Jerseyville Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Jerseyville, Illinois.
- Location
- 1251 North State Street, Jerseyville, Illinois 62052
- CMS Provider Number
- 145733
- Inspections on file
- 29
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Jerseyville Manor during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and significant behavioral and psychiatric histories were allowed to interact in a hallway without effective protection from resident-to-resident abuse. One resident, known to pace the unit and at high risk for falls, stopped outside another resident’s room while ambulating independently. The other resident, who had documented verbal and physical behaviors, wandering, territoriality, and rejection of care, came out of her room, ran toward the pacing resident, and pushed her to the floor, causing a severe left hip fracture and head impact. Staff had prior knowledge of both residents’ behavioral patterns, including the aggressor’s tendency to become easily annoyed and to put hands on others, yet the incident occurred in an unsupervised context. Hospital and facility records linked the fracture from this push to the resident’s subsequent surgery and death, and the facility’s own abuse policy defined such willful acts causing injury as abuse, forming the basis of the deficiency for failure to prevent resident-to-resident abuse.
A resident with dementia, severe cognitive impairment, incontinence, and need for substantial/maximal assistance with mobility had documented fall-risk interventions including use of a concave mattress and other fall approaches. After being found on the floor on two separate occasions, with the second fall followed by reluctance to ambulate and lower extremity stiffness, imaging confirmed an acute transverse fracture of the left patella. During surveyor observation, the resident’s bed had a regular mattress rather than the ordered concave mattress, and multiple CNAs reported the resident had not had a special mattress, while the DON and MD indicated that interventions should be in place after each fall; the facility also lacked a specific fall-prevention policy, relying instead on an undated accident/incident prevention document.
A resident with Parkinson’s disease and a deep brain stimulator (DBS) had physician orders and a care plan directing that the DBS be charged on specific days using a chest-placed charging disk, yet the resident reported that staff did not know how to charge it and that it was sometimes not charged. Multiple LPNs and an RN stated they had not been inserviced on how to use, read, or charge the DBS, did not know how to confirm it was charging, and relied on the resident or family for guidance, while describing various Parkinson’s symptoms they observed when the DBS was not charged. The DON and ADON acknowledged there had been no formal staff education on the DBS, and although a written DBS policy existed, there was no indication it had been implemented through staff training, despite expectations from the medical director and neurologist’s office that staff would be educated on device use and related symptoms.
A resident with Alzheimer’s disease, cerebral infarction, and dysphagia, who was on a mechanically altered diet and had documented coughing and choking during meals, experienced a choking episode when a piece of bread became lodged in the throat during a meal and was later expelled before an LPN arrived. Despite a physician order for speech therapy to evaluate and treat swallowing and a referral made to the SLP, the swallow evaluation was not completed until many days after the incident, while the DON was unsure about the expected timeframe for such evaluations and the medical director stated they are normally done the next day. The facility’s therapy policy did not define a required timeframe for SLP evaluation after a choking-related referral.
Failure to Prevent Resident-to-Resident Abuse Resulting in Fatal Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident abuse, resulting in one resident pushing another resident to the floor and causing a left hip fracture that required surgery and was listed as the immediate cause of death. The resident who was pushed (R157) had severe cognitive impairment with a BIMS score of 3 and multiple diagnoses including dementia without behavioral disturbance, schizoaffective disorder, anxiety disorder, psychosis, repeated falls, weakness, unsteadiness on feet, reduced mobility, COPD, osteoporosis, heart failure, and depression. She was known to pace the unit, ask repetitive questions, display anxiety, and exhibit verbal/physical expressions related to rejection of care and delusions, as well as other behaviors such as pacing and picking at her skin. Her care plan identified her as at risk for falls related to cognitive deficits, altered safety awareness, need for ADL assistance, incontinence, and use of psychotropic and opioid medications. The resident who pushed her (R136) also had severe cognitive impairment with a BIMS score of 2–3 and extensive psychiatric and neurologic diagnoses including Alzheimer’s disease, paranoid schizophrenia, dementia with agitation, delusional disorders, depressive episodes, and severe dementia with psychotic