Hallmark Healthcare Of Pekin
Inspection history, citations, penalties and survey trends for this long-term care facility in Pekin, Illinois.
- Location
- 2501 Allentown Road, Pekin, Illinois 61554
- CMS Provider Number
- 145691
- Inspections on file
- 26
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hallmark Healthcare Of Pekin during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter did not have Enhanced Barrier Precautions (EBP) implemented as required. Staff provided personal care using only gloves and a mask, without donning gowns or following EBP protocols, and there was no EBP signage or isolation cart outside the room. The facility's policy required EBP for residents with indwelling devices, but these measures were not followed.
A resident with multiple chronic conditions experienced a significant decline over two weeks, including severe dehydration, weight loss, and decreased responsiveness. Despite clear signs of deterioration, staff did not notify the physician or update the care plan, and failed to monitor fluid intake, weight, and catheter care as required. The resident was eventually hospitalized in critical condition with multiple life-threatening complications, and hospital staff documented evidence of prolonged neglect.
A resident with chronic kidney disease and an indwelling urinary catheter was not properly monitored for catheter obstruction, and required documentation of urinary output and catheter changes was not completed as ordered by the physician. Staff failed to report and document changes in the resident's condition, including decreased urine output and altered mental status. The resident was ultimately hospitalized with acute renal failure, bladder obstruction, and a complicated UTI, with hospital staff noting poor catheter care and severe dehydration.
A resident with severe protein-calorie malnutrition, dementia, and diabetes experienced a 13.9% weight loss over six months due to the facility's failure to obtain weekly weights as ordered, lack of documentation and monitoring of nutritional supplement intake, and failure to notify the physician and dietitian of ongoing meal refusals and declining intake. The care plan was not updated to address these issues until just before the resident was hospitalized in a severely malnourished and dehydrated state.
A resident was transferred to the hospital for increased confusion and lethargy, where a CT scan revealed a new head bleed suspected to be from an unwitnessed fall. Nursing staff notified the DON, but no incident report, investigation, or state agency notification was completed, despite facility policy requiring such actions for injuries of unknown origin.
A resident was transferred to the hospital where a CT scan revealed internal bleeding of unknown origin. Despite being notified by the family that the injury may have resulted from an unwitnessed fall, staff did not initiate an incident report or conduct an investigation, and no report was made to the state agency. Facility policies requiring investigation and documentation of such incidents were not followed.
A resident with multiple chronic conditions experienced a sudden decline, including confusion, lethargy, and inability to self-feed, but staff failed to perform or document nursing assessments, vital signs, or neurological checks, and did not ensure timely provider notification. The LPN relied solely on fax to contact the provider and did not escalate when no response was received, resulting in delayed medical intervention until the resident was eventually sent to the hospital and diagnosed with a brain bleed.
A resident admitted with multiple comorbidities and a stage 3 pressure ulcer did not receive a complete skin inspection assessment or timely treatment orders upon admission. Required daily skin checks and weekly documentation were not performed, and the wound was not properly documented or treated until two weeks after admission, as confirmed by the DON and Administrator.
The facility failed to respond to call lights in a timely manner, affecting four residents who reported extended wait times, sometimes exceeding 30 minutes. These residents, who are cognitively intact, require assistance for activities of daily living due to various medical conditions. The administration acknowledged the issue, and the Resident Council expressed a desire for quicker response times.
The facility did not educate residents on grievances, lacked publicly available grievance forms, and did not allow anonymous submissions. Residents were unaware of these processes, and the administrator admitted to not implementing the facility's grievance policy, which allows for anonymous complaints. The facility houses 59 residents.
A cognitively intact resident alleged that a CNA yanked her arm, causing shoulder pain. Despite reporting the incident to an RN, the CNA was not removed from resident care and continued working. The RN, new to the facility, was not trained on the abuse policy, which requires immediate removal of staff suspected of abuse. This failure potentially affected all 59 residents.
The facility did not provide annual QAPI training to direct care staff, as confirmed by the Administrator and evidenced by the absence of such training in the Annual Training Logs. This deficiency could affect all 59 residents in the facility.
The facility failed to properly manage respiratory care equipment for several residents, including undated oxygen tubing and nebulizer masks not stored in bags. A resident was using oxygen without a physician's order, and staff confirmed that equipment should be changed weekly and labeled, as per facility policy.
