacodyl suppositories. Additionally, an opened multidose vial of tuberculin solution was found without a date indicating when it was opened. The Registered Nurse (RN) acknowledged that the medications, including the suppositories, abrysvo vial, and tuberculin solution, were used as needed for all residents in the unit and noted that the refrigerator required defrosting. Both the Administrator and the Director of Nursing (DON) expressed that they expected medications to be dated when opened and stored in a clean manner. The facility's Storage of Medications Policy, revised in November 2020, mandates that drugs and biologicals be stored safely, securely, and orderly, with proper temperature, light, and humidity controls, and that medication storage areas be maintained in a clean, safe, and sanitary manner.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the areas of hand hygiene and glove use, during the care of five residents. Certified Nurse Assistants (CNAs) were observed not performing hand hygiene before donning gloves, between glove changes, or after removing gloves. This was noted during the provision of incontinence care for residents who were cognitively impaired and dependent on staff for activities of daily living (ADLs). The CNAs involved did not follow the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent the spread of infections. For instance, one resident with Alzheimer's disease and severe cognitive impairment was transferred to bed by CNAs who donned gloves without hand hygiene, changed the resident's soiled brief, and performed incontinence care without changing gloves or washing hands. Another resident, also with Alzheimer's and dependent on staff for toileting, was similarly handled by CNAs who failed to perform hand hygiene before and after care, and improperly disposed of soiled linens. These actions were repeated across multiple residents, indicating a systemic issue with infection control practices. The facility's policy, revised in August 2019, clearly states that glove use does not replace hand hygiene and that all personnel should be trained and regularly in-serviced on these procedures. Despite this, CNAs were observed not adhering to these guidelines, as evidenced by their actions during the care of residents. Interviews with staff, including the Administrator and Director of Nursing, confirmed that the expectation was for CNAs to perform hand hygiene before, during, and after providing care, which was not met in these instances.
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.
