Hillsboro Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsboro, Illinois.
- Location
- 1300 East Tremont Street, Hillsboro, Illinois 62049
- CMS Provider Number
- 145500
- Inspections on file
- 52
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Hillsboro Rehab & Hcc during CMS and state inspections, most recent first.
Multiple residents with dementia, intellectual disabilities, bipolar disorder, and documented behavior problems engaged in repeated physical altercations, including hitting, slapping, and attempted choking, in dining room and hallway areas. In several events, a resident reported being struck in the face and chest by another resident, two residents were observed yelling and striking each other with fists and open hands, and wheelchair-bound residents became entangled and one swung his arm and hit the other. Staff often heard yelling and then observed residents already hitting each other before they could intervene, and documentation reflects pain, redness, and new skin issues following these incidents.
The facility failed to ensure adequate nursing staff and a licensed nurse in charge on each shift, as resident council notes and multiple cognitively intact residents reported chronic understaffing, especially at night, with long delays in call light response and care. On one documented night, only one RN was on duty for about 80 residents, despite the scheduler stating two nurses were needed for the census and acuity. The evening nurse’s relief did not arrive, the evening nurse refused to stay, and efforts to secure another nurse were unsuccessful, leaving the RN alone for the building while residents experienced changes in condition requiring hospitalization. A CNA confirmed the RN was the only nurse on duty, the DON acknowledged there was no staffing policy, and the administrator stated the facility followed CMS regulations.
Surveyors found that controlled and refrigerated medications were not properly secured and an expired medication was in use. An unlocked medication-room refrigerator contained a bottle of oral lorazepam solution for a resident, contrary to policy requiring locked or securely fastened refrigeration for medications. On a medication cart, an open vial of insulin glargine with a manufacturer’s expiration date already passed was still in use for a resident. On another cart, the narcotic lock box was not latched and could be opened with a finger, yet it contained multiple open and unopened controlled drugs, including morphine, lorazepam, oxycodone, hydrocodone/APAP, alprazolam, and tramadol for several residents. Nursing staff acknowledged the lock malfunction and confirmed these medications were in active use, despite facility policy requiring a double-locked system for controlled substances.
Three vulnerable residents with severe cognitive impairment experienced physical abuse from another resident with a history of aggression. The facility did not update care plans with progressive interventions after repeated incidents, and staff expressed uncertainty about observation protocols and policy implementation. The abuse resulted in physical and emotional harm to the affected residents.
A resident who required a two-person assist for transfers was improperly transferred by a single CNA, resulting in a fall and a leg fracture. The incident was not promptly reported, and the care plan was not immediately updated to reflect the new need for a mechanical lift. Additionally, two residents who experienced falls did not have timely updates to their care plans with progressive interventions, and there was confusion among staff regarding documentation and transfer policies.
A resident who was alert and had a history of leg injuries sustained swelling and bruising during a transfer, leading to an ER visit. Although facility policy required notifying the resident's emergency contact in such situations, staff did not make the notification. The emergency contact only learned of the incident when the resident called from the ER, expressing distress at not being informed by staff.
A resident with multiple comorbidities and high risk for skin breakdown was not provided with the prescribed hospice wound care interventions, including the use of a pressure-relieving mattress. Facility staff failed to implement the ordered air mattress overlay, did not consistently perform or document wound assessments, and did not ensure proper wound dressing. As a result, the resident developed multiple new pressure ulcers in addition to existing wounds before passing away.
A resident with multiple medical conditions and intact cognition was subjected to alleged verbal abuse by the Social Service Director, witnessed by several CNAs who did not report the incident due to lack of confidence in management response. The event was not documented in the medical record or reported to the Administrator or State Agency as required by facility policy, resulting in a deficiency for failure to ensure timely reporting of abuse allegations.
A resident requiring substantial assistance with bathing did not receive showers as care planned while on isolation for ESBL, despite having a private room with a shower. Staff provided only bed baths, citing concerns about using the shower chair, even though it could be cleaned. There was no documentation of shower refusals, and the facility's policy required individualized care, resulting in a deficiency.
The facility failed to provide sufficient nursing staff, resulting in unmet resident needs. Residents reported unaddressed call lights and missed showers due to staffing shortages. One resident, requiring substantial assistance, did not receive scheduled showers, while another had no shower documentation for over a month. Staff confirmed that showers and restorative care were deprioritized due to insufficient staffing, and the Director of Nursing acknowledged the challenges.
Due to staffing shortages, a facility failed to provide scheduled showers for four residents, impacting their personal hygiene care. Residents reported missed showers and inadequate care, with some managing their own hygiene due to lack of staff. The facility's administration acknowledged the staffing challenges, and CNAs confirmed that showers were deprioritized when short-staffed.
A facility failed to provide restorative services for a resident with a cerebral infarction diagnosis, as documented restorative programs were not performed. Staffing issues led to the deprioritization of restorative care, despite recommendations from therapy discharge summaries. Interviews with CNAs and the DON confirmed the absence of a restorative nurse or aides, resulting in unmet care needs.
A facility failed to prevent abuse when two residents, both with cognitive impairments, were involved in an altercation where one resident struck the other. Despite care plans identifying both residents as vulnerable and having potential for aggression, the facility did not prevent the incident, which was witnessed by another resident. The facility's policy prohibits abuse, yet the residents had a history of altercations, indicating a deficiency in managing and preventing such incidents.
Two residents with severe cognitive impairments were involved in separate physical altercations, resulting in one resident being struck on the cheek and another sustaining a skin tear. The facility's abuse prevention policies were not effectively implemented, leading to these incidents.
A facility failed to report an alleged sexual assault of a resident to law enforcement. The resident informed the Admissions Coordinator about the assault, who then notified the Assistant Director of Nurses. However, the Assistant Director did not contact the police, assuming the hospital had already done so, which violated the facility's abuse reporting policy.
A resident with Type 2 Diabetes Mellitus had multiple instances of blood sugar levels exceeding 200, but the physician was not notified as required by the order. Facility staff confirmed the lack of documentation for these notifications, which is against the facility's policy to inform medical practitioners of significant changes.
A facility failed to perform wound care as ordered for a resident with a right femur fracture. The resident had three incisions on the right hip, but only two were covered with dressings, leaving one incision exposed. The resident noted that nurses did not apply a dressing daily. The Treatment Administration Record lacked documentation of treatment on two shifts, despite a physician's order to cleanse and dress the incisions every shift.
