Goldwater Care Gibson City
Inspection history, citations, penalties and survey trends for this long-term care facility in Gibson City, Illinois.
- Location
- 620 East First Street, Gibson City, Illinois 60936
- CMS Provider Number
- 145911
- Inspections on file
- 40
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Goldwater Care Gibson City during CMS and state inspections, most recent first.
The facility failed to protect a resident from physical abuse by another resident on two separate occasions, despite having an abuse prevention policy and a care plan identifying the aggressor’s risk factors. In one hallway incident, a housekeeper observed one resident push another in the chest, and the victim verbally expressed pain. In a later hallway incident, a CNA saw the same resident strike the same peer on the forearm when the victim attempted to help move the aggressor’s wheelchair after it became caught on equipment. One resident was cognitively intact, while the other had moderate cognitive impairment with mood disturbances related to dementia and a care plan directing staff to monitor for behaviors that could place others at risk.
A resident with severe Parkinson’s disease, prior stroke with left arm paralysis, and on anticoagulant therapy was care-planned as non–weight bearing, totally dependent for ADLs, and at high risk for falls, with an intervention for the bed to be kept in a low position and the resident positioned in the middle of the mattress. On one night, the assigned CNA left the resident after observing him asleep and went to the nurse’s station; when she later resumed rounds, she found the resident on the floor next to a waist-high bed with side rails up. The resident reported he had been calling for help and had chest pain, and staff used a mechanical lift to return him to bed. Hospital evaluation the same day documented multiple acute right rib fractures, and the resident stated his bed was usually kept at about waist height. The DON confirmed the care plan required a low bed and that the bed should not have been in a high position while the resident was in it, indicating the fall-prevention intervention was not implemented as planned.
Multiple incidents occurred in which residents with cognitive impairments physically abused other residents, despite care plans and interventions intended to prevent such events. In each case, staff witnessed the altercations and attempted to intervene, but were unable to prevent physical contact, resulting in minor injuries or distress. The facility's policies prohibiting abuse were not effectively implemented, leading to repeated resident-to-resident abuse.
The facility did not update care plans or implement new interventions after a resident with dementia exhibited aggressive behaviors, including physically striking other residents in the dining room. Staff were not consistently aware of or following seating arrangements meant to prevent further incidents, and there was no documentation of psychiatric evaluation after the altercations.
The facility did not document multiple resident-to-resident altercations involving individuals with dementia/Alzheimer's disease, nor did it record notifications to families and physicians as required. These incidents, witnessed by CNAs and a family member, were not reflected in the residents' medical records, despite facility policy mandating such documentation.
Two residents did not receive timely toileting assistance and incontinence care, as required by facility policy. One resident was left in soiled conditions for extended periods, with family members reporting that staff did not return to provide care, resulting in discomfort and skin irritation. Another resident experienced long delays in call light response, leading to episodes of incontinence and distress. Staff acknowledged that insufficient staffing contributed to these delays, especially during busy times.
Two residents with complex medical conditions received as-needed opioid medication that was signed out by an LPN on the controlled drug record, but the administration was not documented on the MAR as required by facility policy. Staff and administrator interviews confirmed the missing documentation, which did not follow established medication administration guidelines.
Two residents with severe cognitive impairment were involved in an incident where one resident, known for aggressive behaviors, physically struck and verbally abused another resident. Staff and resident interviews confirmed a pattern of aggression, and the abused resident experienced psychosocial harm, as evidenced by crying after the event.
A CNA repeatedly engaged in unprofessional and disrespectful behavior, including rough handling, failure to assist with toileting, and inappropriate language toward residents, some of whom were cognitively intact or had significant care needs. Despite multiple disciplinary actions and staff reports, the CNA continued to provide care, resulting in a failure to uphold resident dignity and rights.
The facility did not follow its Abuse Prevention and Reporting Policy after an incident where one resident hit and yelled at another. Although a CNA reported the event to the Administrator, there was no notification to the State Agency or to the residents' representatives, and no documentation of the incident was found in the medical records.
Two residents with severe cognitive impairment were involved in a physical and verbal altercation, witnessed by a CNA, where one resident hit and yelled at another. Although staff notified the administrator, the incident was not investigated, documented in the medical record, or reported to the state survey agency, contrary to facility policy.
Two residents were involved in a physical and verbal altercation, with one resident hitting and threatening another. Although staff intervened and an LPN assessed the affected resident for injury, the facility failed to provide a complete and chronological investigation record. Required details such as the timing of the incident, notifications, interviews, and follow-up assessments were missing from the documentation, contrary to facility policy.
The facility failed to respond to call lights in a timely manner for several residents, resulting in delays of up to 45 minutes or more for assistance. Residents, including those with cognitive impairments and requiring substantial help, reported ongoing issues with call light response times during resident council meetings. Despite staff education efforts, the problem persisted, as acknowledged by the facility administrator.
