Evercare At Edwardsville
Inspection history, citations, penalties and survey trends for this long-term care facility in Edwardsville, Illinois.
- Location
- 401 St Mary Drive, Edwardsville, Illinois 62025
- CMS Provider Number
- 145555
- Inspections on file
- 37
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 13 (2 serious)
Citation history
Health deficiencies cited at Evercare At Edwardsville during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was alleged by a family member to have not received prescribed medications, with video footage and MARs providing conflicting information. The administrator reviewed the situation but did not report or investigate the allegation as required, and key clinical leaders were not notified, resulting in a failure to follow the facility's abuse prevention policy.
A resident with severe cognitive impairment and multiple diagnoses was prescribed oxycodone, which was reported missing after a nurse failed to administer it as scheduled. The incident was brought to the attention of the facility administrator by a CNA, but the administrator did not report the alleged misappropriation to authorities or follow up with the family, contrary to facility policy.
A resident with severe cognitive impairment and dependency was reported by a family member to have not received prescribed oxycodone. The administrator reviewed video footage and MARs, but did not conduct a formal investigation or notify the DON or VP of Clinical Operations, as required by facility policy. This resulted in a failure to properly investigate an allegation of medication misappropriation.
A resident with cognitive impairment and complex medical needs was transferred to another facility following an altercation, without proper involuntary discharge paperwork or advance written notice. The resident and her family were not informed of their rights, and staff were unaware of the discharge until it was occurring. The ombudsman intervened, and an administrative law judge ordered the resident's return, highlighting the facility's failure to follow required discharge procedures.
A resident with cognitive impairment and significant care needs was discharged without the required medical information being communicated to the receiving provider. The responsible RN was unaware of the discharge until the last minute, resulting in the absence of necessary paperwork and documentation that should have accompanied the resident, in violation of facility policy.
A resident with ESRD was admitted without dialysis services being arranged, resulting in 12 days without treatment and subsequent hospitalization due to critical lab values and symptoms. Additionally, two residents with behavioral issues were involved in repeated altercations, including physical aggression and bruising, despite staff awareness and care plan updates. The facility did not ensure proper care coordination or prevent neglect and abuse as required.
A resident with end-stage renal disease was admitted without dialysis services being arranged, resulting in 12 days without treatment. The resident developed symptoms such as shortness of breath and jaundice, and was found to have critical lab values before being hospitalized. Facility staff did not coordinate or document necessary dialysis care, and there was no interim plan to address the missed treatments.
A resident with end-stage renal disease did not receive dialysis for 12 days due to the facility's failure to notify the physician of missed treatments, resulting in hospitalization for elevated potassium and other complications. The care plan and physician orders lacked documentation of dialysis needs, and the facility did not follow its policy for timely physician notification regarding significant changes in condition.
The facility did not provide enough licensed nursing staff during the evening shift, resulting in multiple residents with complex medical needs receiving their scheduled medications, including pain management, late—sometimes after midnight. Both residents and staff confirmed that the reduction from four to three nurses made it difficult to complete timely medication passes, and Resident Council records documented ongoing complaints about late medications and delayed call light responses.
Surveyors found that multiple residents did not receive their scheduled medications on time, with repeated late administration of pain, cardiac, and sleep medications. Residents and staff reported that the issue was due to insufficient nurse staffing during the evening shift, following a reduction in the number of nurses. Facility records and interviews confirmed that late medication administration was a widespread and ongoing problem, resulting in increased pain and frustration among residents.
A resident with a history of aggression and psychiatric diagnoses struck another resident in the face after the latter attempted to open his door to assist him. The incident resulted in physical injury and fear for the affected resident, despite prior documentation of the aggressor's behavioral risks and interventions such as frequent checks.
A deficiency was found due to the facility's failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, as well as inadequate catheter care and insufficient measures to prevent UTIs.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found that staffing levels and shift leadership did not comply with regulations.
