Duquoin Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Du Quoin, Illinois.
- Location
- 514 East Jackson St, Du Quoin, Illinois 62832
- CMS Provider Number
- 145008
- Inspections on file
- 27
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Duquoin Nursing & Rehab during CMS and state inspections, most recent first.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restricted their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with moderate cognitive impairment was physically struck on the elbow with a cane and verbally threatened by a cognitively impaired roommate during an altercation. An LPN witnessed the incident after hearing yelling and cursing, and documentation confirmed the abuse occurred despite facility policies intended to prevent such events.
A cognitively impaired resident with a known history of elopement risk and recent exit-seeking behaviors was able to leave the facility unsupervised. An LPN followed the resident outside but lost sight of her while seeking help, resulting in the resident being unsupervised for over two hours until found by police. Staff interviews revealed inconsistent awareness of elopement protocols and the resident's risk status.
A resident with severe cognitive impairment and anxiety was administered increasing doses of Xanax and a one-time dose of Risperidone without adequate behavioral assessment or documentation, following an elopement incident. After receiving these medications, the resident became drowsy and unsteady, was kept in a wheelchair for safety, and ultimately fell while attempting to ambulate, resulting in a hip fracture that required surgery. Staff and physician interviews confirmed concerns about the appropriateness of the medication regimen and its contribution to the resident's fall.
A resident with moderate cognitive impairment was sent to the hospital due to symptoms like vomiting and fruity-smelling breath. The family was not informed of the transfer until several hours later, despite facility policy requiring prompt notification. The LPN admitted to forgetting to contact the family due to multiple incidents that day.
A resident with a history of breast cancer and recent mastectomy did not receive daily wound dressing changes as ordered by a physician. The facility failed to document dressing changes for 13 days due to a breakdown in communication and process, as orders faxed by the clinic were not received. Despite the oversight, the resident did not suffer adverse events.
The facility failed to maintain proper sanitizer levels in the dish machine and prevent potential contamination of bulk stored foods. A scoop was found in food bins with the handle touching the food, and the dish machine showed no sanitizer concentration. The Dietary Manager admitted to not keeping a log of sanitizer levels, contrary to the facility's policy requiring regular checks.
A resident with multiple health conditions did not receive adequate assistance with ADLs, including shaving and denture care, despite having a care plan requiring staff participation. The resident was not shaved regularly and had unclean dentures, and was also woken up at 3 am for a bed bath, which he found disruptive. Staff acknowledged the issues, citing scheduling challenges, and the facility's procedures for personal care were not followed.
A resident with multiple wounds was admitted to the facility without proper wound care orders being initiated. Despite having specific discharge instructions from the hospital, the facility did not document or execute wound care for several days. Staff interviews revealed confusion and lack of communication regarding the orders, with attempts to contact the hospital for clarification proving unsuccessful. The facility's physician noted he should have been contacted to provide necessary orders.
A facility failed to ensure a resident was free from unnecessary medications, specifically psychotropic drugs. The resident was observed to be excessively tired, attributed to Haloperidol, which was prescribed without consistent evidence of Tourette's syndrome. The facility's process for medication review and behavior tracking was inadequate, with incomplete documentation and lack of follow-up on pharmacy recommendations. Staff noted the resident's increased lethargy and need for assistance, highlighting deficiencies in medication management.
A facility failed to properly label and store a resident's lorazepam, a controlled substance, which was brought in by family members. The medication was kept in a plastic cup with inadequate labeling and was not documented in the narcotic log, contrary to facility policy requiring proper packaging and logging of controlled substances.
The facility failed to provide timely assistance with toileting and bathing for several residents, leading to deficiencies in their care. A resident reported issues with staff not responding to call lights promptly, resulting in inadequate hygiene care. Observations noted residents with oily hair, odors, and unkempt appearances, indicating a lack of proper hygiene care. Inconsistencies in documentation and a lack of a specific shower policy contributed to these deficiencies.
A resident with lymphedema and chronic venous hypertension did not receive prescribed wound treatments on multiple occasions, with no documentation explaining the omissions. Staff interviews confirmed lapses in care and documentation, and some staff were unaware of proper procedures.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. One resident with moderate cognitive impairment was struck on the left elbow with a cane by a roommate who has severe cognitive impairment. The incident occurred during a verbal altercation in their shared room, where the aggressor also threatened to kill the other resident. The altercation was witnessed by an LPN who was passing medications nearby and heard yelling and cursing coming from the room. Upon entering, the LPN observed the physical assault and heard the verbal threats. The resident who was struck confirmed the incident and reported that the aggressor becomes upset and acts out when agitated, specifically mentioning concerns about a missing watch. The facility's records, including progress notes and interviews, document that the incident was reported to facility leadership and the appropriate authorities. The facility's abuse prevention policy states that residents have the right to be free from abuse, including abuse by other residents. Despite this policy, the facility did not prevent the physical and verbal abuse that occurred between the two residents, resulting in a failure to ensure a safe environment as required.
Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired ambulatory resident with a history of dementia, severe cognitive impairment, and previous elopement attempts was not adequately supervised, resulting in the resident exiting the facility unsupervised. The resident's care plan and assessments documented significant elopement risk, including recent behaviors of exit seeking, packing belongings, and expressing intent to leave. Despite these documented risks and recent incidents of exit-seeking behavior, the resident was able to leave the facility early in the morning, triggering a door alarm. A Licensed Practical Nurse (LPN) responded to the alarm and followed the resident outside, attempting to redirect her back to the facility. The resident was agitated, refused redirection, and continued walking through public areas, including crossing a main highway. The LPN continued to follow but lost sight of the resident in a local business parking lot while attempting to seek assistance. Surveillance footage and witness interviews confirmed that the LPN was separated from the resident, who then left the area unsupervised for over two hours until located by police in a nearby garage. Interviews with staff revealed gaps in knowledge regarding elopement risk assessments, inconsistent communication about the resident's behaviors, and uncertainty about staff responsibilities during elopement incidents. Several staff members did not hear the door alarm, and some were unaware of the resident's elopement risk or recent exit-seeking behaviors. The failure to provide continuous supervision and maintain line of sight with the resident, despite clear documentation of elopement risk, directly led to the resident's unsupervised absence from the facility.
Failure to Prevent Unnecessary Psychotropic Medication Use Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was free from unnecessary psychotropic medications, resulting in a significant adverse event. The resident, who had severe cognitive impairment, anxiety, and a history of dementia without behavioral disturbances, was admitted with a PRN order for Xanax. Over time, the administration of Xanax was increased from as-needed to scheduled dosing, and a one-time dose of Risperidone was also administered. The decision to increase and add these medications was made following an elopement incident, with the physician relying on staff suggestions and family input, despite the lack of documented behavioral tracking or clear psychiatric indications for the medications. The facility's own policy required thorough assessment and documentation of behavioral symptoms before initiating psychotropic medications, which was not followed in this case. The resident received multiple doses of Xanax and was given Risperidone after initial refusal, with the involvement of family and a police officer to convince her to take the medication. Staff observations and interviews indicated that after the administration of these medications, the resident became increasingly drowsy, confused, and unsteady, with staff noting that she was kept in a wheelchair for safety due to her unsteady gait. Despite these changes, documentation in the medical record inaccurately reflected that the resident's gait was at baseline, and there was no evidence of ongoing behavioral tracking or reassessment of the necessity and effects of the psychotropic medications. Ultimately, the resident attempted to ambulate independently, lost her balance, and sustained a fall resulting in a right hip fracture that required surgical intervention. Staff interviews revealed concerns about the appropriateness of the psychotropic medication regimen, particularly the use of benzodiazepines in an elderly, ambulatory resident, and the lack of communication and assessment regarding the resident's changing condition. The physician acknowledged that the medications likely contributed to the fall and that the prescribed dosages were higher than typically recommended for geriatric patients.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's responsible party of a change in condition and transport to the emergency room. This deficiency was identified for one of the seven residents reviewed for notification of changes. The resident, who was moderately cognitively impaired, was sent to the hospital due to symptoms including vomiting dark brown emesis and fruity-smelling breath. The resident's family member was not informed of the hospital transfer until several hours later, at 10 PM, despite the transfer occurring around 12:30 PM. The Licensed Practical Nurse (LPN) involved admitted to forgetting to contact the family due to multiple incidents occurring that day. The Director of Nursing confirmed the protocol for notifying the family after contacting the doctor and arranging the ambulance. The facility's policy requires prompt notification of the resident's representative in the event of a change in the resident's condition or status, which was not adhered to in this instance.
