Hillcrest Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Geneseo, Illinois.
- Location
- 14688 Illinois Highway 82, Geneseo, Illinois 61254
- CMS Provider Number
- 145949
- Inspections on file
- 23
- Latest survey
- May 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hillcrest Home during CMS and state inspections, most recent first.
A dietary aide was observed placing meal tickets in her mouth, retrieving one from the floor with her bare hand, and then preparing and serving drinks to a resident without performing hand hygiene. The aide subsequently delivered additional meal trays without washing her hands, despite having completed required food handler training. The dietary supervisor confirmed these actions did not meet infection control standards.
The facility did not have a licensed Administrator overseeing daily operations, as required by policy and regulation. Over several days of observation, no Administrator was present or had a posted license. The DON confirmed acting in the Administrator role since the position became vacant, with oversight from the County Administrator. This affected all residents in the facility.
The facility did not notify the Ombudsman of hospital discharges and transfers for several Private Pay residents, as required. The omission occurred because the report sent to the Ombudsman excluded Private Pay residents, and staff were unaware that these residents should be included.
A wound nurse brought a treatment cart containing wound care supplies for multiple residents into a resident's room during pressure ulcer care, contrary to facility policy requiring the cart to remain outside. This practice, observed and confirmed by staff, increased the risk of cross-contamination among residents receiving wound care.
A resident who was cognitively intact was listed as DNR in the POLST and care plan, but there was no documentation of any discussion with the resident about code status. When interviewed, the resident stated a preference for full resuscitation, indicating the facility did not ensure advance directives reflected the resident's wishes.
Two residents experienced falls due to improper transfer techniques and lack of supervision, with one resident not having safety straps fastened during a mechanical lift transfer and another falling from a wheelchair without brakes locked. Both incidents were not thoroughly investigated or monitored according to policy, with missing documentation, incomplete assessments, and delayed interdisciplinary review.
The facility posted its daily nurse staffing information in a format that was unclear and did not include the facility's name. The posted sheet showed calculations for licensed nurse and direct care hours, with actual RN, LPN, and CNA numbers written off to the side. The DON confirmed this was the standard posting method used for some time.
A resident with severe cognitive impairment and on anticoagulant medication experienced an unwitnessed fall. The facility delayed notifying the physician by five hours and failed to mention the anticoagulant use, which is crucial due to the increased risk of bleeding. Staff interviews revealed inconsistencies in the notification process, and no policy for notification of changes was provided.
The facility quarantined six residents without clear reasoning, causing one resident to become very upset. Staff members were confused and frustrated, noting that the symptoms were consistent with seasonal allergic rhinitis. The Infection Preventionist later admitted to overreacting and acknowledged that the resident could have been allowed to leave his room with a mask on.
The facility failed to implement its Antibiotic Stewardship Program, as the Infection Preventionist stated that no protocols are in place to review clinical signs and symptoms or lab reports before administering antibiotics. Instead, staff call the doctor for an antibiotic order if they believe one is needed, affecting all 62 residents.
The facility failed to ensure that call lights were equipped to communicate directly to staff, leading to long wait times for residents needing assistance. Staff were not always aware of activated call lights, and the system's sound alerts were often turned down or not functioning properly. Interviews and observations confirmed that the new system hindered prompt responses, especially during busy times.
A resident with impaired cognition and a history of falls experienced a fall due to the absence of a non-slip mat in her wheelchair, despite it being a documented fall prevention intervention in her care plan. The facility's failure to ensure the mat was in place led to the deficiency.
A facility failed to ensure that PRN psychotropic medications were not prescribed for more than 14 days for a resident. Despite the facility's policy, a resident's PRN order for Lorazepam was extended for six months without proper justification, and staff interviews revealed that this practice was common, leading to the deficiency.
A CNA, inadequately trained on a specific facility van, failed to yield at an intersection while transporting a resident from the hospital, resulting in a collision with two other vehicles. Both the CNA and the resident were evaluated at the ER with no injuries reported. The CNA received a traffic citation for failure to yield.
