Hawthorne Inn Of Danville
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, Illinois.
- Location
- 3222 Independence Drive, Danville, Illinois 61832
- CMS Provider Number
- 146090
- Inspections on file
- 23
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Hawthorne Inn Of Danville during CMS and state inspections, most recent first.
A resident with multiple pressure ulcers did not receive wound care in accordance with infection control protocols and physician orders. An RN failed to perform hand hygiene and change gloves between wound cleansing and dressing application, and a physician's order for a skin protectant was not entered into the EMR, resulting in missed treatment.
A resident admitted after CABG surgery did not have complete or accurate documentation of skin assessments, incisions, or bruising in their medical record. Nursing staff and the DON confirmed that the presence of incisions and bruising was not recorded at admission, despite being reported by the hospital. The facility's process for tracking and uploading provider notes and auditing records was not followed, resulting in incomplete documentation.
A resident admitted with multiple cardiac and neurological diagnoses did not have complete physician orders for key medications, as the orders lacked dosage, route, and administration times. The DON confirmed that these omissions were not identified or clarified at admission, contrary to facility policy requiring complete and clear medication orders.
A resident did not receive prescribed medications on time due to incomplete hospital discharge orders and delays in both order clarification and pharmacy delivery. Nursing staff did not promptly clarify medication orders lacking dosage and timing details, and the pharmacy did not provide the medications according to the intended start dates. Established procedures for obtaining medications outside regular hours were not followed, resulting in the resident missing several doses.
A resident admitted after a hospital stay for atrial flutter and electro-cardioversion experienced significant medication errors when incomplete discharge orders for Fosinopril, Metoprolol Succinate, and Mirtazapine were not promptly clarified by staff or providers. Delays in communication and pharmacy delivery led to multiple missed doses of these critical medications, as confirmed by MAR and staff interviews. Facility staff acknowledged the errors and contributing factors, including incomplete orders, delayed responses, and lack of backup pharmacy use.
A resident's medical records contained multiple inconsistencies, including conflicting documentation of code status between the POLST form and the Physician Order Sheet, incomplete provider signatures, and inaccurate progress notes regarding discharge status. Additionally, a nurse documented administration of a medication before it was delivered to the facility. These errors were confirmed by facility leadership and involved inaccurate and incomplete recordkeeping.
Two residents experienced unmanaged pain due to the facility's failure to consistently assess, document, and report pain to providers. One resident with spasticity and another with a recent hip fracture both had severe pain episodes that were not promptly addressed, resulting in missed therapy and decreased participation in daily activities. Pain assessments and follow-up documentation were incomplete, and provider notification was delayed, contrary to facility policy.
Several newly admitted residents did not receive prescribed medications as ordered due to unavailability, lack of follow-up with pharmacy or physician, and incomplete documentation. Nursing staff did not consistently check backup medication supplies or notify appropriate parties when medications were missing, and one resident's antibiotic order was incorrectly transcribed, leading to improper scheduling.
The facility did not follow its antibiotic stewardship policy and the McGreer Criteria for UTI diagnosis, resulting in antibiotics being prescribed and administered to several residents without proper documentation of symptoms or urine culture results. In some cases, antibiotics were started without confirming the presence of infection or reviewing culture findings, and required forms were not completed as per protocol.
A resident who was ambulating with a walker in the memory care unit was struck and knocked down by a door when a dietary aide opened it without first checking the blind spot mirror, as required. Staff interviews confirmed the mirror was intended to prevent such incidents, but it was not used at the time, resulting in the resident's fall.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, affecting all 74 residents. The Dietary Manager admitted to not having the necessary qualifications, and the facility dietician only provided services one day per month. During the survey, the facility also failed to prevent cross-contamination of food and ice, did not date and label TCS food, and did not maintain sanitary food storage equipment.
The facility failed to prevent cross-contamination of stored food and ice, did not date and label TCS food, and did not maintain sanitary food storage equipment. Issues included a leaking walk-in freezer evaporator, an ice scoop stored in stagnant water, unlabeled cream cheese, a soiled can opener, and a dusty walk-in cooler evaporator. These conditions potentially affect all 74 residents.