A resident with dementia and a history of elopement attempts successfully left the facility without staff knowledge, highlighting inadequate supervision and monitoring. Despite known risks, the facility's interventions were insufficient, leading to the resident being found 60 miles away. Previous incidents and warning signs were not adequately addressed in the resident's care plan, contributing to the elopement.
The facility failed to prevent abuse between residents, including a physical altercation where one resident pulled out another's hair and verbal threats involving violent language. The incidents involved residents with cognitive impairments and PTSD, and there was a lack of documented interventions to prevent future occurrences.
The facility failed to properly label and manage medications, including an undated Tuberculin vial and expired medications, potentially affecting all 93 residents. An LPN acknowledged the use of an undated Tuberculin vial for staff and residents, and expired medications were found during an inspection. Facility policies require medications to be dated and discarded after 30 days, which was not followed.
The facility's assessment was not updated to include necessary components per current standards, affecting all 93 residents. It lacked identification of resources for care during regular and emergency operations, evaluation of staff needs, and pertinent resident information. The facility also failed to evaluate its training program and risk assessments. The administrator was suspended, and no updated assessment or policy was available.
The facility failed to implement effective infection control during a COVID-19 outbreak, with staff not wearing proper PPE and COVID-positive residents not isolated from COVID-negative ones. There was no system to track or test during the outbreak, and vaccinations were not offered since 2022. A resident who was COVID-positive was placed on hospice and later passed away, highlighting the facility's inadequate cohorting and infection control measures.
The facility failed to offer, provide, and track COVID-19 vaccines and boosters, affecting all 93 residents. The DON and ADON did not maintain a list of residents' vaccination statuses, and staff reported inconsistencies in testing and vaccination offers. The facility's SARS-CoV-2 Infection Policy was not followed, and the Infection Surveillance log was not updated, contributing to the deficiency.
The facility failed to ensure CNAs completed the required 12 hours of education annually, affecting all 93 residents. Employee files showed CNAs with insufficient education hours, and interviews revealed uncertainty about the requirements. The facility lacked a clear method to track education hours and did not have a policy for CNA education.
The facility failed to maintain proper food safety and hygiene practices, including improper hand hygiene, glove usage, and food storage. The Interim Dietary Manager could not locate temperature logs, and several food items were improperly stored. During lunch service, the cook did not change gloves or check food temperatures, and staff did not follow hand hygiene protocols. Expired and improperly stored food items were found, and grievances documented complaints about cold meals.
The facility failed to provide education, obtain consents, and administer the influenza vaccine to four residents. One resident had not been offered the vaccine since 2021, despite severe cognitive impairment. Another resident, also with severe cognitive impairment, had no documentation of receiving or being offered the vaccine. Two additional residents, one with Alzheimer's and another who was cognitively intact, had no records of being offered or receiving the vaccine. The DON could not provide a list of vaccination statuses, indicating a lack of proper documentation and tracking.
The facility failed to protect two residents during an abuse investigation, where one resident made threatening comments towards another. Despite updating care plans, there was no documentation of specific interventions or Social Services visits to prevent further abuse. Staff were unaware of any measures in place, and the residents remained in close proximity, indicating a lack of adequate response to the incident.
Two residents in the facility did not receive adequate assistance with activities of daily living (ADLs). One resident with ALS reported not receiving showers or feeding assistance, and another resident complained about not getting scheduled showers. The facility lacked documentation to confirm the provision of these services, and the Director of Nursing admitted there was no specific policy on ADLs, relying instead on best practice guidelines.
A resident with a stage 3 pressure ulcer experienced deterioration of the existing ulcer and the development of a new pressure area due to inadequate wound care and monitoring. The dressing was found missing, and feces were present in the incontinence brief. Staff failed to communicate changes in the resident's condition, leading to non-compliance with the facility's wound care protocols.
The facility failed to provide timely and proper incontinent care for three residents, leading to potential risks of UTIs. A resident with ALS was left waiting for a bedpan, resulting in an incontinent episode, and care was provided without drying the perineal area. Another resident with a UTI and urinary catheter was not properly cleaned or dried after an incontinent episode. A third resident was found with a saturated diaper and linens, and care was provided without proper hand hygiene or the use of appropriate cleansers.
A resident with PTSD and depression expressed a suicide threat to an LPN, but the facility failed to document the threat or notify the physician, leaving the care plan unaddressed. Staff interviews revealed a lack of awareness and communication about the threat, and the facility's policy on suicide threats was not followed. The issue was only addressed after a second threat led to the resident's hospitalization.
The facility failed to monitor and document antibiotic use and infection control for two residents. One resident with a UTI had no urine culture follow-up, while another with C. difficile was not included in the infection log. The DON admitted to lapses in checking culture results and updating infection control logs, indicating a failure in the facility's antibiotic stewardship program.
A resident was discharged without proper documentation of the reason in their EMR and without being informed of their rights to appeal the discharge. The resident, who had multiple diagnoses and was cognitively intact, was transported to an acute facility after exhibiting confusion and agitation. The facility's investigation revealed the discharge was due to cocaine use, but this was not documented or communicated as required by the facility's discharge policy.
Failure to Prevent Multiple Resident-to-Resident Physical Altercations
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse and resident-to-resident altercations. One resident with Klinefelter syndrome, intellectual disabilities, moderate cognitive impairment, and depression-related behavior problems reported that another cognitively intact resident with bipolar disorder and a history of aggression hit him on the right cheek and chest in the dining room. Documentation shows a new red area on his cheek, pain requiring Tylenol, and an undated statement in which he described being hit three times in the face and chest after taking back his candy. The facility’s report to the state agency notes there were no witnesses and that staff encouraged the two residents to remain in different areas of the dining room. Another incident involved two residents with dementia and bipolar or behavioral disturbances who engaged in a physical altercation in the dining room. One resident, who was moderately cognitively impaired and required partial assistance with mobility, reported that the other resident began yelling, talking badly to her, grabbed her arm, and tried to choke her before staff intervened. A CNA’s written statement and subsequent interview describe hearing yelling, then seeing one resident hitting with a fist and the other slapping, with both residents’ hands making contact. Progress notes and the facility’s report to the state agency document that both residents were yelling and slapping each other before staff could reach them. Additional altercations occurred involving residents with severe cognitive impairment and behavioral problems. In one case, a resident with vascular dementia and severe cognitive impairment struck another resident whose wheelchair had become entangled with his; staff statements and the facility’s report differ on whether the blow landed on the arm or face, but consistently describe the resident swinging his arm in agitation and making contact. In another case, a severely cognitively impaired resident with vascular dementia and potential for aggression was involved in a hallway altercation with a resident with dementia and behavioral disturbance; staff statements describe both residents yelling and hitting or slapping each other on the arms, chest, face, and hands before being separated. Across these events, residents with known behavior problems and aggression potential engaged in physical contact with one another, resulting in multiple instances of resident-to-resident physical abuse and altercations.
