Hilltop Skilled Nsg & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, Illinois.
- Location
- 910 West Polk Street, Charleston, Illinois 61920
- CMS Provider Number
- 145862
- Inspections on file
- 43
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Hilltop Skilled Nsg & Rehab during CMS and state inspections, most recent first.
The facility failed to provide palatable, attractive meals at safe and appetizing temperatures, as evidenced by Food Committee notes and multiple cognitively intact residents reporting that meals were often cold, overcooked, burned, soggy, or unrecognizable, with complaints about poor quality evening meals and refusal of simple preferences such as chocolate milk. Observations of a test tray showed mixed vegetables below appropriate temperatures, and a manager in training handled the food with bare hands while attempting to warm it. A dietary manager acknowledged multiple complaints about overcooked, unappealing, and cold food amid significant dietary staffing turnover.
Staff failed to prevent cross contamination during a lunch meal when a manager in training wiped her bare hands on her pants, then grasped a food thermometer by the shaft and used it repeatedly to check the internal temperature of fried chicken in multiple pans without cleaning her hands or the thermometer. She also used potholders that had been on a contaminated counter to handle the pans while cycling them in and out of the oven, affecting food prepared for all residents in the facility.
Surveyors found that several cognitively intact residents with complex cardiopulmonary conditions, including COPD, CHF, chronic respiratory failure, OSA, and use of devices such as BI-PAP, oxygen concentrators, nebulizers, and a pacemaker monitor, had these medical devices plugged into outlet strip extension cords rather than directly into wall outlets. In multiple rooms, several high-demand medical devices were connected to a single outlet strip or to multiple outlet strips, sometimes sharing the only available wall outlet with the resident’s bed. A maintenance leader acknowledged that plugging multiple medical devices into outlet strips could be a fire hazard, and the administrator confirmed that many residents relied on extension cords for their medical equipment and that the facility had no policy governing this practice.
A resident with advanced dementia and high fall risk attempted to stand unassisted from a wheelchair and fell, sustaining a left femoral neck fracture. The chair alarm, intended to alert staff, did not sound due to improper setup, as the pull-tab string was too long and failed to activate. Staff did not ensure the alarm was correctly placed and functioning, leading to the resident's fall and injury.
A resident with multiple medical conditions was affected when 60 tablets of Tramadol and two count sheets went missing due to an LPN not verifying the quantity of controlled medication received from the pharmacy. The discrepancy was discovered after a pharmacy refill was denied, and the DON confirmed that the reconciliation process was not followed, making it impossible to account for the missing medication.
The facility failed to provide meals at safe and appetizing temperatures, affecting several residents with specific dietary needs. Residents reported consistently receiving cold and inedible meals, with some missing meals entirely. Observations confirmed that meal carts were not plugged in, and meals were served on room-temperature plates, highlighting a systemic issue in maintaining meal quality.
A resident's mattress was found with smeared clumps of a white food substance over two days, indicating a failure in maintaining cleanliness. The resident, who has dementia and limb absences, was affected by this deficiency. Staff interviews revealed that mattresses are only cleaned during deep cleaning sessions, and CNAs did not wipe the mattress clean, leading to the observed issue.
The facility inaccurately encoded MDS assessments for two residents' dental conditions, failing to note issues with their dentures. Observations showed both residents had upper dentures falling while speaking, but the MDS inaccurately documented no issues and marked them as 'unable to examine.' The assessments were completed offsite by a former MDS Coordinator, contrary to the MDS Manual's requirement for in-person examinations.
The facility failed to develop comprehensive care plans for two residents with denture problems, as their MDS assessments did not document any issues with denture fit, and their care plans lacked focus on denture care. The MDS assessments were completed offsite by a former coordinator, leading to the omission of denture issues. The dental CAA was not triggered, contrary to the MDS Manual's guidelines for individualized care planning.
A facility failed to document a recapitulation of stay for a resident who required maximum assistance and had multiple medical diagnoses, including COPD and diabetes. The resident's discharge plan had a blank section for this information, and the facility's administrator confirmed the lack of documentation and absence of a policy for completing such records.
A resident with multiple medical conditions requiring assistance for showering did not receive adequate care, missing several scheduled showers. The resident reported feeling unsafe due to a CNA's refusal to assist or leaving them unattended, leading to fewer showers than scheduled. The DON confirmed the resident's need for assistance and the facility's procedure to not leave residents unattended.
