Generations At Rock Island
Inspection history, citations, penalties and survey trends for this long-term care facility in Rock Island, Illinois.
- Location
- 2545 24th Street, Rock Island, Illinois 61201
- CMS Provider Number
- 145950
- Inspections on file
- 40
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 24 (2 serious)
Citation history
Health deficiencies cited at Generations At Rock Island during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and recent COVID-19 illness, who was clearly documented as full code, was found unresponsive and not breathing by a CNA, who notified an LPN. The LPN confirmed full code status, initiated chest compressions, and called 911 while the CNA assisted. When EMS arrived, staff were performing compressions and attempting ventilation with a BVM that lacked a mask and was not connected to O2, contrary to facility policy requiring use of a face mask or resuscitator bag to provide effective breaths. EMS noted the improper BVM setup, that compressions were stopped during the handoff, and that the resident was cold with rigor mortis present, indicating the facility failed to perform CPR in a manner that provided adequate oxygenation.
A resident with a non-removable lower extremity cast did not receive required shift assessments or documentation for cast care after readmission, as previous orders were not continued and new ones were not obtained. The resident later experienced increased pain, a wet and odorous cast, and was found to have complications including a wound and signs of sepsis, with staff confirming that regular assessments were not performed.
A resident with significant physical impairments was transferred without the required full mechanical lift when the device's battery failed. Staff manually transferred the resident using a gait belt, contrary to the care plan and facility policy, and there was confusion among staff regarding whether proper authorization was obtained. The DON confirmed no approval was given and that backup equipment was available.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A facility licensed for 177 beds did not employ a full-time qualified social worker, instead assigning the Social Service Director role to a former CNA with no social work license, certificate, degree, or prior experience, contrary to the facility's own job requirements.
A resident with multiple medical conditions and dependent on staff for toileting was denied assistance to use the bathroom by a CNA, who instructed the resident to use an incontinence brief instead. The resident was left unassisted until the next shift, resulting in distress and a significant mess. The DON confirmed that staff should honor such requests, and the incident was identified as a dignity concern.
A resident with multiple medical conditions voiced a grievance regarding a CNA, but was not interviewed or informed of the outcome by administration. Staff confirmed that while internal actions were taken, the resident was not kept updated as required by the facility's grievance policy.
A resident with multiple medical conditions and dependent on tube feeding did not receive the registered dietician's recommended feeding regimen or liquid protein supplement. Despite clear recommendations, staff did not initiate the changes, and the resident continued on the previous feeding schedule. Staff interviews revealed confusion about the process for implementing dietician recommendations, and the facility lacked a policy on this matter.
A resident with a G-tube and multiple complex medical conditions did not have current physician orders for G-tube site care, despite the care plan indicating the need for such care. An LPN and the DON confirmed that these orders were missing, and facility policy requires physician orders for essential care upon admission.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with a history of respiratory issues and enteral feeding exhibited increased anxiety, persistent cough, and unusual behaviors, but the assigned LPN did not assess lung status or check oxygen saturation as required by facility policy. Later, another LPN found the resident with low oxygen saturation and unresponsiveness, prompting emergency intervention. Staff interviews and documentation review confirmed that respiratory assessments and monitoring were not performed or recorded as per protocol.
The facility's Infection Preventionist lacked complete specialized training, having only completed 15 of 23 required modules in the CDC's training program. This deficiency could potentially impact all 79 residents, as the IP has been in the role since December 2023 without full certification.
The facility failed to provide written bed hold policy notices to two residents and their representatives within 24 hours of hospital transfers, as required. This deficiency was identified through record reviews and interviews, revealing that the facility did not communicate the policy during multiple hospitalizations for both residents.
A facility failed to include a resting hand splint in a resident's care plan. The resident's orders required wearing the splint at specific times, but it was observed on a shelf instead. The care plan lacked documentation of the splint, as confirmed by the RN/Care Plan Coordinator.
The facility failed to update the care plans for two residents undergoing dialysis. One resident's care plan did not reflect the removal of an AV fistula and the placement of a new central dialysis port, lacking specific dialysis orders and emergency contact information. Another resident's care plan did not document a dialysis catheter in the left upper inner thigh, missing monitoring instructions for the site. These deficiencies were confirmed by nursing staff.