Insufficient Nursing Staff and Lack of Coverage on Night Shift
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff on all shifts to meet residents’ needs and to have a licensed nurse in charge on each shift. Resident council minutes documented that residents reported a need for more night staff. A daily staffing sheet for a specific date showed that only one RN (identified as V21) was working the entire midnight shift for a census of 80 residents, despite the staff scheduler stating that, based on census and level of care, there should have been two nurses on that shift. The staff coordinator/scheduler (V22) reported that when the evening nurse’s relief did not arrive, she instructed the evening nurse to stay, but the nurse refused, and despite offering bonuses, no additional nurse could be obtained. V22 stated she is a CNA and could not perform nurse duties, and there was no other nurse available to cover the shift. Multiple cognitively intact residents reported that staffing was inadequate, especially at night, and that call lights took a long time to be answered. One resident stated the facility had problems with staffing and needed to hire more staff; another stated there were no staff and it was worse on nights, and another reported staff told them they were short and that it took a long time to receive care. A CNA confirmed that V21 was the only nurse in the building for the entire night shift. V21 stated he was the only nurse for the entire building from around 11 p.m., that the evening nurse left despite his refusal to cover the hall alone, and that his attempts to contact management for assistance went unanswered. He described the night as challenging, with residents experiencing changes in condition requiring hospitalization and no additional nursing help. Another cognitively intact resident reported that staffing was bad and slow, that the facility relied heavily on agency staff who might not show up, leaving residents without care or with poor care. The DON stated the facility did not have a staffing policy, while the administrator stated the facility followed CMS regulations.
Improper Storage and Expired Use of Controlled and Refrigerated Medications
Penalty
Summary
Surveyors identified a failure to properly secure and store controlled medications and to discard expired medications for seven residents reviewed for medication storage. During inspection of the medication room, the refrigerator was found unlocked while containing a resident’s bottle of oral lorazepam concentrated solution, despite facility policy requiring biologicals or medications requiring refrigeration to be kept in a securely fastened or locked refrigerator system. On a medication cart, an open and partially used vial of insulin glargine solution for another resident was found with a handwritten open date of 1/5/26, while the manufacturer’s expiration date on the vial was November 2025, indicating the insulin was in use past its expiration date. Further inspection of another medication cart on a different hall revealed that the lock box intended for controlled substances was unlocked and could be opened simply by lifting the lid. Inside this unlocked lock box were multiple open and unopened controlled medications in active use for several residents, including morphine sulfate oral solution, lorazepam concentrated solution, oxycodone, hydrocodone/APAP, alprazolam, and tramadol tablets. A LPN acknowledged that the lock sometimes gets stuck and does not latch, and verified that these controlled medications were in use while stored in the unlocked lock box. Another LPN later stated that all narcotics and controlled medications are supposed to be under a double-locked system, and that controlled medications in the refrigerator and on the medication cart should be secured according to this standard, as reflected in the facility’s written policies on storage of drugs and Schedule II controlled substances.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse and did not document progressive interventions for three residents who were identified as vulnerable due to severe cognitive impairment and dementia. Multiple incidents occurred in which one resident, who had a history of aggressive behavior related to dementia, physically assaulted other residents. These incidents included one resident placing her hands around another resident's neck, hitting another on the head, pushing down on a resident's chest, and slapping another resident. In each case, the residents involved were unable to provide statements due to their cognitive status, and staff intervened to separate the individuals and conduct assessments. The care plans for the residents involved did not include documentation of abuse or progressive interventions following these incidents. The aggressive resident's care plan noted the potential for aggression and included general interventions such as calm redirection, removal from situations, and 1:1 observation, but did not reflect updates or specific interventions after each incident. The facility's records show that the same resident was repeatedly placed on 1:1 observation and sent to the hospital after each event, but there was no evidence of care plan updates or additional measures to address the ongoing risk. Staff interviews confirmed that the aggressive behaviors were witnessed and responded to in the moment, but there was uncertainty about the duration and implementation of 1:1 observation and a lack of clarity regarding the facility's policy on managing such behaviors. The administrator acknowledged the absence of updated progressive interventions in the care plan and ongoing challenges with the resident's power of attorney, which impacted decision-making for further placement. The facility's abuse policy prohibits mistreatment and requires staff education, but the documented failures resulted in residents experiencing physical and emotional harm.
Failure to Ensure Safe Transfers and Timely Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident, who was care planned and ordered to be transferred with the assistance of two staff members due to instability and a history of falls and fractures, was transferred by only one CNA. The CNA admitted to transferring the resident alone because the facility was short-staffed, resulting in the resident's left foot becoming caught in the wheelchair wheel and a subsequent fall back onto the bed. The resident sustained swelling, bruising, and was later diagnosed with an acute on chronic distal tibial fracture. The CNA did not immediately report the fall to nursing staff, and the injury was only discovered when therapy staff assessed the resident for therapy later that morning. The care plan was not updated promptly to reflect the new transfer status (mechanical lift) after the incident. Another deficiency was identified regarding a second resident with a history of falls and cognitive impairment. After experiencing two unwitnessed falls, the resident's care plan was not updated with progressive interventions to prevent future falls until several days later. There was also a discrepancy in the documentation dates for when new fall prevention interventions, such as a scoop mattress and low bed, were implemented. Staff were unable to clarify when these interventions were actually put in place, and there was confusion regarding the accuracy of the electronic medical record. The facility lacked a clear policy on following physician's orders for transfer status, and some staff were unaware of where to find residents' transfer requirements. This contributed to improper transfers and delayed implementation of necessary interventions to prevent further accidents. The failures resulted in injury to one resident and inadequate fall prevention measures for another.
Failure to Notify Emergency Contact After Resident Injury and ER Transfer
Penalty
Summary
The facility failed to notify a resident's emergency contact after the resident sustained an injury and was transferred to the emergency room. According to the resident's face sheet, a specific individual was listed as the emergency contact. The resident, who was alert and had a history of previous injuries and hardware in her left leg, experienced swelling and bruising on her left lower extremity after her feet gave out during a transfer. Physical therapy staff informed the RN, and a nurse practitioner assessed the resident, resulting in an order to send her to the ER for imaging. The resident was transported to the ER via EMS. Despite the facility's policy requiring notification of the resident's representative in the event of significant changes such as swelling, skin discoloration, or transfer from the facility, the emergency contact was not informed by facility staff. Instead, the resident herself called her emergency contact from the emergency room to report the injury and transfer. The emergency contact expressed upset at not being notified by the facility, stating she would have provided family support at the ER if she had been informed.