Three residents in the facility had their medical equipment improperly plugged into extension cords due to insufficient wall outlets. A resident's oxygen concentrator and two residents' electric beds were connected to extension cords, posing potential safety hazards. The Maintenance Director confirmed that medical equipment should be plugged directly into wall outlets, but the facility lacked a policy to enforce this.
The facility failed to obtain timely physician responses to pharmacist recommendations, affecting two residents. One resident experienced a delay in starting a prescribed antidiabetic medication due to a missed entry in the electronic medical record. Another resident's use of Lorazepam PRN without a stop date was not addressed by a physician despite multiple pharmacist recommendations. The facility's policy lacked specific timeframes for obtaining physician responses.
A resident with Hindu faith was served a meal containing pork, contrary to their religious dietary restrictions. The facility failed to document the resident's food preferences in their medical record, and no alternatives were offered. The Dietary Manager admitted to issues with maintaining a list of resident preferences, which is required by facility policy.
A resident with a documented onion allergy was served a meal containing onions, despite clear documentation of the allergy on their diet ticket. The resident, who has multiple medical conditions, did not consume the meal items containing onions, aware of the potential for severe illness. The Dietary Manager confirmed the oversight, acknowledging that the resident should not have been served onions, as per facility policy.
The facility failed to document evaluations for cognitively impaired residents' capacity to consent to intimate relationships. Two residents with severe cognitive impairment were observed engaging in intimate behavior without formal assessments of their consent capacity. The facility's policy lacked guidelines for documenting and maintaining these evaluations, affecting additional residents.
The facility failed to protect two residents, both with severe cognitive impairment due to dementia, from sexual abuse. An LPN observed inappropriate contact between the residents but did not intervene, assuming it was consensual. Despite their friendly interactions, no formal assessments were conducted to evaluate their capacity to consent, leading to a deficiency in safeguarding the residents.
The facility did not include documentation of an intimate relationship and privacy needs in the care plans of two residents. A nurse observed intimate behavior between the residents but did not act, assuming it was consensual. The facility's policy requires such documentation, but it was missing from the care plans.
A resident with cognitive impairment engaged in inappropriate sexual behavior towards two other residents, causing emotional distress and discomfort. Additionally, a staff member verbally abused another resident, leaving him feeling isolated and afraid. The facility failed to protect these residents from abuse, as required by their policy.
A resident with moderate cognitive impairment exhibited inappropriate sexual behaviors towards two cognitively intact residents. Despite these behaviors, the resident was not placed on continual observation immediately, leading to further incidents of inappropriate touching. The affected residents expressed feelings of vulnerability and discomfort, avoiding shared areas to stay away from the resident. The facility's administrator acknowledged the oversight in monitoring, which left residents at risk.
Two residents were involved in a physical altercation, which was not reported to the facility's Administrator or proper authorities as required by the facility's 'Abuse Policy'. Despite one resident being cognitively intact and reporting the incident to a CNA, the facility failed to document or act on the allegation, resulting in a deficiency.
Failure to Provide Palatable, Properly Prepared and Tempered Meals
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for its 64 residents. Food Committee Meeting Minutes documented ongoing concerns, including broccoli soup that tasted scorched and was not mixed well, tomato soup that was watered down, and general dissatisfaction with evening meals, which were described as not good. Multiple cognitively intact residents reported that food was often cold, inedible, and difficult to identify. One resident stated that while the meal on the day of observation looked and tasted good, this was a welcome surprise because the food was usually awful, cold, and sometimes unrecognizable. Another resident described the food as atrocious, reporting soggy french fries, burned food with black crust, dry and leathery chicken, dried-out bread, pasta that was either mushy or crunchy, and meals that were cold and unappealing, even when ordered from the alternative menu. This resident also reported being told that chocolate milk was a luxury and too extravagant and expensive to provide. A third resident reported a major problem with the kitchen not serving hot, appetizing, and tasty meals, and provided photographs of severely burned garlic toast with one side white and the other side entirely black with a thick layer of butter, a ground red ball of food identified as lasagna with only one visible noodle piece, and a supposed chicken pot pie served as mixed vegetables in gravy on a plate without any crust. During a test tray observation, a manager in training recorded food temperatures showing mixed vegetables at 110–125 degrees and used bare hands to push the vegetables together in an attempt to increase their temperature, stating they were not at the right temperature and felt cold. The Certified Dietary Manager reported multiple resident complaints of overcooked, unappealing, and cold food, along with significant staffing turnover and kitchen concerns prior to her arrival.