The facility failed to provide scheduled showers and nail care for two residents. One resident, with moderate cognitive impairment, reported receiving only one shower since admission, despite being scheduled for twice-weekly showers. Another resident, cognitively intact, reported not receiving the scheduled two showers per week. Facility records confirmed these deficiencies, and the DON acknowledged the failure to provide the required care.
A resident with severe cognitive impairment and multiple medical conditions, including Parkinson's Disease and right-sided hemiplegia, was left unsupervised in her room with a meal tray, contrary to her care plan. This lack of supervision led to the resident falling while attempting to reach for a call light or to turn on the light, resulting in a head laceration requiring sutures. Staff interviews confirmed the resident required total care and should not have been left alone during meals.
A resident with Alzheimer's and other conditions was improperly transferred by a CNA using a mechanical lift without assistance, contrary to facility policy. This resulted in the resident sustaining a shoulder hematoma and a distal femoral fracture. The CNA admitted to the solo transfer, and the facility's investigation confirmed the lack of assistance during the incident.
A resident in a LTC facility received an incorrect Warfarin dosage for 24 days due to the facility's failure to follow physician orders and monitor PT/INR levels. The resident, with a complex medical history, experienced Warfarin toxicity, leading to internal bleeding and death. Facility staff confirmed the failure to adhere to medication orders and monitoring protocols.
A resident was prescribed Plavix but was given Warfarin, leading to critical PT/INR levels and eventual death due to Warfarin toxicity. The facility's quality improvement program failed to address medication errors, and key personnel were unaware of the issue until after the incident.
The facility failed to respond to call lights promptly for several residents, as identified through interviews and record reviews. Resident Council Meetings documented concerns about long wait times across all shifts, with reports of nearly hour-long waits during the second shift. Multiple residents expressed frustration over delays, attributing them to staff shortages and busy schedules. The Resident Council President confirmed that long wait times were frequently discussed in meetings.
The facility failed to serve meals at an appropriate temperature, affecting several residents. Meal trays were delivered uncovered, and residents were left without assistance, leading to meals cooling down before consumption. Staff and residents reported issues with meal service timing and staffing shortages, resulting in cold food complaints. The Dietary Manager acknowledged these issues, indicating a recurring problem with meal temperature and service timeliness.
A resident, dependent on staff for bathing, did not receive scheduled showers due to staff being too busy or understaffed. The resident's showers were supposed to occur twice weekly, but documentation showed gaps in June and no showers in July. The facility's policy requires showers to be offered twice weekly and documented, which was not followed.
Two residents experienced mental and physical abuse by agency CNAs, V13 and V14, who were rude and dismissive of their care needs. One resident was handled roughly, exacerbating her leg pain, while the other was forced to attempt tasks beyond her physical capability, causing fear and distress. The facility's administrator confirmed the abuse, highlighting a failure to protect residents from such treatment.
Two residents reported abuse by agency CNAs, but the facility failed to notify the Administrator and State Agency promptly. Despite being aware of the abuse prevention policy, staff delayed reporting the incidents, and the CNAs were only asked to leave after the complaints. The Administrator did not report the incidents as abuse, affecting all residents in the facility.
The facility failed to immediately suspend two agency CNAs after a resident reported mental and physical abuse, allowing them to continue working and potentially harm other residents. Despite allegations from three residents, the CNAs were not promptly removed, violating the facility's abuse policy. Additionally, there was no documentation of abuse training for the CNAs involved, highlighting a compliance gap.
The facility did not provide mandatory QAPI training to its staff, affecting all 60 residents. Despite a January 2024 assessment stating annual training would occur, a CNA with over eight years of experience reported never hearing of QAPI training. The administrator confirmed the lack of ongoing training and documentation for the past year.
The facility failed to provide required annual Ethics training to staff, potentially affecting all 60 residents. A CNA with over eight years of service was unaware of any Ethics training, and the Administrator confirmed the lack of ongoing training and documentation.
The facility did not ensure nurse aides received the required twelve hours of in-service training, including dementia management and abuse prevention, affecting all 60 residents. The Administrator and HR staff lacked documentation of such training, highlighting a deficiency in compliance with training requirements.
The facility failed to protect two residents from physical abuse. One resident with Alzheimer's and Dementia wandered into another resident's room, leading to a physical altercation where both residents sustained injuries. The facility's administrator confirmed the incident and acknowledged that the altercation should not have occurred.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by another resident, contrary to its Abuse Prevention and Reporting policy that affirms residents’ right to be free from abuse and prohibits physical abuse such as hitting and pushing. According to the Abuse Investigation Checklist, an allegation of physical abuse occurred when two residents were in the hallway and one resident (R2) reached out with a flat hand and pushed the other resident (R1) in the chest. A housekeeper (V6) witnessed the altercation, observed the push, and heard R1 yell, “Ouch, he pushed me.” R1 later stated that he and R2 had been talking in the hallway when R2 pushed him in the chest with his hand. R1’s MDS documents that he is cognitively intact. A second incident of physical abuse between the same two residents was documented when a CNA (V7) observed R2 strike R1 on the right forearm while R2’s wheelchair was in the hallway. R1 reported that R2’s wheelchair had become caught on a piece of equipment and that when he attempted to assist by moving the wheelchair, R2 struck him on the right forearm. R2’s MDS documents moderate cognitive impairment with fluctuating disorganized thinking, and R2’s care plan identifies mood disturbances related to dementia and directs staff to monitor and report indicators that R2 may be at risk of harming others, such as increased anger, agitation, or feelings of being threatened. The Administrator (V1) and DON (V2) confirmed both incidents and stated that R1 sometimes enters R2’s personal space, which R2 dislikes and sometimes responds to with physical behaviors.
