Heartland Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Neoga, Illinois.
- Location
- 101 Trowbridge Road, Neoga, Illinois 62447
- CMS Provider Number
- 146030
- Inspections on file
- 32
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Heartland Senior Living during CMS and state inspections, most recent first.
A newly admitted high fall-risk resident, identified as needing supervision for unsteady gait and unsafe transfers, activated a bathroom call light that was not promptly answered. Facility policy requires prompt response to call lights, but one CNA at the nurses’ station did not monitor the call light panel, assuming most residents were in the dining room, while another CNA saw the call light while passing meal trays and assumed it would be answered, delaying response for about seven minutes. When the second CNA finally entered the room, the resident was found prone on the bathroom floor and unresponsive, with a bleeding skin tear; an LPN was notified and EMS was called. The DON stated that all new admissions are treated as fall risks and that staff are expected to respond immediately to call lights or within a few minutes if occupied, and to communicate to ensure call lights are answered. A subsequent brain scan showed acute swelling and bleeding on both sides of the brain related to the fall.
A resident with significant mobility deficits and a need for two-person assist was transferred by a single CNA without a gait belt, resulting in a fractured arm. The CNA was unaware of the resident's transfer requirements and did not follow facility policy, leading to the resident experiencing severe pain and requiring hospital treatment.
A resident was struck by another resident in the sunroom, violating their right to be free from abuse. The resident who was struck is cognitively intact, while the aggressor has dementia with agitation. An LPN witnessed the incident, and the facility's abuse prevention policy was not upheld.
A facility failed to follow physician orders for insulin administration for a resident with Type II Diabetes Mellitus. The resident's insulin was administered without checking blood sugar levels as required, despite specific instructions to hold insulin if levels were below 90. The DON acknowledged the oversight, noting the resident was a brittle diabetic with changing insulin orders.
The facility failed to provide necessary interventions to prevent and manage pressure injuries for several residents. A resident developed a new deep tissue injury due to the absence of heel protectors, while another resident's existing pressure injury worsened. Inconsistent and missing wound assessments were noted for two other residents, highlighting gaps in wound care management.
The facility failed to prevent injuries during mechanical lift transfers for a resident, resulting in skin tears on both shins. Additionally, a dementia resident was able to elope from the facility due to inadequate supervision when a visitor propped open a door, allowing the resident to exit unnoticed.
A facility failed to obtain the necessary consent for administering Sertraline, a psychotropic medication, to a resident. The facility's policy requires written consent before administering such medications. However, the resident's medical record lacked signed consents for the prescribed 75mg and 100mg doses, as confirmed by the DON, who only had consents for 25mg and 50mg doses.
A resident with cognitive intactness and significant medical needs reported being roughly handled by a CNA, resulting in bruises. Despite the resident's complaints and visible bruises, staff failed to report the allegations to the facility's Administrator, violating the facility's abuse reporting policy.
A resident with chronic kidney disease and benign prostatic hypertrophy experienced unsafe catheter care, with tubing dragging on the floor and improper handling during transfer, leading to urine backflow. The catheter was not anchored, causing pain and redness around the urinary meatus. The resident was on antibiotics for recurrent UTIs, and the DON acknowledged the catheter bag should be kept below bladder level.
A resident with multiple health conditions was at risk of infection due to improper IV medication administration by an LPN. The LPN opened the catheter system, contrary to protocol, and allowed blood to drip while priming Vancomycin, leading to a deficiency in safe and aseptic IV administration.
The facility failed to ensure proper respiratory care for two residents by not having orders for oxygen use and not changing oxygen/nebulizer equipment as per policy. One resident had an oxygen concentrator without a documented order or dated tubing, while another used a nebulizer with undated equipment, contrary to facility policy.