The facility failed to timely complete MDS assessments for four residents, as required by their policy. The MDS/Care Plan Coordinator and the DON confirmed that the March MDS assessments for these residents were incomplete and not updated within the required timeframe.
The facility failed to timely transmit an MDS assessment for a resident due to the MDS/Care Plan Coordinator's unfamiliarity with completing the CAA section, resulting in a late submission.
The facility failed to ensure that two residents received the recommended and ordered amount of enteral feeding. Observations and interviews revealed that the feeding pumps were not consistently turned on, resulting in the residents not receiving the prescribed amounts on multiple days. Despite this, the residents did not appear dehydrated or malnourished, and there was no significant weight loss documented.
The facility failed to obtain a physician's order for oxygen administration and did not include the use of oxygen in the care plan for a resident with multiple diagnoses, including Alzheimer's Disease and Acute Upper Respiratory Infection. The resident was observed with oxygen administered via nasal cannula without a specified order for liter flow or type of administration.
The facility failed to accurately assess and document side rail use for two residents, including obtaining consent and documenting alternative interventions. The assessments were incomplete and inaccurate, and the care plans did not include side rail use.
The facility failed to complete quarterly psychotropic medication assessments, document specific behaviors and nonpharmacological interventions, include a duration for PRN psychotropic medication orders, obtain consent for psychotropic medication use, and rule out underlying causes of behaviors for three residents. These deficiencies were identified through medical record reviews and staff interviews, revealing significant lapses in adherence to the facility's policies.
A resident with a history of UTIs was prescribed Cipro without obtaining a culture to ensure the appropriate antibiotic was used. Despite a urine dip test and labs being drawn, no urinalysis or culture and sensitivity test was ordered. The resident required another course of antibiotics less than 30 days after the final dose of Cipro.
The facility failed to offer and administer the pneumonia vaccine as recommended for two residents. One resident with Cerebral Palsy did not receive the required PCV15 or PCV20 vaccine, and another resident did not receive the necessary PCV15 or PCV20 vaccine despite multiple attempts to obtain consent. The RN/Infection Preventionist did not document these attempts and was initially unaware of the vaccination requirements.
Failure to Prevent Cross Contamination and Implement Wound Care Orders
Penalty
Summary
The facility failed to prevent cross contamination during wound care and did not implement physician-ordered pressure ulcer treatments for one resident with multiple wounds. Specifically, a registered nurse (RN) did not perform hand hygiene or change gloves after cleansing a resident's sacral wound and before applying a clean dressing, contrary to the facility's wound care policy and standard infection control practices. The RN believed that hand hygiene and glove changes were only necessary after removing soiled dressings, not after wound cleansing. This lapse was observed during a wound treatment procedure and confirmed by the RN involved. Additionally, the facility did not ensure that all physician orders for wound care were entered into the resident's electronic medical record (EMR). A wound physician had ordered a skin protectant for the resident's heels, but this order was not entered into the EMR prior to a certain date, resulting in the treatment not being administered as prescribed. The resident had a history of an unstageable pressure ulcer of the coccyx, a deep tissue injury to the right heel, and a stage four sacral pressure ulcer. Staff interviews and record reviews confirmed that the required interventions were not consistently implemented according to physician orders and facility policy.
Incomplete and Inaccurate Medical Record Documentation for New Admission
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident who was admitted following a coronary artery bypass grafting (CABG). Upon admission, nursing notes did not document an assessment of the resident's skin or indicate the presence of any skin issues or bruising. Although the admission observation stated there were no alterations in the resident's skin, a subsequent skin assessment several days later noted incisions and bruising, but did not specify the location of the bruising. There was no documentation in the nursing notes between admission and the later assessment that referenced any bruising. Interviews with nursing staff revealed that the resident was admitted with closed incisions and bruising, which had been reported by the hospital prior to admission. However, the facility's admission assessments, skin assessments, and notes did not document the presence of incisions or bruising at the time of admission. The Director of Nursing confirmed the lack of documentation and was in the process of obtaining provider progress notes to verify the resident's condition upon admission. The facility's job description for medical records staff includes responsibilities for tracking and uploading physician notes and auditing records for discrepancies, which was not adequately performed in this case.