Cross Contamination During Hot Food Temperature Checks
Penalty
Summary
The facility failed to prevent cross contamination during meal service when a manager in training handled a food thermometer and other items in an unsanitary manner while checking the internal temperature of fried chicken prepared for 64 residents. During the lunch meal, which included fried chicken, mashed potatoes with gravy, creamed corn, a drink, and banana pudding, the manager in training determined the fried chicken was not at a high enough internal temperature to serve, then wiped her bare hands on her pants and picked up a thermometer by the shaft with her palm and fingers making full contact. She used this contaminated thermometer to test multiple pieces of chicken in a full pan, then used potholders that were laying on a contaminated counter to return that pan to the oven and remove a second pan of chicken. She again picked up the thermometer with her palm and fingers and used the same contaminated thermometer to test additional pieces of chicken from the second pan, repeating this process with both pans two more times until the internal temperature was safe to serve, without cleaning her hands or the thermometer between uses. The daily midnight census documented that 64 residents resided in the facility at the time of this meal service, and the contaminated thermometer and potholders were used in the preparation of food intended for these residents.
Improper Use of Extension Cords for Multiple Medical Devices
Penalty
Summary
The facility failed to ensure a safe physical environment by allowing multiple residents to use outlet strip extension cords for essential medical equipment instead of direct wall outlets. One cognitively intact resident with obstructive sleep apnea, chronic respiratory failure, heart failure, and atrial fibrillation had a nebulizer machine, oxygen concentrator, and BI-PAP machine all plugged into an outlet strip extension cord, which was then plugged into the single wall outlet in the room, along with the resident’s bed. Another cognitively intact resident with asthma, morbid obesity, atrial fibrillation, pericardial effusion, obstructive sleep apnea, heart failure, cardiomyopathy, chronic respiratory failure, and hypoxia had a pacemaker monitor and nebulizer machine plugged into an outlet strip extension cord attached to the wall; this resident commented that it looked like a fire hazard. A third cognitively intact resident with chronic respiratory failure, obstructive sleep apnea, tachycardia, and COPD had a BI-PAP and nebulizer machine plugged into one outlet strip extension cord connected to a wall outlet, while an oxygen concentrator was plugged into a separate outlet strip extension cord behind a recliner. A fourth cognitively intact resident with obstructive sleep apnea, COPD, malignant neoplasm of bronchus and lung, pulmonary fibrosis, emphysema, and chronic pulmonary edema had an oxygen concentrator plugged into an outlet strip extension cord and reported sometimes putting on or taking off the nasal cannula but not handling the plugs. The Maintenance Director stated that room outlets were being changed to hospital-grade circuit breaker types over time and acknowledged that plugging multiple medical devices requiring higher electrical draw into an outlet strip could be a fire hazard. The Administrator stated that multiple residents with multiple medical devices were using extension cords because that was the only option and confirmed the facility did not have a policy for the use of medical devices plugged into extension cords.
Failure to Properly Implement Fall Interventions Resulting in Resident Injury
Penalty
Summary
The facility failed to properly implement fall interventions for a resident with advanced dementia, poor balance, and a history of impulsiveness. The resident, who was at high risk for falls and required substantial assistance for transfers, attempted to stand up unassisted from her wheelchair and fell. At the time of the fall, the resident's chair alarm did not sound because the pull-tab alarm string was too long and remained attached to her shirt and the magnetic tab, preventing activation. Staff were required to ensure the alarm was properly placed and functioning each shift, but this was not done effectively, resulting in the alarm failing to alert staff as the resident attempted to stand. Following the fall, the resident complained of pain and was found to have sustained a mildly impacted non-displaced left femoral neck fracture. The resident's care plan included multiple fall interventions, such as a low bed, fall mats, a scoop mattress, anti-rollbacks on her wheelchair, and a pull-tab alarm, all intended to address her lack of safety awareness and high fall risk. Despite these interventions being documented, the improper setup of the alarm directly contributed to the resident's fall and subsequent injury.
