Dixon Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dixon, Illinois.
- Location
- 800 Division Street, Dixon, Illinois 61021
- CMS Provider Number
- 145906
- Inspections on file
- 25
- Latest survey
- January 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Dixon Rehab & Hcc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and high risk for pressure injuries developed a stage 3 pressure ulcer due to the facility's failure to identify and manage the wound appropriately. Despite the resident's risk factors and a request for professional evaluation, the wound was not seen by a wound care professional due to COVID-19 isolation and holiday scheduling. The facility's documentation was inconsistent, and the wound progressed to a stage 4 upon transfer to another facility.
A facility failed to prevent and manage pressure injuries for two residents, leading to a Stage 3 infected heel wound for one and two Stage 2 sacral wounds for another. Delays in treatment orders, inadequate monitoring, and poor communication contributed to the worsening of these conditions, despite existing interventions and policies.
A resident in an LTC facility was allegedly slapped by a new roommate, who exhibited aggressive behavior due to a change in condition, including altered mental status and infection. The incident also involved the resident kicking and striking a CNA. Both residents had cognitive impairments, and the facility's investigation concluded the incident was isolated and linked to the aggressor's medical condition.
The facility failed to properly assess and treat pressure ulcers for several residents, leading to deficiencies in care. A resident with a stage 3 coccyx ulcer did not receive the prescribed treatment, and another with a stage 2 ulcer was found without a dressing. Documentation gaps and delayed treatment orders were also noted, contrary to the facility's pressure ulcer prevention policy.
A resident with multiple health conditions experienced significant weight loss, which was not accurately assessed or addressed by the facility. Despite being on a diet with increased protein, the resident continued to lose weight, and the dietitian did not physically assess the resident, relying on incorrect information. The recommended increase in liquid protein was not reflected in the physician's orders, indicating a lack of communication and implementation of necessary interventions.
A resident with severe cognitive impairment and a history of falls experienced multiple falls while attempting to go to the bathroom unassisted. Despite being identified as a high fall risk, the facility's interventions, such as reminders and call lights, were ineffective due to the resident's dementia. The resident sustained injuries, including a hip fracture requiring surgery, highlighting the inadequacy of the fall prevention measures in place.
A resident experienced severe pain after hip surgery due to the facility's failure to update and administer the correct pain medication regimen as per hospital discharge orders. The resident's outdated pain medication order was not revised, leading to inadequate pain management despite evident distress.
A dietary aide in an LTC facility failed to wash hands between handling dirty and clean dishes, risking cross-contamination for 89 residents. The dietary manager confirmed the requirement for handwashing between tasks, as outlined in the facility's policy.
A facility failed to perform daily weights for a resident with CHF as ordered. The resident, with multiple health conditions including heart failure and chronic kidney disease, had a physician's order for daily weights. However, records show numerous missed weight recordings over several months. The DON confirmed the importance of daily weights for CHF residents to monitor for fluid overload, as per facility policy.
A resident with a stroke-related impairment did not receive necessary passive range of motion exercises or have a splint applied to her contracted hand, as required by her care plan. Staff were unaware of her needs, assuming she preferred to exercise independently, despite her inability to move her left side. This oversight contradicts the facility's policy to maintain optimal physical function.
A resident with a history of depression and self-harm behaviors did not receive timely psychiatric services as ordered. Despite a Nurse Practitioner's directive for immediate psychiatric evaluation due to increased depression, the consultation was delayed by seven days. The delay was attributed to a lack of communication and the psychiatric provider's unavailability, highlighting a failure to adhere to the facility's policy for individualized mental health interventions.
A resident was found with eight pills on her bedside table without a nurse present, contrary to the facility's medication administration policy. The resident claimed she took the pills after breakfast, although the RN had already administered her morning medications. The DON confirmed that leaving medications in a resident's room is against facility practice, as it prevents ensuring the medication was taken.
A facility failed to limit the use of PRN psychotropic medications for a resident, as required by regulations. The resident's orders for Haloperidol Lactate and Lorazepam lacked the necessary stop dates, and the facility did not comply with the 14-day limit for PRN antipsychotic medications. The DON confirmed that orders should include a stop date and be limited to 14 days unless extended by a physician.
