Goldwater Care Princeton
Inspection history, citations, penalties and survey trends for this long-term care facility in Princeton, Illinois.
- Location
- 515 Bureau Valley Parkway, Princeton, Illinois 61356
- CMS Provider Number
- 145437
- Inspections on file
- 32
- Latest survey
- August 15, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Goldwater Care Princeton during CMS and state inspections, most recent first.
Two residents, both with dementia and behavioral risks, were involved in a physical altercation in which one resident, unable to stand or transfer independently, was struck by another resident who was known to have aggressive tendencies. Staff responded to calls for help and witnessed the incident, confirming the physical abuse occurred.
The facility failed to provide bedtime snacks to all residents, as required by their policy. Several residents reported not being offered snacks, despite the Dietary Manager stating that snacks are sent out with drinks for CNAs to distribute. The Director of Nursing confirmed that CNAs are responsible for offering snacks and documenting acceptance or refusal, but the survey revealed inconsistencies in providing snacks to the 66 residents.
The facility failed to maintain proper kitchen cleanliness and food handling procedures, affecting 66 residents. Observations showed significant cleanliness issues, such as burnt crumbs and greasy substances in the kitchen. A cook used gloved hands instead of tongs for serving food. The Dietary Manager and Administrator confirmed the absence of a cleaning schedule.
The facility failed to follow its Water Management Program, neglecting essential maintenance to prevent Legionella growth, potentially affecting all 66 residents. Additionally, proper transmission-based precautions were not implemented for a resident with a Foley catheter, and infection control practices were compromised during wound care for another resident, as observed by surveyors.
The facility failed to ensure residents were informed about the grievance process, including the identity of the Grievance Official and how to file a grievance. During a survey, residents expressed a lack of knowledge about these procedures, and the Social Service Director acknowledged the need for more frequent communication and education on the grievance process.
The facility failed to ensure proper storage and labeling of medications, affecting 28 residents. An LPN did not check or record the medication refrigerator's temperature, and an undated, partially used Tuberculin bottle was found. The DON confirmed missing temperature records from January to June, indicating a lapse in adherence to storage policies.
A facility failed to maintain a resident's dignity during a transfer, as a CNA was observed transporting a resident on a shower chair with her dress pulled up, leaving her exposed. The resident confirmed this was a common occurrence and expressed discomfort. The CNA acknowledged the resident should have been covered with a bath blanket.
The facility failed to conduct PASARR rescreens for two residents with newly diagnosed severe mental illnesses. One resident was admitted with Bipolar Disorder, but no rescreen was done despite previous indications of behavioral health symptoms. Another resident had a history of severe mental illness, including Major Depression and Anxiety, but the initial PASARR screen showed no severe mental illness. The facility did not perform the required rescreens upon admission.
A resident with chronic diastolic congestive heart failure was not weighed daily as ordered by the physician, despite the importance of weight monitoring for managing her condition. The resident's MAR showed inconsistent documentation of daily weights over several months. Both the DON and Administrator acknowledged the failure to perform daily weights consistently.
The facility failed to implement safety interventions for two residents, including improper transfer techniques and lack of required safety equipment. Additionally, the facility did not adhere to its elopement policy for a resident at high risk of wandering, with missing documentation and untested door alarms.
A resident with significant weight loss was not provided with the necessary nutritional support as ordered. Despite being severely cognitively impaired and requiring assistance with eating, the resident's health shake remained unopened on her meal tray on multiple occasions. Staff did not assist the resident in consuming the shake, which was part of her dietary plan to address weight loss. A CNA noted the shake was frozen and was unsure about obtaining another, while an LPN did not mix the shake with milk as usual. This lack of intervention contributed to the deficiency in maintaining the resident's health.
A facility failed to consistently monitor a resident's respiratory status, who was receiving oxygen therapy for COPD. Despite the facility's policy requiring ongoing assessments using a pulse oximeter, the resident's medical records showed sporadic documentation of SPO2 levels. The DON confirmed that the resident received continuous oxygen therapy, but staff did not consistently monitor SPO2 levels until a later date.
A facility failed to assess a resident's dialysis fistula as ordered, with inconsistent documentation and reports from the resident indicating assessments were not conducted as required. The physician's order required checking the bruit and thrill of the fistula every shift, but many assessments were marked 'No,' and the resident stated the assessments were not always done.