A resident with multiple health conditions, including COPD and diabetes, was found without a call light within reach while in a wheelchair with oxygen. The CNA discovered the call light on the floor, and the DON confirmed it should have been accessible, as per facility policy.
A cognitively intact resident reported that a CNA was rough and hurt her shoulder during care. The allegation was communicated to an RN and another CNA, but neither reported it to the administrator as required by the facility's Abuse Policy. The RN, who had been employed for three weeks, claimed she was not trained on the abuse policy and did not report the incident, assuming it was a racial issue. However, the administrator confirmed that the RN had received abuse training earlier in the month.
A resident at high risk for pressure ulcers developed a stage four ulcer on the left heel due to the facility's failure to implement physician-ordered interventions. Despite being cognitively intact and having a care plan that included heel floating devices and repositioning, the resident's heels were often left on the mattress without pressure relief. Staff were unaware of the orders for pressure-relieving boots, leading to the ulcer becoming infected and requiring surgical debridement.
A resident did not receive a physician-ordered medication, Cyclobenzaprine Hydrochloride, due to the facility's failure to obtain it from the pharmacy. The LPN administering medications was aware of the issue but did not notify the resident's doctor. The resident missed six doses over two days, and the DON confirmed the medication was not given, highlighting a breach in the facility's policy on handling unavailable medications.
A facility failed to conduct necessary assessments and documentations for a resident on anti-psychotic medication. Despite the resident's diagnosis of dementia and regular Seroquel use, there were no attempts at gradual dose reduction or physician documentation for contraindications. Observations and interviews indicated no behaviors justifying the medication, and the resident expressed a desire to reduce medication due to tiredness.
The facility failed to properly explain the arbitration agreement to residents or their representatives, leading to misunderstandings about waiving the right to sue. Interviews revealed that residents and their representatives were not informed about the 30-day rescission period and were unaware of the agreement's implications. The administrator acknowledged the lack of a policy on this matter.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter, as required by their infection prevention and control program. The resident's physician order sheet documented the need for EBP due to the presence of a urinary drainage catheter. During observation, the resident was found in bed with a urinary drainage bag, but there was no EBP sign on the door, and no isolation cart was present outside the room. Staff interviews revealed that the hospice certified nursing assistant providing personal care to the resident only wore gloves and a mask, and was unaware of the facility's EBP requirements. The assistant director of nursing confirmed that residents with indwelling urinary catheters should be on EBP, with appropriate signage and equipment in place, which was not observed for this resident. The facility's policy, revised on 12/10/24, specifies that EBP should be used in conjunction with standard precautions, including donning gowns and gloves during high-contact care activities for residents with indwelling medical devices. The policy also outlines the specific care activities and situations where EBP is indicated. Despite these requirements, the staff did not follow the policy for the resident with a urinary catheter, as evidenced by the lack of signage, equipment, and proper use of personal protective equipment during care.
Failure to Notify Physician and Provide Timely Medical Care Results in Resident Harm
Penalty
Summary
A significant deficiency occurred when facility staff failed to notify the physician and seek medical treatment for a resident who experienced a marked decline in condition over a two-week period. Despite clear signs of deterioration, including decreased oral intake, weight loss, increased weakness, and changes in behavior, staff did not document or communicate these changes to the resident's physician or dietitian. The facility's own policies required prompt recognition and reporting of acute changes in condition, but these were not followed. Multiple staff interviews confirmed that although the resident's decline was observed and discussed among staff and with family, no physician notification or medical intervention was initiated during this period. The resident, who had a history of multiple chronic conditions including diabetes, malnutrition, chronic kidney disease, and obstructive uropathy with an indwelling urinary catheter, was not properly monitored for fluid intake, weight, or catheter care. Documentation revealed missed weekly weights, inconsistent meal consumption records, and a lack of monitoring of urinary output. The care plan was not updated to address the resident's rapid weight loss, decreased intake, or increased risk for infection and contractures until just before the resident was sent to the hospital. Staff failed to change the resident's urinary catheter as ordered, and there was no evidence of physician notification regarding the resident's significant decline or catheter-related issues. When the resident was finally sent to the hospital, he was found to be in critical condition, suffering from severe dehydration, acute encephalopathy, hypernatremia, bladder obstruction, lactic acidosis, complicated urinary tract infection, sepsis, metabolic acidosis, contractures, and bacterial pneumonia. Hospital staff documented evidence of poor hygiene, inadequate oral and catheter care, and severe malnutrition. The admitting hospital physician and nurse both noted that the resident's condition indicated prolonged neglect, and the facility's failure to provide necessary medical care and monitoring resulted in the resident's admission to the ICU for treatment of multiple life-threatening conditions.