Failure to Manage Pressure Ulcer Progression
Penalty
Summary
The facility failed to identify and appropriately manage a pressure ulcer for a resident, resulting in the development of a stage 3 pressure ulcer with 90% slough and necrotic tissue on the resident's sacrum. The resident, who had severe cognitive impairment and required maximal assistance with activities of daily living, was admitted with a risk of developing pressure injuries but did not have any upon admission. Despite the resident's high risk due to conditions such as spinal stenosis, Type 2 Diabetes Mellitus, and incontinence, the facility did not adequately monitor or document the skin breakdown. The resident's Power of Attorney (POA) was informed of a stage 2 pressure injury, but upon transfer to another facility, it was determined to be a stage 4 pressure injury. The facility's Director of Nursing (DON) and staff failed to have the wound evaluated by a wound care professional due to the resident's COVID-19 isolation and subsequent holiday period. The wound care professional contracted by the facility did not see the resident, and the facility's staff continued treatment without professional evaluation, believing the wound was improving. The facility's documentation was inconsistent, with no evidence of wound measurement or monitoring from late September to mid-October, despite orders for wound care. The facility's policy required weekly wound assessments, but the resident's wound was not properly assessed or documented, leading to a significant oversight in care. The facility's failure to adhere to its wound care policy and ensure timely professional evaluation contributed to the progression of the pressure ulcer.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to prevent and adequately manage pressure injuries for two residents, leading to significant health issues. One resident, admitted for a hysterectomy with no initial skin integrity issues, developed a Stage 3 pressure injury on her right heel. The injury began as a deep tissue injury, progressed to an unstageable wound, and became infected. Despite the presence of heel protective boots and a mechanical lift sling, the wound worsened over time, with the resident experiencing pain and requiring antibiotics and wound doctor consultations. The facility's documentation showed delays in treatment orders and inadequate monitoring of the wound's progression. Another resident developed two Stage 2 pressure injuries on the sacrum, which were not initially reported or treated by the staff. The resident was at risk for pressure injuries due to decreased mobility, incontinence, and other factors, and had interventions in place such as a low air loss mattress and regular repositioning. However, the redness and open areas on the sacrum were not addressed promptly, and the staff failed to apply necessary creams or report the condition until it was observed by a surveyor. The facility's policies on pressure ulcer prevention were not effectively implemented, as evidenced by the lack of timely intervention and monitoring for both residents. The documentation and communication between staff and medical professionals were insufficient, contributing to the worsening of the residents' conditions. The facility's failure to adhere to its own pressure ulcer prevention policy resulted in preventable pressure injuries and inadequate care for the affected residents.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident (R1) from physical abuse by another resident (R2), as evidenced by an incident where R2 allegedly slapped R1. The incident occurred after R2, who had recently moved into R1's room, exhibited aggressive behavior due to a change in condition, including altered mental status and a newly diagnosed infection. During the altercation, R2 also kicked and struck a CNA who attempted to intervene. Despite the lack of visual proof or witnesses to the slap, the facility's investigation concluded that the incident was an isolated event linked to R2's medical condition. Interviews with staff and family members revealed that R2 had not previously exhibited such behaviors, and both residents had some level of cognitive impairment. R1's daughter reported that R2 had claimed R1's belongings as his own, leading to the physical altercation. Staff members, including the DON and nurses, confirmed the altercation and noted R2's aggressive behavior towards the CNA. R1's care plan indicated he was social and enjoyed interacting with others, while R2's care plan noted his cognitive impairment but did not document any prior behavioral issues. The facility's policy on abuse prevention and prohibition emphasizes that residents must not be subjected to abuse by anyone, including other residents. The policy defines willful actions as deliberate, regardless of intent to harm. In this case, R2's actions were considered deliberate due to his cognitive impairment, but the facility attributed the behavior to his medical condition and deemed it an isolated incident. The report highlights the need for careful monitoring and management of residents with cognitive impairments to prevent similar incidents.