Failure to Obtain Complete Physician Orders for Medications on Admission
Penalty
Summary
The facility failed to obtain complete and clarified physician orders for medications at the time of admission for a resident with multiple complex diagnoses, including paroxysmal atrial fibrillation, atrial flutter, cardiac murmur, hypertension, Alzheimer's disease, and various vitamin deficiencies. Upon admission from a local hospital following a cardioversion procedure for atrial flutter with rapid ventricular rate, the resident's discharge medication list included Metoprolol Succinate, Mirtazapine, and Fosinopril. However, the orders for these medications were incomplete, lacking essential details such as dosage, route, and time of administration, with instructions simply stating "See instructions" and no further clarification provided. The Director of Nursing confirmed that these medication orders were not clarified upon the resident's admission, acknowledging that this oversight should have been identified during the nurse's confirmation of orders. Facility policy requires that all physician medication orders be complete, including the date, medication name, dosage, route, time of administration, and, if appropriate, the duration of therapy. The policy also mandates that all new orders be promptly communicated to the pharmacy. The failure to clarify and obtain complete medication orders on admission resulted in a deficiency in meeting the immediate care needs of the resident.
Delayed Medication Delivery Due to Incomplete Orders and Pharmacy Process Failures
Penalty
Summary
The facility failed to provide pharmaceutical services in a timely manner for one resident, as evidenced by repeated delays in the delivery and administration of prescribed medications following hospital discharge. Upon admission, the resident had incomplete physician orders for Fosinopril, Metoprolol Succinate, and Mirtazapine, with instructions listed as 'See instructions' and lacking specific dosage, route, or administration times. Facility staff did not clarify these orders promptly, resulting in delays in both order clarification and medication delivery. The pharmacy did not provide the medications according to the start dates indicated in the clarified physician orders, with Fosinopril not available until several days after the intended start date, and similar delays for Metoprolol Succinate and Mirtazapine. Documentation shows that staff signed off on medication deliveries days after the orders were clarified and after the medications were due to be administered. Interviews and record reviews revealed that both nursing staff and pharmacy personnel failed to follow established procedures for obtaining and delivering medications, especially outside of regular pharmacy hours. The facility's corporate nurse consultant acknowledged that staff did not clarify the incomplete hospital discharge orders in a timely manner and did not utilize the pharmacy's after-hours process to obtain urgently needed medications. The pharmacy's hours of operation and procedures for STAT orders were not effectively followed, contributing to the delay in providing necessary medications to the resident.
Failure to Prevent Significant Medication Errors Due to Delayed Order Clarification and Pharmacy Delivery
Penalty
Summary
The facility failed to prevent significant medication errors for a resident admitted after a hospital stay for atrial flutter and electro-cardioversion. Upon admission, the resident's hospital discharge medication orders for Fosinopril, Metoprolol Succinate, and Mirtazapine were incomplete, lacking clear instructions for dosage, route, or administration times. The facility did not promptly clarify these orders with the prescribing providers, resulting in delays in obtaining and administering the medications. Communication between facility nurses and providers was delayed, with significant gaps in response times documented in the electronic messaging system. As a result of these delays, the resident missed multiple doses of critical medications, including six doses of Fosinopril, one dose of Metoprolol Succinate, and three doses of Mirtazapine. The Medication Administration Record (MAR) and pharmacy delivery records confirmed that these medications were not available or not administered as ordered during the initial days following admission. The errors were attributed to incomplete hospital discharge orders, delayed clarification by facility staff and providers, and delays in pharmacy delivery, including the lack of use of backup pharmacy services. Interviews with facility staff, including the DON, Nurse Practitioner, and Corporate Nurse Consultant, confirmed the sequence of events and acknowledged the significance of the medication errors. The family member of the resident also expressed concerns about the lack of timely medication administration. The facility's own Medication Error Report documented the delay in starting the medications and the contributing factors, with staff acknowledging that the errors were significant.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, resulting in multiple inconsistencies and errors. The resident's code status was documented inconsistently across various records: the admission observations and face sheet listed the resident as Full Code, while the POLST form, signed by the resident, indicated Do Not Attempt Resuscitation (DNAR). The POLST form was not signed by a provider until 13 days after the resident's admission, and after the resident had already been transferred to the hospital. The Physician Order Sheet (POS) continued to list the resident as Full Code, which conflicted with the POLST. The Director of Nursing and Resident Service Director confirmed these discrepancies and acknowledged that the POLST and POS were incongruent and incomplete at the time of the resident's transfer to the hospital. Additional documentation errors were identified in the resident's progress notes. The Social Service Director documented that the resident was discharged home from the hospital, which was inaccurate, as the resident had expired in the hospital. The Social Service Director admitted to not verifying this information with the family before documenting it. Furthermore, the Medication Administration Record (MAR) indicated that a nurse had administered Fosinopril to the resident before the medication had been delivered to the facility, which was confirmed by pharmacy delivery records and the Director of Nursing. The nurse acknowledged that the medication could not have been administered as documented. These findings demonstrate failures in maintaining accurate and complete medical records for the resident.