A facility failed to prevent resident-to-resident abuse, involving three incidents where residents with cognitive impairments and behavioral issues engaged in altercations. One resident was hospitalized after being pushed, while another was struck in the face. The facility attributed these incidents to the residents' dementia and confusion, concluding they were not premeditated.
A resident experienced increased pain and discomfort due to the facility's failure to ensure timely availability of prescribed Oxycodone. The resident, who requires monthly prescription renewals for chronic pain management, was left without medication for several days due to ineffective reordering processes and communication issues between staff and the prescribing doctor. The facility's pain management policy was not adequately followed, resulting in incomplete pain assessments and lack of alternative pain relief options.
A resident experienced discomfort and withdrawal symptoms due to the facility's failure to ensure timely refills of scheduled opioid medication. Despite the resident's predictable need for monthly prescription renewals, the facility did not manage the reordering process effectively, leading to missed doses. Staff acknowledged the issue but were unable to secure the necessary prescription in a timely manner, highlighting a breakdown in communication and coordination between the facility, pharmacy, and prescribing doctor.
A facility failed to complete PASRR recommendations for a resident with intellectual disabilities and disruptive behaviors. The resident exhibited aggressive behavior, causing fear among other residents and requiring police intervention. Staff reported inadequate training and lack of policies for managing such behaviors, leading to ongoing disruptions and an unsafe environment.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in care plans and treatment. One resident's MDS inaccurately documented pain management, despite reports of significant pain and Oxycodone administration. Another resident's MDS did not reflect behaviors like wandering and potential psychosis, despite observations of such behaviors. The facility lacked a policy on assessment accuracy, contributing to these deficiencies.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed oxycodone due to unavailability. The facility faced issues with the hospice company responsible for medication refills, leading to multiple missed doses. The RN eventually administered the medication from the emergency kit after receiving approval.
Two residents in a LTC facility received inadequate incontinent care, as observed during a survey. A CNA failed to provide timely and thorough care, using incorrect cleansing methods and not adhering to the facility's perineal care policy. One resident reported long wait times for changes and had a recent history of UTI, while the other was left with feces on her skin. The facility's policy required more frequent checks and proper cleansing techniques, which were not followed.
Failure to Report and Investigate Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to follow its abuse prevention policy by not reporting and investigating an allegation of misappropriation of medication for a resident with severe cognitive impairment and dependency for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone every four hours. The resident's family member reported that the resident did not receive any medications during a specific shift, and video footage was reviewed by the administrator, who determined that the nurse had entered the room but did not verify medication administration. The Medication Administration Records (MARs) indicated that medications had been given, but the family member and oncoming nurse reported that the medications were missing and had been documented as administered. Despite the allegation and conflicting accounts, the administrator did not report the incident or initiate an investigation as required by the facility's abuse prevention policy. The Director of Nursing and the Vice President of Clinical Operations were not notified of the allegation, and standard procedures such as checking medication counts and narcotic logs were not followed. The facility's policy mandates prompt and thorough investigation of all reports of misappropriation, but this process was not initiated in this case.
Failure to Report Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of medication for one resident who was severely cognitively impaired and dependent on staff for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone. According to interviews and record review, a nurse did not enter the resident's room during her shift and informed a family member that the oncoming nurse would administer the medication. The oncoming nurse then reported that the medication was missing, although it had been documented as given. A certified nursing assistant notified the administrator of the situation, but the administrator did not follow up with the family member as promised and did not report the incident to the state health department or law enforcement, as required by the facility's abuse prevention policy.
Failure to Investigate Allegation of Medication Misappropriation
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of medication for one resident with severe cognitive impairment and dependency for transfers. The resident, diagnosed with metabolic encephalopathy and Alzheimer's disease, was prescribed oxycodone to be administered every four hours. The resident's family member reported that the resident did not receive her medications on a specific date. The administrator reviewed video footage and checked the Medication Administration Records (MARs), which indicated the medications had been given, and concluded the issue was resolved without further investigation. Despite the family member's report that the nurse did not enter the resident's room and that the oncoming nurse stated the medications were missing but documented as given, the administrator did not notify the Director of Nursing or the Vice President of Clinical Operations, nor did she conduct a formal investigation as outlined in the facility's abuse prevention policy. The policy requires prompt and thorough investigation of all reports of misappropriation, including checking medication counts and documentation, and reporting findings to appropriate agencies. The failure to follow these procedures resulted in the deficiency.