Failure to Monitor and Document Catheter Care Leading to Resident Hospitalization
Penalty
Summary
A resident with chronic kidney disease, obstructive and reflux uropathy, and benign prostatic hyperplasia was not properly monitored or cared for in relation to their indwelling urinary catheter. The facility failed to monitor for catheter obstruction, did not document physician-ordered urinary output every shift, and did not perform required catheter changes every 30 days or as needed. Documentation was missing for multiple shifts regarding urine output, and there was no record of catheter changes for several months, despite physician orders and facility policy requiring these actions. The resident's care plan identified high risk for urinary tract infection due to catheter use and included interventions such as monitoring intake and output, observing for signs of infection, and changing the catheter and drainage bag per physician orders. However, nursing progress notes and treatment administration records showed gaps in documentation of urine output and catheter changes. Staff interviews revealed that changes in the resident's condition, such as decreased activity, reduced urine output, and changes in urine color, were either not reported to the physician or not documented. The LPN responsible did not notify the physician of the resident's decline, and abnormal lab results were not promptly communicated to the physician, resulting in delayed treatment. The resident was eventually sent to the emergency room after exhibiting severe symptoms, including lethargy, hypotension, and purulent drainage from the catheter. Hospital records indicated the resident had acute renal failure, bladder obstruction, complicated urinary tract infection, and severe dehydration. The hospital staff noted poor catheter care, excoriation, and lack of cleanliness around the catheter site. The facility's failure to follow physician orders, monitor and document catheter care, and respond to changes in the resident's condition led to a significant decline in the resident's health and subsequent hospitalization.
Failure to Monitor and Report Significant Weight Loss and Nutritional Decline
Penalty
Summary
A facility failed to obtain physician-ordered weekly weights and did not notify the physician or registered dietitian of a resident's repeated refusals of nutritional supplements, decreased meal consumption, and significant weight loss. The resident, who had a diagnosis of severe protein-calorie malnutrition, dementia, and type 2 diabetes with chronic kidney disease, experienced a 13.9% weight loss in less than six months. Documentation showed that weekly weights were not consistently recorded as ordered, and there was a lack of documentation regarding the amount of nutritional supplement consumed. The resident's meal intake was also inconsistently documented, with frequent low consumption and multiple meal refusals over an eleven-day period. Despite clear evidence of declining intake and significant weight loss, there was no documentation that the physician or dietitian was notified of these changes. The care plan was not revised to address the resident's rapid weight loss, decreased meal consumption, or supplement refusals until two days before the resident was hospitalized. Interviews with staff confirmed that they observed the resident's decline, including decreased activity, poor intake, and refusal to eat or drink, but did not notify the physician or dietitian as required by facility policy. The resident was eventually admitted to a hospital in a severely malnourished and dehydrated state, with diagnoses including hypernatremia, acute metabolic encephalopathy, and severe malnutrition with concern for refeeding syndrome. Hospital staff and the admitting physician noted the resident's poor condition and indicated that the decline had been ongoing for days prior to admission. Facility staff and the director of nursing confirmed that required notifications and care plan updates were not completed in a timely manner.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of injury of unknown origin for one resident, as required by both facility policy and regulatory guidelines. A resident was noted to have increased confusion and lethargy, leading to a transfer to the emergency department. Later, the resident's family informed facility staff that a CT scan at the hospital revealed internal bleeding in the head, which the hospital indicated could be from a possible unwitnessed fall. Nursing staff reviewed records and found no documented falls or incidents in the prior 24 hours. The nurse on duty notified the Director of Nursing (DON) about the new information from the family, but no written investigation or incident report was completed, and the event was not reported to the state agency. The facility's policies require that all accidents and incidents, including injuries of unknown origin, be reported to the department supervisor, documented with an incident report, and reported to the abuse coordinator and state agency. Despite these requirements, the DON confirmed that no investigation or report was made because the source of the injury was unknown and there were no documented falls. The administrator, who serves as the abuse coordinator, was not informed of the injury until after reviewing the nursing note and acknowledged that the incident should have been identified and investigated as an injury of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who was transferred to the emergency department and subsequently to a tertiary hospital, where a CT scan revealed internal bleeding. Nursing notes indicated that the resident had not experienced any documented falls or incidents in the 24 hours prior to the injury, and the last recorded fall occurred several days earlier without head trauma. Despite being informed by the resident's family that the hospital identified a new head bleed possibly due to an unwitnessed fall, staff did not initiate an incident report or conduct an investigation into the cause of the injury. Interviews with facility staff, including the LPN, DON, and Administrator, confirmed that no written investigation or report to the state agency was completed regarding the injury. The facility's own policies require that all accidents and incidents, including injuries of unknown origin, be reported, investigated, and documented, but these procedures were not followed in this case. The Administrator, who serves as the facility's Abuse Coordinator, acknowledged that the incident should have been identified and investigated as an injury of unknown origin, but this was not done.