A resident with a history of kidney disease and UTIs did not receive daily catheter flushes as ordered, leading to a deficiency in care. The MAR showed flushes were given only as needed, and staff failed to document low urine output. Confusion over order changes and lack of communication contributed to the oversight.
A facility failed to apply a resting hand splint for a resident as per the prescribed schedule. The resident's treatment record lacked documentation of the splint's application, and observations showed the splint was not in use. The resident expressed discomfort with the device, and staff were either unfamiliar with or unaware of the splint's use. The physical therapist confirmed the necessity of the splint, highlighting a lapse in adherence to the care plan.
The facility failed to provide specific dialysis orders for two residents requiring dialysis services. One resident, with end-stage renal disease, lacked orders for the type of dialyzer, flow rate, and care of the dialysis port. Another resident's orders were generic, lacking an individualized dialysis prescription. Facility staff confirmed that specific orders were kept in the dialysis unit, and the facility did not have access to them.
The facility failed to document and offer pneumonia vaccinations to two residents upon admission, as required by their policy. One resident agreed to receive the vaccine after surveyor intervention, while another declined. The Infection Preventionist admitted to missing the immunizations on admission and confirmed the residents had no prior vaccinations.
The facility failed to document and offer COVID-19 vaccinations to three residents upon admission. After a surveyor's inquiry, the Infection Preventionist documented that one resident agreed to receive the vaccine at a future clinic, while two others declined. The oversight was acknowledged, and a vaccination clinic was scheduled.
The facility failed to ensure immediate reporting of verbal abuse allegations as required by their policy. A CNA reported hearing another CNA verbally abuse a resident but did not report it immediately to the Administrator. Other staff also witnessed similar incidents but delayed reporting. The resident involved was hard of hearing and confused, and appeared well-cared for at the time of the survey.
Inadequate CPR and Oxygenation for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate CPR and oxygenation to a resident who was a documented full code. The resident had multiple diagnoses, including hemiplegia and hemiparesis, cerebral infarction, type 2 diabetes, vascular dementia with behaviors, anxiety disorder, dysphagia, and a recent COVID-19 illness. The resident’s POLST and care plan clearly indicated full code status, with instructions that CPR would be initiated if the resident’s heart and respirations stopped. On the night in question, a CNA found the resident unresponsive and not breathing around 4:25 a.m. and notified the LPN, who confirmed the resident’s full code status, called 911, and went to the resident’s room to begin CPR. According to nursing progress notes and staff interviews, the LPN checked for a pulse, found none, and began chest compressions, then the CNA took over compressions while the LPN retrieved the crash cart and called 911. When the LPN returned, she resumed compressions and the CNA began bagging the resident. However, the ambulance run report and paramedic interview documented that upon EMS arrival, one staff member was performing chest compressions and another was attempting ventilation with a BVM that did not have a mask attached and was not connected to oxygen. The paramedic stated that the staff member had only the T-piece in the resident’s mouth and that proper oxygenation with a BVM requires application of the mask. The DON also confirmed that without the mask attached to the bag, adequate ventilation cannot be provided. EMS personnel further observed that staff stopped compressions when EMS entered the room to allow EMS to take over, and that the resident was cold to the touch with rigor mortis noted in the jaw. The LPN later acknowledged that the bed likely was not flattened during CPR and that she found the resident cold with no pulse, stating the resident had not just died minutes before. The facility’s CPR policy required provision of basic life support, including CPR, prior to EMS arrival, and specified the use of a face mask or resuscitator bag to ventilate two breaths after 30 compressions, with each breath delivered over one second to cause chest rise. Despite this policy, the staff’s use of a BVM without a mask and without oxygen, and the failure to ensure proper setup for effective ventilation, resulted in CPR that did not provide adequate oxygenation to the resident.
