Elms, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Macomb, Illinois.
- Location
- 1212 Madelyn Avenue, Macomb, Illinois 61455
- CMS Provider Number
- 146033
- Inspections on file
- 21
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Elms, The during CMS and state inspections, most recent first.
A resident with a complex cancer history and ongoing immunotherapy was admitted for skilled rehab after hip surgery under Medicare Part A. During admission, staff failed to identify the active immunotherapy regimen, and the DON/ADON contacted the oncologist’s office requesting that treatment be placed on hold, citing insurance reasons. Social services later told the family that immunotherapy could resume only after the resident came off Medicare A and transitioned to private pay, leading the family to request an early end to skilled coverage so they could restart treatment. The resident and family reported being told that oncology care could not occur while on Medicare benefits, and the oncologist’s office documented multiple calls from facility staff to hold treatment and a later call from the family to resume once Medicare A ended. These actions and miscommunications resulted in delayed immunotherapy and missed oncology appointments, conflicting with the resident’s rights to be informed, participate in care planning, and receive assistance in exercising those rights.
The facility failed to maintain contact precautions for a resident with ESBL, placing them in a shared room without proper PPE use by staff. Additionally, staff did not follow hand hygiene and glove protocols during medication administration for two residents, acknowledging the oversight. These deficiencies were noted during a survey of the facility's infection control program.
A facility failed to implement pressure-relieving interventions for a resident at risk for pressure ulcers, resulting in the development of a painful, unstageable right heel pressure ulcer and a deep tissue injury to the left great toe. The care plan was not updated, and physician-recommended treatments were not consistently applied, leading to avoidable pressure injuries.
The facility failed to assess, monitor, and document the ongoing status of a venous stasis ulcer for a resident. Despite following the physician's orders for wound care, the facility did not conduct or document any wound measurements or assessments, relying solely on the wound clinic's documentation.
The facility failed to use a gait belt during the transfer of a resident who requires staff assistance, contrary to the resident's care plan and the facility's policy. A CNA was observed lifting the resident by placing forearms under her armpits instead of using a gait belt, and an LPN confirmed that a gait belt is typically used for this resident's transfers.
The facility failed to address a significant weight loss in a resident, develop and implement interventions to prevent further weight loss, and ensure dietitian assessment. The resident's care plan and medical record lacked documentation and interventions, and the dietitian was not notified of the weight loss since November 2023.
The facility failed to ensure ongoing communication with the dialysis center and did not implement a care plan for a resident requiring dialysis services. The resident's care plan lacked details on monitoring, care, or emergency management of the dialysis access site, and several Hemodialysis Communication Forms were missing.
The facility failed to document and monitor target behaviors for two residents using antipsychotic medications. One resident with Dementia and Severe Depressive Disorder was prescribed Zyprexa, but their behaviors were not tracked every shift. Another resident with Dementia and Delusional Disorder was prescribed Seroquel, but no behaviors were documented to justify its use. Staff confirmed that behavior tracking was not consistently performed.
A facility failed to ensure accurate administration of a blood pressure medication according to the physician's order. An LPN prepared a double dose of Labetalol for a resident, but upon rechecking the order, corrected the mistake before administration.
The facility failed to apply gloves prior to providing high-contact care and did not ensure appropriate isolation precautions for a resident with an active infection. Despite the facility's Enhanced Barrier Precautions policy, staff were observed transferring the resident without gloves, and the resident was not placed under the required contact isolation precautions.