The facility failed to ensure residents on psychotropic medications had supporting diagnoses and identified targeted behaviors with monitoring. A resident was prescribed Seroquel and Olanzapine without documented alternate therapies or target behaviors, and the DON could not confirm the diagnoses. Another resident on Risperdal lacked documentation for targeted behaviors or non-pharmacological approaches, and a third resident on Haldol and Quetiapine also had no such documentation. Observations showed these residents calm and without noted behaviors.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from resident-to-resident physical abuse. One resident with a history of dementia, mood disturbances, and anxiety was identified as being at moderate risk for abuse and neglect. The care plan for this resident included interventions to ensure safety and to report any incidents of abuse. Another resident, also with dementia and a history of agitation and aggressive behavior, was care planned for the potential to be physically and verbally aggressive due to poor impulse control and ineffective coping skills. On the date of the incident, staff responded to calls for help and found one resident standing over another, hitting him while he was in bed. Multiple staff members witnessed the altercation, and it was documented that the resident being attacked could not stand or transfer independently. The aggressor claimed that the other resident had pulled him out of bed, although staff verified this was not possible due to the victim's physical limitations. The incident was documented in progress notes and an initial abuse investigation report, and all required parties were notified.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide bedtime snacks to all residents, as required by their policy. The policy states that between-meal snacks should be available to residents according to the planned menu or resident preference, and that bedtime snacks should be sent to nursing stations in bulk to be offered to each resident. However, during a survey group meeting, several residents reported not being offered any bedtime snacks. One resident mentioned being informed by a nurse that they should receive a snack at bedtime, but had not seen any snacks available. The Dietary Manager stated that snacks are sent out with drinks around 7 or 7:30 pm for bedtime, and that kitchen staff deliver trays to the halls for CNAs to distribute. The Director of Nursing confirmed that CNAs are responsible for offering and passing out the snacks, and that acceptance or refusal should be documented as per policy. Despite these procedures, the survey revealed that the facility did not consistently provide bedtime snacks to its 66 residents, as evidenced by the residents' testimonies.
Deficiencies in Kitchen Cleanliness and Food Handling
Penalty
Summary
The facility failed to implement proper cleaning procedures and schedules for the kitchen, as well as failed to use appropriate utensils during food service, potentially affecting 66 residents. Observations revealed significant cleanliness issues in the kitchen, including black burnt crumbs on the floor of ovens and steamers, brown greasy substances on oven doors, and a brown greasy buildup on the ventilation hood. Additionally, the wall behind the dishwasher had brown/black streaks, and there was a black crumbly substance on the floor and wall under the dishwasher, along with a brown fuzzy substance on the covering above the dishwasher. During food service, a cook was observed using gloved hands instead of tongs to handle dinner rolls, acknowledging the mistake. The Dietary Manager admitted to not knowing the last time the kitchen was cleaned and was unable to provide a cleaning schedule. The Administrator confirmed the absence of a cleaning schedule for the kitchen. These deficiencies were identified during a survey, with the facility's application for Medicare and Medicaid documenting 66 residents residing in the facility.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its Water Management Program for the Prevention of Legionella Growth, which is crucial for preventing the growth and spread of Legionella bacteria. The Maintenance Director admitted to not performing the required preventative maintenance protocols, such as verifying and documenting the temperature settings of the domestic hot water boiler storage tanks and the water entering the circulating system at the mixing valve. Additionally, the ice machines were not inspected and cleaned as required, and the weekly sanitizing of medical devices was neglected. This oversight has the potential to affect all 66 residents residing in the facility. The facility also failed to implement proper transmission-based precautions for residents requiring such measures. For one resident with an indwelling Foley catheter, the facility did not place appropriate signage on the door to indicate the category of transmission-based precautions and instructions for PPE. Furthermore, during wound care for another resident, a CNA did not fully don the required Personal Protective Gown, and a box of gloves was improperly handled, compromising the cleanliness of the supplies used for wound care. These lapses in infection control practices were observed during the survey, highlighting deficiencies in the facility's adherence to its own policies.
