Doctors Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Illinois.
- Location
- 1201 Hawthorn Road, Salem, Illinois 62881
- CMS Provider Number
- 145247
- Inspections on file
- 39
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Doctors Nursing & Rehab Center during CMS and state inspections, most recent first.
The facility failed to provide sufficient CNA staffing on the 100 hall to meet residents’ needs in a timely manner. A family member and two residents reported that call lights, particularly in the evening and on weekends, were not answered promptly, requiring the family member to walk the halls to locate staff. A CNA described working alone on the 100 hall from early morning, delaying bed checks and allowing her to complete care only for residents needing one-person assistance while residents requiring two-person assistance waited until additional staff arrived. A respiratory therapist confirmed that CNAs perform repositioning every 2 hours, that help is only provided by respiratory therapy as needed, and that having two CNAs on the 100 hall occurs only if they are “lucky,” even though most residents there are dependent on staff. The regional clinical leader stated that staffing assignments are based on public health guidelines and resident needs.
The facility failed to maintain adequate nursing and CNA staffing to meet residents’ assessed care needs in a timely manner. Several residents who were cognitively intact or moderately impaired, and who required substantial assistance with ADLs, toileting, and turning/repositioning, reported long waits for call light responses, delays in receiving help with dressing and toileting, and episodes of incontinence while waiting for staff. A ventilator- and trach-dependent resident described having only one CNA on a high-acuity hall at times and waiting over an hour for repositioning. Multiple CNAs and an RN reported working halls alone, being unable to complete all required care such as q2h turning and incontinence care, experiencing frequent uncovered call-ins, and having call light response times of 15 minutes or more. The DON and a physician acknowledged that the facility did not have enough nurses or CNAs, that staff were rushed and sometimes delayed in assessing residents, and that overnight staffing could be as low as one nurse, one respiratory therapist, and two CNAs for the building, contrary to the facility’s own policy to maintain adequate staffing on each shift.
Surveyors found that the facility failed to follow physician and wound clinic orders for antibiotics and wound care for two residents, including one with extensive bilateral lower extremity venous ulcers and a history of MRSA and pseudomonas infections. IV vancomycin orders were altered due to lack of RN coverage, multiple antibiotic orders (including levofloxacin, Cipro, Bumex, and Invanz) were never entered on the MAR or POS or were not administered, and wound care orders requiring Dakins solution, Vashe, exufiber, kerlix, and ACE wraps were frequently not carried out due to supply unavailability. Staff documented worsening redness, purulent and green drainage, severe pain, heavy weeping through dressings, and episodes of dizziness, hypotension, and SOB, while CNAs observed dressings left on for prolonged periods with drainage seeping through. Another resident with CHF did not receive ordered labs and medications, resulting in exacerbation of CHF and respiratory failure. These failures to implement and monitor ordered treatments resulted in worsening infections, sepsis, hospitalization, and death, and were cited at the Immediate Jeopardy level.
A resident with multiple comorbidities and two stage 4 pressure ulcers was on contact/enhanced barrier precautions for MRSA, ESBL, and CRE, with orders for daily and PRN dressing changes to sacral, vulvar, and buttock wounds. Surveyors observed an RN and assisting staff perform wound care wearing only gloves despite isolation signage requiring gown and glove use. The sacral and buttock dressings were soiled with blood and green drainage, one was dated two days earlier, and there was no dressing on the vulvar wound. The RN admitted the dressings had not been changed the prior day due to lack of time rather than resident refusal and also acknowledged using another resident’s Silvadene cream when the ordered cream for this resident could not be found, contrary to facility medication policies.
A resident with multiple chronic conditions and intact cognition reported verbal abuse by a CNA, but the facility's investigation was incomplete. The administrator failed to document all staff interviews, allowed anonymous responses, and did not ensure all relevant staff were questioned, contrary to facility policy requiring full documentation and participation in abuse investigations.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely.
The facility did not maintain the required temperature in the dietary dry storage area, with the area reaching 90.6°F due to a non-functioning HVAC unit. Staff confirmed the issue had persisted for over a year, and the HVAC company would not provide service until a previous bill was paid. Facility policy requires dry storage areas to remain below 70°F to ensure safe food storage. This deficiency had the potential to affect all 58 residents in the facility.
The facility did not address critical maintenance issues, including non-functioning HVAC and call light systems, due to lack of corporate response and unpaid vendor bills. Despite repeated requests from the administrator and maintenance director, necessary repairs and equipment were not provided, impacting the safety and wellbeing of all residents.