Delay of Oncology Immunotherapy Due to Mismanagement of Medicare Status and Communication Failures
Penalty
Summary
The deficiency involves the facility delaying a resident’s immunotherapy oncology treatment due to misunderstandings and actions related to Medicare Part A coverage and the resident’s payor status. The resident had a complex history of multiple squamous cell carcinomas, basal cell carcinoma, prostate cancer, autoimmune pancreatitis, and imaging showing a hypermetabolic renal mass and pulmonary nodule. Prior to admission, the resident had initiated immunotherapy (cemiplimab) with a plan for eight cycles. Following a ground-level fall and right femoral neck fracture, the resident underwent right hip hemiarthroplasty and was discharged from the hospital to the facility for subacute skilled therapy under Medicare benefits. The admission contract and facility resident rights policy stated that residents would be fully informed of their rights, services, and charges, and that the facility would assist residents in exercising their rights and ensure they were treated with dignity and respect. During the admission and screening process, facility staff did not identify that the resident was actively receiving immunotherapy and had ongoing oncology appointments. Admissions staff reported they did not see any immunotherapy when screening the resident, and social services reported they did not realize the resident was supposed to receive immunotherapy until after admission. The facility assessment referenced cancer-related care needs in general but did not identify any residents currently receiving cancer treatments. After admission, the DON/ADON contacted the oncologist’s office on multiple occasions requesting that the resident’s immunotherapy be placed on hold, initially citing insurance reasons and asking to hold treatment for a few weeks. Oncology documentation showed that the oncologist’s office attempted to return calls, explained that provider approval was needed to withhold treatment, and ultimately pushed out appointments until mid-December, with a note that the facility would call when ready to reschedule. Over the subsequent weeks, facility documentation and interviews show that the resident and family were informed or believed that immunotherapy could not be continued while the resident was on Medicare Part A skilled therapy. Progress notes from February indicated that social services told the family the resident could start immunotherapy once off skilled therapy, and that the resident’s last covered Medicare A day would be set so the resident could transition to private pay and Part B. The daughter then contacted the oncologist to resume immunotherapy, and family provided appointment dates to the facility once they were scheduled. In interviews, the daughter stated she was told immunotherapy had to stop while the resident was receiving therapy on Medicare benefits and that treatment could resume only after switching to private pay, and the resident similarly stated he was told he could not see the oncologist while on Medicare and could resume now that he was private pay. The oncologist’s nurse confirmed receiving calls from facility staff requesting that immunotherapy be put on hold and later a call from the daughter indicating the resident was no longer on Medicare benefits and wanted to restart treatment. These actions and communications resulted in delayed oncology immunotherapy services and missed scheduled appointments for the resident, contrary to the resident’s rights to be fully informed, to participate in care planning, and to receive assistance in exercising those rights.
Infection Control Lapses in Contact Precautions and Medication Handling
Penalty
Summary
The facility failed to maintain proper contact precautions for a resident with a known multidrug-resistant organism (MDRO), specifically ESBL in the urine. The resident, who was frequently incontinent of urine, was placed in a room with another resident under enhanced barrier precautions for wounds. Despite the presence of a sign indicating enhanced barrier precautions, staff, including CNAs, were observed entering and exiting the room without wearing personal protective equipment (PPE). The infection preventionist acknowledged that the resident with ESBL should have been in a separate room under contact precautions, which was not implemented, leading to potential exposure risk to other residents assisted by the same CNAs. Additionally, the facility failed to adhere to hand hygiene and glove use standards during medication administration for two residents. A registered nurse was observed handling medication capsules without sanitizing hands or wearing gloves, and a licensed practical nurse similarly handled medication tablets without proper hand sanitation or glove use. Both staff members acknowledged the oversight, and the Director of Nursing confirmed the necessity of hand hygiene and glove use when handling medications. These lapses in infection control practices were identified during a survey of the facility's infection prevention and control program.