Failure to Implement Care-Planned Low Bed Intervention Resulting in Resident Fall and Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as high risk for falls and bleeding. The resident’s care plan documented multiple diagnoses including severe Parkinson’s disease with dyskinesia, prior stroke with no use of the left arm, atrial fibrillation on anticoagulant therapy, dysphagia, protein-calorie malnutrition, and other chronic conditions. The care plan, initiated months before the incident, specified that the resident was non–weight bearing, totally dependent on staff for all ADLs, and at high risk for falls, with an intervention added for the bed to be kept in a low position and the resident to be positioned in the middle of the mattress. The resident was also identified as being at high risk for bleeding due to anticoagulant use, and the MDS documented that the resident was cognitively intact but totally dependent for functional status. On the night of the unwitnessed fall, the CNA assigned to the resident reported that she had seen the resident sleeping in bed around 1:00 a.m., then went to the nurse’s station to eat with other staff. Afterward, when she resumed rounding, she observed the resident’s feet on the ground from the doorway and found the resident on the floor next to the bed, lying on the left side and propped up on the right arm. The resident stated he had been hollering for help and that his chest hurt. The CNA and other staff, including two LPNs and another CNA, responded; the resident was assessed and returned to bed using a mechanical lift. Multiple staff, including the assigned CNA, another CNA, and an LPN, consistently described the bed as being at about waist height with side rails up at the time the resident was found on the floor. The assigned CNA stated she was new, was unaware the resident was a fall risk, and did not know the bed was supposed to be in a low position. Subsequent hospital records from the same date documented that the resident, who could not get out of bed or ambulate independently and was on a blood thinner, was found on the floor with an unknown time on the floor and complained of mid-sternal and right-sided rib pain. Imaging showed acute right 3rd through 6th rib fractures, with old rib fractures also noted, and the resident was admitted for pain control and monitoring for bleeding. During the surveyor’s observation, the resident confirmed that he had rolled out of bed, had been calling for help, and that his bed was usually higher than its current position, indicating it was normally at about the surveyor’s waist level. The DON confirmed that the care plan contained interventions for the bed to be in a low position and for the resident to be positioned in the middle of the mattress, and acknowledged that the bed should not have been in a high position while the resident was sleeping. Facility policies on incidents/accidents and fall prevention required safety interventions to be implemented and consistently maintained for residents at risk, and assigned nursing personnel were responsible for ensuring ongoing precautions were in place.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse by other residents, as evidenced by multiple incidents involving residents with cognitive impairments. In one incident, a resident with Alzheimer's Disease and a history of combative behavior struck another cognitively intact resident in the dining room. The altercation was witnessed by a CNA, who attempted to intervene but was unable to prevent the physical contact. The aggressor resident was also noted to have been involved in prior altercations with both staff and other residents, and their care plan included interventions to monitor their whereabouts and behaviors. Another incident involved two residents, both with dementia or Alzheimer's Disease, where one resident struck another in the arm after a verbal exchange. This event was witnessed by a CNA and a family member, and the aggressor resident was documented as having severe cognitive impairment and exhibiting verbal and physical behaviors towards others. The care plan for this resident included recognition of their behavioral risks, but the physical altercation still occurred. A third incident involved two residents with Alzheimer's/Dementia, where one resident, known to have aggressive behavior and at risk for abuse/neglect, struck another resident on the thigh after a verbal confrontation. This resulted in a small red mark. Staff were aware of the ongoing verbal conflicts between these two residents and had interventions in place to redirect and separate them, but the physical abuse still occurred. In all cases, the facility's policies affirming residents' rights to be free from abuse were not effectively implemented, leading to physical altercations among residents.
Failure to Update Care Plans and Implement Interventions for Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement appropriate interventions to address dementia-related behaviors for multiple residents diagnosed with dementia or Alzheimer's disease. Specifically, there were documented incidents where one resident with a history of mood swings and aggression physically struck other residents in the dining room. These altercations were witnessed by staff and involved the resident hitting another on the arm and slapping another on the face. Despite these incidents, the resident's care plan was not updated with new interventions, and there was no documentation of evaluation by psychiatric services following the altercations. Additionally, staff interviews and record reviews revealed that seating arrangements intended to prevent further altercations were not consistently followed, and some staff were unaware of the required seating changes. The care plan for the aggressive resident included general interventions, such as monitoring whereabouts and reporting behaviors, but lacked updates or new strategies after the incidents. Staff also expressed uncertainty about what new interventions, if any, had been implemented following the altercations, indicating a lack of communication and follow-through on care planning for residents exhibiting dementia-related behaviors.
