Fair Oaks Rehab & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in South Beloit, Illinois.
- Location
- 1515 Blackhawk Boulevard, South Beloit, Illinois 61080
- CMS Provider Number
- 145702
- Inspections on file
- 43
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Fair Oaks Rehab & Healthcare during CMS and state inspections, most recent first.
A cognitively impaired, non-verbal resident with hemiplegia and severe decision-making impairment was not protected from sexual abuse by a male resident with a documented history of sexually inappropriate behavior toward female residents. Staff had prior knowledge of this male resident’s pattern of touching, kissing, and following cognitively impaired female residents, and his care plan included an intervention not to leave him unsupervised with female residents. Despite this, he was observed with his hand on the female resident’s thigh moving toward her genital area in a common area, and later both residents were seen holding hands in the same area while multiple staff did not intervene. Behavior monitoring tools failed to capture his ongoing behaviors, and the facility’s abuse policy and care plan interventions were not effectively implemented to prevent his access to vulnerable female residents.
Surveyors found that two residents on isolation-level precautions did not have isolation signs posted on their room doors, despite physician orders and care plans for Enhanced Barrier Precautions (EBP) and strict isolation. Both residents were cognitively intact and required assistance with ADLs, and had diagnoses including Parkinson’s disease, surgical aftercare, pressure ulcers, type 2 DM, wound infections, and UTI. The DON confirmed that both residents had EBP orders and that signs should have been on their doors to alert staff to use appropriate PPE, and acknowledged that the signs were not moved when the residents changed rooms, contrary to the facility’s infection prevention and control manual describing EBP use of gown and gloves during high-contact care.
A resident with severe cognitive impairment and incontinence was not provided timely incontinence care, resulting in prolonged exposure to urine and soiled clothing. Staff and family confirmed the resident had not been checked or changed for several hours, despite care plan and facility policy requiring frequent checks and cleaning. The incident was confirmed through observation, interviews, and record review.
Two residents experienced significant medication errors when one did not receive insulin according to updated physician orders due to outdated instructions in the MAR, and another missed scheduled doses of an antibiotic because the medication was not reordered in time. Nursing staff and facility policies were not followed, resulting in these errors.
A resident with a Full Code status was found unresponsive and without vital signs, but the facility staff failed to initiate CPR immediately. Despite instructions from the DON and MOD to start resuscitation, the nurse on duty delayed action, leading to a 42-minute gap before CPR was performed by emergency personnel. This delay resulted in the resident's death and was identified as an Immediate Jeopardy situation.
A resident with a history of cognitive and physical impairments sustained a new spiral fracture to the left distal humerus due to the facility's failure to adequately assess and monitor her post-surgical condition. Despite reports of increased pain and swelling from therapy staff, the nursing staff did not document or act on these changes, leading to a torsional injury that required further surgical intervention.
The facility failed to properly reconcile and secure a delivery of hydrocodone/Norco, affecting 14 residents with current orders for the narcotic. The medication was left unsecured on top of the stat safe over a weekend due to a lack of access by the staff present, resulting in its disappearance.
A resident dependent on staff for daily living activities was found with saturated clothing and a heavily soiled incontinence brief, indicating inadequate care. The resident expressed pain, and her skin showed signs of a Moisture Associated Skin Disorder. Multiple CNAs were unable to confirm when the resident was last changed, and the facility lacked a specific policy for dependent residents' care, relying on standard nursing practice.
A resident's dietary care plan was not followed, as their meal included pea salad despite their documented dislike for peas. The resident did not eat the pea salad and confirmed their dislike when asked.
A resident reported to a CNA that a man twisted her arm, resulting in swelling and redness. The CNA informed an RN, but the RN did not investigate further or report the allegation to the Administrator immediately. The facility's policy requires immediate reporting of abuse allegations, but the incident was not reported until the next day.
The facility failed to test residents for COVID-19 after exposure to a positive Occupational Therapist Aide. Despite the facility's policy requiring testing after exposure, residents who had close contact with the aide were not tested, and their medical records showed no mention of exposure or testing. This breach in infection control was acknowledged by the Assistant Director of Nursing.