Three residents with significant medical and cognitive needs were left without a functioning call light system in their shared room, relying instead on hand bells that could not be heard over loud industrial fans. Staff and a family member confirmed the call lights had been nonfunctional for extended periods, and the maintenance director reported that repairs were delayed due to unpaid bills with the service company.
The facility failed to implement Enhanced Barrier Precautions (EBP) and Standard Precautions for several residents with indwelling catheters and wounds. Observations revealed missing EBP signage and lack of accessible PPE. Staff performed care without donning gowns, despite acknowledging the need for EBP. This indicates a failure to adhere to infection prevention policies, potentially increasing infection transmission risk.
The facility failed to maintain comfortable temperatures for residents, with heating units not functioning properly, leading to residents using multiple blankets and wearing coats indoors. Additionally, water-damaged ceiling tiles were observed throughout the facility, with no mold testing conducted, raising concerns about potential respiratory risks. The facility's maintenance logs lacked specific temperature documentation, and the administrator was unaware of the extent of the heating issues.
The facility failed to follow menu and diet orders for six residents due to a shortage of breakfast items. The cook did not provide substitutes, and the dietician was unaware of the shortage. The facility's policy requires menu adherence and review of changes with a dietician, which was not followed.
The facility failed to provide adequate hydration to 18 residents, as observed during a survey. Several residents were found without water pitchers or any fluids in their rooms, and some reported only receiving drinks with meal trays. The facility's policy requires routine offering of fluids, but staff interviews revealed inconsistencies in its implementation.
The facility failed to maintain its air conditioning systems, leading to uncomfortable temperatures for all residents. Staff and residents reported that the facility had been very warm, with some rooms cooler than others. The maintenance director confirmed that the air conditioning units were frozen and leaking, and the facility was relying on portable air conditioners and fans. Despite no negative health outcomes, residents expressed discomfort, particularly on days with high outside temperatures. The facility's policies on extreme weather were not effectively implemented, and repairs were delayed due to unavailable Freon.
Insufficient CNA Staffing on 100 Hall Delays Call Light Response and Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on the 100 hall to meet residents’ needs in a timely manner and to ensure adequate assistance with care. A family member reported that during evening hours and on weekends it is very hard to get assistance from staff when call lights are activated, and that she has to walk the halls to find staff to assist a resident. During a resident council meeting, two cognitively intact residents stated that in the evening it is difficult to get someone to answer call lights, and one of these residents lives on the 100 hall. The daily census report shows there were 10 residents residing on the 100 hall. A CNA reported that residents need to be turned and repositioned every two hours or as needed, but stated she performs bed checks “as often as I can by myself,” explaining that the next CNA does not arrive until 10:00 a.m. and that residents requiring two-person assistance may not be attended to until that time if she cannot find help. On the morning in question, the CNA stated she had been working alone on the 100 hall since 6:00 a.m. due to a call-in and was only able to begin bed checks at 8:54 a.m., completing care only for residents requiring one-person assistance while no other CNA was present or scheduled on the hall. A respiratory therapist stated that CNAs are responsible for repositioning during two-hourly rounds, that respiratory therapy will help with bed checks if needed, and that there are two CNAs assigned to the 100 hall only “if they are lucky,” despite residents there being mainly dependent on staff. The regional director of clinical services stated that staffing is based on public health guidelines and resident needs when assigning staff.