Failure to Implement Hospice Skin Care Plan and Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement end-of-life and hospice skin care plan interventions for a resident who was at very high risk for skin breakdown and was dependent on staff for all mobility. The resident had multiple diagnoses, including dementia, COPD, severe malnutrition, diabetes, and was re-admitted to the facility with an existing sacral pressure ulcer. Upon re-admission, hospice services were initiated, and the hospice plan of care included specific wound care instructions and the use of an alternating pressure pad. Despite these orders, the facility did not ensure that the prescribed pressure-relieving mattress or overlays were placed on the resident's bed, and the wound care interventions were inconsistently applied. Multiple staff interviews and record reviews revealed that the hospice-provided air mattress overlay was never implemented, with conflicting explanations from staff regarding its safety and appropriateness. The Director of Nursing (DON) and other staff members acknowledged that the overlay remained unused in the resident's closet, and there was no documentation of efforts to obtain or use alternative pressure-relieving surfaces in a timely manner. Additionally, weekly wound assessments and documentation were not consistently performed, and there were lapses in monitoring and dressing the resident's wounds as required by both facility policy and the hospice care plan. The resident's family, who had medical experience, also reported concerns about the lack of appropriate wound care and the absence of a dressing on the sacral wound. As a result of these failures, the resident developed multiple new in-house acquired pressure ulcers in addition to the original wounds, as documented in the facility's records and confirmed by staff and hospice personnel. The facility's own policies required individualized interventions, regular skin assessments, and coordination with hospice providers, but these were not followed. The lack of timely and appropriate interventions directly contributed to the resident's skin breakdown and the development of additional pressure ulcers prior to the resident's death.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse were reported immediately to the Administrator and in a timely manner to the State Agency for one resident. The resident, who was cognitively intact and required some assistance with activities of daily living, reported that the Social Service Director (SSD) yelled at her. Multiple Certified Nursing Assistants (CNAs) witnessed the SSD yelling at the resident, going through her drawers, slamming them, and slamming the door upon leaving. Despite witnessing the incident, none of the CNAs reported the event, expressing a belief that reporting would not result in any action by management. There was no documentation in the resident's electronic medical record regarding the alleged verbal abuse, and the incident was not reported until it was brought to the attention of the facility by a state surveyor. The facility's policy requires immediate reporting of abuse allegations to the Administrator and timely reporting to all required agencies, but this protocol was not followed in this case. The lack of timely reporting and documentation constituted a failure to comply with the facility's abuse prevention and reporting policies.
Failure to Provide Showers for Resident on Isolation
Penalty
Summary
A deficiency occurred when a resident who required substantial to maximal assistance with bathing did not receive showers as care planned. The resident, who was cognitively intact and had a documented need for personal care assistance, was placed in isolation due to ESBL in her urine. Despite having a private room with an attached shower, staff provided only bed baths instead of showers, citing concerns about using the shower chair during isolation. The resident and her daughter expressed dissatisfaction with the quality of the bed baths and the refusal to provide showers, even though the shower chair could be cleaned according to facility procedures. Interviews with staff confirmed that the shower chair was made of cleanable PVC material and should have been used and disinfected between uses. Documentation showed that the resident received only a few showers during the month, with one instance specifically noting a bed bath was given instead of a shower. There was no documentation of the resident refusing showers, and the facility's policy required individualized care based on assessment and care plan, including bathing. The lack of proper documentation and failure to provide showers as required led to the identified deficiency.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of inadequate care. The Resident Council Minutes highlighted ongoing staffing shortages, with residents reporting that call lights were not being answered and showers were not being completed due to insufficient staff. Interviews with residents confirmed these issues, with one resident stating that they had to bathe themselves without supervision due to the lack of available staff. Specific cases further illustrate the deficiency. One resident, who requires substantial assistance with bathing due to obesity and other health issues, reported not receiving scheduled showers because there was only one staff member available, making it impossible to use the necessary mechanical lift. Another resident, who is cognitively impaired and requires assistance with ADLs, had no documentation of receiving showers for over a month, and their restorative programs were not being performed as required. Staff interviews corroborated the residents' experiences, with CNAs acknowledging that showers and restorative care were not prioritized due to staffing shortages. The Director of Nursing admitted to staffing challenges and reliance on agency staff. The facility's policy on sufficient nursing staff was not being adhered to, as there were not enough team members to provide the necessary care, leading to unmet resident needs and compromised care quality.
Staffing Shortages Lead to Missed Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for four residents due to staffing shortages. The Resident Council Minutes highlighted ongoing concerns about insufficient staffing, which affected the ability to provide adequate care, including showers. Residents expressed dissatisfaction with the lack of staff, which resulted in missed showers and inadequate personal hygiene care. The facility's administration acknowledged the staffing challenges and the reliance on agency workers, which contributed to the inconsistency in care. Resident 1, who is cognitively intact, reported that he manages his own showers due to the lack of staff supervision. Resident 2, who requires substantial assistance due to obesity and other health issues, stated that she often receives bed baths instead of showers because there is not enough staff to operate the mechanical lift needed for her care. Resident 3, who is cognitively impaired, had no documented showers for over a month, and Resident 5, who is also cognitively impaired and dependent on staff, had missing shower documentation for several scheduled dates. Interviews with CNAs and the Director of Nursing confirmed the staffing issues, with staff prioritizing other tasks over showers when short-staffed. The facility did not have a specific policy for showers, and the Director of Nursing was aware of the challenges but had not yet implemented a solution. The lack of adequate staffing and prioritization of tasks led to the failure to provide scheduled showers, impacting the residents' care and hygiene.