Failure to Implement Pressure-Relieving Interventions
Penalty
Summary
The facility failed to develop and implement pressure-relieving interventions to prevent pressure wound development for a resident who was at risk for pressure ulcers. Despite the resident's initial Braden scale indicating a risk for pressure ulcer development, the care plan was not updated with appropriate interventions. The resident, who had a history of hip fractures and required total assistance for bed mobility and transfers, developed a painful, unstageable right heel pressure ulcer and a deep tissue injury to the left great toe due to the lack of preventive measures such as offloading the heels with heel protectors and floating heels with pillows while in bed. The resident's condition deteriorated over time, with the right heel pressure ulcer progressing from a stage two pressure injury to an unstageable ulcer covered with eschar. The wound physician had recommended specific treatments and interventions, including the use of collagenase and povidone-iodine, but these were not consistently implemented. Observations revealed that the resident's heels were not offloaded as required, and the resident experienced significant pain during wound care. Additionally, a treatment order for the left great toe was not processed correctly, resulting in a lack of documented treatment for several days. Interviews with facility staff, including the Assistant Director of Nursing and the Wound Physician, confirmed that the pressure ulcers were avoidable and caused by pressure. The staff acknowledged that the necessary pressure-relieving interventions were not implemented, and the resident's care plan was not updated to reflect the risk of pressure ulcer development. The failure to follow the physician's recommendations and update the care plan contributed to the development and worsening of the resident's pressure ulcers.
Failure to Document and Assess Venous Stasis Ulcer
Penalty
Summary
The facility failed to assess, monitor, and document the ongoing status of a venous stasis ulcer for a resident (R18) who was reviewed for non-pressure wounds. The facility's Wound Care policy requires detailed documentation of wound care, including the type of care given, date and time, the individual performing the care, changes in the resident's condition, assessment data, and any problems or complaints. However, R18's medical record lacked any wound measurements, assessments, or progress notes from the facility staff. The resident's care plan indicated a high risk for impaired skin integrity, and the physician's orders specified a detailed wound care regimen, which was followed by the staff during observed dressing changes. Despite this, the facility did not document any ongoing assessments or wound measurements, relying solely on the wound clinic's documentation, which was not integrated into the resident's medical record at the facility. Interviews with the Director of Nursing (V2) and the Assistant Director of Nursing (V3) confirmed that the facility did not conduct or document ongoing wound assessments or measurements for R18's venous stasis ulcer. The staff only documented that the dressing changes were completed as scheduled. The resident, who had a history of moisture-associated skin damage and other risk factors, reported having the wound for several years. The lack of proper documentation and ongoing assessment by the facility staff represents a failure to adhere to their own wound care policy and to ensure comprehensive monitoring and documentation of the resident's wound status.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the use of a gait belt during the transfer of a resident who requires staff assistance with transfers. The facility's Transfer Belt Policy mandates the use of transfer belts for any resident requiring hands-on assistance unless specified otherwise in the care plan. Resident R29's care plan explicitly states the need for a gait belt during transfers due to her decreased mobility, poor cognition, poor activity tolerance, behaviors, and balance deficits. Despite this, a Certified Nursing Assistant (CNA) was observed transferring R29 without using a gait belt, instead lifting her by placing forearms under her armpits and moving her from her wheelchair to her bed. The CNA admitted to not using a gait belt for R29, citing that R29 does not usually get up on her own and does not put much support on her legs during transfers. Further interviews revealed that R29 requires the assistance of one staff member for transfers and does not transfer herself. A Licensed Practical Nurse (LPN) confirmed that a gait belt is typically used for R29's transfers, and no mechanical assistance is employed. The failure to adhere to the care plan and the facility's policy on the use of gait belts during transfers constitutes a deficiency in ensuring a safe environment free from accident hazards and providing adequate supervision to prevent accidents.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss in a resident, develop and implement interventions to prevent further weight loss, and ensure dietitian assessment with significant weight loss. The resident, who was alert with confusion and appeared thin and frail, had a documented significant weight loss over several months. Despite this, the resident's care plan did not include any documentation of the weight loss, risk for impaired nutrition, or interventions to prevent further weight loss. The resident's medical record also lacked documentation regarding nutrition, including dietitian assessments or recommendations since November 2023. The Assistant Director of Nursing acknowledged the significant weight loss and the lack of documentation and interventions in the resident's medical record. The Registered Dietitian confirmed that she had not been notified of the resident's weight loss since the last nutritional assessment in November 2023 and stated that different interventions should have been attempted to improve the resident's caloric and protein intake. The failure to notify the dietitian and update the care plan contributed to the ongoing weight loss in the resident.