Failure to Document Resident Altercations and Required Notifications
Penalty
Summary
The facility failed to ensure that resident medical records were complete and accurate by not documenting resident-to-resident altercations and failing to record notifications to families and physicians for four residents reviewed for abuse. Specifically, an altercation occurred between two residents with dementia/Alzheimer's disease, where one resident struck another on the arm after a verbal exchange. This incident was witnessed by a CNA and a family member, but there was no documentation of the event or of family and physician notification in either resident's medical record. The nurse responsible at the time confirmed that such documentation would typically be included in a nursing note, but it was not done in this case. A similar deficiency was found in another incident involving two additional residents with Alzheimer's disease/dementia. One resident struck another on the thigh after a verbal altercation, resulting in a visible red mark. This event was also witnessed by a CNA, but again, there was no documentation of the altercation or of family and physician notification in the medical records of the residents involved. The administrator acknowledged that a nursing note summarizing the incident and notifications should have been present, but it was not completed. The facility's own policy requires documentation of significant changes in resident condition, including behaviors and notifications, but this was not followed.
Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The facility failed to provide timely toileting assistance and incontinence care for two residents, as required by its own policies. One resident, with multiple diagnoses including cerebral infarction, hemiplegia, and diabetes, was documented as requiring staff assistance for activities of daily living and regular incontinence checks. Despite this, there were instances where the resident was left for extended periods without being checked or changed, resulting in the resident remaining in soiled conditions. Family members reported that staff did not return to provide care after being notified, and on one occasion, a family member had to clean the resident themselves, finding dried feces and causing discomfort and skin irritation to the resident. Another resident, who was cognitively intact and required assistance with toileting, experienced significant delays in response to call lights. Observations showed that the resident's call light was on for over 20 minutes before assistance was provided, during which time the resident was left waiting to use the bathroom. The resident reported that such delays had previously caused her to be incontinent, which she found distressing. Staff confirmed that staffing levels were insufficient to meet the needs of the residents in a timely manner, particularly during busy periods such as morning care routines. The facility's policies require that call lights be answered promptly and that incontinent residents be checked at least every two hours, with perineal care provided after each episode. However, the documented events show that these policies were not consistently followed, resulting in residents experiencing prolonged periods without necessary care and assistance, and being left in uncomfortable and undignified situations.
Failure to Accurately Document PRN Opioid Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for two residents who were prescribed as-needed Hydrocodone-Acetaminophen for severe pain. For both residents, the Controlled Drug Receipt Record/Disposition Form showed that an LPN signed out the medication, but there was no corresponding documentation on the Medication Administration Record (MAR) indicating that the medication was actually administered. The facility's guidelines require that the individual administering the medication must record the administration on the MAR immediately after giving the medication, including the date, time, dose, route, and their signature or initials. Both residents involved had complex medical histories, including chronic pain conditions and other significant diagnoses. Interviews with staff confirmed the process for signing out and documenting controlled substances, and the administrator acknowledged that the required documentation was missing from the MAR for both residents, despite the medication being signed out on the controlled drug record. This lack of documentation is not in accordance with the facility's own medication administration guidelines.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by another resident, as evidenced by an incident involving two residents with severe cognitive impairment and diagnoses of dementia and Alzheimer's disease. One resident, known to have a history of aggressive behaviors including screaming, cursing, and physical aggression, was observed by a CNA striking another resident in the back and verbally threatening them. The incident occurred in a common area, with the aggressor yelling at the other resident to be quiet before physically hitting them. Staff interviews confirmed that the aggressor is frequently verbally aggressive towards others and does not like other residents nearby. Following the altercation, the resident who was struck was observed crying and rubbing their arm, indicating psychosocial harm. Multiple staff members and another resident corroborated the aggressor's pattern of abusive behavior, including cursing at other residents. The facility's own Abuse Prevention and Reporting Policy prohibits such abuse, yet the incident and subsequent staff accounts demonstrate a failure to prevent and protect residents from abuse as required.
Failure to Ensure Resident Dignity and Respectful Care
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, as required by resident rights policies. Multiple residents reported and staff confirmed that a Certified Nursing Assistant (CNA) engaged in unprofessional and disrespectful behavior towards residents. One cognitively intact resident reported being intentionally hit in the stomach and described the CNA as mean, while also stating that the CNA left a former roommate to wait for an hour before attempting to use the bathroom independently. Staff assignment records confirmed the CNA worked in the relevant hallway during the reported period. Another resident, also cognitively intact, required varying levels of assistance due to a femur fracture and was not assisted with toileting as needed. A third resident with severe cognitive impairment was spoken to in an unprofessional manner by the same CNA, as witnessed by another CNA who was also the resident's Power of Attorney. The CNA in question had a documented history of disciplinary actions for unprofessional conduct, including written warnings and suspensions for inappropriate language and actions with residents and their families, as well as failure to provide necessary assistance. Staff interviews corroborated ongoing concerns about the CNA's behavior, including rough handling and lack of responsiveness to resident needs. Despite these incidents and repeated reports to facility administration, the CNA continued to provide care to the affected residents. Facility policies emphasized the importance of respectful, prompt, and professional care, but these standards were not upheld in the cited cases.