Failure to Reconcile Controlled Medication Results in Missing Tramadol
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of their medication, specifically Tramadol, by not following established procedures for receiving and reconciling controlled substances. According to the facility's policies, controlled substances are to be verified upon receipt by both the receiving nurse and the individual delivering the medication. However, on the date in question, the nurse who received the delivery did not verify the quantity of Tramadol tablets received and simply signed the paperwork before passing the medication to another nurse. As a result, 60 tablets of Tramadol and two corresponding count sheets were found to be missing, and the discrepancy was only discovered when the pharmacy denied a refill request, citing a recent delivery. The resident involved had medical diagnoses including depression, anxiety, osteomyelitis, and a history of breast cancer, and had a physician's order for Tramadol 50 mg to be administered four times daily. Review of the medication administration records indicated that all doses were documented as given according to the order, but the lack of proper reconciliation and missing count sheets made it impossible to account for all the medication. The Director of Nursing confirmed the failure to follow the reconciliation process and was unable to determine what happened to the missing medication.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled meals to residents, as evidenced by multiple complaints and observations. Resident Council Minutes from July to September 2024 documented ongoing concerns about cold and sometimes burned food. The facility acknowledged these issues but did not implement effective solutions, as evidenced by the dietary manager's admission of inadequate equipment to maintain food temperatures. Several residents, including those with specific dietary needs due to medical conditions, were affected by these deficiencies. For instance, a resident with heart failure and end-stage renal disease reported consistently receiving cold meals and missing a meal entirely after dialysis. Another resident with severe protein-calorie malnutrition and chronic kidney disease received meals that were not in line with their dietary restrictions, such as being served a cold bologna sandwich instead of a heart-healthy meal. Observations on specific dates revealed that meal carts were not plugged in to maintain warmth, and meals were served on room-temperature plates. Residents consistently reported meals being cold, inedible, or not meeting their dietary needs. The dietary manager confirmed the lack of necessary equipment to serve warm meals, indicating a systemic issue in the facility's ability to provide adequate nutrition to its residents.
Failure to Maintain Cleanliness of Resident's Mattress
Penalty
Summary
The facility failed to maintain the cleanliness of a resident's mattress, affecting one resident out of 24 reviewed for environmental cleanliness. The resident, identified as R3, has medical conditions including Dementia and the acquired absence of both legs, one above the knee and the other below. On two separate occasions, surveyors observed smeared and mounded clumps of an unidentified white food substance resembling cake at the foot end of R3's mattress. The residue remained on the mattress over a period of two days, indicating a lack of proper cleaning. Interviews with facility staff revealed that the housekeeping staff only clean mattresses during deep cleaning sessions, which occur once daily for one resident room. The Certified Nursing Assistant (CNA) mentioned that CNAs and nurses have access to sanitizing bleach wipes but did not confirm a regular cleaning schedule for mattresses on residents' shower days. The Housekeeping Supervisor confirmed that the CNAs had brushed off the mattress on the resident's shower day but did not wipe it clean, leading to the observed deficiency.
Inaccurate MDS Assessments for Dental Conditions
Penalty
Summary
The facility failed to accurately encode the Minimum Data Set (MDS) assessments concerning dental conditions for two residents. During observations, both residents were noted to have issues with their upper dentures falling down to their lower lips while speaking, requiring them to push the dentures back into place with their tongues and lower lips. Despite these observations, the MDS assessments for both residents inaccurately documented that they had no broken or loosely fitting dentures and marked them as 'unable to examine.' The MDS Coordinator revealed that the assessments were completed by a former MDS Coordinator who worked offsite and did not conduct in-person examinations, leading to the 'unable to examine' coding. The MDS Manual specifies that a proper dental and oral assessment requires a physical examination using a gloved finger and light source, and dentures should be inspected for cracks, chips, and cleanliness. The manual also states that the 'unable to examine' code should only be used for uncooperative residents, which was not the case for the residents in question.
Failure to Address Denture Issues in Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for residents experiencing denture problems, affecting two residents out of three reviewed for dental issues. On separate occasions, both residents were observed with upper dentures falling down to their lower lips while speaking, requiring them to push the dentures back into place with their tongues and lower lips. Despite these observations, the residents' Comprehensive Minimum Data Sets (MDS) did not document any issues with broken or loosely fitting dentures, and their care plans lacked any focus on denture fit or cleaning care. The MDS Coordinator revealed that the MDS assessments were completed by a former coordinator who worked offsite and was unable to examine the residents directly, leading to the omission of denture issues in the assessments. The facility's failure to address these denture problems in the care plans was further compounded by the fact that the dental Care Area Assessment (CAA) was not triggered in Section V of the MDS. The MDS Manual emphasizes the importance of ensuring proper denture fit and care for individualized care planning, which was not adhered to in these cases.