Failure to Follow Proper Involuntary Discharge Procedures
Penalty
Summary
The facility failed to follow proper procedures for the transfer and discharge of a resident with cognitive impairment and significant care needs. The resident, who had a diagnosis of malignant neoplasm of the colon and chronic pain, was admitted for long-term care and had a care plan goal to remain in the facility. After an altercation with another resident, the facility sent the resident to the hospital for a psychological evaluation and subsequently transferred her to another facility without her consent. The resident expressed distress about the transfer, and her family was not informed of their rights or provided with appropriate discharge information. Staff interviews revealed that the resident did not want to leave, and the transfer occurred without the knowledge or preparation of her assigned nurse. The facility did not provide the required involuntary discharge (IVD) paperwork to the resident or her representative, nor did they notify them in writing of the reasons for the move as required by policy. The administrator confirmed that no IVD paperwork was filed, and the social services director was unaware of the transfer until after it had occurred. The ombudsman intervened, and an administrative law judge ordered the facility to take the resident back. Documentation and interviews consistently indicated that the facility did not follow established procedures for involuntary discharge, including providing advance notice and ensuring the resident's preferences and needs were considered.
Failure to Communicate Required Resident Information at Discharge
Penalty
Summary
The facility failed to communicate required resident information to the receiving provider during the discharge of one resident. The resident, who had diagnoses including malignant neoplasm of the colon and chronic pain, was cognitively impaired and required substantial assistance with transfers. On the day of discharge, the registered nurse responsible was not aware of the discharge until informed by another staff member as the resident was preparing to leave. As a result, the nurse did not have the resident's paperwork ready and was unable to provide a report to the receiving facility. There was no documentation that the necessary paperwork, such as the medication list, progress notes, care plan, and face sheet, was sent with the resident, contrary to the facility's policy and procedures for discharge communication.
Failure to Coordinate Dialysis Care and Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) was free from neglect during the admission process. The resident was transferred from another nursing home and had been receiving dialysis five days per week prior to admission. Upon arrival, no dialysis services were set up or scheduled, and there was no alternate dialysis treatment provided while waiting for a new provider. The resident did not receive dialysis for 12 days, during which time she experienced symptoms including shortness of breath, sweating, weakness, jaundice, and critical laboratory values such as elevated potassium, BUN, and creatinine levels, ultimately requiring hospitalization. Documentation showed that the resident's care plan and physician orders did not include dialysis, and there was no evidence of physician notification or follow-up regarding the missed treatments. Additionally, the facility failed to prevent resident-to-resident altercations involving two residents with behavioral and psychiatric diagnoses. There were multiple documented incidents where one resident was verbally and physically aggressive toward another, including hitting and pulling hair. Staff and other residents witnessed these altercations, and skin assessments confirmed bruising. Despite these repeated behaviors, care plans and interventions did not prevent further incidents, and both residents continued to have conflicts. The deficiencies were identified through interviews, record reviews, and observations, revealing lapses in care coordination, communication, and supervision. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the lack of timely action to secure necessary dialysis treatments and to prevent ongoing resident-to-resident altercations. The events led to significant harm and risk for the residents involved.
Removal Plan
- The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on neglect related to coordination of care by not setting up dialysis treatments.
- All department heads on abuse and neglect policy and procedure and no staff was allowed to work until they were in-serviced on abuse and neglect.
- A 24-hour report sheet was made up to ensure that there were no dialysis residents that missed/needed set up for treatment.
- A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect related to coordination of care for all new residents and dialysis treatment.