Failure to Change Wound Dressing as Ordered
Penalty
Summary
The facility failed to ensure that a resident's wound dressing was changed in accordance with physician's orders. The resident, who was moderately cognitively impaired, had a history of breast cancer and had undergone a mastectomy. The physician's orders, which were faxed to the facility, specified that the dressing on the surgical site should be changed daily. However, the Treatment Administration Record (TAR) showed no documentation of dressing changes for a period of 13 days, and there were no initials indicating that the dressing change was completed on several specific dates. The deficiency was partly due to a breakdown in communication and process within the facility. The Director of Nursing (DON) stated that the Social Services/Transportation staff member was responsible for receiving and forwarding new orders from outpatient appointments to the nursing staff. However, it was noted that this staff member often became overwhelmed and sometimes failed to forward orders. In this case, the orders were reportedly faxed by the clinic but were not received by the facility, leading to a lack of proper wound care for the resident. The Physician's Assistant expressed concern that the dressing was not changed for 13 days, especially given the resident's recent major surgery and history of cellulitis. Although the resident did not suffer any adverse events, the lack of wound care could have led to serious complications. The facility's policy on medication and treatment orders was not followed, contributing to the oversight in the resident's care.
Sanitizer and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper levels of sanitizer in the dish machine and ensure bulk stored foods were free from potential contamination. During an initial tour of the kitchen, a scoop with a handle was found inside bulk food bins containing thickener and flour, with the handle touching the food substance. The Dietary Manager acknowledged the issue and indicated that containers were available for storing the scoops, but they were not used. This oversight could lead to contamination of the food products. Additionally, the sanitizer concentration in the dish machine was found to be inadequate, as no sanitizer was registering when checked with a test strip. The Dietary Manager admitted that there was no log kept for the sanitizer levels, and it was only checked every few days. The last check for proper sanitization of dishes could not be verified. The facility's policy from 2016 requires the dishwashing machine to be checked three times weekly and after the sanitizer is changed, ensuring proper temperature and chemical concentration are maintained. However, these procedures were not followed, potentially affecting the cleanliness and safety of the tableware and equipment used for food preparation and service.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a resident, identified as R157, who was admitted with multiple health conditions including an unspecified open wound, Type 1 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Peripheral Vascular Disease, and an acquired absence of the right leg below the knee. The resident's care plan indicated a need for staff assistance with bathing and personal hygiene. However, observations and interviews revealed that the resident was not receiving timely assistance with shaving and denture care. R157 expressed frustration over not being shaved despite repeated requests and was observed with facial hair, which he stated he did not prefer. Additionally, the resident's dentures were found to be unclean, covered with thick greenish-yellow matter, indicating a lack of regular oral hygiene care. The report also highlighted inappropriate scheduling of bed baths, with the resident being woken up at 3 am for a bed bath, which he found disruptive to his sleep. Staff members acknowledged the issue, citing a need to spread out shower schedules across shifts. The facility's own documents outlined procedures for denture care and bathing, which were not adhered to, as evidenced by the resident's unclean dentures and dissatisfaction with the timing of his personal care. Interviews with staff, including the Director of Nursing and the Regional Nurse, confirmed that the expected standards of care, such as regular shaving and nightly denture cleaning, were not met for this resident.
Failure to Initiate Wound Care Orders for Resident
Penalty
Summary
The facility failed to initiate physician's orders for wound care for a resident with multiple wounds, including an unspecified open wound on the left ankle, a surgical incision on the right knee, and an abrasion on the left great toe. The resident was admitted from an out-of-state hospital with specific discharge instructions for wound care, including the use of a wound vac for the left lateral ankle. However, from the time of admission until several days later, no wound care orders were documented or executed for any of the resident's wounds. The Treatment Administration Record indicated that no wound care was provided during this period. Interviews with facility staff revealed that there was confusion and a lack of communication regarding the wound care orders. The Infection Preventionist and a Licensed Practical Nurse both stated that they did not receive any wound care orders upon the resident's admission and attempted to contact the hospital for clarification without success. The local wound care provider was unable to treat the wounds due to the absence of orders. The facility's physician expressed that he should have been contacted to provide orders if none were available at the time of admission.