Failure to Document Recapitulation of Stay for Discharged Resident
Penalty
Summary
The facility failed to complete a recapitulation of stay for a resident who was reviewed for discharge. The resident, who was cognitively intact, required maximum assistance with activities such as toileting, bathing, dressing, personal hygiene, and transfers. The resident had multiple medical diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), repeated falls, amnesia, intervertebral disc degeneration, benign prostatic hyperplasia, obstructive sleep apnea, acute respiratory failure with hypoxia, and diabetes mellitus type II. Despite these needs and conditions, the resident's electronic medical record did not document a completed recapitulation of stay, and the discharge plan and instruction report had a blank section for this information. The facility's administrator acknowledged the absence of this documentation and stated that there was no policy in place for completing a resident's recapitulation of stay.
Inadequate Shower Assistance for Resident
Penalty
Summary
The facility failed to provide safe and adequate assistance with showers to a dependent resident, identified as R39, who was reviewed for Activities of Daily Living. R39 has multiple medical diagnoses, including Lumbar Spondylopathies, Spinal Cord Injury of the Lumbar Region, Neuromuscular Dysfunction of the Bladder, Depression, Left and Right Foot Drop, and Neurogenic Bowel. R39 is cognitively intact and requires varying levels of assistance for showering and dressing, as documented in the Minimum Data Set. The care plan specifies that R39 needs one-person staff assistance for bathing and is at risk for falls, necessitating observation for unsteady gait and balance. Despite being scheduled for showers twice a week, records show that R39 missed eight out of twenty scheduled showers over a two-month period. R39 reported feeling unsafe and uncomfortable due to inadequate assistance from a specific CNA, identified as V8, who either refused to assist or left R39 unattended in the shower room. This lack of assistance led R39 to refuse showers when V8 was assigned, resulting in R39 receiving only about one shower per week instead of the scheduled two. The Director of Nurses confirmed that staff should never leave residents unattended in the shower and that R39 requires assistance due to being a fall risk. The facility's procedure mandates that staff stay with residents throughout the shower and document the process in the resident's electronic health record, which was not consistently followed in R39's case.
Improper Use of Extension Cords for Medical Equipment
Penalty
Summary
The facility failed to ensure that resident medical equipment was properly utilized, leading to potential safety hazards for three residents. Resident 8, who has multiple medical conditions including chronic respiratory failure and dependence on supplemental oxygen, was observed using an oxygen concentrator plugged into a pink extension cord instead of a wall outlet. This was done due to a lack of sufficient wall outlets in the room, as stated by the resident. The Maintenance Director later confirmed that the oxygen concentrator should not be plugged into an extension cord. Similarly, Resident 18, who is cognitively intact and has several medical diagnoses including chronic congestive heart failure and epilepsy, had their bed plugged into a power strip nailed to the wall. The resident mentioned the need to use an extension cord due to insufficient wall outlets. Additionally, Resident 42's electric bed was also plugged into an extension cord power strip, along with a personal refrigerator. The Maintenance Director acknowledged that all resident beds and medical equipment should be plugged directly into wall outlets to prevent potential fire hazards. The facility lacked a policy explicitly stating that medical equipment should not be plugged into extension cords, as noted by the Administrator.
Failure to Obtain Timely Physician Responses to Pharmacist Recommendations
Penalty
Summary
The facility failed to obtain timely physician responses to pharmacist recommendations and did not develop a policy with specific timeframes for the monthly medication regimen reviews. This deficiency affected two residents. For one resident, R16, there was a delay in starting a prescribed antidiabetic medication, Semaglutide (Rybelsus), due to a missed entry in the electronic medical record. The consultant pharmacist identified the missing medication order and recommended clarification with the physician, but the physician did not sign off on this recommendation until nine days later. The Director of Nursing acknowledged that the admitting nurse may have overlooked the medication and that a second nurse should have reviewed the admission orders to prevent such errors. For another resident, R44, the facility did not obtain physician responses to multiple pharmacist recommendations regarding the use of Lorazepam PRN without a stop date. Regulations require a physician to document a rationale for continued use of PRN medications beyond 14 days. Despite receiving three separate recommendations from the consultant pharmacist, none were signed or addressed by a physician. The Director of Nursing noted that the resident was receiving hospice services but could not find any physician response to the recommendations. The facility's policy did not specify timeframes for obtaining physician responses to pharmacist recommendations.