Failure to Coordinate Dialysis Care Resulting in Missed Treatments and Hospitalization
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, who was dependent on hemodialysis, was admitted to the facility without any dialysis services being set up or scheduled prior to admission. The resident had been receiving dialysis five times per week at the previous facility, but upon transfer, no arrangements were made to continue this essential treatment. The facility did not implement any alternative dialysis treatment while waiting for a new provider, and there was no documentation of dialysis orders or appointments in the resident's records. The care plan and progress notes failed to address the resident's ongoing need for dialysis or any interim measures to manage her condition. During the 12 days following admission, the resident did not receive any dialysis treatments. She began to exhibit symptoms including shortness of breath, sweating, weakness, and jaundiced eyes. Laboratory results revealed critical values, such as elevated potassium, BUN, and creatinine levels. Despite these symptoms and the absence of dialysis, there was no documented follow-up or escalation of care to address the missed treatments. The resident's family ultimately requested that she be sent to the hospital, where she was found to have critical lab values and required a five-day hospitalization. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's dialysis needs. Staff members, including the DON, ADON, and Social Service Director, indicated that it is standard practice to ensure dialysis is arranged before admitting a resident who requires it, but in this case, the process was not followed. The transportation staff attempted to refer the resident to a dialysis center, but the referral did not go through, and there was no effective follow-up. The nephrologist and medical doctor both confirmed that missing dialysis treatments can cause serious harm and that the facility failed to coordinate care to prevent this outcome.
Removal Plan
- The Administrator and Assistant Director of Nursing (ADON) were in-serviced by the VP of clinical services on dialysis care related to coordination of care by not setting up dialysis treatments.
- All department heads on dialysis and procedure and no staff was allowed to work until they were in-serviced on dialysis.
- A 24-hour report sheet was made up to ensure that there were no dialysis residents that missed/needed set up for treatment.
- A quality assurance tool was implemented: On-going audit of the 24-hour report will be completed to ensure that no resident missed dialysis or needed dialysis set up and a Root cause analysis was completed for neglect related to coordination of care for all new residents and dialysis needs are addressed.
Failure to Notify Physician of Missed Dialysis Leading to Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician regarding a resident who did not receive dialysis for 12 days, resulting in the resident's hospitalization. The resident had multiple diagnoses, including end-stage renal disease and dependence on renal dialysis, but the Physician Order Sheet did not include an order for dialysis, only for monitoring the dialysis catheter. The care plan also did not document that the resident was receiving or awaiting approval for dialysis treatments. Progress notes indicated that the resident complained of symptoms such as shortness of breath, weakness, and sweating, and reported missing a dialysis session. Although the physician was notified of a missed dialysis day and low glucose, there was no documentation that the physician was informed about the ongoing lack of dialysis treatments or that the resident went 12 days without dialysis. The medical director confirmed that he was not made aware that the resident had not received dialysis as recommended and stated that, had he known, he would have sent the resident to the hospital for treatment. Hospital records confirmed that the resident had not received dialysis for about two weeks since transfer to the facility, resulting in elevated potassium, BUN, and creatinine levels. The hospital provided dialysis, and the resident was hospitalized for five days before being discharged back to the facility. The facility's policy requires timely notification of the physician and family when there is a significant change in a resident's condition or a need to alter treatment. In this case, the lack of communication and documentation regarding the resident's dialysis needs and missed treatments led to a significant lapse in care and a failure to follow established protocols for physician notification.