Failure to Provide Effective Pain Management and Timely Provider Notification
Penalty
Summary
The facility failed to provide effective pain management, assess for pain, and report pain to the provider for two residents who required such services. For one resident with a history of stroke and right-sided spasticity, there were multiple documented instances of severe pain, including pain rated as high as 10 out of 10, facial grimacing, moaning, missed therapy sessions, and refusal to eat. Despite these clear signs of uncontrolled pain, there was no documentation that the provider was notified of the resident's increased pain until several days after the onset of symptoms. Pain assessments were inconsistently documented, and follow-up pain ratings after administration of PRN pain medications were not recorded, only noting whether the medication was effective. The resident's care plan included pain management as needed, but the interventions were not adequately implemented or communicated among staff, and therapy staff reported pain to nursing without evidence of timely provider notification or care plan adjustment. Another resident admitted for therapy following a left hip fracture did not receive a comprehensive pain assessment upon admission. The initial assessment only asked if the resident was experiencing pain at that moment and did not prompt further questions about pain history or potential for pain related to the hip fracture. The resident reported significant pain (rated 8 out of 10) on the first night, but no pain medication was ordered until the following day. Nursing staff did not report the resident's pain to the provider on the day of admission, resulting in a delay in pain management. The comprehensive pain assessment was not completed until seven days after admission, and follow-up pain ratings after PRN medication administration were not documented. The facility's pain management policy required pain assessments on admission, quarterly, with significant changes, and every shift, with provider notification as needed. However, these procedures were not followed for the two residents, leading to unmanaged pain, missed therapy, and decreased participation in activities of daily living. Staff interviews confirmed gaps in communication, documentation, and timely provider notification regarding residents' pain.
Failure to Provide Timely and Accurate Medication Administration for New Admissions
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for four newly admitted residents. In multiple instances, prescribed medications such as Latanoprost, Rosuvastatin, Trazodone, Triamcinolone, Clarithromycin, Amitriptyline, Aspirin, Metoprolol, Levofloxacin, and Atorvastatin were not given because they were not available at the time of administration. Facility policy required that medications be transcribed accurately and administered as ordered, and that backup medication supplies be checked and pharmacy, physician, and family be notified if medications were unavailable. However, these steps were not consistently followed. For each affected resident, there was a lack of documentation indicating that the pharmacy or physician had been notified about the unavailability of medications or missed doses. Nursing staff acknowledged that they did not always follow up with the pharmacy or physician, and in some cases, they were unsure if they had taken any action regarding the missed medications. Additionally, there was no evidence that medications were obtained from the backup supply when unavailable, and required documentation in nursing notes was missing. One resident's hospital discharge order for Levofloxacin was incorrectly transcribed, resulting in the medication being scheduled at the wrong interval. The Director of Nursing confirmed that the backup medication safe was not used to obtain the missing medications and that required notifications and documentation were not completed. These failures resulted in residents not receiving their prescribed medications as ordered upon admission.