Failure to Assess and Document Cast Care Leading to Delayed Identification of Complications
Penalty
Summary
The facility failed to implement and document appropriate interventions for the assessment and care of a non-removable lower extremity cast for one resident. According to the facility's Cast Care policy, staff are required to assess the cast every shift for tightness, circulation, motion, sensation, drainage, odor, and skin irritation, and to document these assessments and report abnormal findings to a physician. After the resident was readmitted from the hospital, there were no orders in place for cast care, and staff did not obtain new orders or continue previous ones. The resident's Treatment Administration Record previously included orders to check circulation, movement, sensation, and temperature (CMST) every shift, but these were discontinued upon readmission, and no new orders were obtained. The resident subsequently reported increased pain in the right lower extremity, and it was noted that the cast was damp and had an odor. Staff did not perform or document regular cast assessments as required, and the wound nurse only became aware of the lack of cast care orders after being informed of a wound inside the cast. The orthopedic evaluation later identified increased pain, a wet splint, concerns for neurovascular compromise, infected pressure ulcers, and sepsis. Staff interviews confirmed that regular assessments were not performed and that the wound could have been identified sooner if proper procedures had been followed.
Failure to Follow Care Plan for Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident using a full mechanical lift as required by the resident's care plan. The resident, who had diagnoses including congestive heart failure, morbid obesity, muscle weakness, and muscle wasting, was assessed as having no cognitive impairment and being dependent on staff for transfers. The care plan specified that transfers should be performed with a mechanical lift and two staff members. However, during an incident, the mechanical lift's battery died while transferring the resident, and staff proceeded to manually transfer the resident using a gait belt, with one staff member lifting under the resident's arms and another guiding the hips. The resident reported feeling unsafe and stated that she was told she needed the lift at all times for transfers. Staff interviews revealed inconsistent accounts regarding whether permission was obtained from the DON to perform the manual transfer, with one CNA stating that approval was given and another denying the DON's involvement. The DON confirmed that he was not present and had not authorized a change in the resident's transfer method, emphasizing that such changes require therapy evaluation or a physician's order. Facility policy required the use of mechanical lifting devices for high-risk residents except in emergencies, and backup batteries and additional lifts were available on each floor. Despite these policies and resources, the staff did not follow the resident's care plan or facility protocols during the transfer.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient monitoring or preventive measures to address these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing the necessary supervision to safeguard residents from potential accidents.
Failure to Employ Qualified Social Worker in Facility Over 120 Beds
Penalty
Summary
The facility, licensed for 177 beds with a current census ranging from 66 to 81 residents, failed to employ a full-time qualified social worker as required. The individual serving as the Social Service Director (SSD) was previously a Certified Nursing Assistant (CNA) and assumed the SSD position at the end of May, without holding a license, certificate, or degree in social work or any related field, and without prior social work experience. The Administrator in Training confirmed that the SSD was not licensed and could not provide documentation of qualifications in social work. The facility's job description for the Director of Social Services requires at least a bachelor's degree in psychology, sociology, or social work, or a Licensed Clinical Social Worker's certificate, none of which were met by the current SSD.
Resident Denied Dignified Assistance with Toileting
Penalty
Summary
A resident with diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia, hemiparesis, cerebral infarction, dysphagia, and Raynaud's syndrome, who was assessed as having no cognitive impairment and being dependent on staff for toileting, reported being denied assistance to use the bathroom upon returning from the hospital. The resident stated that after requesting to be taken to the bathroom due to an urgent need for a bowel movement, a Certified Nursing Assistant (CNA) told him to use his incontinence brief instead of assisting him to the restroom, stating, "We aren't going to walk you in there today. You can just go in your depends and we can clean it up." The resident expressed shock and distress at this response and reported having to wait until the next shift for assistance, resulting in a significant mess that required cleaning. The CNA involved confirmed that the resident was already wet when she began changing him and, upon his request to use the bathroom, told him it was unnecessary since he was already wet. The CNA relayed the request to another aide but did not assist the resident further. The Director of Nursing acknowledged that staff are expected to honor resident requests to use the bathroom unless it is unsafe, which was not the case in this situation. The incident was identified as a dignity concern, as the resident's request for assistance with toileting was not respected, contrary to facility policy and residents' rights.
Failure to Inform Resident of Grievance Status
Penalty
Summary
A deficiency occurred when the facility failed to follow its grievance policy by not keeping a resident informed about the status of a grievance. The resident, who had diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia, cerebral infarction, dysphagia, and Raynaud's syndrome, reported frustration over a complaint involving a certified nursing assistant (CNA). The resident stated that while staff were aware of the complaint and had reported it, no one from administration interviewed them or provided any follow-up information regarding the outcome of the grievance. Interviews with facility staff revealed that the Director of Nursing was informed of the incident and that the administrator categorized it as a customer service issue, resulting in a staff in-service and a temporary suspension for the CNA involved. However, staff acknowledged that the resident was not spoken to about the investigation or informed of the resolution. The facility's grievance policy requires prompt acknowledgment and a timely written response to grievances, which was not provided in this case.