Deficiencies in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper assessment and treatment of pressure ulcers for several residents, leading to deficiencies in care. For instance, a resident with a stage 3 coccyx pressure ulcer did not receive the prescribed medicated cream during wound care, and there was a lack of documented wound assessments after admission. The Director of Nursing (DON), who also serves as the wound nurse, acknowledged that wounds should be assessed on admission and weekly, but this was not consistently done. Another resident with a stage 2 pressure ulcer on the buttock was found without a treatment dressing, and bloody drainage was noted on the incontinent pad. The Registered Nurse (RN) was unsure why the dressing was missing, suggesting it might have been removed during a bed bath. The DON confirmed that the resident should have had a treatment dressing in place, but this was not adhered to. Additionally, a resident with sacral pressure wounds had inconsistent documentation and treatment orders. The Pressure Ulcer Weekly Wound Evaluation report did not include all open areas, and there was a significant gap in documentation. The DON admitted to falling behind on wound assessments, which should occur weekly. Another resident's treatment orders were not updated for 13 days, resulting in the resident not receiving the prescribed treatment. The facility's pressure ulcer prevention policy emphasizes the need for timely identification and treatment, which was not followed in these cases.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to accurately assess and address a resident's significant weight loss, which was observed in one of the five residents reviewed for weight loss. The resident, a male with multiple health conditions including muscle wasting, diabetes, and a chronic leg ulcer, experienced a notable weight loss of 6% in one month and 11% since admission. Despite being on a regular diet with double portions of protein, the resident continued to lose weight, dropping from 208.8 pounds to 182.2 pounds over a period of less than two months. The dietary note indicated that the weight loss might be partially related to the removal of a cast, although the resident reported never having a cast, and there was no documentation of a cast in his electronic health record. The dietitian, who is responsible for monitoring weight loss, did not physically assess the resident and relied on incorrect information about the resident's condition. The dietitian recommended increasing the resident's liquid protein intake, but the physician's orders did not reflect this change, indicating a lack of communication and implementation of necessary interventions. The facility's policy on unplanned weight loss was not followed, as the resident's significant weight loss was not adequately addressed, leading to continued weight loss without appropriate interventions being put in place.
Inadequate Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement effective fall interventions for a resident, R45, who was at high risk for falls due to severe cognitive impairment and a history of falls. R45, an elderly resident with vascular dementia, hypertension, and weakness, experienced multiple falls while attempting to go to the bathroom unassisted. Despite being identified as a high fall risk, the interventions in place were inadequate, as they relied on reminders and call lights, which were ineffective due to R45's dementia. R45's fall incidents were documented, showing a pattern of falls occurring when the resident attempted to self-transfer to the bathroom. The care plan interventions, such as not leaving the resident unattended in the bathroom and encouraging the use of call lights, were not sufficient to prevent these falls. The resident's daughter expressed disappointment, noting that R45 had fallen multiple times while trying to use the bathroom, resulting in injuries, including a forehead laceration and a hip fracture requiring surgical repair. The facility's investigation confirmed that all of R45's falls involved attempts to go to the bathroom unassisted. Staff interviews revealed that reminders for R45 to wait for assistance were ineffective due to the resident's dementia. The Director of Nursing acknowledged that more frequent checks and a toileting schedule would have been more appropriate interventions. The facility's fall policy emphasized an interdisciplinary approach to fall prevention, but the specific interventions for R45 were not resident-centered or effective in preventing falls.
Inadequate Pain Management Post-Hip Surgery
Penalty
Summary
The facility failed to manage a resident's pain effectively after the resident underwent hip surgery. The resident, who had a history of a fractured left hip, dementia, hypertension, and weakness, was readmitted to the facility following surgical repair of the hip fracture. On multiple occasions, the resident was observed to be in severe pain, moaning and crying out, particularly during transfers and while using the toilet. Despite the resident's evident distress, the nursing staff did not administer the correct pain medication as per the hospital discharge orders. Instead, the resident continued to receive an outdated pain medication regimen that was insufficient for the increased pain levels following surgery. The hospital discharge orders specified a new pain medication regimen of Norco 5/325 to be administered every four hours, but this was not reflected in the resident's medication administration records. The outdated order, which prescribed Norco four times a day, remained in place, leading to inadequate pain management. The Director of Nursing later confirmed that the hospital discharge orders had not been correctly implemented, resulting in the resident experiencing severe pain that was not appropriately addressed by the facility's staff.
Sanitation Breach in Dish Handling
Penalty
Summary
The facility failed to ensure that dishes were handled in a sanitary manner to prevent cross-contamination, potentially affecting all 89 residents. During an observation, a dietary aide was seen placing dirty dishes and cups onto a dishwasher rack and pushing it into the dishwasher. Without washing her hands, she then handled clean dishes, placing them onto a storage rack. This process was repeated, indicating a lack of adherence to proper hand hygiene protocols. The dietary manager confirmed that staff members operating the dishwasher are required to wash their hands after handling dirty dishes and before touching clean ones to prevent cross-contamination. The facility's Dish Machine Operation policy also mandates the use of clean, washed hands when handling clean racks. The failure to follow these procedures was observed and acknowledged by the dietary manager.