Failure to Follow Infection Control Practices During Meal Service
Penalty
Summary
A deficiency was identified when a dietary aide was observed engaging in improper infection control practices while serving meals in the dining room. Specifically, the aide placed two meal tickets in her mouth, dropped one on the floor, picked it up with her bare hand, and then proceeded to pour apple juice and prepare hot chocolate for a resident without performing hand hygiene. The aide then delivered the drinks and meal trays to residents without washing her hands. The dietary supervisor confirmed that the aide had completed the required food handler training and acknowledged that the actions taken were not in accordance with proper infection control procedures.
Failure to Employ Licensed Administrator to Oversee Facility Operations
Penalty
Summary
The facility's governing body failed to employ a licensed Administrator to oversee and manage daily operations, as required by policy and regulation. Review of the facility's census roster and matrix confirmed that 46 residents were present in the facility. The Administrator's job description specifies that the Administrator must hold a current, unencumbered nursing facility Administrator's license and is responsible for supervising all departments and ensuring compliance with applicable laws and regulations. Observations conducted over several days revealed that there was no licensed Administrator present in the building, nor was an Administrator's license posted. The Director of Nursing confirmed that the facility had not had an Administrator since a specific date and that she was acting in that capacity, with the County Administrator serving as a resource. The absence of a licensed Administrator was acknowledged by facility leadership.
Failure to Notify Ombudsman of Hospital Transfers for Private Pay Residents
Penalty
Summary
The facility failed to notify the Ombudsman of all hospital discharges and transfers for four residents who were hospitalized, as required. Review of the Hospital Tracking Portal showed that these residents were transferred to the hospital, but their information was not included in the facility's Admit Discharge report for the relevant period. An interview with the Business Office Manager revealed that the report sent to the Ombudsman excluded residents with Private Pay as their primary payer source, due to a lack of awareness that these residents should also be included. The Daily Census confirmed that the affected residents were Private Pay at the time of their hospital transfers.
Failure to Prevent Cross-Contamination During Wound Care
Penalty
Summary
The facility failed to maintain a contamination-free environment during wound care for a resident receiving treatment for a pressure ulcer. Specifically, the wound nurse brought the facility's treatment cart, which contained wound care supplies for multiple residents, into the resident's room and placed supplies on top of the cart before performing wound care. This action was observed during wound care for a resident with physician orders for daily cleansing and dressing of a sacral pressure ulcer. The facility's policy for clean dressing technique specifies that the treatment cart should not be brought into the resident's room and that a clean field should be established using clean linen or a plastic field, not on the treatment cart itself. Interviews with facility staff confirmed that the treatment cart is intended to remain outside the resident's room, and the infection control coordinator verified that bringing the cart into the room is against facility policy. The wound care supplies for all residents receiving wound care were stored in the same treatment cart, which was moved from room to room, increasing the risk of cross-contamination. This practice was observed and acknowledged by staff, and the facility's own policy documentation was provided to confirm the correct procedure.
Failure to Honor Resident's Advance Directive Preferences
Penalty
Summary
The facility failed to ensure that advance directives accurately reflected a resident's current preferences regarding life-sustaining treatment. According to the facility's policy, the POLST (Practitioner Order for Life-Sustaining Treatment) form should be completed or reviewed with the resident and/or their legal representative and updated periodically to reflect the resident's wishes. For one resident, the POLST form and care plan documented a Do Not Resuscitate (DNR) status, but there was no evidence in the clinical record that any discussion had occurred with the resident regarding their code status preferences. During an interview, the resident, who was documented as cognitively intact on both admission and quarterly MDS assessments, stated that no one had asked about their wishes in the event of cardiac or respiratory arrest and clearly expressed a desire for full resuscitation efforts. The Social Service Director reported that code status is typically discussed with residents or their representatives, but in this case, decisions were made by the state guardian without documented input from the resident, despite the resident's capacity to make such decisions.