Failure to Maintain Adequate Nursing Staff to Meet Resident Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on a daily basis to meet residents’ needs in a timely manner and to ensure adequate licensed nurse coverage on each shift. Multiple residents with significant ADL, toileting, and repositioning needs reported prolonged waits for assistance despite care plans specifying frequent turning, toileting assistance, and incontinence care. The facility’s own staffing policy states that adequate staffing will be maintained on each shift to meet resident needs and regulatory requirements, yet interviews and record review showed that staffing levels were often inadequate for the 47 residents in-house. One resident with polyosteoarthritis, morbid obesity, COPD, a sacral pressure ulcer, and dependence for toileting and turning/repositioning reported that she is supposed to be repositioned at least every two hours but sometimes goes longer than that. She stated that when she activates her call light or yells out, it can take staff a very long time to respond, and that there are times when it takes a long time for a nurse to come to her room or bring pain medication. Another resident with moderately impaired cognition, muscle weakness, and a history of repeated falls, who requires substantial/maximal assistance with toileting and transfers, reported that he feels the facility is very short-staffed. He described waiting up to 20 minutes or longer for call lights to be answered and recounted a recent fall that occurred after he put on his call light, became impatient while waiting for staff, and attempted to move on his own. Additional residents described similar delays and unmet care needs. One cognitively intact resident who is dependent for toileting and needs assistance with transfers stated that it takes staff "forever" to help him get dressed in the morning and that he has experienced incontinence episodes while waiting for staff to answer his call light. Another resident requiring substantial/maximal assistance with toileting and transfers reported waiting over 30 minutes at times for call lights to be answered and having incontinence episodes while waiting, then needing assistance with cleanup. A ventilator- and tracheostomy-dependent resident with muscular dystrophy, contractures, and dependence for toileting and turning/repositioning stated that there are times when only one CNA is assigned to her hallway, which includes multiple residents with vents and trachs, and that she has waited over an hour for assistance with repositioning and for call lights to be answered. Staff interviews corroborated that staffing was frequently insufficient to meet resident needs. Multiple CNAs reported working entire halls alone for extended periods, including a CNA who worked a 12-hour shift alone on one hall and was unable to complete all resident care, such as turning/repositioning, incontinence care, and showers. CNAs stated that when short-staffed, call light response times could be 15 minutes or longer, and residents who required turning every two hours were not consistently turned on schedule, with intervals stretching to 2.5–3 hours while staff tried to balance feeding and other care tasks. CNAs also reported that call-ins were sometimes not covered, that they had to borrow staff from other halls to complete transfers and repositioning, and that some resident care likely went unfinished on short-staffed days. The Director of Nursing acknowledged that the facility did not have enough nurses or CNAs and stated that they were losing staff "left and right." She reported that staffing patterns left, after 3 a.m., only one nurse, one respiratory therapist, and two CNAs to cover a specialized trach/vent unit and other high-acuity halls, and that she did not feel this was a safe number of staff to provide proper care. She stated that nurses and CNAs were in a hurry to get as much done as possible and might be missing things or delaying assessments and care. A physician also indicated that there had been discussions about resident care in relation to current staffing and that decisions about staffing were up to the facility company. These statements, combined with resident reports and care plan requirements, demonstrate that the facility failed to maintain adequate staffing on each shift to meet residents’ assessed needs in a timely manner.
Failure to Follow Antibiotic and Wound Care Orders Leading to Sepsis and Death
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and adequately monitor and treat worsening bilateral lower extremity venous wounds and infections for a resident with multiple comorbidities, including lymphedema, cellulitis of both lower limbs, MRSA infection, pseudomonas, severe sepsis with septic shock, diabetes with neuropathy, and chronic edema. The resident had intact cognition per a BIMS score of 15 and an active diagnosis of wound infection and venous/arterial ulcers on the MDS. The care plan documented sepsis and a history of bilateral lower extremity wounds, with approaches specifying treatment and antibiotics per order and to report ineffective treatment or adverse effects to the physician. Despite this, multiple antibiotic and wound care orders from a consulting wound clinic and from a hospital were not entered into the electronic record, not available on the POS or MAR, or not administered as ordered. The consulting wound clinic ordered IV vancomycin 1 g BID for 14 days, but facility staff documented they could not administer IV medications every 12 hours due to lack of RNs on night shift. The order was changed to vancomycin 1 g daily and later to 1.5 g daily, yet the MAR showed multiple days where vancomycin was not administered, marked as the resident being unavailable or the medication being on hold. Additional