Failure to Implement Abuse Prevention and Reporting Policy
Penalty
Summary
The facility failed to implement its Abuse Prevention and Reporting Policy when an incident occurred involving one resident hitting and yelling at another resident. A Certified Nursing Assistant (CNA) reported the incident to the Administrator, but the Administrator did not notify the State Agency or conduct an investigation as required by facility policy. Additionally, there was no documentation in either resident's medical record indicating that the incident was reported to the State Agency or to the residents' representatives. Interviews confirmed that the CNA notified the Administrator of the altercation, but the residents' representatives were not informed of the event. The facility's policy requires prompt investigation and notification of both the State Agency and the residents' representatives in cases of alleged abuse. The lack of documentation and failure to follow reporting procedures resulted in the facility not meeting its own standards for abuse prevention and reporting.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident physical and verbal abuse to the state survey agency, as required by policy. Two residents with severe cognitive impairment and diagnoses of dementia and Alzheimer's disease were involved in an incident where one resident was witnessed by a CNA hitting and yelling at another resident. The incident was reported by the CNA to the facility administrator, but no investigation was initiated, and there was no documentation of the incident in either resident's medical record. Additionally, there was no abuse investigative file created for the altercation, nor was the incident reported to the state survey agency. Multiple staff interviews confirmed knowledge of the incident, with one CNA stating they witnessed the altercation and another staff member reporting that the affected resident was visibly upset and stated they had been hit. The facility's own Abuse Prevention and Reporting Policy requires prompt investigation and reporting of all abuse allegations to the state agency and documentation of all incidents, but these steps were not followed in this case.
Failure to Thoroughly Investigate and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and document an allegation of resident-to-resident physical and verbal abuse involving two residents. According to the facility's Abuse, Neglect and Exploitation Policy, an immediate and comprehensive investigation is required when abuse is suspected or reported. However, the incident narrative provided was undated and incomplete, lacking critical details such as the time of the incident, the date and time of required notifications, and documentation of which staff and residents were interviewed, the results of those interviews, and the date and time of those interviews. The investigation was not documented chronologically, and there was no evidence of subsequent monitoring or assessment of the residents' psychosocial outcomes following the incident. The incident involved one resident physically hitting another in the back and verbally threatening them, as witnessed by a CNA. Nursing staff separated the residents and assessed the victim for injury. Despite these actions, the facility's documentation did not meet policy requirements for a thorough investigation, including notification of the attending physician and the resident's family or legal representative, as well as ongoing monitoring and documentation of the residents' conditions after the event.
Delayed Call Light Response Times in Facility
Penalty
Summary
The facility failed to provide timely responses to call lights for four residents, leading to significant delays in receiving necessary assistance. Residents reported waiting times of up to 45 minutes or more for staff to respond to their call lights, particularly during the afternoon and midnight shifts. This delay in response was corroborated by multiple residents, including those with cognitive impairments and those requiring substantial assistance with daily activities such as bathing and toileting. The issue was highlighted during a resident council meeting, where residents expressed ongoing dissatisfaction with the call light response times, indicating that the problem had been raised in previous meetings without resolution. Specific instances included a resident who had to wheel down the hall to find staff to assist their roommate, and another resident who experienced incontinence due to delayed assistance. The facility's call light policy mandates timely responses to residents' requests, yet the ongoing complaints suggest a failure to adhere to this policy. The facility administrator acknowledged awareness of the issue and noted that despite staff education efforts, residents continued to report delays. The activity director confirmed that call light response times had been a recurring concern in resident council meetings.
Failure to Provide Scheduled Showers and Nail Care
Penalty
Summary
The facility failed to provide scheduled showers and nail care for two residents, R206 and R45, as documented in the survey findings. R206, who has moderate cognitive impairment and requires moderate assistance with bathing, reported receiving only one shower since admission, despite being scheduled for showers twice a week. The facility's records confirmed that R206 received a shower on one occasion and had no documented refusals or alternative bed baths. Additionally, R206's nails were not trimmed, as required by the facility's shower documentation guidelines. Similarly, R45, who is cognitively intact and requires substantial assistance with bathing, reported not receiving the scheduled two showers per week. The facility's records showed that R45 received showers on specific dates but also had several refusals without being offered a bed bath. R45's nails were also not trimmed, contrary to the facility's shower documentation requirements. The Director of Nursing acknowledged the failure to provide the scheduled showers and nail care for both residents.