Failure to Ensure Safe Transfers and Adequate Post-Fall Monitoring
Penalty
Summary
The facility failed to ensure safe transfer practices and adequate post-fall monitoring for two residents, resulting in deficiencies related to accident prevention and investigation. One resident, identified as being at moderate risk for falls, experienced a fall during a transfer from the toilet to a wheelchair using a mechanical lift. The CNA responsible did not position the resident's feet correctly on the lift platform, failed to fasten the safety strap behind the resident's legs, and did not listen to the resident's concerns about foot positioning. This improper technique led to the resident's foot slipping and a subsequent fall to the floor. The care plan required these safety measures, but they were not followed during the incident. Another resident, with a history of falls and multiple risk factors such as impaired balance and weakness, fell while attempting to hang up a phone from her wheelchair, which did not have the brakes locked. The resident sustained a deep laceration to her right elbow, which was not appropriately assessed or monitored according to facility policy and physician orders. The wound was not identified by therapy staff who witnessed the fall until the following day, and there was a lack of documentation of vital signs and wound assessments for the required periods post-fall. The interdisciplinary team did not review the incident until nine days after the fall, and key witness interviews were missing from the investigation. The facility's fall prevention policy required thorough investigation, monitoring, and documentation following any fall, including witness statements, post-fall huddles, and ongoing resident assessments. In both cases, these procedures were not fully implemented, resulting in incomplete investigations and insufficient monitoring of the residents' conditions after their accidents. The failures included not following care plan interventions, not conducting timely and complete assessments, and not ensuring all relevant staff were interviewed as part of the investigation.
Deficient Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that its posted nurse staffing information was presented in a clear format and included the name of the facility. On the date of observation, the Minimum Daily Staffing Calculations sheet was posted in the front hallway, but it did not display the facility's name and was not easily readable. The posted sheet documented calculations for total licensed nurses and non-nurse staffing hours, with the actual numbers of RNs, LPNs, and CNAs written off to the side. The Director of Nursing confirmed that this calculation sheet is the one used for posting and has been used for an extended period. At the time of the survey, 46 residents resided in the facility.
Failure to Timely Notify Physician of Resident Fall and Anticoagulant Use
Penalty
Summary
The facility failed to notify a physician in a timely manner following an unwitnessed fall of a resident, who was on anticoagulant medication. The resident, identified as R2, had severe cognitive impairment and was taking Eliquis for chronic atrial fibrillation. After the fall, the resident was found on the floor, and although vital signs were within normal limits and no injuries were noted, the physician was notified five hours later via fax. The notification did not include the critical information that the resident was on anticoagulant medication, which is essential due to the increased risk of bleeding. Interviews with facility staff revealed inconsistencies in the notification process. The Assistant Director of Nursing stated that the physician should have been notified immediately and informed about the anticoagulant medication. The LPN mentioned that she would typically call the physician rather than fax them, and the Medical Director expressed a preference for phone calls in such situations. The facility did not provide a policy for notification of changes, indicating a lack of clear guidelines for staff to follow in these situations.
Unnecessary Quarantine of Residents
Penalty
Summary
The facility quarantined six residents to remain in their rooms without clear reasoning, causing one resident to become very upset and anxious. The facility's policy for outbreak investigation requires measures to be instituted when there is an incidence of infections above what would normally be expected. However, upon entry to the facility, no staff members were wearing masks, and the receptionist stated there were no known outbreaks or illnesses. Later, staff members were observed passing out surgical masks and instructing others to mask up due to an outbreak status. The Infection Preventionist decided to implement masking because of an uptick in respiratory issues but did not indicate that residents were being asked to remain in their rooms at that time. Multiple staff members expressed confusion and frustration over the decision to quarantine residents, noting that the symptoms were consistent with seasonal allergic rhinitis rather than an outbreak of infectious disease. One resident, in particular, was very upset about being confined to his room, expressing his frustration to staff members and questioning the inconsistency of the quarantine measures. The resident had been experiencing respiratory symptoms for about a week but was starting to feel better. Despite this, he was kept in his room unnecessarily for several meals. The Infection Preventionist later admitted to overreacting and acknowledged that the resident could have been allowed to leave his room with a mask on. The lack of clear communication and investigation into the residents' symptoms before implementing the quarantine measures led to unnecessary confinement and distress for the affected residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, which has the potential to affect all 62 residents. The facility's policy requires the Infection Preventionist to encourage and educate staff to use McGeer's definitions of infections and to monitor vital signs, intake and output, lung sounds, and other signs of infection. However, the Infection Preventionist stated that the facility does not implement any protocols to review clinical signs and symptoms or laboratory reports before administering antibiotics. Instead, they simply call the doctor to get an antibiotic order if they believe one is needed. This lack of protocol adherence was confirmed through interviews and record reviews.