Failure to Provide Sufficient Licensed Nursing Staff Results in Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff to meet the needs of all residents, as evidenced by interviews and record reviews for four residents with complex medical conditions. These residents reported that their scheduled evening medications, including pain management and other critical treatments, were frequently administered late. Residents described being woken up to receive medications well past the scheduled times, sometimes after midnight, resulting in increased pain and dissatisfaction. The issue was corroborated by the residents' cognitive status, as documented in their Minimum Data Set (MDS) assessments, and by their direct statements regarding the impact of late medication administration. Multiple staff members, including LPNs and the wound care nurse, confirmed that the reduction in evening nursing staff from four to three nurses between 6 PM and 10 PM made it difficult to complete medication passes on time. Staff reported that the change was made by facility ownership to save money, and that three nurses were insufficient to manage the medication needs of the resident population during the evening shift. The facility's own policy requires staffing levels to be based on resident census and needs, and the daily census showed 100 residents at the time of the survey. Resident Council meeting memoranda further documented ongoing concerns, with residents expressing frustration about waiting until after 11 PM for medications and call lights not being answered promptly. The Director of Nursing acknowledged awareness of the issue and the difficulty nurses faced in completing all required tasks with the reduced staffing. The administrator also confirmed that medication administration times were being documented as late, consistent with resident and staff reports.
Failure to Administer Medications at Scheduled Times Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to administer medications at the scheduled times for four residents reviewed for medication administration. Documentation showed repeated late administration of critical medications, including acetaminophen, carvedilol, oxycodone, trazodone, and hydromorphone. Medication Administration Records (MARs) indicated that evening medications were often given hours after the scheduled time, with some doses administered after midnight. Residents reported experiencing increased pain and disrupted sleep due to these delays, and several stated that nurses had to wake them up late at night to take their medications. Interviews with residents and staff revealed that the late administration of medications was a persistent issue, particularly during the evening shift. Residents, including the President of the Resident Council, expressed frustration and discomfort, noting that the problem had become more pronounced in recent months. Staff members, including LPNs and the wound care nurse, consistently attributed the delays to insufficient nurse staffing during the 6 PM to 10 PM shift. They reported that the facility had recently reduced the number of nurses from four to three during this critical period, making it difficult to complete medication passes on time. Facility leadership, including the Administrator and DON, acknowledged awareness of the issue, as documented in Resident Council meeting memoranda and interviews. The facility's own medication administration policy requires medications to be given within one hour of the scheduled time, but records and staff statements confirmed that this standard was not being met. The deficiency affected all residents in the facility, as the late administration of medications was not limited to the sampled residents but was reported as a widespread concern.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving one resident who was struck in the face by another resident. The incident occurred when one resident, who has a history of inappropriate contact, physical aggression, and paranoia, reacted aggressively after another resident attempted to open his door to assist him. The aggressor, who is cognitively intact but has multiple psychiatric diagnoses including Alzheimer's Disease, psychosis, and obsessive-compulsive disorder, became agitated and hit the other resident, resulting in redness to the face and arm, as well as bleeding from the head. The affected resident, who is also cognitively intact and has diagnoses including cerebral infarction and Alzheimer's Disease, reported feeling fearful of the aggressor and stated he does not feel safe around him, although he generally feels safe in the facility when staff are present. Prior to the incident, the aggressor's care plan documented a history of physical aggression, poor impulse control, and a dislike of having his personal space invaded. The care plan also noted previous encounters with other residents and interventions such as 15-minute checks. Despite these documented risks and behaviors, the incident occurred when the other resident, unaware of the behavioral symptoms, attempted to help by opening the door, which triggered the aggressive response. The facility's abuse prevention policy states that residents must not be subjected to abuse by anyone, including other residents, and defines resident-to-resident abuse as willful, deliberate actions.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder. It also notes failures in providing appropriate catheter care and in implementing measures to prevent urinary tract infections. The deficiency is based on observations or findings that the facility did not consistently ensure proper care practices for these residents, as required by regulatory standards.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving three residents, resulting in one resident being sent to the hospital. The incidents involved residents with varying degrees of cognitive impairment and behavioral issues. In one case, a resident with severe cognitive impairment and a history of wandering struck another resident in the face, leading to redness and the need for medical evaluation. The facility's investigation concluded that the incident was isolated and not premeditated, attributing it to the resident's dementia and confusion. In another incident, two residents with dementia and behavioral issues were involved in an altercation. One resident attempted to take items from a table, leading to a confrontation where the other resident swung a cup, causing a minor injury. Both residents were separated and placed under one-on-one monitoring. The facility's report indicated that neither resident had a history of aggressive behavior, and the incident was not considered premeditated or targeted. A third incident involved a resident with a personality disorder and Alzheimer's disease pushing another resident, causing a fall and subsequent hospital visit. The facility did not view this as abuse, citing the resident's peculiar behavior and lack of malicious intent. Despite the incidents, the facility's staff and administration did not perceive these behaviors as aggressive or intentional, and they continued to monitor the residents involved.