Lack of Resident Awareness of Grievance Procedures
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process, including the identity of the Grievance Official, how to file a grievance, and the location of grievance forms. This deficiency was identified during a survey group meeting with four residents, all of whom expressed a lack of knowledge regarding the grievance procedures. The facility's grievance policy, revised in 2017, outlines the residents' right to voice grievances without fear of reprisal and specifies that grievances can be filed orally, in writing, or anonymously. However, the residents involved in the survey were unaware of these procedures, indicating a gap in communication and education regarding their rights. The Social Service Director, who is designated as the Grievance Officer, acknowledged that while new residents are informed about the grievance process, there was no ongoing discussion or reinforcement of this information in Resident Council meetings. The Resident Council minutes from the past year did not include any discussions on how to file a grievance, further highlighting the lack of awareness among residents. The Social Service Director admitted to not being aware of the residents' lack of knowledge and recognized the need for more frequent communication and education on the grievance process.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, which has the potential to affect all 28 residents currently residing in the facility's Safe Unit. The facility's policy on medication storage, revised on July 2, 2019, directs staff to ensure proper storage, labeling, and expiration dates of medications and biologicals. However, during an observation on June 10, 2024, a Licensed Practical Nurse (LPN) was found to have not checked or recorded the temperature of the medication refrigerator, which contained a thermometer iced to the shelf. Additionally, an undated and partially used bottle of Tuberculin was found, indicating a failure to follow the policy of recording the date opened on medication containers with shortened expiration dates. Further review revealed that the facility's Back Hall Medication Refrigerator had missing temperature records for several months, from January to June 2024. The Director of Nurses (DON) confirmed that the refrigerator's temperature was supposed to be checked daily by the night shift nurse, and acknowledged the undated Tuberculin solution and the missing temperature records. This oversight in medication storage and labeling practices highlights a significant deficiency in the facility's adherence to its own policies and procedures, potentially impacting the safety and well-being of the residents.
Failure to Maintain Resident Dignity During Transfer
Penalty
Summary
The facility failed to uphold the resident's right to personal dignity during a transfer, as observed in the case of one resident among a sample of 49. The facility's Dignity policy, revised in April 2028, emphasizes promoting care that maintains or enhances each resident's identity and respect. Additionally, the Resident Rights policy underscores the right to privacy and confidentiality of personal and medical records. However, on June 10, 2024, a Certified Nursing Assistant was observed pushing a resident down the hall on a shower chair with the resident's dress pulled up to her upper waist, leaving her upper thighs and buttocks uncovered. The following day, the resident confirmed that she is rarely covered when being transported to the shower room and expressed her discomfort with this practice. The Certified Nursing Assistant acknowledged that the resident should have been covered with a bath blanket during the transport.
Failure to Conduct PASARR Rescreens for Residents with Severe Mental Illness
Penalty
Summary
The facility failed to perform a PASARR rescreen for two residents after the emergence of newly diagnosed severe mental illnesses. Resident 59 was admitted with a diagnosis of Bipolar Disorder, but the PASARR screen from a previous facility indicated only low-level behavioral health symptoms. Despite the requirement for a status change and a new Level 1 screen if symptoms did not improve within 30-60 days, the facility did not conduct a rescreen upon admission, as confirmed by the Director of Social Services. Resident 61 was admitted with a diagnosis of Severe Major Depression with Anxiety and Suicidal Intent. Despite having a long history of severe mental illness, the initial PASARR Level 1 screen indicated no severe mental illness. The resident's medical records, including progress notes and physician orders, documented multiple severe mental health diagnoses and the use of psychotropic medications. The facility administrator acknowledged that a new PASARR should have been conducted for this resident.
Failure to Perform Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to perform physician-ordered daily weights for a resident with chronic diastolic congestive heart failure, as part of their Congestive Heart Failure Program. The resident, who was supposed to be weighed daily, reported that she was not weighed every day as ordered and occasionally had to weigh herself. The resident's Medication Administration Record (MAR) showed significant inconsistencies in the documentation of daily weights over several months, with many days missing recorded weights. This inconsistency in monitoring the resident's weight is critical given her medical condition, which requires close monitoring to manage her heart failure effectively. The resident's medical history includes an acute exacerbation of congestive heart failure, dyspnea, and hypoxia on exertion, with a noted weight fluctuation from 268.8 pounds to 256.4 pounds during a hospital stay. The Director of Nursing and the Administrator both acknowledged that the daily weights were not being done consistently as ordered. The resident's condition, including edema and frequent changes in diuretics due to kidney and heart concerns, underscores the importance of adhering to the physician's orders for daily weight monitoring to manage her health condition effectively.
