Fireside House Of Centralia
Inspection history, citations, penalties and survey trends for this long-term care facility in Centralia, Illinois.
- Location
- 1030 Martin Luther King Blvd, Centralia, Illinois 62801
- CMS Provider Number
- 145791
- Inspections on file
- 20
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Fireside House Of Centralia during CMS and state inspections, most recent first.
A staffing shortage occurred when several CNAs did not report for their shifts, leading to inadequate staff coverage. As a result, a resident with dementia and mobility issues was transferred using a mechanical lift by a single CNA, contrary to care plan requirements. Staff interviews confirmed that the shortage caused delays in care, including answering call lights and providing incontinence care, and that typical staffing levels were not met.
Four residents with significant medical conditions did not receive their ordered nutritional supplements for several days due to a supply shortage caused by a delivery and billing issue. Staff confirmed the supplements were unavailable for about a week, and MARs documented multiple missed doses during this period.
A CNA transferred a resident with dementia, muscle weakness, and vision loss using a mechanical lift without assistance from another staff member, despite the resident's care plan and facility policy requiring two staff for such transfers. The CNA acted alone due to staffing shortages, while the LPN was occupied with medication administration. The resident was dependent for transfers and required a mechanical lift, but no injury or fall was reported during the incident.
A cognitively impaired resident with dementia, previously identified as an elopement risk and placed on 15-minute visual checks, exited the facility without staff knowledge and was found over a mile away by two individuals who took her to a hospital. Staff failed to communicate the resident's elopement risk during shift changes, did not perform required visual checks, and did not properly respond to a door alarm, resulting in the resident's unsupervised exit.
The facility failed to maintain adequate staffing levels, leading to delays in resident care and assistance. Interviews and observations revealed that the facility often operated with insufficient CNAs, particularly on weekends and nights, affecting the timely delivery of care such as transfers and showers. Despite the administrator's efforts to assist, the lack of a specific plan for addressing staffing shortages and the absence of agency staff for over six weeks contributed to the deficiency.
The facility failed to provide the correct textured diets for four residents who required easy to chew (mechanical soft) diets. Despite specific dietary orders, these residents received meals inconsistent with their needs, including items like toasted garlic bread and ambrosia. The dietary manager confirmed the error, acknowledging the meals did not adhere to the prescribed texture-modified diets.
The facility failed to provide prescribed dietary supplements for four residents, including ice cream and double protein, as part of their nutritional care plans. Observations revealed that these supplements were not consistently provided, despite being ordered by physicians to address specific health conditions such as chronic kidney disease, dementia, and diabetes. The Dietary Manager acknowledged the oversight, confirming that residents should have received the prescribed nutritional support.
A long-term care facility failed to maintain infection control practices, as observed in multiple instances involving several residents. Staff members did not perform hand hygiene or change gloves appropriately during medication administration and personal care tasks. Additionally, enhanced barrier precautions were not followed for residents requiring such measures. The facility's policies on infection control were not adhered to, leading to deficiencies in care.
Two residents with cognitive impairments were not provided dignified feeding assistance. CNAs stood over them while feeding, failed to engage with residents, and one used a clothing protector to clean a resident's mouth. The DON expected CNAs to be seated and engage with residents during meals.
The facility failed to refer two residents with mental illness diagnoses for a Level II PASARR evaluation. One resident with Bipolar II disorder and Major Depressive Disorder was not properly assessed due to a lack of notification to the screening agency. Another resident with schizophrenia lacked documentation of a Level II PASARR, as only a Level I was available. The facility's policy on coordinating with the PASARR program was not adequately followed.
Insufficient Staffing Resulting in Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by direct observation, interviews, and record review. On the evening in question, several Certified Nursing Assistants (CNAs) did not report for their scheduled shifts, resulting in inadequate staffing levels. One CNA was observed transferring a resident with dementia, muscle weakness, and vision loss using a mechanical lift without the required assistance of another staff member, as specified in the resident's care plan and physician orders. The CNA stated she performed the transfer alone because other CNAs were occupied with other residents and there was not enough staff available at the time. Multiple staff interviews confirmed that the facility was short-staffed that evening, with only two CNAs and a nurse on one unit with 35 residents, and two CNAs and a nurse on another unit with 17 residents, instead of the typical three to four CNAs per unit. Staff reported that this shortage led to delays in answering call lights, providing incontinence care, and monitoring resident behaviors. The Assistant Director of Nursing acknowledged that staffing is only sufficient when there are no call-ins, and the Administrator was not aware of the staffing shortage at the time. The facility's staffing policy requires sufficient numbers of staff to meet resident needs in accordance with care plans and facility assessment.