Failure to Ensure Effective Call Light System
Penalty
Summary
The facility failed to ensure that call lights were equipped to communicate directly to staff, affecting the response time to residents' needs. The Software User Guide indicated that the nurse call system was designed for Independent and Assisted Living facilities, requiring staff to be at their computers to receive alerts. Multiple residents reported long wait times for assistance, with one resident stating they had waited up to 70 minutes. Observations confirmed that staff were not always aware of activated call lights, and the system's sound alerts were often turned down or not functioning properly. Additionally, the system required frequent restarts, and staff had to manually check computers to identify alarms, leading to delays in response times. Interviews with staff revealed that the new system hindered their ability to respond promptly to call lights, especially during busy times. Physical and occupational therapists noted that they were no longer alerted to nurse calls, further impacting response times. Observations showed that call lights remained active for extended periods without staff intervention, and the system's volume was often turned down due to its annoying sound. The facility's administrator acknowledged that in case of power or Wi-Fi loss, alternative measures like bells and 15-minute checks were implemented, but these were not sufficient to address the ongoing issues with the call light system.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure fall interventions were implemented to prevent further falls for a resident reviewed for falls. The resident, who was nonverbal and had impaired cognition, was found lying in a low bed with a fall mat next to her bed. The resident's care plan indicated a risk for falls due to impaired balance, poor coordination, and poor safety awareness. Despite this, the resident experienced a fall when she slid out of her chair in the dining room, and it was noted that a non-slip mat, which was a previously implemented fall prevention intervention, was not in place in her wheelchair at the time of the fall. The facility's Fall Reduction Program policy required that all residents receive adequate supervision, assistance, and assistive devices to prevent falls. However, after the investigation of the resident's fall, it was confirmed that the non-slip mat was missing from the resident's wheelchair, and staff had to be re-educated to ensure the mat was in place. This lapse in following the care plan and ensuring the necessary fall prevention measures were in place led to the deficiency identified by the surveyors.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that psychotropic medications given on an as-needed (PRN) basis were not prescribed for more than 14 days for one resident. The facility's policy requires that residents with dementia receive appropriate treatment to maintain their highest practicable well-being. However, the Physician Order Sheet for the resident documented a prescription for Lorazepam 0.5 mg every eight hours for anxiety, which was extended beyond the 14-day limit without proper justification. Observations of the resident showed no behaviors that would necessitate the continued use of the medication, and staff interviews indicated that the resident's behaviors were typically related to urinary tract infections rather than ongoing anxiety or aggression. The Medication Administration Records indicated that the last administration of Ativan on a PRN basis was several months prior, yet the PRN order was extended for six months without a documented stop date. Staff interviews confirmed that it was not the facility's policy to extend PRN psychotropic orders beyond 14 days, but it was a common practice. This discrepancy between policy and practice led to the deficiency, as the facility did not adhere to its own guidelines for the administration of psychotropic medications on a PRN basis.
Failure to Operate Facility Van Safely
Penalty
Summary
Facility staff failed to operate the facility van safely, resulting in an accident involving a resident. The incident occurred when a Certified Nursing Assistant (CNA) was instructed to pick up a resident from the hospital using a facility van. The CNA, who had not been adequately trained on the specific van, struggled with its operation and was under pressure due to the weather conditions and the urgency of the task. The CNA failed to yield at an intersection, causing a collision with two other vehicles. Both the CNA and the resident were taken to the emergency room for evaluation, with no injuries reported. The facility's policy on transportation requires employees to use facility vehicles for transporting residents and mandates immediate reporting of any accidents. The CNA involved had been employed at the facility for several years and had some prior training in transportation but was not familiar with the specific van used on the day of the incident. The CNA expressed dissatisfaction with the situation, citing a lack of proper training and the stressful circumstances under which the task was assigned. The police report confirmed that the CNA failed to yield at the intersection, leading to the accident. Witnesses and the CNA's own account corroborated the sequence of events. The CNA was issued a traffic citation for failure to yield. The incident highlights a lapse in ensuring that staff operating facility vehicles are adequately trained and familiar with the specific equipment they are required to use, as well as the importance of following designated routes to avoid hazardous intersections.
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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