disturbance. Her MDS and care plan documented a history of verbal and physical behaviors directed toward others, rejection of care, wandering, exit-seeking, and territoriality when others entered her room or personal space. Progress notes described that she might scream, curse, shove, kick, hit, or scratch staff providing care, and that she had been placed on a behavior tracking program for increased wandering and exit-seeking. Staff notes also documented an incident where she was kissing a relative in the dining room and became verbally upset when separated, and that she had verbal/physical behaviors related to rejection of care, with formal behavioral programming in place. On the day of the incident, R157 was walking laps on the unit, consistent with her usual pacing behavior, and walked past the doorway of R136’s room, stopping approximately 5–6 feet outside the doorway while saying something and pointing her finger. A CNA (V19) witnessed R136 come out of her room running with both arms extended and push R157 to the floor, then run back into her room laughing and shut the door. The CNA reported that R157’s head hit the floor very hard, and she was bleeding, crying in pain, and complained of severe pain everywhere. The nurse’s fall event documentation and progress note recorded that a loud noise was heard, R157 was found on the floor on her left side with painful and limited ROM in the left lower extremity, shallow skin tears to the left eyebrow and forearm, and severe pain. The fall safety event and hospital ER note both documented that another resident pushed her in an unsupervised context. Hospital records confirmed a proximal left femur fracture requiring ORIF, and the death certificate listed the acute displaced left femur intertrochanteric fracture, status post intramedullary nail insertion, with underlying dementia and contributing pulmonary edema and schizoaffective disorder, as the causes of death. Staff interviews indicated that some staff were aware that both residents had behavioral issues, though they generally described R157’s behaviors as not directed toward other residents and R136’s behaviors as primarily verbal toward staff. However, the CNA who witnessed the event stated that prior to this incident, R136 had “a few issues” at the supper table where she would put her hands on residents who annoyed her and that she was easily annoyed by other residents. Another CNA reported that R136 stayed in her room most of the time but would verbally curse or tell other residents to stay away, and staff would attempt to redirect her with snacks, TV, or diversion. The facility’s Abuse Prohibition and Reporting Policy stated that special attention would be given to identifying behaviors that increase a resident’s potential for abusing others or being a victim of abuse, including residents with a history of aggressive behaviors and those who enter other residents’ rooms. Despite documented behavioral histories and risk factors for both residents, the incident occurred when R157 was walking independently on the unit and R136 was able to leave her room and physically push R157 in the hallway, resulting in the injury and subsequent death. The facility’s internal investigation concluded that the root cause of the fall was directly linked to the actions of R136, who pushed R157, and that due to R136’s cognitive status she was unable to account for or explain her actions. The investigation noted that neither resident could provide credible details of the fall or what led up to it, and that staff who were nearby did not witness any behaviors immediately beforehand that would indicate the event would occur. The investigation also stated that R136 had no prior physical incidents since admission and that there was no sufficient evidence to suggest the actions were intentional. Nonetheless, the event met the facility’s own definition of abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, where “willful” means the individual acted deliberately, regardless of intent to cause harm. The deficiency centers on the facility’s failure to prevent this resident-to-resident abuse, despite known behavioral risks and documented patterns of wandering, territoriality, and behavioral expressions in both residents. The Medical Director later stated that, in her opinion, the incident between the two residents was unexpected and that neither resident had displayed physical behaviors toward others, and she attributed the resident’s death to poor postoperative monitoring at the hospital. However, the death certificate and hospital documentation directly linked the acute displaced left femur fracture, caused by the push and fall, to the resident’s death. The facility’s abuse policy emphasized protecting residents from all types of abuse and giving special attention to residents with aggressive behaviors or those who enter other residents’ rooms, but the events described show that R157 was able to ambulate independently in the hallway near R136’s room and that R136 was able to exit her room and physically push her, resulting in serious injury. These facts and observations form the basis of the cited deficiency for failure to protect residents from abuse, specifically resident-to-resident abuse.