Failure to Promptly Respond to Call Light for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly respond to a call light for a newly admitted resident who had been identified as a high fall risk and required staff supervision due to unsteady gait and safety concerns with transfers and ambulation. The facility’s undated Call Light System policy requires staff to respond promptly when a call light is activated, address the resident’s need or request, and, if unable, locate another staff member who can meet the need. The resident was admitted and within approximately five hours sustained an unwitnessed fall with suspected injury and loss of consciousness, with nursing notes documenting a bleeding skin tear on the left arm and an emergency transfer to the hospital. The incident report shows that at approximately 4:25 p.m., a CNA going to respond to the resident’s bathroom call light found the resident on the bathroom floor, unresponsive and lying prone. Interviews revealed that one CNA was at the nurses’ station at the time of the fall and was not paying attention to the call light panel, assuming most residents were in the dining room. Another CNA observed the resident’s call light blinking and sounding while passing meal trays and assumed the CNA at the nurses’ station would answer it, continuing to pass trays. When this CNA later returned to the hall, the call light was still flashing and sounding; she then entered the room and found the resident on the floor, estimating about seven minutes had passed from when she first noticed the call light. The LPN reported arriving to find the resident unresponsive with a bleeding skin tear and contacting EMS. A brain scan documented acute swelling and bleeding on both sides of the brain as a result of the fall. The DON stated that newly admitted residents are treated as fall risks and that his expectation is that any staff member aware of a call light should respond immediately, or within five to eight minutes if actively assisting another resident, and that communication between CNAs should have ensured the call light was answered.
Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments and a documented need for maximum assistance of two staff for transfers was transferred by a single certified nurse aide (CNA) without the use of a gait belt. The resident, who had diagnoses including unsteadiness on feet, muscle weakness, osteoarthritis, and polyneuropathy, was dependent on staff for mobility and required hands-on assistance for all transfers, as documented in the care plan and quarterly assessment. On the day of the incident, the resident activated the call light for assistance to use the bathroom, and the CNA responded alone, transferring the resident from the wheelchair to the toilet using a 'bear hug' technique without a gait belt. During the transfer, the resident became weak and complained of left arm pain immediately after being seated on the toilet. The CNA later stated that they believed the resident required only one-person assistance, despite documentation indicating a two-person assist was necessary. The CNA also confirmed that a gait belt was not used during the transfer, contrary to facility policy, which requires gait belts for all hands-on transfers unless contraindicated. The Director of Nursing confirmed that multiple communication methods were in place to inform staff of residents' transfer status, and there were no staffing shortages at the time of the incident. Following the transfer, the resident exhibited severe pain and was sent to the hospital, where an acute fracture of the left upper arm was diagnosed. Medical records and staff interviews confirmed that the injury was consistent with improper transfer technique and lack of appropriate assistance. The resident, who previously experienced minimal pain, reported daily pain following the incident and was placed on a non-weight bearing order for the affected arm.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident where one resident struck another on the cheek in the sunroom. The incident report dated 1/19/25 documents that the resident who was struck is cognitively intact, while the resident who committed the act has unspecified dementia with agitation and cognitive communication deficit. The care plan for the resident who was struck indicates a risk for inappropriate altercations with other residents, while the care plan for the resident who struck indicates a history of verbal abuse towards roommates and new residents. On 1/28/25, the resident who was struck reported being backhanded in the mouth by the other resident, possibly after bumping into them with a wheelchair. The resident who struck claimed that the other resident was trying to block their path. A Licensed Practical Nurse (LPN) witnessed the aftermath, hearing the struck resident yell and the other resident express that the action was deserved. The facility's Abuse Prevention Program, dated October 2022, affirms the residents' right to be free from abuse, which was not upheld in this incident.