Failure to Implement Antibiotic Stewardship and UTI Criteria
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required by its own policy and the McGreer Criteria for infection surveillance. Specifically, the facility did not ensure that symptoms met the criteria for urinary tract infection (UTI) and did not consistently obtain or review urine cultures before initiating antibiotic treatment for four out of six residents reviewed for antibiotic stewardship. The policy required tracking antibiotic use daily and using the McGreer Criteria to guide UTI diagnosis and treatment, including documentation of symptoms and microbiological evidence. For several residents, antibiotics were prescribed and administered without adequate documentation of symptoms or urine culture results. One resident was treated with Ciprofloxacin for UTI symptoms, but no urine culture was obtained, and there was no documentation of a McGreer form. Another resident received two courses of antibiotics for UTI, but there were no recorded symptoms for one course, and the urine culture showed mixed flora without a repeat culture. A third resident was treated with Nitrofurantoin despite a urine culture indicating resistance to this antibiotic, and there was no evidence that the culture results were reviewed or that follow-up with a physician occurred. In another case, a resident received antibiotics for UTI, but the urine culture was only obtained later and not reviewed during treatment. Interviews with facility staff confirmed that infection control logs did not consistently document symptoms or urine cultures for the affected residents. The Infection Preventionist and Director of Nursing acknowledged that required documentation, including completion of the McGreer form and review of culture results, was missing in several cases. The staff also confirmed that antibiotics were sometimes started based on family requests or preliminary urine dipstick results, without following the full protocol for confirming UTI diagnosis and appropriate antibiotic use.
Failure to Use Blind Spot Mirror Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to utilize a blind spot mirror before opening a set of double doors, resulting in a fall for a resident. The resident, who was admitted for skilled nursing and rehabilitation, was observed ambulating with a four-wheeled walker in the memory care unit. According to the fall investigation report, the resident was walking near the front door when a dietary aide opened the door, which struck the resident and caused her to lose balance and fall. A certified nursing assistant witnessed the incident and confirmed that the aide did not see the resident due to a blind spot. Interviews with staff revealed that a blind spot mirror was installed on the wall to allow visibility of the other side of the door before opening it. The dietary aide involved in the incident acknowledged that she should have checked the mirror prior to opening the door. The administrator confirmed that staff are expected to use the mirror to prevent such accidents, but in this instance, the procedure was not followed, directly leading to the resident's fall.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 74 residents. On 4/15/2024, the Dietary Manager (V16) was observed supervising dietary operations but admitted to not being a clinically qualified Certified Dietary Manager or having equivalent training. V16 also reported that the facility dietician only provides services one day per month. V16 confirmed not meeting the State of Illinois standards for a food service manager or dietary manager and lacked the necessary qualifications and experience required for the position. Throughout the survey from 4/15/2024 to 4/17/2024, the facility failed to prevent direct cross-contamination of stored food and ice, failed to date and label TCS (time/temperature control for safety) food, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food storage equipment. These deficiencies were observed in the facility's kitchen and food storage areas, indicating a lack of proper food safety and sanitation practices. The facility's Long-Term Care Facility Application for Medicare and Medicaid documented that 74 residents reside in the facility.