Failure to Provide Restorative Services Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative services for a resident, identified as R3, who was admitted with a diagnosis of cerebral infarction due to embolism of the right anterior artery. R3's care plan indicated a need for assistance with activities of daily living (ADLs) due to impaired balance and required a restorative program for bed mobility and grooming. Despite these documented needs, R3's electronic record did not show any documentation of restorative programs being performed. The physical therapy discharge summary recommended a restorative nursing program for passive range of motion and transfers, but these were not documented in R3's care plan or tasks. Interviews with various CNAs and the Director of Nursing revealed that the facility was experiencing staffing issues, which led to the deprioritization of restorative programs and showers. CNAs reported that when short-staffed, they had to prioritize tasks, often leaving restorative programs incomplete. The Director of Nursing confirmed the absence of a restorative nurse or aides, with duties being divided among existing staff. Despite the facility's policy to provide restorative nursing to promote independence and safety, the lack of adequate staffing and documentation resulted in a failure to meet R3's restorative care needs.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically involving an altercation between two residents, R3 and R4. R4, who was severely cognitively impaired and required assistance with mobility, was involved in an incident where R3, who was moderately cognitively impaired and independent with mobility, struck R4 on the cheek. This incident occurred despite R4's care plan identifying her as a vulnerable person with potential for aggression due to cognitive deficits, and R3's care plan noting her potential for aggression related to dementia. The altercation was witnessed by another resident, R1, who observed R3 yelling at and striking R4. No staff witnessed the incident, but staff intervened immediately after R1 called for help. The facility's policy prohibits mistreatment, neglect, or abuse of residents, yet R3 and R4 had a history of altercations, indicating a failure to adequately prevent such incidents. The Assistant Director of Nurses acknowledged that R3 and R4 had more than one altercation and that R3 would often say things to R4 when passing her room. Although R3 was moved to another hall to prevent further incidents, the altercation on the 200 hall still occurred. The facility's response included 1:1 supervision for both residents post-incident, but the repeated nature of the altercations suggests a deficiency in effectively managing and preventing resident-to-resident aggression.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent physical abuse between residents, as evidenced by two separate incidents involving resident-to-resident altercations. In the first incident, a resident with Alzheimer's disease and severe cognitive impairment, identified as R2, physically assaulted another resident, R3, who also had severe cognitive impairment and was identified as vulnerable due to intellectual disabilities. The altercation occurred in a common area, where R2 held R3's forearm and struck her on the cheek. This incident was witnessed by a CNA, who intervened by separating the residents and notifying the nurse. In a second incident, another resident, R1, who was also severely cognitively impaired, was involved in an altercation with R2. R1 reportedly hit R2 on the hand, causing a skin tear, and knocked R2 to the ground. Although the altercation was not directly witnessed, staff observed R1 standing over R2, who was on the floor, and heard R1 yelling about hitting R2. The facility's investigation could not substantiate whether the skin tear was caused by R1 or resulted from the fall. The facility's policies on abuse prevention and prohibition were not effectively implemented to prevent these incidents. The facility's abuse prohibition program includes components such as screening, training, prevention, identification, investigation, protection, and reporting/response. However, the incidents indicate a failure in monitoring and managing resident behaviors, as well as in reassessing care plan interventions to prevent abuse. The facility's inability to determine the cause of the skin tear in the second incident further highlights deficiencies in their investigation and documentation processes.
Failure to Report Alleged Sexual Assault to Law Enforcement
Penalty
Summary
The facility failed to notify law enforcement of an allegation of sexual assault involving a resident, identified as R2, who was part of a sample of six residents reviewed for abuse reporting. The incident came to light when a Sexual Assault Nurse Examiner (SANE) at a regional hospital contacted local law enforcement after R2 reported being sexually assaulted in a grocery store. The facility's Admissions Coordinator, who was the weekend manager, was informed by R2 about the assault during a conversation to complete re-admission paperwork. The coordinator ensured R2's safety and attempted to notify the Director of Nurses, who was unavailable, and subsequently informed the Assistant Director of Nurses. The Assistant Director of Nurses did not contact the police, citing being occupied with the investigation and noting that the hospital had already notified law enforcement. This inaction was contrary to the facility's Abuse, Prevention and Prohibition Policy, which mandates that any employee or agent must report such incidents to law enforcement and the facility. The failure to report the incident directly to law enforcement by the facility staff constitutes a deficiency in adhering to the established policy for handling allegations of abuse.
Failure to Notify Physician of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician of abnormal blood sugar levels for a resident diagnosed with Type 2 Diabetes Mellitus. The physician's order required notification if the resident's blood sugar exceeded 200. On multiple occasions, the resident's blood sugar levels were recorded above this threshold, specifically at 215, 235, and 205, but there was no documentation indicating that the physician was informed as required by the order. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nurses, confirmed the lack of documentation regarding physician notification. The facility's policy mandates notifying the resident's family and medical practitioner of significant changes, such as abnormal blood glucose results. Despite this policy, the necessary notifications were not made, leading to a deficiency in the facility's compliance with its own procedures and physician orders.
Failure to Perform Ordered Wound Care
Penalty
Summary
The facility failed to perform wound care as ordered for one resident, identified as R2, who was admitted with a diagnosis of orthopedic aftercare following a right femur fracture. On a specific date, it was observed that R2 had three incisions on the right hip, with a dressing applied to only two of the lower incisions, leaving the upper incision without a dressing. R2 expressed that nurses seemed to check his hip incision but did not apply a dressing daily. The Treatment Administration Record (TAR) for December 2024 showed a physician's order to cleanse the surgical incision sites and apply a dry dressing every shift, but there was no documentation of treatment being administered on two specific shifts. The facility's Wound Prevention Policy requires documentation of all wound prevention measures and interventions in the resident's service plan and medical records.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with a known history of elopement attempts and dementia. The resident, identified as R49, was last seen in the facility at 11:30 AM and was later found 60 miles away at his past home residence. This incident occurred without the staff's knowledge, indicating a significant lapse in supervision and monitoring of residents at risk for elopement. R49 had a documented history of cognitive impairment and a desire to leave the facility, as noted in his care plan and elopement assessments. Despite these known risks, the facility's interventions, such as frequent visual monitoring and providing distracting activities, were insufficient to prevent the resident from leaving the facility unattended. The facility's elopement policy required that residents at risk for elopement be provided with safety precautions, such as door alarms or personal safety devices, but it appears these measures were not effectively implemented or monitored in R49's case. Interviews with staff revealed that there were previous incidents where R49 attempted to leave the facility, including an instance where he was found outside by a CNA. Despite these warning signs, the facility did not adequately update or enforce the resident's care plan to prevent further elopement attempts. The lack of effective supervision and failure to implement appropriate interventions contributed to the resident's successful elopement, resulting in an Immediate Jeopardy situation.
Removal Plan
- The DON and the Administrator initiated staff re-education on the elopement policy and procedure. All staff was educated, no staff worked without being educated.
- The door alarm policy including door alarms should never be shut off or disengaged for any reason.
- Care plan for the resident involved has been revised to include resident specific interventions related to the resident's risk for elopement.