Failure to Honor Resident's Religious Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically related to religious dietary restrictions. The resident, who is of Hindu faith, was served a meal containing pork, which is against their religious beliefs. The resident's electronic medical record did not include a food preferences interview, and their nutritional care plan lacked a focus area, goal, or interventions prior to a specific date. The resident expressed that no staff offered alternatives for the meal, and they typically do not request alternatives when served food they cannot eat due to religious reasons. The Dietary Manager acknowledged that there were issues with documenting resident preferences and that no list of preferences had been maintained for several months. The facility's policy requires that food preference interviews be entered into the medical record and that tray assembly tickets reflect diet orders, allergies, intolerances, and preferences. However, this process was not followed, leading to the resident being served inappropriate food. The Dietary Manager indicated plans to address these issues by updating diet slips for all residents.
Failure to Adhere to Resident's Documented Food Allergies
Penalty
Summary
The facility failed to provide meals consistent with a resident's documented allergies, leading to a deficiency in meal service. A resident, identified as R6, who has multiple medical diagnoses including Diabetes Mellitus Type II and allergies to several substances including onions, was served a meal containing onions. Despite the resident's diet ticket clearly indicating an allergy to onions, the lunch meal included macaroni salad and spinach with pieces of onion. The resident did not consume these items, aware of the potential adverse reaction, and expressed that consuming onions would result in severe illness requiring hospitalization. The Dietary Manager acknowledged the oversight, confirming that the resident's diet ticket documented the onion allergy and that onions should not have been served. The facility's policy on Food and Nutrition Services requires that food preferences and allergies be documented and adhered to during meal preparation and service. This incident highlights a failure in the facility's adherence to its own policy, resulting in a potential risk to the resident's health.
Failure to Document Consent Capacity in Cognitively Impaired Residents
Penalty
Summary
The facility failed to document evaluations to determine the capacity of cognitively impaired residents to consent to a known sexual relationship. This deficiency was identified during a survey where it was found that the facility did not have a developed policy on intimate resident behavior that included criteria for initial evaluation and the frequency of evaluating a cognitively impaired resident's capacity to consent. The facility's policy also lacked specifications on where and how these evaluations and determinations would be documented and maintained. This failure affected two residents, both diagnosed with dementia and rated as severely cognitively impaired, and had the potential to affect 22 additional cognitively impaired residents. The report details specific incidents involving two residents, both with severe cognitive impairment, who were observed engaging in intimate behavior. Staff members, including CNAs and an LPN, witnessed these interactions but did not take action due to the belief that the interactions were consensual. However, there was no formal documented evaluation of the residents' capacity to consent to such activities. Interviews with the residents' POAs and facility staff revealed differing opinions on the residents' ability to consent, but no formal assessments had been conducted to support these opinions. The facility's policy on intimate resident behavior was found to be lacking in specific guidelines for documenting and maintaining evaluations of residents' capacity to consent to intimate relationships. The policy did not specify the frequency of these evaluations, and there was no documentation available during the survey to demonstrate that such evaluations had been conducted. This oversight in policy and documentation has the potential to affect a significant number of cognitively impaired residents within the facility.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that residents were free from sexual abuse, as evidenced by an incident involving two residents, R1 and R2, both diagnosed with dementia and rated as severely cognitively impaired. On a specific date, a Licensed Practical Nurse (LPN) observed R1 with his genitals exposed while R2 was touching them. Despite witnessing this, the LPN did not intervene, believing the interaction to be consensual based on the residents' previous interactions. However, there were no documented assessments in the residents' medical records to confirm their ability to consent to sexual relationships. Further interviews with staff, including Certified Nursing Assistants (CNAs) and the Director of Nursing (DON), revealed that there was a general assumption of consent between R1 and R2 due to their friendly behavior and history of knowing each other from a previous nursing home. However, none of the staff, including the Social Services Director, had conducted formal evaluations to assess the residents' capacity to consent to sexual activity. This lack of formal assessment and documentation contributed to the facility's failure to protect the residents from potential abuse.