Failure to Implement Dietician Recommendations for Tube Feeding
Penalty
Summary
The facility failed to implement the registered dietician's recommendations for a resident who was dependent on tube feedings for all nutrition and hydration needs. The resident had multiple diagnoses, including acute and chronic respiratory failure with hypoxia, hemiplegia, cerebral infarction, dysphagia, and Raynaud's syndrome, and was noted to have a low BMI and significant weight loss over a short period. The dietician recommended a specific tube feeding regimen (Osmolite 1.5cal at 60ml/hr for 20 hours daily) and the addition of liquid protein twice daily. However, these recommendations were not initiated, and the resident continued to receive continuous feedings over 24 hours without the prescribed liquid protein supplement. Interviews with staff revealed a lack of clarity and follow-through regarding the process for implementing dietician recommendations. The LPN stated that dietary recommendations are typically acted upon by earlier shifts and that it is standard practice to obtain physician orders for such recommendations promptly. The DON indicated that recommendations should be implemented within 24 hours but was unsure if this occurred in practice. The facility was unable to provide a policy regarding the implementation of dietician recommendations, and as of the time of the survey, the recommended changes had not been made to the resident's care.
Lack of Physician Orders for G-Tube Site Care
Penalty
Summary
A deficiency was identified when a resident with a G-tube, who had diagnoses including acute and chronic respiratory failure with hypoxia, hemiplegia, cerebral infarction, dysphagia, and Raynaud's syndrome, did not have physician orders for G-tube site care during the review period. The resident's care plan indicated a need for tube feeding and specified that local care to the G-tube site should be provided as ordered, with monitoring for signs and symptoms of infection. However, a review of the physician's orders for the relevant period showed no orders for G-tube site care. During interviews, an LPN confirmed that there were previously orders for G-tube site care but none were currently present in the system, despite the importance of cleaning the site to prevent infection. The DON also stated that standard orders for residents with G-tubes should include head of bed elevation, G-tube flushing, and site care, and acknowledged that the absence of these orders was an oversight. Facility policy requires physician orders for essential care at admission, but this was not followed in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess Respiratory Status Following Change in Condition
Penalty
Summary
The facility failed to assess the respiratory status of a resident who exhibited notable respiratory changes, including increased anxiety, a persistent dry cough, and behaviors such as repeatedly wiping his tongue. Despite these symptoms, the assigned LPN did not perform a lung assessment or obtain an oxygen saturation level, only taking vital signs, which were not documented. Later, another LPN found the resident to be lethargic and pale, with an oxygen saturation of 78%, and the resident became unresponsive, requiring emergency intervention and transfer to the hospital. Staff interviews revealed uncertainty about protocols for respiratory assessment, and documentation showed that required assessments and monitoring were not consistently performed or recorded as per facility policy. The resident had a medical history including dysphagia, cerebral infarction, generalized anxiety disorder, gastrostomy, and acute respiratory failure with hypoxia, and was receiving enteral nutrition. Facility policies required respiratory assessments with any change in condition, especially for residents with risk factors such as tube feeding and respiratory diagnoses. However, these protocols were not followed when the resident displayed respiratory changes, resulting in a delay in assessment and medical intervention.