Failure to Ensure Timely Pain Medication Availability
Penalty
Summary
The facility failed to ensure that pain medications were readily available for a resident, leading to increased pain and discomfort. The resident, who is cognitively intact, relies on Oxycodone for chronic pain management due to hip deterioration. Despite the predictable need for monthly prescription renewals, the facility did not manage the reordering process effectively, resulting in the resident being without medication for several days. The resident reported severe pain and withdrawal symptoms during these periods without medication. Interviews with staff revealed a lack of clarity and responsibility in the medication ordering process. A staff member mentioned that the medication card indicates when to reorder, but there was confusion about whether the pharmacy or the doctor was at fault for the delay. The Nurse Practitioner, who was in charge, could not write prescriptions for controlled substances, and the facility's attempts to contact the doctor were not timely or effective, leading to gaps in medication availability. The facility's pain management policy requires regular pain assessments and timely interventions, but these were not adequately followed. The resident's pain assessment was incomplete, and there was no PRN Tylenol order to manage pain in the absence of Oxycodone. The Director of Nursing acknowledged the oversight in pain assessment and the need for a referral to pain management. Despite the facility's policy, the resident experienced significant pain and distress due to the unavailability of prescribed pain medication.
Failure to Ensure Timely Opioid Medication Refill
Penalty
Summary
The facility failed to ensure the availability of scheduled opioid medication for a resident, resulting in the resident missing several doses of pain medication and experiencing discomfort and withdrawal symptoms. The resident, who is cognitively intact, relies on Oxycodone for chronic pain management due to hip deterioration. Despite the predictable need for a monthly prescription renewal, the facility did not manage the reordering process effectively, leading to the resident being without medication for several days. Interviews with staff and the resident revealed a lack of communication and coordination between the facility, the pharmacy, and the prescribing doctor. The resident expressed frustration over the recurring issue of running out of medication and the lack of proactive measures to prevent it. Staff members, including the Director of Nursing and the Assistant Director of Nursing, acknowledged the problem but indicated that they were unable to compel the doctor to provide the necessary prescription in a timely manner. The facility's Controlled Substance Prescription Policy outlines the process for obtaining and renewing prescriptions, but it appears that these procedures were not followed effectively. The policy requires the pharmacy to notify the facility if a prescription is not obtained before the medication runs out, but this did not prevent the resident from experiencing a gap in medication availability. The nurse practitioner involved was unable to write the prescription due to not having a DEA number, further complicating the situation.