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for the administration of insulin to a resident diagnosed with multiple conditions, including Type II Diabetes Mellitus. The resident had a physician order for Insulin Lispro to be administered subcutaneously at 10:00 AM within ten minutes of eating a meal, with specific instructions to hold the insulin if blood sugar levels were below 90 and to notify the endocrinologist if levels were below 70 on three consecutive occasions. However, the medication administration record for June 2024 indicated that the insulin was administered daily from June 6 to June 23 without checking the resident's blood sugar levels prior to the 10:00 AM administration, as required by the physician's order. Interviews with the Director of Nursing revealed that the resident was considered a brittle diabetic, and the insulin orders had been changed multiple times during the resident's stay. Despite this, the facility did not document the resident's blood sugar levels before administering the insulin, which was a clear deviation from the physician's orders. This oversight in following the prescribed protocol for insulin administration represents a failure in the facility's medication management practices.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary interventions to prevent the development and worsening of pressure injuries for several residents. Resident R10, who was at risk for pressure ulcer development due to decreased strength and mobility, was observed without heel protectors, which were part of her care plan to prevent pressure injuries. This lack of intervention led to the development of a new deep tissue injury on R10's right heel. Staff members, including the Director of Nursing and a Licensed Practical Nurse, acknowledged that the absence of heel protectors likely contributed to the injury. Resident R47 also experienced a failure in care, as she was observed without heel protectors despite physician orders requiring them. This oversight resulted in a new deep tissue injury on R47's right heel and the worsening of an existing unstageable pressure injury on her left heel. The facility's weekly wound reports documented the progression of R47's injury, but there were gaps in the measurements and assessments, indicating a lack of consistent monitoring and intervention. Additionally, residents R53 and R39 experienced deficiencies in wound care management. R53's medical records showed inconsistent and missing measurements for a pressure wound on the sacrum, with unexplained discrepancies in assessments. Similarly, R39's records lacked documentation of wound assessments and measurements for a pressure ulcer on the coccyx, with only one recorded measurement. The Director of Nursing confirmed the missing assessments and attributed them to the absence of a wound nurse, highlighting a gap in the facility's ability to provide adequate wound care management.
Failure to Prevent Injuries and Supervise Residents
Penalty
Summary
The facility failed to prevent injuries during mechanical lift transfers for a resident, identified as R10, who suffered skin tears on both shins. Observations revealed open areas with dried, blood-soaked dressings on R10's shins. The facility's documentation noted a new skin tear on R10's right shin on 4/24/24, but no new interventions were recorded. A subsequent risk evaluation on 5/3/24 identified a skin tear on R10's left shin caused by the mechanical lift. Despite these incidents, the facility's weekly wound report on 5/27/24 only documented the left shin tear, omitting the right shin injury. The Director of Nursing confirmed that the mechanical lift was the cause of the injuries. Additionally, the facility failed to supervise a dementia resident, R56, to prevent an elopement. R56, who is severely cognitively impaired and requires maximum assistance for daily activities, was found outside the facility in a wheelchair, having followed a visitor who had propped open a door. The visitor had paused the alarm on the back sliding doors, allowing R56 to exit unnoticed. The facility's administrator acknowledged that staff should have been more vigilant and noted that the facility's elopement policy only addresses actions after a resident is found missing, lacking guidance on monitoring residents when doors are left open.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent for administering a psychotropic medication to one of the residents reviewed. According to the facility's Psychotropic Medication Use-Management Policy dated 10/1/2019, consent must be obtained from the resident or their representative before administering any psychotropic medication, and this consent should be documented in writing. However, for a resident with a physician's order dated 4/26/24 for Sertraline 75mg to be administered daily, the medical record lacked a signed consent for both the 75mg and 100mg doses. The Director of Nursing confirmed the absence of consents for these doses, noting that only consents for 25mg and 50mg doses were available.