Failure to Ensure Resident Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically psychotropic medications, as required by regulations. The resident, identified as R26, was observed to be excessively tired and lethargic, which was attributed to the administration of Haloperidol, a medication that requires a specific diagnosis such as Tourette's syndrome. However, the resident did not exhibit behaviors consistent with Tourette's syndrome, and the diagnosis was only added after a pharmacy consultation report requested it. The facility's Director of Nursing acknowledged that the resident's behaviors were not adequately tracked, and the staff was not properly documenting resident behaviors. The resident's care plan included the use of anti-anxiety medications and interventions for insomnia, but there was a lack of consistent documentation and tracking of the resident's behaviors and medication effects. Observations showed that the resident was often asleep during meal times and required assistance to eat, indicating potential overmedication. The facility's process for gradual dose reduction and pharmacy consultation reports was not effectively implemented, as evidenced by the lack of follow-up on the pharmacy's recommendations and the physician's acknowledgment of the resident's lethargy. Interviews with staff revealed that the resident was initially more alert and independent but had become increasingly tired and required more assistance. The hospice nurse also noted that the Haloperidol might need to be reduced due to the resident's lethargy. The behavior tracking for the resident was incomplete, with many dates lacking documentation of behaviors or medication effects, further indicating a deficiency in monitoring and managing the resident's medication regimen effectively.
Improper Storage and Labeling of Controlled Medication
Penalty
Summary
The facility failed to ensure that medications were labeled as prescribed by a physician for a resident reviewed for controlled medication storage. The resident, admitted with diagnoses including anxiety disorder and insomnia, had lorazepam 0.5 mg tablets brought in by family members. These tablets were stored in a white plastic cup with a brown self-adhering bandage and labeled with the resident's name and a number, but not in a proper container with appropriate identifying information. The medication was kept in the narcotic box of the medication room without a documentation log of the medication being counted, as it was not considered the facility's medication. The Director of Nursing (DON) acknowledged that the lorazepam had been locked up in this manner for over a month and that all controlled substances should be counted and logged prior to each shift. The facility's policy requires medications brought in by families to be sent to the pharmacy for proper packaging and storage. The policy also mandates that medications with missing or incorrect labels should be returned to the pharmacy or family. The facility's failure to adhere to these policies resulted in the improper storage and labeling of the resident's lorazepam, which is a controlled substance.
Deficiencies in Resident Hygiene and Care
Penalty
Summary
The facility failed to provide timely assistance with toileting and bathing for several residents, leading to deficiencies in their care. Resident 1, who is moderately cognitively impaired and dependent on staff for toileting and bathing, reported issues with staff not responding to call lights promptly. Observations noted that Resident 1 had oily hair, smelled of urine, and wore the same clothes over consecutive days, indicating a lack of proper hygiene care. Despite the presence of shower sheets, there were inconsistencies in the documentation, and Resident 1 expressed dissatisfaction with the care received, including being left in soiled conditions for extended periods. Resident 3, also moderately cognitively impaired, required substantial assistance with toileting and bathing. Observations showed that Resident 3 had dirty nails, an unkempt appearance, and a slight odor, suggesting inadequate hygiene care. A family member expressed concerns about Resident 3 not receiving regular showers and being left in soiled incontinence products, which contributed to skin irritation and frequent urinary tract infections. The family member also noted that Resident 3's oral hygiene was neglected, as evidenced by an unused toothbrush. Resident 7, who is dependent on staff for bathing and toileting, reported that showers were less frequent than before and that staff often assumed refusals without asking. Resident 9, severely cognitively impaired, was observed with oily hair, a slight smell of urine, and food-stained clothing, indicating insufficient hygiene care. The facility's documentation and tracking of showers were inconsistent, with some staff members signing off on shower sheets for showers they did not perform. The facility's transition to a new computer charting system and lack of a specific shower policy contributed to the deficiencies in care.
Failure to Provide Wound Treatments as Ordered
Penalty
Summary
The facility failed to provide wound treatments as ordered for a resident with lymphedema and chronic venous hypertension with ulcers. The resident's treatment administration records (TARs) showed multiple instances where wound care was not administered as prescribed, with no documentation explaining the omissions. The resident reported that dressings were not changed as required, sometimes going several days without treatment. Interviews with staff confirmed the lapses in care and documentation. The resident's medical records indicated specific orders for wound care, including the application of betadine solution, gauze, and absorbent pads, to be changed twice daily and as needed. However, the TARs documented numerous days where the treatments were not performed, and no reasons were provided for these omissions. The Director of Nursing (DON) acknowledged that a progress note should be made to explain why treatments were not given, but this was not done. Further interviews revealed that some staff were unaware of the proper documentation procedures. The Licensed Practical Nurse (LPN) responsible for some of the missed treatments admitted to not knowing how to chart in the TARs. Despite these lapses, the resident's wounds showed some improvement over time. The facility's wound care policy required detailed documentation and reporting, which was not adhered to in this case, leading to the identified deficiency.
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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