Failure to Assess and Notify Provider During Acute Change in Condition
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including atrial fibrillation, hypertension, diabetes, Parkinson's disease, congestive heart failure, and Lewy Body dementia, experienced an acute change in condition that was not properly assessed or managed by facility staff. The resident, who was typically able to feed himself with only setup help or cuing, became suddenly confused, lethargic, and unable to eat independently. Family members and another resident observed these significant changes, noting that the resident was not making sense and could not pick up his fork at lunch, which was a marked departure from his baseline. Despite these clear signs of acute deterioration, the nursing staff did not perform or document a nursing assessment, vital signs, or neurological checks on the day of the incident. The last recorded assessment and vital signs were from the previous day, and there was no evidence of timely provider notification or response. The assigned LPN recognized the change in the resident's condition around mid-morning, notified the family, and attempted to contact the provider by fax, but did not follow up with a phone call or escalate the situation when no response was received. The resident's condition remained unchanged for several hours before being sent to the emergency department. Upon arrival at the hospital, the resident was found to have a fresh brain bleed and was transferred to a higher level of care for neurosurgical evaluation and blood pressure management. The facility's own policy required prompt assessment, collection of pertinent information, and direct communication with providers in the event of an acute change of condition, but these steps were not followed. The Director of Nursing confirmed that the expected assessments and provider notifications were not completed during the critical period when the resident was exhibiting significant new deficits.
Failure to Assess and Treat Pressure Ulcer Upon Admission
Penalty
Summary
The facility failed to fully assess and document a pressure ulcer for a resident upon admission, as well as to obtain timely treatment orders and perform required ongoing assessments. The resident, who was admitted with multiple significant diagnoses including gangrene, diabetes, muscle wasting, and a recent above-the-knee amputation, was identified as high risk for pressure ulcers. Upon admission, an open area on the sacrum was noted, and the care plan documented a stage three pressure injury to the coccyx. However, there was no completed skin inspection assessment at admission, and no initial treatment orders were obtained for the pressure ulcer until 14 days after admission, when a nurse practitioner evaluated the wound and provided treatment recommendations. Additionally, the facility did not perform daily skin checks or provide weekly documentation assessments for the pressure ulcer as required by policy. Although weekly skin inspections were signed off on the Treatment Administration Record, there was no corresponding documentation in the medical record regarding the status of the pressure ulcer prior to the late treatment order. The Director of Nursing and Administrator confirmed these omissions, acknowledging the lack of assessment, documentation, and timely intervention for the resident's pressure ulcer.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to maintain resident dignity by not responding to call lights in a timely manner for four residents. Resident 1 reported a significant delay in response time, waiting two hours for assistance after being incontinent. This resident, who is cognitively intact with a BIMS score of 15, requires two-person assistance for toileting due to a self-care deficit related to recent hospitalization and weakness from sepsis. Resident 2 also experienced extended call light wait times, sometimes exceeding 30 minutes, and resorted to calling his wife for help. This resident, with a BIMS score of 13, requires one-person assistance for toileting due to a self-care deficit following hospitalization for a urinary tract infection and sepsis. Similarly, Resident 3 and Resident 4 reported waiting over 30 minutes for call light responses. Both residents are cognitively intact with BIMS scores of 15 and require staff assistance for activities of daily living due to various medical conditions. The facility's administration, including the Administrator and Assistant Director of Nurses, acknowledged the issue of extended call light wait times. The Social Service Director also confirmed receiving multiple complaints from residents about the delays. The Resident Council Minutes further documented the residents' desire for quicker response times. The facility's Call Light Guidance Policy states that call lights should be answered within a reasonable time, indicating a failure to adhere to this policy.