Failure to Implement Dialysis Care Plan
Penalty
Summary
The facility failed to provide ongoing communication with the dialysis center and ensure a care plan was implemented for a resident requiring dialysis services. The resident, diagnosed with End Stage Renal Disease and dependent on renal dialysis, attended hemodialysis sessions three times a week. The resident reported that the dialysis staff were responsible for monitoring and caring for her dialysis access site, and that the facility's staff did not engage with it. The resident's care plan lacked any mention of the dialysis access site or interventions for its monitoring, care, or emergency management. Additionally, the facility could not provide records of Hemodialysis Communication Forms for several of the resident's dialysis appointments, and the Assistant Director of Nursing confirmed the absence of a care plan for the dialysis access site since the resident's admission.
Failure to Document and Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to document and monitor residents' target behaviors with the use of antipsychotic medication for two residents reviewed. Resident 8 (R8) has severely impaired cognition and a diagnosis of Dementia, and is prescribed Zyprexa for Severe Depressive Disorder. Despite the psychiatric note indicating improved behaviors, R8's medical record does not document target behaviors or monitor them every shift. The Director of Nursing confirmed that specific behavior tracking forms are not completed by staff and that target behaviors are not tracked every shift, only potentially for 14 days when starting a new psychotropic medication. Resident 52 (R52) has moderately impaired cognition with a diagnosis of Dementia and is prescribed Seroquel for Delusional Disorder. R52's medical record also lacks documentation of target behaviors for the use of the antipsychotic medication. Behavioral progress notes do not indicate any behaviors to justify the use of the medication, and observations confirmed no exhibited behaviors. The Assistant Director of Nursing stated that nurses document behaviors in progress notes but not every shift, and that Certified Nurse Aides do not document resident behaviors. R52 does not have any behaviors that justify the use of an antipsychotic medication.
Failure to Administer Medication Accurately
Penalty
Summary
The facility failed to ensure a medication to lower blood pressure was accurately administered according to the Physician's Order for one resident. The facility's Medication Administration policy and Medications Errors policy both emphasize the importance of administering medications safely and accurately as prescribed by the physician. However, during an observation, a Licensed Practical Nurse (LPN) prepared two 200 mg tablets of Labetalol for a resident, despite the physician's order specifying only one 200 mg tablet to be administered twice a day for hypertension. When questioned by the surveyor, the LPN initially confirmed that the resident takes two tablets in the morning. Upon rechecking the order, the LPN realized the mistake and removed the second tablet from the medication cup. The LPN admitted that if not prompted to recheck the order, she would have administered a double dose of Labetalol, resulting in a medication error. This incident highlights a failure in adhering to the facility's policies on medication administration and error prevention.
Failure to Apply Gloves and Implement Isolation Precautions
Penalty
Summary
The facility failed to apply gloves prior to providing high-contact care and did not ensure appropriate isolation precautions were in place for a resident (R19) with an active infection. The facility's Enhanced Barrier Precautions policy requires the use of gowns and gloves during high-contact resident care activities, such as dressing, bathing, transferring, and catheter care. Despite this, two Certified Nursing Assistants (V15 and V25) were observed transferring R19 to bed without applying gloves, even though they were wearing gowns. R19's room had a sign indicating Enhanced Barrier Precautions, but the staff did not fully adhere to the required protocols. R19 had a chronic indwelling urinary catheter and a history of chronic urinary tract infections, with a current order for an antibiotic to treat an ESBL E. coli-related urinary tract infection. The Infection Control Preventionist (V26) confirmed that R19 should have been placed under contact isolation precautions due to the active infection, which would require staff to wear gowns and gloves at all times in the room. However, this was not implemented, and the Infection Control Preventionist was unaware of the oversight due to limited presence in the facility over the past few weeks.
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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