Failure to Address Behavioral Health Needs and Ensure Accurate Assessments
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screen Resident Review (PASRR) recommendations were completed for a resident with a qualifying diagnosis and disruptive behaviors. The resident, identified as R4, had a diagnosis of mild intellectual disabilities, schizoaffective disorder, and bipolar disorder. Despite the PASRR indicating that a resident review should be completed when the short-term approval was ending, this was not done. Additionally, the resident's Minimum Data Set (MDS) inaccurately documented that R4 did not have potential indicators of psychosis, such as hallucinations or delusions, and did not reject evaluation or care, nor wander, which contradicted observations and reports from staff and other residents. Multiple interviews with residents and staff revealed that R4 exhibited disruptive and aggressive behaviors, including using foul language, making other residents feel unsafe, and requiring police intervention on several occasions. Staff and residents reported feeling intimidated and scared by R4's behavior, which included cursing, making inappropriate comments, and unpredictable actions. Despite attempts to redirect R4 and provide one-on-one care, the interventions were unsuccessful, and the behavior continued to affect the well-being of other residents. The facility lacked adequate staff training and policies related to behavioral health services, as noted by the Director of Nursing and other staff members. The facility's administrator was unaware of R4's PASRR requirements, and there was no policy in place for managing residents with behavioral health issues. The facility's failure to address R4's behavioral health needs and ensure accurate assessments and interventions contributed to the ongoing disruptive behavior and the negative impact on the facility's environment.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their care plans and treatment. For one resident, the Minimum Data Set (MDS) inaccurately documented that the resident had not received scheduled or PRN pain medications, despite the resident's reports of significant pain and the administration of Oxycodone as per physician's orders. The resident's care plan noted potential for pain and required monitoring of pain interventions, yet the quarterly pain assessment was incomplete, and the resident's diagnoses related to pain were not updated in the facility's records. The Director of Nursing acknowledged the inaccuracies in the MDS and the need for a referral to pain management. Another resident's MDS failed to reflect behaviors such as wandering and potential indicators of psychosis, despite observations and reports of the resident walking anxiously and talking to imaginary people. The care plan documented the resident's behavior of walking throughout the facility and cursing, which was not successfully managed by the interventions attempted. The facility had a behavioral health counselor available, but the resident refused to see her. The facility did not provide a policy related to the accuracy of assessments, contributing to the deficiencies noted.
Failure to Administer Prescribed Medications Due to Unavailability
Penalty
Summary
The facility failed to administer prescribed medications to a resident, identified as R2, who was part of a sample reviewed for pharmacy services. R2, who was admitted with diagnoses including metabolic encephalopathy, Alzheimer's, and interstitial cystitis, was severely cognitively impaired and dependent on staff for daily activities. The care plan for R2 included monitoring for pain and ensuring medication compliance. However, the Medication Administration Record (MAR) indicated that R2's prescribed oxycodone was not administered multiple times over several days due to the drug being unavailable. Interviews and record reviews revealed that the facility experienced issues with the hospice company responsible for R2's medication, leading to a lack of timely refills. The Assistant Director of Nursing acknowledged the problem with the hospice company, and the Director of Nursing was unaware of the situation due to a lack of documentation by the RN who had been contacting hospice. The RN confirmed the absence of oxycodone in the medication drawer and the need for a prescription to access the emergency kit. Eventually, the RN received approval to administer oxycodone from the emergency kit, but this was after several missed doses.
Inadequate Incontinent Care for Two Residents
Penalty
Summary
The facility failed to provide timely and thorough incontinent care for two residents, R1 and R5, as observed during a survey. R1 reported that it sometimes takes up to two hours to be changed when incontinent and that she had not been changed since the previous night. During an observation, a CNA, V9, provided inadequate care by not checking R1's incontinence status earlier, using a soap that required rinsing without rinsing or drying the areas, and failing to clean R1's inner vaginal folds. R1's adult diaper and gown were saturated with urine, and she had redness in her groin and buttocks areas. R1 had a recent history of hospitalization for sepsis and a urinary tract infection, and her care plan did not address her urinary incontinence or UTI. R5 also experienced inadequate care, as she reported not being checked or changed since early morning. When V9 provided care, he used a no-rinse peri-wash incorrectly, did not clean R5's inner vaginal folds, and left feces on her left buttock before putting on a new adult diaper. V9 also failed to dry any areas after cleansing. R5's care plan indicated she was at risk for irritant contact dermatitis due to incontinence and required care after each incontinent episode. The facility's policy on perineal care was not followed, as it required separating the labia, washing, rinsing, and drying the area from front to back. The Assistant Director of Nurses stated that incontinent residents should be checked and changed at least every two hours and that staff should thoroughly cleanse all areas affected by urine or feces. The facility's failure to adhere to these standards resulted in inadequate care for R1 and R5.
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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