Failure to Perform Daily Weights for CHF Resident
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of congestive heart failure (CHF) received daily weights as ordered. The resident, who has multiple diagnoses including acute on chronic combined systolic and diastolic heart failure, myocardial infarction, atrial fibrillation, chronic kidney disease, shortness of breath, hypertension, chronic obstructive pulmonary disease, and atherosclerotic heart disease, had a physician's order dated 2/28/24 for daily weights due to CHF. However, the Weights and Vitals summary indicated that between 7/13/24 and 10/22/24, the resident did not receive weights on numerous specified dates. The Director of Nursing confirmed that daily weights are crucial for CHF residents to monitor for weight gain or fluid overload and should be recorded in the electronic medical record. The facility's policy mandates that weights be recorded in the individual's medical record.
Failure to Provide Required Range of Motion Care
Penalty
Summary
The facility failed to provide appropriate care for a resident, identified as R27, to maintain or improve her range of motion (ROM) and mobility. R27, who has intact cognition, suffered a stroke resulting in impairment of her left upper and lower extremities. Despite her condition, the facility did not ensure that passive range of motion (PROM) exercises were performed on her left arm and leg, nor was a splint applied to her contracted left hand as required by her care plan. Observations over several days confirmed that R27 did not have a splint on her left hand and reported that she had not received the necessary exercises. Interviews with facility staff revealed a lack of communication and understanding of R27's needs. The Restorative Aide, V10, was unaware that R27 required PROM and assumed she preferred to perform exercises independently. Additionally, the Physical Therapy Assistant, V9, acknowledged that R27 could not move her left side due to flaccidity but noted that a splint had been tried in the past without success. The facility's Restorative Nursing Policy emphasizes the importance of maintaining optimal physical function, yet the care plan's directives for R27 were not followed, leading to the deficiency.
Failure to Provide Timely Psychiatric Services for Resident
Penalty
Summary
The facility failed to ensure timely psychiatric services for a resident experiencing increased depression. The resident, a male with a history of major depressive disorder, anxiety, and other medical conditions, was observed making self-harm threats and exhibiting behaviors such as placing a garbage bag over his head. On 9/9/24, a Nurse Practitioner noted the resident's increased depression and ordered an immediate psychiatric evaluation. However, the psychiatric consultation did not occur until 9/16/24, seven days later, due to a lack of communication and the unavailability of the psychiatric provider, who was on vacation. The Director of Nursing (DON) acknowledged that the referral was sent but was unaware that the order required same-day attention. The facility's policy mandates individualized interventions for changes in mental status, but the delay in psychiatric evaluation indicates a failure to adhere to this policy. The resident's care plan, which includes monitoring for suicidal ideations and arranging for psychiatric consultations, was not effectively implemented, contributing to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's medications were administered according to standards of practice. On the morning of 10/21/24, a resident was observed with eight pills in a medication cup on her bedside table while she was eating breakfast, with no nurse present. The resident stated that those were her morning pills. A registered nurse, V6, confirmed that she had already administered the resident's morning medications and was unaware of any medications left on the bedside table. V6 acknowledged that medications should never be left in a resident's room and that the nurse should ensure the resident takes the medications before leaving. Later, V6 re-entered the resident's room and found that the pills were gone. The resident stated she had taken the pills after finishing breakfast, which she claimed the nurse had left for her. The Director of Nursing, V2, confirmed that it is not the facility's practice to leave medications in a resident's room, as it prevents the nurse from ensuring the medication was taken. The nursing notes indicated that the nurse had observed the resident take her morning medications with the nurse present, and there was no cup of medication at the bedside after administration. The physician was updated on the probable ingestion of additional unknown medications.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to adhere to regulations regarding the administration of PRN psychotropic medications for a resident. Specifically, the facility did not limit the use of an as-needed antipsychotic medication, Haloperidol Lactate, to 14 days, nor did it include a stop date on the Physician's Order Sheet (POS). Additionally, the facility did not ensure that an as-needed antianxiety medication, Lorazepam, had a stop date documented on the POS. These omissions were identified during a review of the resident's medication orders, which showed that the orders for both medications lacked the required end dates. The Director of Nursing (DON) acknowledged that all psychotropic medications should be ordered for only 14 days unless extended by a physician, and that orders must include a stop date. The facility's policy on psychotropic medication use, dated September 2022, also stipulates that PRN psychotropic medications should be limited to 14 days unless a longer duration is justified by the attending physician. Despite these policies, the facility did not comply with the CMS requirement for a 14-day limit on PRN antipsychotic orders, nor did it ensure proper documentation and evaluation for extending the use of these medications.
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.