Failure to Document Intimate Relationship in Care Plans
Penalty
Summary
The facility failed to develop care plans for two residents to include their intimate relationship and the need for privacy. This deficiency was identified during interviews and record reviews. A Licensed Practical Nurse (V7) observed one resident with exposed genitals while another resident was engaging in intimate behavior with them. Despite witnessing this, V7 did not intervene, believing the relationship to be consensual. A Certified Nursing Assistant (V5) also reported observing intimate behavior between the two residents. The facility's policy on Intimate Resident Behavior, Privacy, and Relationships requires documentation of issues or concerns related to intimacy and sexual expression in the residents' care plans. However, as of the time of the survey, neither resident had such documentation in their care plans.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from sexual and verbal abuse, as evidenced by multiple incidents involving a resident identified as R1 and other residents. R1, who was documented as moderately cognitively impaired, engaged in inappropriate sexual behavior towards residents R2 and R3. R2, who was cognitively intact, reported that R1 touched her breasts in the hallway, causing her emotional distress and discomfort. Despite being informed of the incident, R1 was allowed to return to the facility, leading R2 to feel unsafe and avoid shared areas. Similarly, R3, also cognitively intact, reported that R1 attempted to touch her breast on two separate occasions, which made her feel vulnerable and uncomfortable. In addition to the incidents involving R1, the facility also failed to protect resident R5 from verbal and mental abuse by a staff member, identified as V8, a Certified Nurse Aide (CNA). R5, who was cognitively intact and dependent on staff for assistance due to multiple medical conditions, reported that V8 used foul language and refused to assist him with his requests. R5 expressed fear of V8, as he was left unattended in his chair for hours during the night shift, feeling isolated and afraid to ask for further assistance. The facility's policy on abuse clearly prohibits any form of abuse, including sexual and verbal abuse, and emphasizes the residents' right to be free from such mistreatment. However, the facility's inaction in promptly addressing R1's inappropriate behavior and V8's verbal abuse towards R5 highlights a significant deficiency in protecting residents from abuse. The failure to implement immediate and effective measures to prevent further incidents contributed to the residents' feelings of fear, discomfort, and vulnerability.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from inappropriate behaviors and sexual abuse by another resident, resulting in a deficiency. Resident 1, who was moderately cognitively impaired, exhibited inappropriate sexual behaviors towards other residents, including attempting to touch staff and residents inappropriately. Despite these behaviors, Resident 1 was not placed on continual observation immediately after the first incident involving Resident 3, who was cognitively intact. Resident 3 reported that Resident 1 attempted to touch her inappropriately twice, with the first attempt being witnessed by a Certified Nurse Aide. Resident 3 expressed feeling vulnerable and uncomfortable, choosing to avoid shared areas when Resident 1 was present. Resident 2, also cognitively intact, reported that Resident 1 rubbed his hands over her breasts after an earlier incident involving Resident 3. Resident 2 expressed distress and discomfort, stating that she felt unsafe and had to avoid Resident 1. The facility's administrator acknowledged that Resident 1 should have been placed on continual observation immediately after the first incident with Resident 3 to prevent further incidents. The failure to implement immediate protective measures left residents at risk of abuse, as Resident 1 was not adequately monitored or sent for evaluation after the initial inappropriate behavior.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse between two residents to the Abuse Coordinator and the State Agency in a timely manner. Resident R5, who is cognitively intact, reported to a Certified Nurse Aide (CNA) that a couple of months ago, they had a fist fight with their roommate, R1. Despite this disclosure, the CNA did not report the incident to the facility's Administrator or any other appropriate authority. R5 expressed concerns about being roommates with R1 again due to the potential for further altercations. The facility's Administrator, V1, was unaware of the incident and stated that any allegations of abuse should be reported to them for further investigation. The facility's 'Abuse Policy' mandates the immediate reporting of all abuse allegations to the Administrator and timely notification to the proper authorities, including the Illinois Department of Public Health, Ombudsman, Local Police Department, Power of Attorney, and Physician. However, there was no documentation to show that R5's allegation was ever reported, indicating a failure in adhering to the facility's policy and state regulations.
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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