The facility failed to provide adequate pressure ulcer care and prevention for two residents. A resident with a stage 2 coccyx pressure ulcer and MRSA infection was found without the prescribed dressing, and another resident with hemiplegia was observed with heels resting on the bed, contrary to her care plan. Staff acknowledged the deficiencies, which were against the facility's pressure injury prevention policy.
The facility failed to provide adequate ROM care and restorative interventions for two residents. One resident with hemiplegia was not receiving prescribed ROM exercises, and documentation was incomplete. Another resident with Parkinson's disease lacked necessary palm guards and finger separators, with staff admitting to losing equipment. The absence of a restorative nurse and inadequate documentation contributed to these deficiencies.
A resident with chronic kidney disease and other health issues experienced significant weight loss due to the facility's failure to implement prescribed nutritional interventions. Despite recommendations for extra protein with meals, the resident's diet card did not reflect these changes, and he was not consistently provided with the additional protein portions. The dietitian communicated the need for extra protein, but the dietary manager confirmed inconsistencies in the diet card and meal provisions, leading to continued risk for weight loss.
The facility did not offer pneumococcal vaccinations to three residents, as required by their policy. A review of records showed no documentation of consent or refusal for the PCV20 vaccine for these residents. The facility's administrator confirmed the lack of documentation. The facility's policy states that residents over 65 should receive a dose of PCV20 if they have completed a series of PCV13 and PPSV23 vaccines, or a dose of PCV20 or PCV15 and PPSV23 a year apart if they have no history of pneumonia vaccines.
Failure to Protect Cognitively Impaired Resident From Known Sexually Inappropriate Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, non-verbal resident (R7) from sexual abuse by another resident (R8) with a known pattern of sexually inappropriate behaviors. R7 had a history of multiple strokes, hemiplegia on the right side, aphasia resulting in no speech and rare understandability, memory impairment, and severely impaired decision-making. She used a wheelchair, self-propelled, and required maximum assistance with activities of daily living. Her care plan did not identify any behaviors, despite her tendency to hold hands with others and wheel herself toward people to grab their hands. On the evening of 3/2/2026, staff observed R8 in the resident common area with his hand on R7’s thigh, moving toward her genital area. An agency LPN (V17) immediately separated the residents, called for R7’s nurse, and directed R8 to leave the area after witnessing his hand on R7’s thigh moving up toward her private area. Prior to this incident, multiple staff were aware that R8 had a history of sexually inappropriate behavior toward female residents. The care plan for R8, initiated in 2025, documented that he might be socially inappropriate with other residents and included an intervention added on 3/20/2025 to not allow him to be unsupervised with female residents, as well as an intervention to remove him from situations to protect the rights and safety of others. Progress notes showed that after Depo-Provera was started in 7/2025 for abnormal sexual behavior, R8 continued to engage in inappropriate conduct, including touching a female resident’s abdomen, kissing another female resident’s hand, following a female resident around while trying to hold her hands and rub her arms, and kissing another cognitively impaired female resident (R6) on the mouth. Staff interviews confirmed that R8 had been caught touching and kissing female residents, engaging in multiple instances of inappropriate touching around breasts, and being sexually inappropriate with another resident in his room. Despite this documented and observed pattern, behavior monitoring tools for R6, R7, and R8 showed no behaviors for the last 30 days. On the day of the incident, an RN (V11) had already taken steps to move R7 to another unit earlier in the shift after R8 called out for staff to bring R7 to him, due to R8’s known history with female residents. However, this information was not communicated to the agency LPN (V17), who stated that if she had known, she would have kept a closer eye on the situation and kept female residents away from R8. The responding police officer’s report documented that the nurse witness stated R8’s hand was on R7’s lap, close to her vaginal area, and that R7 could not speak or move well enough to give consent. A resident witness reported seeing R7 swat away R8’s hand and stated that this was not the first time R8 had touched female residents inappropriately. Despite the incident and R8 being charged with criminal sexual abuse, the surveyor later observed R7 and R8 holding hands in the common area while numerous staff were present and did not intervene until the administrator noticed the surveyor observing the situation. The facility’s abuse policy stated that residents have the right to be free from abuse, defined sexual abuse as behavior without consent or capacity to consent (including kissing and hugging), required monitoring of resident behaviors for abuse triggers, reassessment of care plan interventions, and removal of alleged perpetrators from further resident contact, but these measures were not effectively implemented to prevent or promptly address R8’s access to cognitively impaired female residents such as R7.