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to prevent direct cross-contamination of stored food and ice, failed to date and label TCS (time/temperature control for safety) food, failed to prevent the potential for physical cross-contamination of food, and failed to maintain sanitary food storage equipment. Specifically, the kitchen walk-in freezer evaporator cooling unit was leaking condensate into a plastic bin, which overflowed onto shelving beneath it, exposing numerous boxes of food items, including an open box of cookies, to the leaked condensate. This leak had been present for three years according to the Dietary Manager. Additionally, an ice scoop was stored in stagnant water containing debris, and a package of cream cheese in the kitchen reach-in cooler was not labeled with a date or time opened or a use-by date. The kitchen can opener was soiled with metal shavings and food debris, and the kitchen walk-in cooler evaporator cooling unit was excessively soiled with dust, covering the entire front surface and fan guards. These deficiencies were observed over multiple days, with the Dietary Manager acknowledging the issues and taking some immediate actions such as discarding the unlabeled cream cheese and requesting staff to clean the can opener. The facility's Long-Term Care Facility Application for Medicare and Medicaid documents that 74 residents reside in the facility, all of whom could potentially be affected by these unsanitary conditions.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to timely complete Minimum Data Set (MDS) assessments for four residents (R4, R44, R49, R58) out of 18 reviewed in a sample of 36. The facility's policy requires quarterly MDS assessments to be completed at least every three months, with the MDS Coordinator responsible for ensuring their completion and weekly transmission. However, the MDS assessments for R49, R4, R44, and R58 were found to be incomplete and not updated within the required timeframe. Interviews with the MDS/Care Plan Coordinator and the Director of Nursing confirmed that the March MDS assessments for these residents had not been completed timely, with the last completed MDS assessments for these residents dating back to earlier months.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to timely transmit a Minimum Data Set (MDS) assessment for one of 18 residents reviewed for MDS assessments in the sample list of 36. The facility's MDS Completion policy requires the MDS Coordinator to ensure completion and transmission of MDS assessments at least weekly, with comprehensive assessments transmitted within 14 days of the Care Plan completion date. However, the electronic medical record for the resident indicated that the Annual MDS was completed but not submitted. The MDS/Care Plan Coordinator admitted that the MDS had not been submitted because they were unfamiliar with how to complete the Care Area Assessment (CAA) section of the MDS, confirming that the MDS would be submitted late.
Failure to Administer Ordered Enteral Feeding Amounts
Penalty
Summary
The facility failed to ensure that two residents received the recommended and ordered amount of enteral feeding. For Resident 53, the care plan included diagnoses such as traumatic brain injury, aphasia, spastic hemiplegia, encephalopathy, gastro-esophageal reflux disease, and dysphagia. The physician's order specified that the resident should receive 1890 ml of Fibersource HN per day. However, observations on multiple occasions revealed that the feeding pump was not turned on, and the resident did not receive the ordered amount of feeding on 12 out of 16 days reviewed. Despite these deficiencies, the resident did not appear dehydrated or malnourished, and there was no significant weight loss documented over the past six months. For Resident 11, who had diagnoses including multiple sclerosis and dysphagia, the physician's order specified that the resident should receive 1900 ml of Fibersource per day. Observations and interviews indicated that the resident did not receive the ordered amount of feeding on 13 out of 16 days reviewed. The resident communicated that there were no concerns regarding the feedings and did not appear dehydrated or malnourished. The resident's weight fluctuated but did not show any significant weight loss or gain over the past six months. The Director of Nursing confirmed that both residents were not receiving the ordered amount of feeding via their G-tubes. The facility's failure to administer the prescribed enteral feeding amounts as ordered by the physician constitutes a deficiency in care, as documented by the surveyors.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration and did not include the use of oxygen in the care plan for a resident. The resident had diagnoses including Alzheimer's Disease with Late Onset, Anxiety Disorder, Acute Upper Respiratory Infection, Cough, and Wheezing. Despite an order to change oxygen tubing and humidification bottle weekly, there was no order specifying the amount of liter flow or the type of administration (nasal cannula or mask). The resident was observed in bed with oxygen administered via nasal cannula, but the oxygen setting was not visible. The Director of Nursing confirmed that nurses can start oxygen as a nursing measure but must obtain a doctor's order, which was not present in the resident's electronic medical record.