clinic orders for Bumex, Levaquin, and Cipro were not found on the MAR or POS. Later, the clinic ordered levofloxacin 750 mg daily for 10 days and a Medrol dose pack; staff documented awareness of the resident’s allergy to levofloxacin, faxed the clinic for clarification, and noted that the antibiotic order was not clarified, but the levofloxacin order never appeared on the MAR or POS. Another clinic order for Invanz 1 g daily for 14 days for ESBL UTI was documented in progress notes, but Invanz was not present on the MAR or POS, and multiple nurses stated they did not remember the resident ever receiving Invanz. Staff notes show repeated attempts to contact the clinic and pharmacy about missing Invanz orders, but also show that follow-up was not consistently completed or clearly handed off. Wound care orders were also not consistently implemented as written. The clinic and hospital ordered specific wound care regimens, including Dakins 0.25% solution wet-to-dry dressings, Vashe wound solution, exufiber dressings, ABD pads, kerlix, and ACE wraps. The MAR documented numerous instances where ordered treatments were not administered due to drug or item unavailability, with nurses substituting wound cleanser and available dressings instead of Dakins, Vashe, exufiber, or kerlix. Staff interviews confirmed that Dakins solution, Vashe, exufiber, and kerlix were often unavailable, that dressing changes were sometimes not done when scheduled, and that some nurses still checked off treatments as completed per order despite not having the correct supplies. CNAs reported dressings with old dates, unraveling, and drainage seeping through, and nurses documented worsening bilateral lower extremity redness, bleeding, purulent and greenish drainage, increased pain, and extensive weeping through dressings. The resident experienced episodes of dizziness, hypotension, and shortness of breath, was repeatedly sent to the hospital, and was ultimately diagnosed with septic shock secondary to bilateral leg wound infection and cellulitis due to pseudomonas and MRSA, with hospital records and the death certificate listing septic shock and skin and soft tissue infections as causes of death. A second resident with congestive heart failure was also cited in the deficiency for failure to complete ordered lab work and administer medications as ordered, resulting in worsening CHF, respiratory failure, hospitalization, and subsequent death, but the detailed narrative in the report focuses on the first resident’s course. The surveyors determined that the facility failed to follow physician orders for antibiotics and wound care, failed to ensure availability and administration of ordered medications and supplies, and failed to adequately monitor and respond to the resident’s declining condition. These failures led to worsening infection of bilateral lower extremity venous wounds, development of sepsis, and the resident’s death, and contributed to an Immediate Jeopardy determination for failure to provide treatment and care according to orders, resident preferences, and goals for two of three residents reviewed for death.
Failure to Follow Wound Care Orders and Isolation Protocols for Pressure Ulcer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and adhere to infection control protocols for a resident with multiple complex medical conditions and stage 4 pressure ulcers. The resident was admitted with diagnoses including muscular dystrophy, muscle wasting and atrophy, muscle weakness, osteomyelitis of the sacral and sacrococcygeal vertebrae, paresthesia of the skin, underweight status, and multiple sclerosis. The MDS documented intact cognition and the presence of two stage 4 pressure ulcers. The care plan identified the resident as requiring contact isolation for MRSA, ESBL, and CRE involving the nares, sacrum, and vagina, and also documented risk factors for skin breakdown, including decreased mobility, contractures, history of ulcers, chronic osteomyelitis, and underweight status. Surveyors observed a wound dressing change during which staff did not follow the facility’s enhanced barrier precautions policy. An enhanced barrier precaution sign was posted on the resident’s door, but the RN performing the dressing change and assisting staff only wore gloves and did not don gowns. The RN removed a sacral dressing that was dated two days earlier and appeared dirty and soiled through with blood and green drainage, and a right buttock dressing that was also soiled with blood and green drainage and lacked a date. There was no dressing present on the vulvar wound at the time of observation. The RN then cleansed each wound with normal saline and applied calcium alginate and Silvadene cream mixed with collagen powder. Interviews and record review showed that physician orders required daily and as-needed dressing changes to the sacrum, vulva, and right buttock, and that the resident was on contact isolation for infected wounds. The RN acknowledged that the wound dressings had not been changed the previous day, not due to resident refusal but because she did not have time, despite the daily order. The RN also stated she could not locate the resident’s Silvadene cream and instead used another resident’s prescribed wound medication, contrary to facility policy that medications supplied for one resident are never administered to another. Additional staff confirmed they forgot to wear gowns during the wound care, despite the isolation signage and policies requiring gown and glove use for high-contact care under enhanced barrier or contact isolation precautions. The administrator confirmed expectations that staff follow physician orders, use resident-specific prescription creams, and wear required PPE for residents on isolation or enhanced barrier precautions.
Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident verbal abuse involving a resident who was cognitively intact and had multiple chronic medical conditions, including chronic atrial fibrillation, congestive heart failure, and chronic kidney disease. The resident reported that a certified nurse assistant (CNA) was verbally abusive on more than one occasion, describing incidents where the CNA spoke to her in a loud and mean tone. The resident was unable to recall the CNA's name but provided a physical description. The facility's records show that the administrator initiated an investigation, notified the police and physician, and submitted a report to the state health department. However, the investigation was incomplete and lacked critical documentation. The administrator collected 18 staff questionnaires, but only 12 were identified by name, while the remaining 6 were anonymous with no way to determine who provided the information. The administrator admitted to not keeping a list of interviewed staff and could not confirm whether all relevant staff, including those scheduled during the alleged incidents, were interviewed. Several CNAs who worked during the relevant period stated they were not made aware of the allegation, were not interviewed, and did not complete any questionnaires regarding the incident. The facility's abuse prevention policy requires that all interviews be documented with names and contact information, and that all staff participate in investigations. The administrator stated that some staff refused to sign their names and that she could not force them to cooperate. The regional operations director clarified that participation is mandatory and that refusal could result in termination. The investigation file did not meet the facility's policy requirements, as it lacked a complete list of interviewed staff and failed to ensure all relevant staff were questioned and identified.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Maintain Safe Temperature in Dietary Dry Storage Area
Penalty
Summary
The facility failed to maintain the required temperature of less than 70 degrees Fahrenheit in the dietary dry storage area, as observed during a survey. The ambient air temperature in the dry storage area was measured at 90.6 degrees Fahrenheit using a calibrated thermometer. The Dietary Manager confirmed that the HVAC unit in the dry storage area had not been functioning and that the area had been very hot since the start of summer. The Maintenance Director reported that the HVAC company would not service the unit until an outstanding bill from previous work was paid. The Former Administrator stated that requests to corporate for HVAC repairs had been ongoing for over a year. Facility policy requires dry storage areas to be kept at temperatures not exceeding 70 degrees Fahrenheit to ensure food is stored safely and sanitarily. At the time of the survey, 58 residents were residing in the facility.
Failure to Address Facility Maintenance and Safety Needs Due to Corporate Inaction
Penalty
Summary
The facility failed to ensure effective and efficient use of its resources to maintain the safety and wellbeing of all 58 residents. The former administrator reported repeatedly contacting corporate regarding non-functioning HVAC and PTAC systems, as well as the need for dining room floor repairs, but received no response or authorization to address these issues. The maintenance director stated that the HVAC repair company and the call light repair company refused to provide services due to unpaid bills, resulting in unresolved HVAC problems and at least one resident room without a functioning call light system. Despite requests for 33 PTAC units for resident rooms, only 4 were provided. The regional director of operations indicated that corporate was unaware of these ongoing issues.
Failure to Maintain Functioning Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system for three residents who required assistance, as observed during the survey. All three residents had significant medical conditions, including hemiplegia following cerebral infarction, vascular dementia, chronic respiratory failure, and other motor neuron disease, with varying levels of cognitive impairment. The call lights in their shared room were not operational, and instead, the residents were given hand bells to use for summoning assistance. Interviews with the residents revealed that the call lights had been nonfunctional for periods ranging from about a week to several months. The Maintenance Director confirmed awareness of the issue and stated that the company responsible for repairing the call lights refused service due to unpaid bills. The deficiency was further compounded by the presence of large, loud industrial fans in the hallway, which made it difficult or impossible for staff to hear the hand bells when residents attempted to call for help. Staff interviews confirmed that the noise from the fans significantly interfered with their ability to hear the bells, especially when they were not in the immediate vicinity. A family member also observed the use of hand bells and was informed by staff that the call light was not working. The facility's policy required prompt reporting of defective call lights to the nursing supervisor, but the issue persisted without resolution, and the administrator was unaware of the payment issue with the repair company until the time of the survey.
Failure to Implement Enhanced Barrier Precautions and Standard Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Standard Precautions for five residents reviewed for infection control. The facility's policy requires the use of EBP for residents with certain conditions, such as indwelling catheters or chronic wounds, to prevent the spread of infections. However, observations revealed that EBP signage was missing, and personal protective equipment (PPE) was not readily available outside the rooms of residents who required these precautions. For instance, a resident with an indwelling urinary catheter did not have EBP signage on their door, and PPE was not accessible. A registered nurse performed catheter care without donning a gown, despite acknowledging that EBP should be used for such care. Similarly, another resident with multiple wounds and an indwelling catheter did not have EBP signage, and the Director of Nurses did not wear a gown while performing wound care, although proper hand hygiene and glove use were observed. Additionally, a resident with a history of cellulitis and actively weeping wounds did not have EBP or PPE in place. The infection control nurse confirmed that EBP should be implemented for residents with tracheostomies, indwelling catheters, wounds, or open areas. These observations indicate a failure to adhere to the facility's infection prevention and control policy, potentially increasing the risk of infection transmission among residents and staff.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain comfortable temperatures for nine residents, with heating units in their rooms either not functioning or blowing cold air. Observations revealed residents using multiple blankets and wearing coats indoors to keep warm. The facility's maintenance logs did not document specific temperatures, and the heating units were reported as non-operational by both staff and residents. The facility's policy on extreme weather was not effectively implemented, as the heating systems were not adequately maintained, leading to discomfort among residents. Additionally, the facility had issues with water-damaged ceiling tiles, which were observed in multiple areas, including near the nurse's station and various halls. The water damage was attributed to condensation from piping between the ceiling and ceiling tiles, as explained by the facility administrator. Staff confirmed that during the summer, the heating units leaked water, requiring makeshift solutions like trash cans and bath blankets to manage the leaks. Despite replacing numerous ceiling tiles, the facility had not conducted any mold or mildew testing, raising concerns about potential respiratory risks for residents. The facility's maintenance director acknowledged the ongoing issues with the heating units and the need for new systems, but cited cost as a barrier. The administrator was unaware of the extent of the heating problems and had not initiated any environmental policy regarding the water-damaged ceiling tiles. The lack of specific temperature documentation and the absence of mold testing further highlighted the facility's inadequate response to maintaining a safe and comfortable environment for its residents.