Removal Plan
- Place R8 on one-on-one care until discharge.
- Identify female residents that gravitate to him and closely monitor them to ensure staff are following care plans for interventions.
- Educate nursing staff regarding R8's one-on-one status and the need to re-direct females from his vicinity while he remains in the facility.
- Educate all staff on the abuse policy and procedure including how to identify inappropriate sexual behavior with a focus on residents that don't have the cognitive ability to consent.
- Educate nursing staff on where to find the care plan of residents to include any interventions for behaviors.
- Review all behaviors in the morning clinical meeting to ensure proper interventions are put into place and the care plan is updated to reflect such, and ensure any changes are communicated to the staff.
- Hold an Ad Hoc QAPI meeting with QAPI team members and the Medical Director to review the abuse policy and procedure, the state regulation, and the measures being put in place to ensure this deficient practice doesn't happen again.
Failure to Post Isolation Signage for Residents on Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when two residents on isolation-level precautions did not have isolation signage posted on their room doors. One resident was admitted with diagnoses including Parkinson’s disease, surgical site aftercare, and a urinary tract infection, was cognitively intact, and required moderate assistance with ADLs. A physician order dated 12/12/2025 directed the use of Enhanced Barrier Precautions (EBP) for this resident. Another resident was admitted with diagnoses including surgical aftercare, pressure ulcers, type 2 diabetes, and wound infections, was cognitively intact, and required partial assistance with ADLs. This second resident had a physician order dated 11/4/2025 for contact isolation, and a care plan dated 11/6/2025 with a revision on 12/19/2025 indicating a need for strict isolation precautions. On 3/3/2026 at 1:00 PM, surveyors observed that there were no isolation signs on the doors of either resident’s room, despite the existing orders and care plan for EBP and isolation. At 1:30 PM the same day, the Director of Nursing confirmed that both residents had orders for EBP and acknowledged that signs should have been on their doors to alert staff to use appropriate PPE to prevent the spread of infections. The Director of Nursing further explained that one resident’s contact isolation had been changed to EBP after diarrhea resolved, and stated that the signs should have been moved when the residents changed rooms. The facility’s undated infection prevention and control manual for EBP states that EBP is intended to reduce transmission of multi-drug-resistant organisms and involves the use of gown and gloves during high-contact resident care, underscoring that signage was an expected component of implementing these precautions.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, Lennox-Gastaut Syndrome, epilepsy, autistic disorder, and incontinence of urine and bowel was not provided timely incontinence care. The resident's care plan required frequent checks for incontinence and perineal care after each episode. On the day of observation, the resident had not been changed since getting up in the morning, resulting in a saturated incontinence brief, soiled clothing, and a strong urine odor. Staff confirmed that the resident had not been checked or changed for several hours, despite facility policy and care plan directives to check at least every two hours. Interviews with staff and the resident's family member confirmed the lapse in care, with staff acknowledging the resident's high risk for skin breakdown due to incontinence and inability to reposition independently. The facility's policy on pressure injury assessment and treatment also required prompt cleaning of soiled skin, but there was no specific incontinence care policy in place at the time of the incident. The deficiency was identified through direct observation, interviews, and record review.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two cases involving medication administration. In the first case, a resident with brittle diabetes did not receive insulin according to the most recent physician orders. The resident's endocrinology summary included a revised sliding scale for Novolog insulin, but the Medication Administration Record (MAR) did not reflect these updated orders, and nursing staff continued to follow the outdated scale. The Assistant Director of Nursing confirmed that the revised orders from the endocrinologist were not implemented, resulting in the resident not receiving the correct insulin doses as prescribed. In the second case, a resident with multiple diagnoses, including hepatic encephalopathy, did not receive both scheduled doses of the antibiotic Rifaximin on a specific day because the facility had run out of the medication. The Assistant Director of Nursing stated that the medication was not available due to a failure to reorder it in advance, as required. The facility's policy requires that all medication orders be accurately documented and administered according to the five rights of medication use, but these procedures were not followed in these instances.