Failure to Educate and Provide Grievance Forms
Penalty
Summary
The facility failed to educate residents on the concept of a grievance, did not have grievance forms readily available in a public area, and did not allow residents to file grievances anonymously. During a group meeting, several residents expressed that they were unaware of what a grievance was, where to find forms, how to file one, and that it could be done anonymously. The residents indicated an interest in having these options available for future use, with one resident specifically mentioning the desire to report issues without revealing their identity. The facility's administrator acknowledged that residents are encouraged to report issues to staff, but they refer to them as concerns rather than grievances. The administrator also admitted that grievance forms were not displayed for residents or families to fill out and had not considered the possibility of anonymous submissions. The facility's grievance policy, dated 2019, states that individuals have the right to file grievances or complaints anonymously, but this was not being implemented. The facility currently houses 59 residents.
Failure to Remove Alleged Perpetrator Following Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Policy by not removing an alleged perpetrator from direct care of residents following an abuse allegation. A Certified Nursing Assistant (CNA) was accused by a resident, who is cognitively intact, of yanking her arm and causing shoulder pain. Despite the report of this incident to a Registered Nurse (RN) on the same day, the CNA was not removed from resident care and continued to work until the end of her shift. The RN, who had only been employed at the facility for three weeks, admitted to not being trained on the abuse policy. The facility's policy mandates that any staff member suspected of abuse should be escorted out of the facility and not allowed to return until the investigation is complete. However, this procedure was not followed, as the CNA continued to provide care to residents, including the one who made the allegation. The facility's documentation confirms that 59 residents were residing in the facility at the time, potentially putting all at risk due to the failure to adhere to the abuse policy.
Lack of QAPI Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff received annual in-service training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through a review of the facility's Annual Training Logs, which lacked evidence of QAPI training for employees. During an interview, the Administrator confirmed that the facility does not conduct QAPI training for any staff and does not have a policy in place for providing such training. This oversight has the potential to impact all 59 residents currently residing in the facility, as documented in the facility's CMS Long Term Care Facility Application for Medicare and Medicaid Form 671.
Deficiencies in Respiratory Care Equipment Management
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents, as evidenced by undated and improperly stored respiratory equipment. For one resident, oxygen tubing was not dated, and the resident was unsure of how often it was changed. The Director of Nursing confirmed that oxygen tubing should be changed weekly and labeled with the date. Another resident had undated oxygen tubing and a nebulizer mask and tubing that were not stored in a bag, contrary to facility policy. The Director of Nursing stated that nebulizer tubing should be labeled, and the mask should be stored in a plastic bag when not in use. Additionally, a resident was found using oxygen without a physician's order, and the nasal cannula tubing was undated. The Director of Nursing was unaware of why there was no order for the resident to wear oxygen, despite the resident always having it on. Another resident's nebulizer tubing and mask were also undated and unbagged, which was verified by a Licensed Practical Nurse who acknowledged that the equipment should be changed weekly and stored properly. These deficiencies highlight a lack of adherence to the facility's policies on respiratory care equipment management.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. The resident, who was admitted with multiple diagnoses including COPD, chronic respiratory failure, emphysema, hypertension, chronic kidney disease, and type 2 diabetes mellitus, was observed sitting in a wheelchair with oxygen but without the call light in reach. The resident reported not having the call light since being assisted out of bed by staff. A CNA later found the call light on the floor near the head of the resident's bed, confirming it was not accessible. The Director of Nursing acknowledged that the call light should always be within reach, as per the facility's policy dated 8/20/24.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse Policy by not reporting staff-to-resident abuse allegations to the administrator immediately. A resident, who is cognitively intact, reported that a CNA was rough and hurt her shoulder during care. This allegation was communicated to an RN and another CNA, but neither reported it to the administrator as required by the facility's policy. The RN, who had been employed for three weeks, claimed she was not trained on the abuse policy and did not report the incident, assuming it was a racial issue. However, the administrator confirmed that the RN had received abuse training earlier in the month. The facility's policy mandates that all staff report any allegations of abuse immediately to the administrator.