- 100% Audit of the elopement risk assessment for all facility residents has been completed.
- The facility residents that trigger at a risk for elopement have had their care plans reviewed and revised to include resident specific interventions.
- The Facility has a book in place with pictures and pertinent information of residents that trigger at risk for elopement. Staff can identify where the book is located.
- Door codes to be changed and staff educated that at no time are residents to be given the door alarm code.
- Staff are to input the code for anyone needing to exit the community.
- The facility will provide ongoing education to all new employees and agency at the time of hire on the facility elopement policy and procedure and the door alarm policy. Education will be provided prior to a new employee being allowed to work in the facility as well as agency staff members.
- Concerns will be addressed immediately and discussed during the monthly QAPI Committee for resolution.
- The resident was placed on 1:1 in memory unit, then for 15-minute checks, 30-minute observations and no issues were identified upon return to facility. Staff continue to provide 1:1 supervision to resident while at Dialysis. He remains a resident on the Memory unit.
- The resident remains on the secured courtyard unit where the door alarms sound if a resident attempts to leave without entering a security code. Doors are managed by an egress exiting. The exterior courtyard is secured by a gate that is alarmed.
- The Elopement Policy and Procedure was reviewed by the Administrator, Regional Director of Operations, and RN Regional Nurse.
- The Regional Nurse, DON, and the Administrator immediately initiated education on the Elopement Policy and Procedure to all staff. All staff educated on location of Elopement books and identifiers of POC and PCC. No staff are to work without receiving education.
- The Regional Nurse, DON, and the Administrator immediately initiated education on the Door alarm policy including door alarms should never be shut off or disengaged for any reason to all staff.
- All residents have been reviewed and completed for risk of elopement. The assessments were completed by the Social Service Director, MDS, and Admission Coordinator.
- All residents identified at high risk for elopement have current care plans that have been reviewed for appropriate interventions. The high risk for elopement care plans were reviewed and updated by MDS.
- All staff will be educated at the time of hire on the Elopement Policy as part of the orientation process by the Administrator or designee.
- All staff will be educated at the time of hire on the door alarm policy as part of the orientation process by the Administrator or designee.
- Elopement drill will be completed Quarterly.
- The SSD will randomly question 5 staff per week on what to do in the event there is an elopement.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent verbal and physical abuse between residents, specifically involving four residents. One incident involved a resident with Alzheimer's Disease and severe cognitive impairment, who wandered into another resident's room. This resident, who also had severe cognitive impairment and a history of dementia, pulled out a fistful of the first resident's hair. The incident was immediately reported, and the residents were separated, but the care plan for the first resident did not document any risk for abuse. Another incident involved verbal threats between two residents, one of whom was cognitively intact and had a history of PTSD and behavior problems. This resident made threatening comments towards another resident, who was moderately cognitively impaired and had a history of depression and anxiety. The threats included violent language, and although staff intervened, there was no documentation of any interventions put in place to prevent future occurrences. The facility's policy on abuse prevention and prohibition states that residents have the right to be free from abuse, including resident-to-resident altercations. However, the incidents described in the report indicate a failure to adhere to this policy, as evidenced by the lack of documented interventions and care plans addressing the risk of abuse for the involved residents.
Medication Management Deficiency
Penalty
Summary
The facility failed to properly manage and label medications, which could potentially affect all 93 residents. During an inspection of the medication room, a Tuberculin vial was found without an open date, and a Lantus Insulin Pen was discovered without a resident name or date. The Licensed Practical Nurse (LPN) acknowledged that the Tuberculin vial is used for all staff and residents and should be discarded if found without an open date. Additionally, a bottle of Oyster Shell Calcium capsules was found with an expiration date that had passed, and a vial of Humalog Insulin was past the 30-day usage period since being opened. The facility's policies require that all medication vials be dated when opened and discarded after 30 days, and that medications be checked for expiration monthly. The Assistant Director of Nursing (ADON) confirmed that nurses are responsible for dating medication vials and discarding them after 30 days. The facility's documentation specifies that insulin vials should be discarded 28 days after opening, and multi-dose vials should be discarded 28 days after opening or according to the manufacturer's recommendation. The failure to adhere to these protocols was observed during the survey, indicating a lapse in medication management and storage practices.
Facility Assessment Lacks Critical Components
Penalty
Summary
The facility failed to update its facility-wide assessment to include all necessary components as per current standards of practice. The assessment, which was supposed to cover the period from July 11, 2022, to July 10, 2023, lacked critical elements such as identifying resources needed for resident care during both regular operations and emergencies, including nights and weekends. It also did not evaluate the overall number of staff required to meet residents' needs, nor did it include pertinent information about the resident population, such as race, ethnicity, disability, and other factors affecting access to care and health outcomes. Additionally, the assessment failed to evaluate the facility's training program for staff and volunteers, and it did not include an evaluation of applicable policies and procedures or a facility-based and community-based risk assessment using an all-hazards approach. During the survey, it was revealed that the facility did not have an updated facility assessment for 2024. The administrator, identified as V1, was unable to provide an updated assessment and was later suspended due to an abuse allegation. The regional director, V33, confirmed the absence of a 2024 facility assessment and stated that there was no policy on facility assessment. This deficiency has the potential to affect all 93 residents residing in the facility.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement an effective infection prevention and control program during a COVID-19 outbreak, leading to multiple deficiencies. Staff members were observed not wearing appropriate personal protective equipment (PPE) such as eye protection while on the COVID-positive unit. COVID-positive residents were not isolated properly and were allowed to mingle with COVID-negative residents, increasing the risk of cross-contamination. There was also a lack of signage indicating the COVID-19 outbreak status, and visitors were seen entering the COVID-positive unit without PPE. The facility did not properly cohort COVID-positive residents, resulting in positive and negative residents sharing rooms. This improper cohorting was observed multiple times, with staff failing to encourage or enforce mask-wearing among residents. Additionally, there was no system in place to track, trend, and test residents and staff during the outbreak, and the facility had not offered or educated residents and staff about COVID vaccinations since 2022. Specific cases highlighted include a resident who was COVID-positive and placed on hospice care, later passing away. The resident's physician was unaware of the cohorting situation and expressed concerns about the practice. Staff members, including CNAs and LPNs, were observed not following proper PPE protocols, and there was a lack of communication and education regarding COVID-19 testing and vaccination among staff. The facility's infection preventionist was overwhelmed with duties, leading to a lapse in infection surveillance and control measures.