Inadequate Training of Infection Preventionist
Penalty
Summary
The facility failed to have a qualified Infection Preventionist (IP) with specialized training in infection prevention and control, which could potentially affect all 79 residents in the facility. The job description for the Infection Preventionist Nurse, reviewed in November 2021, requires maintaining current knowledge of federal, state, and local regulations and compliance with infection control procedures. However, the current IP, who has been in the position since December 2023, had only completed 15 out of the 23 required modules of the CDC's Nursing Home Infection Preventionist Training. During an interview, the IP acknowledged the incomplete training and the need to finish the remaining modules and posttest to obtain the certification. The facility provided documentation of the completed modules, confirming the deficiency in the IP's training.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide the required written bed hold policy to residents and their representatives within 24 hours of transfer to a hospital, as mandated by regulations. This deficiency was identified for two residents, R50 and R60, during a review of their records. For R50, the medical records indicated multiple hospitalizations on specific dates, yet there was no documentation that the bed hold policy was communicated to R50 or their family. The facility administrator confirmed that the policy was not sent or discussed with R50 or their family during these hospitalizations. Similarly, for R60, the resident census record showed several hospital transfers in 2024, but the facility failed to provide the bed hold notices for any of these transfers. The resident, R60, stated they did not recall receiving a bed hold form upon discharge to the hospital, and the administrator confirmed that R60 did not receive a bed hold notice during these transfers. This lack of communication regarding the bed hold policy constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Document Resting Hand Splint in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident requiring a resting hand splint. The resident's current orders specified a schedule for wearing the left upper extremity resting hand splint, which included wearing it two hours prior to each meal and at night, with removal during hygiene, bathing, and feeding. The orders also instructed discontinuation and contacting therapy if red or white spots appeared. However, during observations on two separate occasions, the resident's hand splint was found sitting on a shelf in her room, indicating non-compliance with the prescribed schedule. Additionally, the resident's care plan did not document the use of the resting hand splint, as confirmed by the Registered Nurse/Care Plan Coordinator.
Failure to Update Dialysis Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, R13 and R50, who were undergoing dialysis treatment. R13's care plan was not updated to reflect the discontinuation of an AV fistula and the placement of a new central dialysis port in the right chest. The care plan also lacked specific dialysis orders, such as the type of dialyzer, flow rate, length of time, target weights, and emergency contact information. Additionally, there was no assessment or care plan for the new dialysis port. This oversight was confirmed by the Registered Nurse/Care Plan Coordinator, who acknowledged that the care plan needed updating. Similarly, R50's care plan was not revised to document the presence of a dialysis catheter in the left upper inner thigh, as per the physician's orders. The care plan failed to include monitoring instructions for the catheter site, such as checking for bleeding and signs of infection. This deficiency was confirmed by both the Registered Nurse/Care Plan Coordinator and the Licensed Practical Nurse/Restorative Nurse, who noted the absence of documentation regarding the dialysis catheter in R50's care plan.
Failure to Follow Catheter Flush Orders
Penalty
Summary
The facility failed to adhere to physician orders regarding the flushing of an indwelling urinary catheter for a resident, leading to a deficiency in care. The resident, who has a history of diabetes mellitus with chronic diabetic kidney disease, chronic kidney disease, and urinary tract infections, was supposed to have their catheter flushed daily with acetic acid and normal saline, as well as on an as-needed basis for increased sediment or blockage. However, the Medication Administration Record (MAR) indicated that the resident only received flushes on an as-needed basis, contrary to the physician's orders. On one occasion, a registered nurse (RN) discovered that the resident had no urine output and the urine in the catheter tubing was mucusy, milky, and amber-colored, which was unusual for the resident. The RN proceeded to flush the catheter and perform a bladder scan, which showed no urine in the bladder, indicating a possible blockage. The previous shift's licensed practical nurse (LPN) had noted low urine output but did not take action to flush the catheter or document the urine output, which contributed to the oversight. Additionally, there was confusion regarding the resident's orders, as a nurse practitioner reportedly changed the flush orders to as-needed only, but there was no documentation or recollection of this change by the nurse practitioner. The director of nursing stated that it was up to the nurse's discretion to flush the catheter based on urine appearance, but the RN's actions were deemed appropriate given the circumstances. The lack of documentation and communication among staff members led to the failure to provide appropriate care as per the resident's care plan.
Failure to Apply Resting Hand Splint for Resident
Penalty
Summary
The facility failed to apply a resting hand splint for a resident, identified as R65, who was reviewed for devices. The facility's Splint-Brace Assistance policy, reviewed on June 24, states that when splints and other contracture devices are part of the plan, therapy will instruct nursing staff on their use and recommend a schedule for applying and removing the device. R65's current orders for August 2024 specify a schedule for wearing the left upper extremity resting hand splint (RHS) two hours prior to each meal and at night, with specific instructions to discontinue use if red or white spots are present. However, there was no documentation in R65's treatment record or CNA charting regarding the application of the resting hand splint. Observations on August 27 and August 29 revealed that R65 was in bed without the resting hand splint, which was found on a shelf in her room. During an interview, R65 expressed discomfort with the trough, stating it pinched her arm and was not helpful. A CNA, identified as V12, was unfamiliar with R65's arm splints and referred to the nurse. An LPN, identified as V7, acknowledged that R65 did not like wearing the trough due to discomfort but was unaware of the hand splint. The physical therapist, identified as V14, confirmed that R65 should be using both the trough and resting hand splint as ordered.