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to immediately provide cardiopulmonary resuscitation (CPR) to a resident, identified as R9, who was found not breathing and pulseless. R9 had a physician's order indicating she was a Full Code, meaning resuscitation efforts should have been initiated immediately. However, the staff did not start CPR until 42 minutes after R9 was found unresponsive, which resulted in her death at the facility. This incident was identified as an Immediate Jeopardy situation. The deficiency occurred when V22, a Registered Nurse, discovered R9 unresponsive and without vital signs. Despite R9's Full Code status, V22 did not initiate CPR immediately. V22 was unsure of the policy for handling a deceased resident and did not verify R9's code status promptly. Instead, V22 called the Director of Nursing (V2) and other staff members, delaying the initiation of CPR. V22 eventually called 911, but CPR was not started until emergency medical personnel arrived. Interviews with other staff members, including V23 (CNA), V25 (RN), and V24 (Manager on Duty), revealed that there was confusion and a lack of urgency in responding to R9's condition. V24 and V2 both instructed V22 to start CPR, but V22 refused, citing R9's mottled appearance and the belief that she was already deceased. The facility's policy required immediate CPR for Full Code residents, but this was not followed, leading to the delay in resuscitation efforts and R9's subsequent death.
Removal Plan
- The Director of Nursing, Assistant Director of Nursing, Post Acute Nurse, MDS Nurses, Wound Care Nurse, Regional Director of Nursing, Charge Nurse or Designee educated clinical staff regarding the CPR policy and procedure and Advanced Directive policy and procedure including identification of when CPR is needed. All additional staff will be educated prior to working their next scheduled shift and new hires will be educated during the orientation process.
- Current resident orders were reviewed by the regional nurse to confirm resident preferences aligned with code status.
- The facility nurse management team started auditing certified and licensed nursing staff on appropriate action if a resident is found unresponsive with no pulse or blood pressure and not breathing. This will be done four times a week for six weeks. A mock code was conducted on all three shifts to ensure understanding of the CPR policy and procedure. The Director of Nursing or designee will conduct a mock code with clinical staff once per month for 6 weeks to verify understanding of CPR policy and procedure, including identification of when CPR is needed. Any noted issues will be addressed and will be discussed during the QAPI (Quality Assurance and Performance Improvement) process.
- An emergency QAPI meeting with the QAPI team members and Medical Director was held to discuss the deficient practice and review the policies. The CPR policy was reviewed, and no changes were needed to the current policy. The Advance Directive policy was reviewed, and no changes were needed to the current policy.
Failure to Monitor Post-Surgical Condition Leads to New Fracture
Penalty
Summary
The facility failed to adequately assess and monitor a resident's change of condition following surgical repair of a left humerus fracture. The resident, who had a history of cognitive communication deficit, aphasia, hemiplegia, and hemiparesis, was admitted to the facility after a fall that resulted in a left humerus fracture. Despite the resident's complex medical history and the need for careful monitoring, the facility did not perform daily assessments on the resident's left upper extremity, as evidenced by missing documentation in the electronic health record for several days. The resident was discharged from the hospital without a physician's order for a sling, yet the facility's occupational therapist provided one for comfort and protection. However, the nursing staff failed to obtain a physician's order for the sling, and there was a lack of communication and documentation regarding the resident's pain and swelling. Multiple therapy staff reported increased pain and edema to the nursing staff, but these reports were not documented or acted upon. The resident's pain levels increased significantly, reaching a severe level, but this was not adequately addressed by the nursing staff. Ultimately, the resident sustained a new spiral fracture to the left distal humerus, which was discovered during an outpatient appointment. The orthopedic surgeon confirmed that this was a new fracture caused by a torsional injury, likely due to inadequate support and monitoring of the resident's arm. The facility's failure to assess the surgical extremity every shift and to report changes in the resident's condition to the physician contributed to the resident's injury and the need for additional surgical intervention.