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement physician-ordered pressure-relieving interventions for a resident identified as high risk for pressure ulcer development. The resident, who was cognitively intact and had severely limited mobility, developed a painful, facility-acquired stage four pressure ulcer on the left heel. This ulcer became infected with MRSA and Proteus Mirabilis, requiring multiple surgical debridements. The resident's care plan included interventions such as applying a heel floating device, off-loading the ulcer site, and repositioning every two hours, but these were not consistently implemented. Observations revealed that the resident's heels were often lying directly on the mattress without pressure relief or off-loading, and pressure-relieving boots were not applied as ordered. The resident reported that the heel boots were not being used, and a CNA confirmed that they had not attempted to turn the resident or apply the boots. The Assistant Director of Nursing and an LPN were unaware of the physician's orders for pressure-relieving boots, indicating a lack of communication and adherence to the care plan. The facility's policy on pressure ulcer prevention and treatment emphasizes the use of pressure-reducing devices for residents at risk. However, the staff failed to follow these guidelines, resulting in the resident's condition worsening. The wound nurse practitioner confirmed that the ulcer was caused by pressure and was facility-acquired, highlighting the facility's failure to provide adequate care and prevent the development of the pressure ulcer.
Failure to Obtain Physician-Ordered Medication
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for a resident, identified as R2, by not obtaining a physician-ordered medication, Cyclobenzaprine Hydrochloride 10 mg, from the pharmacy. This deficiency was observed when a Licensed Practical Nurse (LPN) was administering scheduled medications and found that the medication was not available in the medication cart. The LPN acknowledged the issue and mentioned ongoing trouble with obtaining the medication from the pharmacy, without knowing the specific reason. Further investigation revealed that the resident missed six scheduled doses of the medication over two days. The LPN admitted to not notifying the resident's doctor about the unavailability of the medication. The Director of Nursing (DON) confirmed that the medication was not administered and stated that nurses should notify both the resident and the doctor immediately when a medication is unavailable. The facility's policy on unavailable medications outlines procedures for notifying the physician and obtaining alternative orders, which were not followed in this case.
Failure to Conduct Anti-Psychotic Medication Assessments and Gradual Dose Reductions
Penalty
Summary
The facility failed to perform necessary assessments and documentation for the use of anti-psychotic medication in a resident diagnosed with dementia. The resident, who was admitted to the facility without a mental illness, was prescribed Seroquel for dementia with psychotic disturbance. Despite receiving Seroquel regularly, there were no attempts at gradual dose reduction, nor was there any physician documentation explaining why such a reduction was clinically contraindicated. Additionally, the facility did not conduct any anti-psychotic medication assessments since the medication was initiated. Observations and interviews revealed that the resident had no documented behaviors that would justify the continued use of Seroquel. The resident expressed a desire to reduce medication due to feeling tired, and staff confirmed the absence of behaviors over the past six months. The facility's Director of Nursing acknowledged the lack of behavior tracking and gradual dose reduction attempts, which are required by the facility's psychotropic medication protocol.
Failure to Explain Arbitration Agreement
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to residents or their representatives in a manner they could understand, and did not inform them that the agreement could be rescinded within 30 days of signing. This deficiency was identified through interviews and record reviews, revealing that the Social Services staff member responsible for admissions incorrectly informed residents and their representatives that they had 60 days to rescind the agreement and did not clarify that signing the agreement meant waiving their right to sue the facility. This oversight potentially affects all 59 residents in the facility. During a Resident Council Meeting, four residents expressed that they were unaware of the arbitration agreement and its implications, and did not know if they or their representatives had signed it. Additionally, a Power of Attorney for one resident stated that he did not understand the legal implications of the agreement and intended to rescind it. Another Power of Attorney confirmed signing the agreement without understanding its significance, indicating a lack of proper communication and understanding. The facility administrator acknowledged the absence of a policy regarding the arbitration agreement and emphasized the importance of residents and their representatives understanding its meaning.
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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