Failure to Supervise Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident, identified as R1, who was at risk for falls due to multiple medical conditions including Parkinson's Disease, right-sided hemiplegia, and severe cognitive impairment. R1's care plan indicated a need for supervision during meals due to these conditions. However, on the day of the incident, R1 was left alone in her room with a meal tray, which was against the care plan's directives. This lack of supervision led to R1 attempting to reach for a call light or to turn on the light, resulting in a fall and a head laceration that required sutures. Interviews with staff members, including Certified Nurse's Aides (CNAs), confirmed that R1 should not have been left unsupervised, especially during meals, due to her confusion and tendency to attempt to get up unassisted. The CNAs acknowledged that R1 required total care and assistance during meals. The facility's Administrator and Director of Nursing also verified that R1 should have been taken to the dining room for her meal to prevent such incidents. This oversight in supervision directly contributed to the fall and subsequent injury.
Improper Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in injuries. The resident, who was on hospice care and diagnosed with Alzheimer's Disease, Dementia, and other conditions, was dependent on staff for all activities of daily living, including transfers. The facility's policy required the use of mechanical lifts with two caregivers for such transfers. However, a Certified Nurses Assistant (CNA) improperly transferred the resident alone, leading to the resident being hit in the shoulder by the lift equipment, causing a hematoma, and the resident's foot becoming caught in the geriatric chair, resulting in a fracture. The facility's investigation revealed that the CNA admitted to transferring the resident without assistance, contrary to the facility's policy. The incident was observed when the resident exhibited signs of pain and decreased range of motion, and a bruise was noted on the shoulder. The resident was later diagnosed with a distal femoral fracture. The CNA involved was suspended pending investigation and subsequently quit. Interviews with other staff members confirmed that the CNA did not receive assistance during the transfer, despite the facility having adequate staff and emphasizing the importance of safe transfer practices.
Failure to Monitor and Adjust Anticoagulant Therapy Leads to Resident's Death
Penalty
Summary
The facility failed to adhere to physician orders for a resident's anticoagulant medication, Warfarin, resulting in the resident receiving an incorrect dosage for 24 days. The resident was supposed to have their Warfarin dosage decreased from 3mg to 2.5mg, but this adjustment was not made. Additionally, the facility did not conduct the necessary PT/INR tests to monitor the resident's blood clotting time as recommended by the drug manufacturer guidelines. This oversight led to the resident's PT/INR levels reaching critical levels, causing internal bleeding. The resident, who had a complex medical history including conditions such as Transient Cerebral Ischemic Attack, Non-Rheumatic Aortic Valve Stenosis, and the presence of a prosthetic heart valve, was at significant risk due to the facility's failure to monitor and adjust the anticoagulant therapy appropriately. The resident's PT/INR levels were consistently out of range, and despite this, the facility continued to administer the incorrect dosage of Warfarin. The lack of proper monitoring and adjustment of the medication dosage resulted in the resident experiencing Warfarin toxicity. Ultimately, the resident was sent to the hospital with Warfarin toxicity and was admitted with lethal bleeding. The hospital notes indicated severe complications, including a left hemothorax and alveolar hemorrhage. The resident's condition deteriorated, leading to their death, which was documented as being caused by cardiopulmonary arrest with acute respiratory failure and a left hemothorax. Interviews with facility staff, including the Director of Nursing and the Medical Director, confirmed that the facility did not follow the correct Warfarin order and failed to monitor the resident's labs as required.
Removal Plan
- All licensed and direct care staff was educated on Administration Procedures for All Medications including but not limited to: medications are administered in accordance with physician order, and physician notification including monitoring and adverse reactions.
- All licensed and direct care staff was educated on referencing and following drug manufacturing guidelines for monitoring of drug side effects, labs, and possible adverse reactions.
- All licensed staff was educated on utilizing the Coumadin Tracking Log to ensure medication dosage, order, and follow-up PT/INR are reviewed and to ensure physician's orders are carried out.
- All licensed and direct care staff was educated on anticoagulant administration, effects, precautions, and monitoring.
- All licensed staff was educated on the facility process to monitor/review/follow-up/coordinate and administer safe use of anticoagulant medications.
- An impromptu QAPI meeting was held with the medical director and staff IDT to discuss deficiency and facility action plan.
- The facility will audit the Coumadin Tracking Log and review resident charts to ensure anticoagulant medication orders were followed, monitoring for anticoagulant side effects, the physician was notified of changes in condition(s) of residents, and that abnormal lab results were reported to the physician. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
- The facility will audit all residents currently receiving an anticoagulant to ensure physician orders are being followed, and monitoring is in place including monitoring side effects, labs, and adverse reactions. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
- Nursing Management will audit all newly admitted and readmitted residents to ensure residents receiving anticoagulant medication are being monitored for side effects and adverse reactions, laboratory orders are in place, and the physician is notified of any change in condition. A QA tool will be completed to verify this practice has occurred. There will be oversight of the QA tool by the RNC.