Failure to Follow Menu and Diet Orders
Penalty
Summary
The facility failed to follow the menu and diet orders for six residents, as observed during a survey. On the morning of October 3, 2024, a resident reported not receiving eggs or double meat with breakfast, contrary to their dietary preferences. On October 8, 2024, during a breakfast meal observation, the cook stated that the kitchen had run out of meats and eggs, and the delivery truck was expected later that day. The cook admitted that no substitutes were provided for the missing items, as the kitchen was also out of yogurt and peanut butter, and no discussion with the dietician occurred regarding substitutions. The dietician confirmed that substitutions should have been made with items of equivalent nutritional value, such as yogurt or peanut butter, but was unaware of the shortage. The administrator also stated that substitutions should be made when items are unavailable. The dietary supervisor noted that one resident's dietary card did not list the required items, which were added after the issue was discovered. The facility's policy requires that menus be followed and any changes due to stock shortages be reviewed with a registered licensed dietician, which was not adhered to in this instance.
Inadequate Hydration for Residents
Penalty
Summary
The facility failed to provide adequate hydration to 18 out of 47 residents, as observed during a survey. Multiple residents were found without water pitchers or any other fluids available in their rooms. For instance, one resident was observed without a water pitcher and stated that they usually only receive drinks with their meal trays. Another resident had a water pitcher that was warm to the touch and had not been refilled with fresh ice water until later in the day. These observations indicate a lack of consistent access to fluids for the residents. The facility's policy on hydration, dated December 2016, requires staff to offer fluids routinely, in addition to those provided on meal trays. However, interviews with the facility's nursing staff revealed inconsistencies in the implementation of this policy. The Assistant Director of Nursing stated that staff are expected to refresh residents' water every four hours, yet observations showed this was not consistently done. The Director of Nursing acknowledged the expectation for water pitchers to be filled before a certain time but was unaware of why this was not adhered to on the day of the survey.
Facility Fails to Maintain Air Conditioning, Causing Resident Discomfort
Penalty
Summary
The facility failed to maintain air conditioning equipment, resulting in uncomfortable temperatures for all 47 residents reviewed. Observations on June 26, 2024, revealed that the dining room was notably warm, with two PTAC units and a portable air conditioner running, yet the temperature remained high. Staff members, including a registered nurse and certified nurse assistants, reported that the facility had been very warm recently, with some rooms cooler than others. The maintenance director confirmed that the air conditioning units on the roof were frozen and leaking, and the facility was relying on portable air conditioners and fans to manage the heat. Interviews with residents indicated discomfort due to the heat, although no negative health outcomes were reported. Residents expressed that their rooms were warmer than usual, particularly on June 25, 2024, when outside temperatures were extremely high. The maintenance director admitted that temperature checks were only logged as completed without recording actual temperatures, and no checks were conducted over the weekends. The administrator was aware of the air conditioning issues and had contacted a repair service, but repairs were delayed due to the unavailability of necessary Freon. The facility's policies on extreme weather and heat index were not effectively implemented, as evidenced by the lack of timely maintenance and monitoring of air conditioning systems. The director of nursing was not informed of the issues over the weekend, and the assistant director of nursing noted that requests for air conditioner repairs had not been approved by corporate. The facility's failure to maintain a comfortable environment for residents, as required by regulations, was evident in the observations and interviews conducted during the survey.
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.
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