Lack of Specific Dialysis Orders for Residents
Penalty
Summary
The facility failed to provide specific dialysis orders for two residents, R13 and R50, who required dialysis services. R13, diagnosed with end-stage renal disease and dependent on renal dialysis, was observed with a right chest long central catheter port wrapped in gauze. Despite attending dialysis five days a week, R13's medical record lacked specific dialysis orders, including the type of dialyzer, flow rate, length of time, target weights, and care of the dialysis port. A Licensed Practical Nurse (LPN) confirmed that the communication form from dialysis did not include specifics on the dialysate or target weight, and care of the dialysis port was managed by the dialysis center. Registered Nurses (RNs) on the dialysis unit, contracted by the facility, stated that the facility did not have access to specific resident orders for dialysis. Similarly, R50's physician orders documented dialysis five times a week but lacked an individualized dialysis prescription. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed that specific individualized dialysis orders were kept in the dialysis unit, as they administered the dialysis. Facility orders for dialysis patients were generic, with additional orders to monitor sites and vital signs post-treatment. The RN mentioned that dialysis communication sheets were sent with the patient to dialysis and returned with documentation from the dialysis center.
Failure to Document and Offer Pneumonia Vaccinations
Penalty
Summary
The facility failed to document pneumonia vaccination records and offer pneumonia vaccinations to two residents out of a sample of five reviewed for pneumonia vaccinations. The facility's policy, revised in July 2022, mandates offering influenza and pneumococcal vaccinations to all residents upon admission unless prior immunization is reported. However, for one resident, there was no documentation of receiving or being offered the pneumonia vaccine upon admission. It was only after the surveyor's intervention that the resident was offered the vaccine and agreed to receive it at a future clinic. Similarly, another resident's record lacked documentation of being offered the pneumonia vaccine upon admission. After the surveyor's inquiry, the resident was offered the vaccine but declined. The Infection Preventionist acknowledged missing the immunizations on admission and confirmed that neither resident had prior vaccinations when asked later.
Failure to Document and Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to properly document COVID-19 vaccination records and offer vaccinations to certain residents, leading to a deficiency. Specifically, three residents, identified as R13, R61, and R65, were not documented as having received or been offered the COVID-19 vaccine upon their admission to the facility. This oversight was discovered during a survey, prompting the Infection Preventionist (IP), identified as V4, to retrospectively document the vaccination status of these residents. For resident R13, there was no initial documentation of a COVID-19 vaccine offer or administration. After the surveyor's inquiry, V4 recorded that R13 was offered the vaccine and agreed to receive it at a future clinic. Similarly, residents R61 and R65 had no initial documentation regarding their vaccination status. Upon follow-up, V4 documented that both residents declined the vaccine, with R61 expressing disbelief in the vaccine. V4 acknowledged missing the opportunity to document their immunization status upon admission and confirmed that a vaccination clinic was scheduled for a later date.
Failure to Immediately Report Verbal Abuse Allegations
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was immediately reported to the Administrator, as required by their Abuse Prevention Guidance Policy. The policy mandates that employees report any incident, allegation, or suspicion of abuse to the administrator immediately. In this case, a Certified Nursing Assistant (CNA), identified as V12, reported hearing another CNA, V5, verbally abuse a resident, R4, by calling them derogatory names. However, V12 did not report this incident immediately to the Administrator, V1, but instead mentioned it to the former Director of Nursing, V2, and the Assistant Director of Nursing, V3, a few days later. This delay in reporting was a violation of the facility's policy. Further investigation revealed that other staff members, including V18, V22, and V23, also witnessed similar incidents of verbal abuse by V5 towards R4 but failed to report them immediately. V18 admitted to hearing V5 make derogatory comments about R4 several months prior but did not report it until much later. The resident, R4, was described as being very hard of hearing and confused, which may have impacted their awareness of the abuse. At the time of the survey, R4 appeared well-cared for and was not in distress, but the failure to report the abuse allegations promptly constituted a deficiency in the facility's adherence to its abuse prevention policy.
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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