Failure to Offer and Track COVID-19 Vaccinations
Penalty
Summary
The facility failed to offer, provide, and track COVID-19 vaccines, boosters, and immunizations, potentially affecting all 93 residents. The Director of Nursing (DON), who is also the Infection Preventionist (IP), along with the Assistant Director of Nursing (ADON), did not maintain a list of residents who have refused, consented, or received vaccinations. The DON admitted to not having a list and mentioned the complexity of the CDC's algorithm for vaccinations. The Medical Director expressed concern that all residents should be vaccinated against COVID-19 and Influenza, emphasizing the potential for serious harm or death if residents contract COVID-19. The facility's staff, including nurses and aides, reported inconsistencies in COVID-19 testing and vaccination offers. Some staff members, such as a Registered Nurse (RN) and a Certified Nursing Assistant (CNA), stated they were not offered the COVID-19 vaccination or education at the facility. The RN mentioned that visitors often entered the 100-unit without wearing masks or other protective equipment, despite the requirement for full PPE. Additionally, a Dietary Manager and other staff members confirmed they had not been offered COVID-19 vaccinations or education, and there was confusion about PPE requirements when entering certain units. The facility's SARS-CoV-2 Infection Policy outlined the need for offering resources and counseling about the COVID-19 vaccine, as well as maintaining infection prevention control practices. However, the Infection Surveillance log had not been updated since the end of August, and the DON admitted to not having time to manage infection control duties. The facility's failure to adhere to its policy and maintain proper documentation and tracking of COVID-19 cases and vaccinations contributed to the deficiency.
Failure to Ensure CNA Education Compliance
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) completed the required 12 hours of education per year, which has the potential to affect all 93 residents residing in the facility. The employee files documented that CNAs hired on various dates had not completed the necessary education hours. Specifically, one CNA had 1.75 hours, another had 0.5 hours, a third had no documented education hours, and a fourth had 2 hours of education for the past year. Interviews with the Director of Nursing and the Regional Director revealed uncertainty about the required education hours for CNAs. Additionally, the facility's computerized education system did not consistently provide hours for each course, and inservice logs did not specify the duration of trainings, leaving the facility without a clear method to track CNA education hours. Furthermore, the facility did not have a policy in place for CNA education.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene practices, as observed during a survey. The Interim Dietary Manager was unable to locate the fridge/freezer temperature logs, and several food items were improperly stored, such as an open bag of bacon and a gallon of chocolate milk without an open date. Additionally, a box of cucumbers was stored on the floor, and a bag of ground meat was being thawed improperly under hot running water. Temperature logs for food were not maintained, and the last recorded temperatures were from a previous date. During lunch service, the cook, V12, did not perform proper hand hygiene or change gloves while plating food. V12 was observed using the same gloves throughout the lunch service, including when leaving the serving line to gather supplies. The cook also failed to check food temperatures before serving, and the thermometer used was not functioning properly. Furthermore, V12's mask and hairnet were not worn correctly, and V13, a dietary aide, was seen with a full beard and no hairnet while handling food. The kitchen staff did not follow proper hand hygiene protocols, and there were no towels available for drying hands after washing. The facility's food storage and hygiene policies were not followed, as evidenced by the presence of expired and improperly stored food items. Open bags of frozen curly fries and bread with mold were found in the kitchen. The facility's grievance forms documented complaints about cold meals, and investigations revealed issues with food temperature maintenance and equipment. The Interim Dietary Manager admitted to not being certified and lacking access to the facility's policies, which contributed to the deficiencies observed during the survey.
Failure to Administer Influenza Vaccinations
Penalty
Summary
The facility failed to provide education, obtain consents, and administer the influenza vaccine to four residents reviewed for immunizations. Resident 61, who was admitted with multiple diagnoses including dementia and COVID-19, had not been offered or given the influenza vaccination since 2021, despite having a severe cognitive impairment and being dependent on staff for daily activities. Similarly, Resident 77, with severe cognitive impairment and requiring assistance for activities of daily living, had no documentation of receiving or being offered the influenza vaccine, nor were there any consents or refusals recorded. Resident 82, admitted with Alzheimer's disease and dementia, also had no record of being offered or receiving the influenza vaccine, with no consents or refusals documented. This resident required partial to substantial assistance from staff for daily activities. Additionally, Resident 23, who was cognitively intact but dependent on staff for daily activities, had not been offered or received the influenza vaccine, and there were no consents or refusals documented in their medical record. The Director of Nursing (DON) was unable to provide a list of residents who had refused, consented, or received vaccinations, indicating a lack of proper documentation and tracking. The facility's policy, dated 2019, stated that residents should be offered immunizations against pneumococcal and influenza diseases, but the facility failed to adhere to this policy. The Infection Preventionist was expected to manage residents' immunizations, but the lack of documentation and administration of vaccines suggests a deficiency in the facility's infection prevention and control program.
Failure to Protect Residents During Abuse Investigation
Penalty
Summary
The facility failed to protect residents during abuse investigations, specifically involving two residents, R17 and R31. R31, who is cognitively intact, has a history of PTSD and behavior problems related to frustration and loss of independence. R17, who is moderately cognitively impaired, has multiple diagnoses including end-stage renal disease, diabetes, and schizophrenia. An incident occurred where R31 made threatening comments towards R17, escalating to verbal abuse and threats of physical harm. The facility's investigation documented that both residents' care plans were reviewed and updated, and R31 was instructed to seek staff assistance instead of responding to other residents. However, the care plans did not document specific interventions to prevent further abuse, and there was no evidence of Social Services conducting the planned visits with R17 and R31. The lack of documentation and follow-through on interventions indicated a failure to adequately address and prevent further incidents. Throughout the survey period, R17 and R31 remained in close proximity, with no changes made to their room assignments or additional interventions communicated to staff. Interviews with staff members revealed a lack of awareness regarding any specific measures in place to prevent further abuse between the two residents. The Social Service Director also confirmed the absence of documented meetings with the residents, highlighting a gap in the facility's response to the abuse incident.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R145 and R33. R145, who was admitted with a diagnosis of Amyotrophic Lateral Sclerosis (ALS) and is totally dependent on staff for ADLs, reported not receiving a shower or bed bath since admission. Observations confirmed that R145's lunch tray was left untouched due to a lack of feeding assistance, and R145 expressed dissatisfaction with the care provided. The Director of Nursing confirmed only one shower sheet for R145, despite the facility's shower schedule indicating showers should occur twice a week. Additionally, R145 reported not receiving assistance with basic grooming tasks such as brushing teeth. Similarly, R33, who requires assistance with personal hygiene and oral care, reported not receiving showers as scheduled. Staff interviews corroborated R33's complaints, and the facility was unable to provide documentation of showers for R33. The facility's shower schedule indicated that R33 should receive showers twice a week, but no shower sheets were available to confirm this. The Director of Nursing acknowledged the absence of a policy on ADLs, relying instead on best practice guidelines, which were not effectively implemented in these cases.