Failure to Report Alleged Abuse of Resident
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident, identified as R22, to the Abuse Coordinator. R22, who has medical diagnoses including Non Traumatic Intracerebral Hemorrhage and Diastolic Heart Failure, reported being pushed and handled roughly by a Certified Nurse Aide (CNA), identified as V3. R22, who is cognitively intact and requires maximum assistance for transfers, stated that V3 pushed her around and left bruises on her right arm. Despite R22's complaints to another CNA, V4, and the presence of bruises, the allegations were not reported to the facility's Administrator or Director of Nurses. Interviews with staff revealed a lack of understanding and adherence to the facility's abuse reporting policy. V6, a Registered Nurse, and V4, a CNA, both observed bruises on R22 but did not report them, believing they were not indicative of abuse. V3, the CNA accused of rough handling, acknowledged that R22 had complained about being hurt but did not report the incident, assuming it was typical behavior for R22. The facility's policy requires immediate reporting of any abuse allegations to the Administrator, which was not followed in this case.
Failure to Maintain Safe and Sanitary Catheter Care
Penalty
Summary
The facility failed to maintain a urinary catheter in a safe, sanitary, and dignified manner for a resident with chronic kidney disease and benign prostatic hypertrophy. The facility's policy on catheter care, revised in September 2005, outlines procedures to prevent urinary tract infections, including keeping catheter tubing and drainage bags off the floor, ensuring the drainage bag is positioned lower than the bladder, and securing the catheter with a leg strap to reduce friction and movement. However, during an observation, the resident was seen with catheter tubing dragging on the floor, and the catheter bag was not contained in a dignity bag. During catheter care, a CNA lifted the catheter bag to the level of the resident's chest, causing urine to backflow into the catheter tubing. The CNA was unaware that the drainage bag should be kept below the bladder level. Additionally, the catheter was not anchored, leading to torsion on the tubing, and the resident reported pain when the tube was pulled. Redness was observed around the urinary meatus, and the resident's medication administration record included an order for an antibiotic for recurrent urinary tract infections. The Director of Nursing acknowledged that the catheter bag should not be above the bladder level and that an anchor device is usually used.
Improper IV Medication Administration
Penalty
Summary
The facility failed to properly administer intravenous medication to a resident, leading to a potential risk of infection. The resident, who had a diagnosis list including cellulitis, diabetes mellitus type two, rhabdomyolysis, insomnia, depression, hypertension, and joint pain, was ordered to receive Vancomycin intravenously. On the specified date, an LPN unscrewed the needleless cap from the end of the intravenous catheter, exposing the catheter line to air, which is against the facility's protocol for maintaining a closed system. The LPN then used an alcohol swab on the open end of the catheter and flushed it with normal saline, allowing blood to drip on the floor while priming the Vancomycin through the tubing. The Director of Nursing later confirmed that the LPN had been instructed to keep the system intact and not to open it, indicating a lack of adherence to proper intravenous administration procedures. The actions taken by the LPN, such as opening the catheter system and wiping the open catheter with alcohol, were not in line with the facility's protocol and could potentially lead to an infection for the resident. This incident highlights a deficiency in the safe and aseptic administration of intravenous fluids and electrolytes as per the facility's documented procedures.
Failure to Ensure Proper Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R265 and R266, by not ensuring proper orders and equipment management. For R265, there was an oxygen concentrator in the room, but the hydration bottle and oxygen tubing were not dated, indicating when they were last changed. Additionally, there was no documented order for oxygen administration or tubing changes in R265's Medication Administration Record, Treatment Administration Record, or Order Summary Report. Despite this, a nurse's note indicated that R265 was using oxygen via nasal cannula, and the Director of Nursing confirmed the absence of an active order for oxygen administration. For R266, the nebulizer machine was observed with tubing and a mask that were not dated to indicate when they were last changed, despite the resident using the nebulizer multiple times that day. The facility's policy requires nebulizer tubing and masks to be changed every 24 hours, but R266's records did not document any orders for such changes. The Director of Nursing stated that all tubing is changed on Saturday nights, but this task was not documented in the resident's Treatment Administration Record. R266 had orders for nebulizer treatments due to pneumonia, but there was no documentation of orders for changing the nebulizer equipment.
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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