Failure to Accurately Assess and Document Side Rail Use
Penalty
Summary
The facility failed to accurately and routinely assess side rail use per its policy, obtain consent for side rail use, document alternative interventions attempted prior to use, and care plan for side rails for two residents. One resident had a half-length side rail in the upright position on one side of the bed, but the resident stated they did not really use the railing. The resident's medical records showed moderate cognitive impairment and independence in bed mobility, but the side rail assessment was incomplete and inaccurate, and there was no documented consent for side rail use. Additionally, the resident's care plan did not document side rail use, and the CNAs were unsure about the side rail's usage and duration on the bed. The Director of Nursing confirmed the assessment's inaccuracies and lack of consent documentation, and the MDS/Care Plan Coordinator confirmed the care plan did not include side rail use. Another resident was observed with half side rails in the upright position on both sides of the bed and stated they used the side rails to assist with turning in bed and to prevent falling out. The resident's medical records showed moderate cognitive impairment and substantial assistance required for bed mobility, but the side rail assessment was incomplete and inaccurate. The assessment inaccurately documented the resident's safety awareness and bed mobility, and there was no documented consent for side rail use. The Director of Nursing and the MDS/Care Plan Coordinator confirmed the assessment's inaccuracies and the care plan's lack of documentation for side rail use. The Director of Nursing stated that side rail assessments are done upon admission and annually, but was unaware that the facility's policy required re-evaluation every 90 days. The assessments were supposed to be completed by the floor nurse, who should observe the resident's use of the side rail, review medication use, and document prior alternative interventions used. The Director of Nursing confirmed the assessments were incomplete and inaccurate, and the care plans did not include side rail use for the residents in question.
Failure to Adhere to Psychotropic Medication Policies
Penalty
Summary
The facility failed to complete quarterly psychotropic medication assessments, identify and document specific targeted behaviors and nonpharmacological interventions, include a duration for PRN psychotropic medication orders, obtain and document consent for psychotropic medication use, and rule out underlying causes of behaviors prior to initiating psychotropic medications for three residents. These deficiencies were identified during a review of the medical records and interviews with staff members, revealing significant lapses in the facility's adherence to its own Psychopharmacologic Drug Usage Procedure dated 10/18/17. One resident, who had moderate cognitive impairment and exhibited delusions and verbal behaviors, had their Seroquel dosage increased without documentation of nonpharmacological interventions being attempted first. The resident's care plan and behavior tracking forms did not accurately reflect the specific behaviors related to delusions about their spouse and stolen items. Additionally, the facility did not conduct psychotropic medication assessments quarterly as required, with a significant gap between assessments. Another resident was prescribed alprazolam and venlafaxine without the required 14-day limitation for PRN orders and without documented consent for the psychotropic medications. A third resident, admitted for therapy following a surgical hip fracture repair, was started on Risperidone without prior behavioral tracking or documentation of delusional behaviors. The facility also failed to investigate the root cause of the resident's aggressive behaviors during perineal care, which were likely related to pain from the surgical site. The facility's Director of Nursing acknowledged these deficiencies and the lack of adherence to the facility's policies and procedures.
Failure to Obtain Culture for Antibiotic Stewardship
Penalty
Summary
The facility failed to obtain a culture to ensure the appropriate antibiotic was being used for a resident with a history of urinary tract infections. On 2/28/24, the resident was noted to be sleeping more than usual, and a urine dip test was performed. However, when labs were drawn on 2/29/24, neither a urinalysis nor a culture and sensitivity test was ordered. Despite this, Cipro 500 milligrams was prescribed and administered twice daily for ten days starting on 2/29/24. The Director of Nursing later confirmed that a culture should have been done to ensure the correct antibiotic was given. Less than 30 days after the final dose of Cipro, the resident had another urinary tract infection that required antibiotics.
Failure to Administer Pneumonia Vaccines as Recommended
Penalty
Summary
The facility failed to offer and administer the pneumonia vaccine as recommended for two residents. The facility's policy, revised on 8/11/22, mandates that all residents aged 65 years or more, and those at high risk, be offered the Pneumococcal vaccine according to CDC guidelines. However, the facility did not adhere to this policy for two residents. Resident R21, who has a diagnosis of Cerebral Palsy and is 65 years old, received a PPSV23 vaccine on 3/9/20 but did not receive the required PCV15 or PCV20 to be up to date. Similarly, Resident R48, who is also 65 years old, received a PPSV23 on 12/9/15 but did not receive the necessary PCV15 or PCV20 vaccine. The Registered Nurse/Infection Preventionist (V9) admitted to not documenting attempts to obtain consent from R48 for the pneumonia vaccine, despite multiple attempts. Additionally, V9 was initially unaware that R21 was due for another vaccine until reviewing the guidelines. These lapses in following the facility's vaccination policy and CDC recommendations led to the deficiency in providing appropriate immunizations to the residents.
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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