Failure to Prevent Pressure Ulcer Deterioration and Development
Penalty
Summary
The facility failed to prevent the deterioration of a pressure ulcer and the development of a new pressure ulcer for a resident. The resident, identified as R85, was admitted with a pressure ulcer and had a physician's order for specific wound care to the sacrum. However, observations revealed that the wound had deteriorated, becoming deeper, and a new reddened area was noted on the right buttocks, indicating the potential development of a new pressure ulcer. The dressing was found to be missing during an assessment, and the resident's incontinence brief contained feces, suggesting inadequate wound care and monitoring. Staff interviews revealed lapses in communication and adherence to wound care protocols. A CNA admitted to removing a soiled dressing without notifying a nurse, contrary to the facility's policy that requires nurses to be informed of any new wounds or changes in skin condition. The Assistant Director of Nursing confirmed that the dressing should have been intact continuously as per the physician's orders, and staff were expected to report any issues with the dressing. These failures contributed to the resident's pressure ulcer deterioration and the emergence of a new pressure area.
Failure to Provide Timely and Proper Incontinent Care
Penalty
Summary
The facility failed to provide timely toileting and incontinent care for three residents, leading to potential risks of urinary tract infections. Resident R145, diagnosed with Amyotrophic Lateral Sclerosis (ALS), was left waiting for a bedpan for an hour, resulting in an incontinent episode. When care was finally provided, the Certified Nursing Assistants (CNAs) did not dry the resident's perineal area after changing the adult brief, which is against the expected practice as stated by the facility's administration. Resident R85, who has a urinary catheter and a diagnosis of Urinary Tract Infection (UTI), was found with feces in his adult brief. The CNA providing care did not use any cleanser on the washcloths and failed to dry the resident's perineal area before applying a new brief. The Director of Nursing and Assistant Director of Nursing confirmed that staff are expected to use body wash or non-rinse peri cleanser, especially after an incontinent episode involving feces, and to pat the area dry. Resident R23, who is frequently incontinent of urine and always incontinent of stool, was found with a saturated adult diaper and linens. The CNA did not perform hand hygiene or change gloves during the care process and used hand soap instead of a no-rinse perineal cleanser. The CNAs also failed to rinse the soap from the resident's skin or dry it before changing the bed linens. The Director of Nursing stated that the facility does not have an incontinence care policy and follows best practices, which were not adhered to in this instance.
Failure to Address Resident's Suicide Threats
Penalty
Summary
The facility failed to adequately monitor and provide necessary behavioral health services for a resident who verbalized suicide threats. The resident, who has a history of PTSD, depression, and other medical conditions, expressed a suicidal threat to an LPN on July 5, 2024. The LPN acknowledged the threat but did not ensure proper documentation or notification to the resident's physician or the facility's administration. Consequently, the resident's care plan was not updated to reflect the suicide risk, and no immediate safety measures were implemented. Interviews with various staff members, including the Social Service Director, LPNs, and CNAs, revealed a lack of awareness and communication regarding the resident's suicide threat. The physician confirmed that he was not informed of the threat and stated that he would have taken immediate action had he been notified. The facility's policy on suicide threats, which requires immediate notification and assessment, was not followed, leading to a significant gap in the resident's care. The deficiency was further highlighted when the resident made another suicide threat on September 18, 2024, prompting the facility to send the resident to the hospital. The Regional Director and Administrator acknowledged the oversight, noting that the care plan was only revised after the second incident. The facility's failure to adhere to its own policy and ensure proper communication and documentation resulted in inadequate care for the resident at risk of self-harm.
Failure in Antibiotic Stewardship and Infection Control Monitoring
Penalty
Summary
The facility failed to adequately monitor, track, and document microbiology organisms on the infection control log and did not properly monitor and follow up on antibiotic use for two residents. Resident R10 was admitted with multiple diagnoses, including Alzheimer's disease and a urinary tract infection (UTI). Despite receiving treatment for the UTI, there was no documentation of a urine culture in R10's medical record, nor was there a follow-up within 48 hours as required. This lack of documentation and follow-up indicates a failure in the facility's antibiotic stewardship program. Resident R61, who was admitted with several diagnoses including dementia and C. difficile infection, was also not properly monitored. Although a stool culture confirmed the presence of C. difficile, R61 was not included in the facility's infection surveillance log. The Director of Nursing (DON) admitted that the facility was not consistently checking culture and sensitivity results to ensure residents were on the correct antibiotics, and there was no follow-up action when treatments were deemed inappropriate. The facility's Infection Prevention and Control Policy outlines the need for a comprehensive infection prevention and control program, including an antibiotic stewardship program. However, interviews with the DON revealed that the facility was not adhering to these protocols, as evidenced by the lack of documentation and follow-up for residents R10 and R61. The DON acknowledged that the infection control log had not been updated since the end of August, and there was no system in place to ensure timely and appropriate antibiotic use.
Failure to Document Discharge Reason and Provide Appeal Rights
Penalty
Summary
The facility failed to document the reason for discharge in the resident's Electronic Medical Record (EMR) and did not provide written documentation of the reason for discharge or inform the resident of their rights to appeal the discharge. This deficiency was identified for one of the three residents reviewed for discharge in a sample of 57. The resident, identified as R20, had a range of diagnoses including pseudarthrosis after fusion, depression, and chronic pain, and was cognitively intact according to the Minimum Data Set (MDS). On the day of the incident, R20 exhibited confusion and agitation, and was in significant pain, requesting additional pain medication. The staff noted the resident's room was in disarray, with furniture moved and items scattered, and advised against such activities due to recent back surgery. Later that day, emergency services were called to transport R20 to an acute facility. The facility's investigation revealed that R20 was discharged due to consuming cocaine in the facility, which posed potential harm to others. However, the facility did not document this reason in the EMR or provide the resident with written notice or appeal rights. The facility's policy on discharge planning, dated November 2022, outlines the need for a comprehensive discharge plan, including resident and family education and collaboration with post-acute care providers. Despite this policy, the Social Service Director confirmed that no discharge planning was conducted for R20. The facility's failure to adhere to its discharge policy and document the necessary information led to the identified deficiency.
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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