Failure to Reconcile and Secure Controlled Narcotic Medication
Penalty
Summary
The facility failed to maintain proper reconciliation of a controlled narcotic medication, specifically hydrocodone/Norco, which affected all 14 residents with current orders for the narcotic. The issue arose when a delivery of Norco was made to the facility on a Friday evening. The medication was signed for by an LPN and handed over to an RN to be placed in the stat safe. However, the RN did not have a second nurse with access to the stat safe to assist in placing the medication inside, as required by policy. Consequently, the RN left the Norco on top of the stat safe, intending to address it later. Over the weekend, the medication remained unsecured on top of the stat safe, and multiple staff members noticed it but did not take action to secure it properly. By Monday, the pharmacy contacted the facility to report that the medication had not been logged into the stat safe. An investigation was initiated, but the narcotic was still unaccounted for as of the survey date. The facility's policy required immediate reconciliation and secure storage of narcotics, which was not followed, leading to the medication's disappearance.
Inadequate Incontinence Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, identified as R5, who was dependent on staff for activities of daily living. R5's Minimum Data Set indicated that she required maximal assistance for personal hygiene and was dependent for toileting. On the day of the incident, R5 was observed sitting in a reclining wheeled chair, and it was noted that she had been changed by a CNA before lunch. However, later in the afternoon, R5 was found in the same position, moaning and expressing pain between her buttocks. Multiple CNAs were unable to confirm the last time R5 had been changed, indicating a lack of communication and documentation regarding her care. When R5 was eventually assisted from the chair to the bed, her outer clothing was found to be saturated with urine, and her incontinence brief was heavily soiled. The absorbent material in the brief was saturated, and R5's skin showed signs of a Moisture Associated Skin Disorder, causing her pain when wiped. The facility's administrator admitted to not having a specific policy for activities of daily living care for dependent residents, relying instead on standard nursing practice. This lack of a structured policy may have contributed to the oversight in R5's care, resulting in her discomfort and potential skin impairment.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to adhere to a resident's dietary care plan by not honoring their food preferences. The resident's care plan, dated 10/28/24, specified that their dietary preferences should be respected, and they disliked peas. However, during an observation on the same day at 12:34 PM, the resident was found in their room with a meal that included pea salad, which they did not consume. When asked, the resident indicated they did not like peas, confirming the oversight in following their dietary care plan.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility staff failed to immediately notify the Administrator, who is also the Abuse Coordinator, of an allegation of physical abuse involving a resident. On the morning of September 15, a Certified Nursing Assistant (CNA) discovered that a resident's right forearm was swollen and red after the resident reported that a man living in the facility had twisted it. The CNA promptly informed a Registered Nurse (RN) about the resident's condition and the allegation. However, the RN did not inquire further about the cause of the arm pain or the resident's statement regarding the alleged abuse. The Director of Nursing and the Administrator both stated that all allegations of abuse should be reported immediately to the Administrator to initiate an investigation. Despite this policy, the allegation was not reported to the Administrator until the following day, September 16. The facility's State Report form for the allegation was also dated September 16, indicating a delay in reporting. The facility's Abuse Prevention and Prohibition Policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately to the Administrator.