Failure to Address Medication Errors in Quality Improvement Program
Penalty
Summary
The facility failed to implement a quality improvement program to address significant medication errors, resulting in harm to a resident. The Quality Assurance Performance Improvement Program Policy required monitoring and evaluation of resident care, including medication errors, but this was not effectively executed. A resident was prescribed Plavix, an anticoagulant, but was instead administered Warfarin, leading to critical PT and INR levels. Despite physician orders to adjust the Warfarin dosage and conduct follow-up PT/INR tests, the facility continued administering an incorrect dosage for 24 days without conducting the necessary tests. The resident was eventually transferred to a hospital with symptoms of Warfarin toxicity, including internal bleeding, and later died due to a left hemothorax. The facility's quality committee minutes did not reflect any discussion of medication errors, and key personnel, including the Medical Director and Consulting Pharmacist, were unaware of the medication error until after the incident. This lack of communication and failure to address medication errors in quality meetings contributed to the deficiency.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to call lights in a timely manner for five out of twelve residents reviewed for call light responsiveness. This deficiency was identified through interviews and record reviews, revealing that residents experienced significant delays in receiving assistance after activating their call lights. Resident Council Meetings held on three separate dates documented ongoing concerns about prolonged call light wait times across all shifts, with reports of waits lasting nearly an hour during the second shift. On a specific date, multiple residents expressed their frustrations, citing staff shortages and busy schedules as reasons for the delays. The Resident Council President confirmed that long wait times for call lights were a frequent topic of discussion in council meetings.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to serve meals at an appropriate or palatable temperature, affecting nine residents out of the 17 reviewed for food. The policy titled In-Room Dining, dated 2020, states that meals served in rooms should be periodically checked for palatable food temperatures, with hot foods preferred to be at 120 degrees Fahrenheit or greater. However, observations revealed that meal trays were delivered uncovered to the assisted dining room, and residents were left without assistance to eat. Dietary staff distributed trays to residents, but there was a delay in assistance from Certified Nursing Assistants (CNAs), leading to meals sitting uncovered and potentially cooling down before consumption. Interviews with staff and residents highlighted issues with meal service timing and staffing shortages. A dietary aide mentioned that food carts might sit for 20 minutes waiting for CNAs to pass them, and there were instances of delayed meal service due to insufficient staff. Residents reported receiving cold food and experiencing delays in being served, with some waiting over an hour in the dining room. The Dietary Manager acknowledged that food could sit if staff were not ready to serve and admitted to multiple cold food complaints in the past, indicating a recurring issue with meal temperature and service timeliness.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers for a resident who is dependent on staff for bathing. The resident, who is cognitively intact, reported that showers or bed baths are supposed to occur twice a week but sometimes do not happen due to staff being too busy or understaffed. The resident's showers were scheduled for Mondays and Thursdays, but the resident did not receive a shower on a recent Monday. Documentation provided by the Director of Nursing confirmed that there were no recorded showers for the resident in July 2024 and gaps in June 2024, including a period from June 14 to June 19 and June 21 to June 26. The facility's policy requires showers to be offered twice weekly or according to the resident's preference, with documentation in the electronic record, which was not adhered to in this case.
Abuse and Neglect by Agency CNAs
Penalty
Summary
The facility failed to protect residents from mental and physical abuse by staff, specifically involving two agency Certified Nurse Aides (CNAs), V13 and V14. Resident R3 reported that these CNAs were rude and did not listen to her care instructions, causing her physical pain and mental distress. The CNAs ignored R3's request to use a lift to get to the commode, instead rolling her roughly in bed, which exacerbated her existing leg pain. This incident left R3 feeling scared and unsafe, resulting in her urinating in bed out of fear. Multiple staff members, including a Registered Nurse (RN) and a Social Service Director (SSD), confirmed R3's distress, noting her crying and the rough treatment she described. Resident R2 also reported abuse by the same CNAs, stating that they were rude and did not accommodate her physical limitations due to arthritis. R2 was unable to wash her face as instructed by the CNAs, who were dismissive of her condition. Later, the CNAs allegedly handled R2 roughly while transferring her to bed, causing her pain and fear. R2 expressed feeling scared and requested that the CNAs not return to her room. An LPN corroborated R2's account, noting that R2 was yelling and visibly upset after the CNAs' visit. The facility's administrator acknowledged the incidents, confirming that both R2 and R3 experienced physical and mental abuse by the CNAs. The report highlights the failure of the facility to ensure residents' rights to be free from abuse, as outlined in their policy. The incidents involving R2 and R3 were part of a broader issue affecting the facility's ability to provide a safe and respectful environment for its residents.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to notify the Administrator and the State Agency in a timely manner regarding allegations of staff-to-resident abuse involving two residents. The facility's policy on 'Abuse, Neglect and Misappropriation of Resident Property' mandates immediate reporting of any suspected abuse to the Administrator, who is then responsible for notifying the State Agency. However, this protocol was not followed when two residents, who were cognitively intact and dependent on staff for various activities of daily living, reported that two agency CNAs were rude and did not listen to their care instructions. One resident expressed that the CNAs twisted her leg, treated her poorly, and made her wet the bed, causing her distress. Despite being informed of the residents' complaints, the Registered Nurse and LPN involved did not immediately report the allegations to the Administrator. The RN delayed reporting until later in the morning, and the LPN, despite being aware of the abuse prevention policy, did not take immediate action due to other ongoing tasks. The Director of Nursing was also not informed of the abuse allegations when initially contacted about scheduling issues related to the CNAs. The Administrator acknowledged that the CNAs were asked to leave due to their behavior but did not report the incidents to the State Agency as abuse, despite staff having been inserviced on the abuse prevention policy.