Failure to Provide Prescribed Nutritional Supplements Due to Supply Shortage
Penalty
Summary
The facility failed to ensure that prescribed nutritional supplements were available and administered as ordered for four out of six residents reviewed for nutrition. These residents had medical conditions such as diabetes, dementia, vitamin deficiencies, muscle weakness, and GERD, and had physician orders for specific supplements to address weight loss and nutritional needs. Medication Administration Records (MARs) showed multiple missed doses of supplements over several days for each resident, despite active physician orders and care plan interventions specifying the need for these supplements. Interviews with staff confirmed that the facility was out of dietary supplements for about a week due to a delivery issue related to a billing problem with the supplier. During this period, staff attempted to purchase some supplements locally but were unable to obtain all required products. Staff acknowledged that the MARs accurately reflected the missed administrations, and the administrator was aware of the shortage, which was described as lasting only a short time.
Mechanical Lift Transfer Performed by Single CNA Without Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a mechanical lift without the assistance of another staff member, contrary to facility policy and the resident's care plan. The resident in question had diagnoses including dementia, muscle weakness, and vision loss, and was assessed as having a moderate cognitive deficit and being dependent on staff for transfers. The care plan and physician orders specified the use of a mechanical lift for all transfers, but did not indicate that single-staff transfers were permitted. During the observed incident, the CNA operated the lift alone, making multiple adjustments to the resident's position while the resident was suspended in the air, as no other staff were available to assist due to staffing shortages. Interviews with staff confirmed that the CNA performed the transfer alone because other CNAs were occupied with resident care and there were not enough staff available at the time. The LPN on duty was preparing medications and did not assist with the transfer. The facility's policy on safe lifting and movement of residents emphasizes the use of appropriate techniques and devices to ensure safety, but this policy was not followed during the observed transfer. The resident did not report any injury or fall during the transfer.
Failure to Supervise Cognitively Impaired Resident Results in Elopement
Penalty
Summary
A cognitively impaired resident with diagnoses of Parkinsonism and unspecified dementia was admitted to the facility and initially assessed as not being at risk for elopement. However, after multiple attempts to leave the facility, the resident was placed on 15-minute visual checks. Despite this intervention, the resident was able to exit the facility without staff knowledge and walked approximately 1.3 miles away, where she was found by two unknown individuals and taken to a local hospital. The incident occurred while the resident was supposed to be under increased supervision due to her recent exit-seeking behavior. The failure to prevent the resident's elopement was due to several lapses in communication and procedure. Staff members responsible for the resident's care were not informed during shift reports that the resident was on 15-minute visual checks, resulting in the checks not being performed or documented. Additionally, the facility's 24-hour report sheets did not consistently include information about the resident's elopement risk or the need for visual checks. Multiple staff members, including nurses and CNAs, reported being unaware of the resident's status and did not perform the required monitoring. Compounding the issue, the facility's door alarm system was not effectively managed. Staff reported that the door alarm frequently sounded during visiting hours and was often reset without verifying the cause or checking on residents at risk for elopement. On the evening of the incident, a staff member reset the alarm after hearing it but did not investigate further or notify others, which may have allowed the resident to leave undetected. These combined failures in communication, documentation, and adherence to policy led to the resident's unsupervised exit and the resulting Immediate Jeopardy finding.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide a sufficient number of staff to ensure residents received timely and safe assistance with care and transfers. This deficiency was observed to potentially affect all 60 residents living in the facility. Interviews with staff and residents revealed that the facility was consistently short-staffed, particularly on weekends, evenings, and nights. Residents reported delays in receiving care, such as assistance with transfers and showers, due to the lack of available staff. Staff members, including CNAs and LPNs, confirmed that they were often unable to complete their duties in a timely manner due to the insufficient number of staff. Observations and interviews indicated that the facility often operated with only 1-3 CNAs on duty, which was inadequate to meet the needs of residents, especially those requiring assistance from two staff members or mechanical lifts. The facility's assessment tool documented that a significant number of residents required assistance with activities of daily living, yet the staffing levels did not align with these needs. Staff members reported that management was not consistently available to assist, particularly on weekends, and that the facility had not used agency staff for over six weeks. The facility's staffing plan outlined the need for more CNAs per shift than were actually present, as documented in the facility's records. Despite the administrator's efforts to assist when possible, the lack of a specific plan for addressing staffing shortages exacerbated the issue. The facility's policy on safe lifting and moving of residents emphasized the need for appropriate techniques and devices, yet the staffing levels did not support the safe implementation of these practices. This deficiency in staffing had the potential to compromise the safety and quality of care provided to residents.