Failure to Test Residents After COVID-19 Exposure
Penalty
Summary
The facility failed to perform COVID-19 testing for residents after exposure to a positive healthcare worker, specifically an Occupational Therapist Aide, identified as V14. On 7/9/24, V14 exhibited symptoms of a runny nose and feeling unwell, leading to a positive COVID-19 test result. Despite being informed of this positive result, the facility did not conduct COVID-19 testing for the residents who had been in close contact with V14 during therapy sessions on 7/8/24 and 7/9/24. These residents, identified as R13, R15, R16, R19, and R33, were not tested for COVID-19, and their electronic medical records did not reflect any mention of exposure or subsequent testing. The facility's COVID-19 policy, dated 3/6/24, mandates testing for residents identified as having exposure to a positive case, regardless of vaccination status. The policy recommends testing immediately after exposure, and if negative, retesting at specified intervals. However, the facility did not adhere to this policy, as confirmed by V2, the Assistant Director of Nursing, who acknowledged that the residents should have been tested following their exposure to V14. The failure to test these residents represents a breach of the facility's infection prevention and control program, as outlined in their policy aligned with CDC guidance.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper treatment and pressure-relieving interventions for two residents at risk for pressure ulcers. Resident 19, who was at high risk for developing pressure ulcers as indicated by her Braden Scale Pressure Score, had a stage 2 coccyx pressure ulcer with MRSA infection. Despite having physician orders for specific wound care, including the application of medihoney and a hydrocolloid dressing, the dressing was observed to be missing during an incontinence care session. The staff, including a CNA and an RN, acknowledged the absence of the dressing and the need for it to be reported if not in place. Resident 12, diagnosed with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, was observed lying in bed with her heels resting on the mattress, contrary to her care plan which required her heels to be floated to relieve pressure. The facility's Pressure Injury Prevention policy emphasized minimizing pressure on heels using pillows or other devices, yet this intervention was not implemented during observations. An LPN confirmed the importance of floating heels to relieve pressure, highlighting the facility's failure to adhere to its own policy and care plan for pressure injury prevention.
Deficiencies in Restorative Care and ROM Interventions
Penalty
Summary
The facility failed to provide adequate range of motion (ROM) care and restorative interventions for two residents, leading to deficiencies in their care. One resident, with a history of hemiplegia and hemiparesis following a cerebral infarction, was not receiving the prescribed passive range of motion exercises for the left ankle and hand. Documentation was incomplete, with only two entries over a month-long period, both lacking details on the duration of exercises. Observations revealed the resident's left arm was contracted and not wearing a splint, despite a therapy evaluation recommending one. Interviews with staff confirmed the absence of a restorative nurse and inadequate documentation of ROM exercises. Another resident, diagnosed with Parkinson's disease and muscle weakness, was not provided with the necessary palm guards and finger separators as ordered. Observations showed the resident's hands were clenched without the required devices, and staff admitted to losing the palm guard for the right hand. The Director of Therapy was unaware of the missing equipment, and there was no documentation of restorative services being provided. The facility's failure to ensure proper restorative care and equipment for these residents highlights significant lapses in their care management.
Failure to Implement Nutritional Interventions for Resident with Weight Loss
Penalty
Summary
The facility failed to provide adequate nutritional interventions for a resident, identified as R33, who experienced significant weight loss. R33, a male resident with multiple diagnoses including chronic kidney disease stage 4, hemiplegia, dementia, and hyperkalemia, was observed to have a weight fluctuation and a notable decrease from 141.2 lbs to 133.7 lbs over a month. Despite the dietary recommendations for extra protein with each meal, the resident's diet card did not reflect these changes, and he was not consistently provided with the additional protein portions as prescribed. On one occasion, R33 was observed eating breakfast without the recommended yogurt for extra protein, indicating a lapse in implementing the dietary plan. The dietitian, V10, acknowledged the resident's weight loss and had communicated the need for extra protein to the dietary manager, V11. However, the dietary manager confirmed that the diet card did not list the extra protein for breakfast, and there was a lack of consistency in providing the additional protein portions during meals. The facility's protocol for addressing unplanned weight loss was not effectively implemented, as evidenced by the failure to adjust the resident's diet card and ensure the prescribed nutritional interventions were followed. This oversight contributed to the resident's continued risk for weight loss, despite the identified need for increased protein intake.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were offered to three residents, as required by their own policy. The deficiency was identified during a review of the records for five residents, where it was found that three residents had no documentation of being offered the PCV20 pneumonia vaccine. Specifically, the electronic records for these residents showed no documentation of consent or refusal for the vaccine. The facility's administrator confirmed the absence of documentation for these residents. According to the facility's pneumonia policy, residents over the age of 65 should receive a dose of PCV20 if they have completed a series of PCV13 and PPSV23 vaccines, or a dose of PCV20 or PCV15 and PPSV23 a year apart if they have no history of pneumonia vaccines.
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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