Failure to Suspend Alleged Abusers Immediately
Penalty
Summary
The facility failed to adhere to its abuse policy by not immediately suspending two agency Certified Nurse Aides (CNAs), V13 and V14, after allegations of mental and physical abuse were made by a resident, R3. Despite R3's report of being mistreated and hurt by these CNAs, they were allowed to continue working and had access to other residents, including R2 and R6, before being removed from the premises. This delay in action exposed other residents to potential harm and violated the facility's policy, which mandates the immediate removal of staff involved in abuse allegations. R3, who is cognitively intact, reported that the CNAs were mean, made her cry, and caused pain in her leg. R2, also cognitively intact and dependent on staff for various activities, alleged physical abuse by the same CNAs, stating they were rough and caused her pain. Despite these allegations, there was no immediate skin assessment or protective measures taken for R2 and R3. Additionally, R6, who is severely cognitively impaired and requires assistance for mobility, also reported negative interactions with the CNAs, describing them as rude and unprofessional. The facility's failure to act promptly on the abuse allegations was compounded by the lack of documentation of abuse training for the CNAs involved. The Human Resources Director could not provide evidence of abuse training for V13 and V14, highlighting a gap in compliance with training requirements. The facility's inaction and inadequate response to the abuse allegations put all residents at risk and demonstrated a significant lapse in following established protocols for handling such incidents.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to its staff, which has the potential to affect all 60 residents residing in the facility. The facility's assessment, dated January 2024, indicated that QAPI training would be provided annually for all staff. However, during an interview on July 3, 2024, a Certified Nurse Aide (CNA) with over eight years of experience at the facility stated they had never heard of QAPI training and that the facility had not communicated about it. Additionally, the facility administrator confirmed that the facility had not provided ongoing annual QAPI training and was unable to provide documentation of such training for the past year.
Failure to Provide Ethics Training
Penalty
Summary
The facility failed to provide staff with required Ethics training, which has the potential to affect all 60 residents residing in the facility. The facility's assessment indicated that Ethics training should be provided annually to all staff. However, during interviews, a Certified Nurse Aide (CNA) who has worked at the facility for over eight years stated that they had never heard of Ethics training and that the facility does not discuss it with staff. Additionally, the facility's Administrator confirmed that the facility has not provided ongoing annual Ethics training and was unable to provide documentation of such training for the past year.
Failure to Ensure Continued Competency for Nurse Aides
Penalty
Summary
The facility failed to ensure continued competency for nurse aides by not providing at least twelve hours of in-service training per year, including dementia management and resident abuse prevention training. This deficiency was identified for four nurse aides, which has the potential to affect all 60 residents residing in the facility. The facility's Facility Assessment Tool requires that all new employees complete an orientation program covering abuse, neglect, and exploitation, and that Certified Nurse Assistants receive the mandated training. However, during interviews, the Administrator and Human Resources staff admitted to not having logs of staff training for abuse or dementia training for the past year, indicating a lack of documentation and oversight in ensuring compliance with training requirements.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect the residents' right to be free from physical abuse by another resident. This deficiency affected two residents, R1 and R2. R1, who is diagnosed with Alzheimer's Disease, Depression, Dementia, and Anxiety, wandered into R2's room uninvited. R2, who is diagnosed with Hemiplegia, Hemiparesis, Depression, and Anxiety, asked R1 to leave, but R1 refused. As R2 attempted to move around R1's wheelchair, R1 hit R2, causing a skin tear. In retaliation, R2 hit R1 back. Staff intervened and separated the two residents after R2 called for help. The incident resulted in R2 sustaining a skin tear on her right hand and left lower leg. The facility's administrator confirmed the physical altercation and acknowledged that R1 should not have been in R2's room. R1's care plan indicated that she is an elopement risk and tends to wander into other residents' rooms, with staff instructed to distract her with diversional activities and encourage her to stay in common areas. R2's care plan noted that she speaks loudly when upset and has been known to throw things. Both residents were identified as being at risk for abuse due to their respective conditions. Despite these care plans, the facility failed to prevent the altercation, resulting in physical harm to R2.
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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