Failure to Provide Correct Textured Diets
Penalty
Summary
The facility failed to provide the correct textured diet as ordered for four residents who required an easy to chew (mechanical soft) diet. The dietary orders for these residents specified a regular diet with easy to chew texture, regular/thin liquid consistency, and additional dietary requirements such as high fiber and double protein. However, during meal service, these residents received meals that did not comply with their prescribed dietary orders. Specifically, they were served spaghetti with meat sauce, beets, toasted garlic bread, and ambrosia, which were not consistent with the easy to chew diet requirements. The residents affected by this deficiency had various medical conditions that necessitated the prescribed dietary modifications. These conditions included chronic kidney disease, type 2 diabetes mellitus, dementia, Parkinson's disease, dysphagia, and muscle weakness. The facility's dietary manager acknowledged that the mechanical soft diets should not have included ambrosia salad or toasted garlic bread, indicating a failure to adhere to the facility's policy on texture-modified diets. This oversight in meal preparation and service led to the deficiency identified by the surveyors.
Failure to Provide Prescribed Dietary Supplements
Penalty
Summary
The facility failed to provide dietary supplements as ordered for four residents, leading to a deficiency in nutritional care. Resident R47, who has chronic kidney disease and other health issues, was prescribed a regular diet with ice cream once daily as a supplement. However, observations on multiple days revealed that R47 did not receive the prescribed ice cream with her meals, and she confirmed receiving it only a few times a week. Her care plan indicated the need for this supplement due to potential nutritional or hydration status alterations. Similarly, Resident R56, diagnosed with muscle weakness, dementia, and dysphagia, was ordered to receive nutritional ice cream with lunch. Observations showed that R56 did not receive the ice cream on several occasions, despite the care plan highlighting the necessity of this supplement for nutritional support. The resident's inability to communicate effectively further complicated the situation, as no BIMS assessment was performed. Resident R45, with severe cognitive impairment and diabetes, was also supposed to receive ice cream daily, but observations indicated this was not consistently provided. Additionally, Resident R8, with multiple health issues including diabetes and muscle wasting, was ordered to receive double protein with meals. However, observations showed that R8 did not receive the double protein as prescribed. The Dietary Manager acknowledged the oversight and confirmed that all residents with orders for additional nutritional items should have received them, as per the facility's policy on therapeutic nutritional support.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices during patient care, as observed in multiple instances involving several residents. A registered nurse, identified as V4, was observed not performing hand hygiene before and after administering medications to residents R64, R32, and R24. Additionally, V4 did not sanitize a bedside table used for a dressing change before serving breakfast on it. The facility's policies on hand hygiene and administering medications were not followed, as confirmed by the Director of Nursing and a Licensed Practical Nurse. In another instance, a CNA, V12, did not change gloves or perform hand hygiene during peritoneal and catheter care for resident R28, who has a history of urinary tract infections. The facility's policy on catheter care, which requires glove changes and hand hygiene between different care tasks, was not adhered to. Similarly, during a treatment for resident R8, a Licensed Practical Nurse, V13, failed to perform hand hygiene between glove changes while treating excoriation and cleaning after a bowel movement. The report also highlights failures in adhering to enhanced barrier precautions for residents R16, R41, and R65, who required such precautions due to their medical conditions. Staff members, including V9 and V3, did not don gowns while performing treatments on these residents, despite the facility's policy requiring gowns and gloves for high-contact care activities. The Infection Preventionist and Director of Nursing acknowledged the staff's confusion and lack of adherence to the enhanced barrier precautions policy.
Failure to Promote Dignity During Feeding Assistance
Penalty
Summary
The facility failed to provide feeding assistance in a manner that promoted dignity for two residents, both of whom required assistance with eating due to cognitive impairments. One resident, diagnosed with Alzheimer's disease and dysphagia, was observed being assisted by a CNA who stood over them while feeding and used the resident's clothing protector to clean their mouth. This behavior was noted on multiple occasions, indicating a lack of respect for the resident's dignity during meal times. Another resident, diagnosed with vascular dementia and dependent on staff for eating, was also observed being assisted by a CNA who stood over them. Additionally, several CNAs were observed talking amongst themselves and not engaging with the residents during meal times, with one CNA wearing earbuds. The Director of Nursing expressed that CNAs are expected to be seated and engage with residents during meals, which was not adhered to in these instances.
Failure to Conduct Level II PASARR for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that individuals admitted with mental illness diagnoses were referred to the appropriate state-designated authority for a Level II PASARR evaluation. This deficiency was identified for two residents, R32 and R35, out of a sample of 35 residents reviewed for PASARR requirements. R32 was admitted with diagnoses of Bipolar II disorder and Major Depressive Disorder, yet the initial OBRA screening incorrectly indicated no reasonable basis to suspect a mental illness. The Business Office Manager, V8, acknowledged that the facility failed to notify the screening agency of R32's qualifying diagnosis, leading to an incorrect assessment. Similarly, R35 was admitted with an active diagnosis of schizophrenia, but the medical record lacked documentation of a Level II PASARR. The preadmission screening for R35 did not include the schizophrenia diagnosis, and V8 confirmed that only a Level I PASARR was available for R35. The facility's policy requires coordination with the PASARR program for individuals with mental disorders, but this was not adequately followed, resulting in the oversight.
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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