Failure to Implement Safety Interventions and Elopement Protocols
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls and ensure safe transfers for two residents. One resident, diagnosed with severe vascular dementia and other conditions, was identified as high risk for falls. Despite this, staff attempted to transfer the resident without using a gait belt or non-skid socks, causing the resident to express pain. The mechanical lift, which was part of the care plan, was not initially used, and the resident was improperly handled by being grabbed under the arms, leading to discomfort and potential harm. Another resident, with diagnoses including severe unspecified dementia and conversion disorder with seizures, was observed without a required helmet while out of bed. The facility's policy required the helmet to be worn to prevent injury, and any refusal to wear it should have been documented. However, there was no documentation of refusal, and staff were unaware of the resident's non-compliance, indicating a lapse in communication and adherence to safety protocols. Additionally, the facility failed to follow its elopement policy for a resident at high risk of wandering. The resident was not wearing the required wander alarm device, and there were multiple instances of missing documentation verifying the device's presence and functionality. The facility's logs also lacked evidence of door alarm tests on weekends, as required by policy. Staff were unaware of their responsibilities regarding the testing of elopement devices, leading to a significant oversight in ensuring the resident's safety.
Failure to Provide Nutritional Support for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss was provided with the necessary nutritional interventions as ordered. The resident, who is severely cognitively impaired and requires assistance with eating, was observed on multiple occasions with an unopened health shake on her meal tray. Despite the presence of the health shake, staff did not assist the resident in consuming it, which was a part of her dietary plan to address her weight loss. The facility's Nutrition Intervention Program policy indicates that residents with significant weight loss should receive additional nutritional interventions, which can be initiated by the food service manager, dietician, or nursing staff. On two separate occasions, the resident's health shake remained unopened on her meal tray, and staff did not make attempts to offer or assist her with it. A CNA mentioned that the health shake was frozen, and they were unsure if they could obtain another one. Additionally, an LPN confirmed that they did not mix the health shake with the resident's milk, which was a usual practice to encourage consumption. The lack of staff intervention and assistance in ensuring the resident consumed the health shake contributed to the deficiency in providing adequate nutrition to maintain the resident's health.
Failure to Monitor Resident's Respiratory Status
Penalty
Summary
The facility failed to perform an ongoing assessment of a resident's respiratory status, specifically for a resident with Chronic Obstructive Pulmonary Disease (COPD) who was receiving oxygen therapy. The facility's policy required licensed nurses to conduct ongoing assessments for oxygen administration using a pulse oximeter to determine oxygen saturation levels. However, the resident's medical records showed sporadic documentation of SPO2 levels, with recorded levels on only a few dates in May and June 2024. The Medication Administration Records for these months also lacked documentation of the resident's SPO2 levels. The Director of Nurses confirmed that the resident was admitted to the facility and received continuous oxygen therapy at 3 liters, but staff did not monitor the resident's SPO2 levels consistently until June 10, 2024.
Failure to Properly Assess Dialysis Fistula
Penalty
Summary
The facility failed to properly assess a resident's dialysis fistula as ordered, which was a requirement for one of the residents reviewed for dialysis care. The physician had ordered that the bruit and thrill of the dialysis fistula in the resident's left forearm be checked every shift to ensure proper blood flow. However, the documentation in the Electronic Medical Record was inconsistent, with many assessments marked as 'No,' making it unclear whether the assessments were conducted as ordered or if 'No' referred to the absence of a bruit or thrill. The Assistant Director of Nursing confirmed that the order required a behavior observed assessment, which should be marked 'yes' for a positive thrill and bruit and 'no' for a negative thrill and bruit. Despite this, the Medication Administration Record showed that a significant number of assessments were documented as 'No,' and the resident reported that the fistula was assessed maybe once a day, not twice as required. This inconsistency in documentation and the resident's statement indicate that the facility did not adhere to the physician's orders for monitoring the dialysis fistula.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents on psychotropic medications had supporting diagnoses and identified targeted behaviors with monitoring. For Resident R26, the Physician Order Sheet documented orders for Seroquel and Olanzapine related to unspecified dementia with severe agitation and major depressive disorder. However, the care plan did not include any alternate therapies or identified target behaviors. Observations showed R26 sitting quietly without any noted behaviors, and the Director of Nursing was unable to confirm the accuracy of the diagnoses or provide documentation for targeted behaviors or alternate therapies. Similarly, Resident R33 was prescribed Risperdal for paranoid schizophrenia and dementia, but the care plan lacked documentation for specific targeted behaviors or non-pharmacological approaches attempted before starting the medication. Observations showed R33 calmly interacting with others. For Resident R44, prescribed Haldol and Quetiapine for mood disorder, anxiety, and dementia, the care plan also did not document targeted behaviors or alternate therapies. Observations showed R44 calm and engaged in conversation. The Director of Nursing confirmed the absence of documentation for targeted behaviors or alternate therapies for both R33 and R44.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