Failure to Implement Fall-Prevention Interventions Resulting in Patellar Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain current fall-prevention interventions for one resident, resulting in a left patellar fracture. The resident had dementia, Alzheimer’s disease, weakness, severe cognitive impairment, used a walker, and required substantial to maximal assistance with bed mobility, transfers, and ambulation. The care plan identified the resident as at risk for falls due to diagnoses, cognitive deficits affecting safety awareness, need for ADL assistance, bowel and bladder incontinence, and use of psychotropic and potential opioid medications. The care plan documented fall interventions including a concave mattress, neon tape to the walker, keeping the walker at bedside, encouraging the resident to ask for assistance when ambulating, alternating call rounds with toileting offers, and using lighter weight pajamas at bedtime. On one date, facility documentation shows the resident was previously resting in bed in the lowest locked position and was later found on the floor lying on her left side with her head against the closet door, incontinent of bladder, with disheveled blankets suggesting she slid out of bed. The fall investigation identified that the resident slid out of bed and noted that a concave mattress was to be used as an intervention. A subsequent fall occurred days later, when the resident was again found on the floor on her left side near the closet, with a small hematoma to the back of the head and an abrasion to the left knee. Staff documented that the resident was able to bear weight but had an unsteady gait with a slight limp, and that she commonly attempted to get up on her own despite requiring assistance to get out of bed and ambulate. Following the second fall, nursing notes describe the resident as reluctant to ambulate, with stiff lower extremity ROM and inconsistent reports of pain location. An x-ray report initially mentioned a patellar fracture without clarifying whether it was old or new, and a reread by the radiologist confirmed an acute left patellar fracture, later specified as a transverse fracture of the patella with apex anterior angulation and articular surface step-off. Surveyor observations on a later date found that no concave mattress was on the resident’s bed; staff CNAs reported that the resident had a regular mattress and denied that a special mattress had been in place. The DON stated that interventions are to be implemented and care plans updated after every fall, and the MD stated that if a concave mattress was ordered after a fall, she would expect it to be in place. The DON also stated the facility did not have a fall prevention policy and provided an undated Accident/Incident Prevention document without a facility name, which generally stated that interventions are to be put in place when a resident is identified as high risk for accidents/incidents.
Lack of Staff Competency in Managing Resident’s Deep Brain Stimulator
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were knowledgeable and competent in the use and monitoring of a deep brain stimulator (DBS) for a resident with Parkinson’s disease. The resident’s face sheet documented diagnoses of Parkinson’s disease and a DBS, and the care plan included an approach to charge the DBS on specified days by placing a round disk on the right side of the chest for approximately two hours or until fully charged. The physician’s orders and the treatment administration record also directed that the DBS be charged three times weekly on night shift. Despite these written directions, the resident reported that staff were supposed to charge his DBS but did not know what they were doing and that sometimes his DBS was not charged. Multiple staff interviews confirmed a lack of formal in-service training and inconsistent knowledge about how to operate the DBS charger, how to verify that it was charging, and what symptoms the resident would exhibit if the DBS was not charged. Several LPNs and an RN stated they had not been inserviced on how to use, read, or charge the DBS device and did not know how to tell if it was charging or what symptoms to look for when it was not charged. One LPN reported learning from the resident’s family and the resident himself, rather than from facility training, and others stated that the family or the resident handled the charging. Staff described various observations when the DBS was not charged, including increased tremors, difficulty swallowing, coughing while eating, delayed or slurred speech, and slow movements, but this knowledge was informal and not based on structured education. Leadership interviews further demonstrated the absence of a systematic training process. The DON, who had been in the role for over ten years, acknowledged she had not inserviced staff on how to use the resident’s DBS and did not know the full extent of symptoms that could occur if it was not charged. The ADON recalled being shown how to charge and read the device by the resident’s family at the time of admission, rather than through a facility-led process. The neurologist’s medical assistant and the medical director both stated that when the DBS is not charged, the resident’s Parkinson’s symptoms increase, such as tremors, slurred speech, shuffling gait, and out-of-control tremors, and both expected staff to be educated on device use and symptoms. A DBS policy dated 1/2013 referenced following manufacturer’s instructions and charging as recommended by the doctor but did not bear the facility’s name, and there was no evidence in the report that this policy had been implemented through staff training.
Delayed Swallow Evaluation After Choking Episode in Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to timely evaluate the swallowing function of a resident with known dysphagia after a choking episode. The resident was admitted with diagnoses including Alzheimer’s disease, cerebral infarction, and dysphagia, and the MDS documented severe cognitive impairment, need for setup or clean-up assistance with eating, a mechanically altered therapeutic diet, food holding in the mouth/cheeks, and coughing or choking during meals or when swallowing medications. The care plan identified dysphagia with increased risk of aspiration, choking, and swallowing difficulties, and the diet order specified a mechanical soft diet. During a noon meal, the resident experienced an episode in which a piece of bread became lodged in the throat; by the time the LPN arrived in response to staff notification, the resident had already expelled the bread. Following this choking event, a physician order was written for speech therapy to evaluate and treat as indicated, and the SLP reported that the LPN had made a referral for a swallow evaluation after the episode. However, the SLP stated that the evaluation had not yet been completed and was only planned for sometime later in the week, and the DON was unsure how soon residents should be evaluated after choking. The medical director stated awareness of the choking incident and was unsure why it took the SLP so long to evaluate, noting that such evaluations are normally done the next day. The resident’s swallowing function was ultimately evaluated 11 days after the choking episode. The facility’s Therapy Evaluation/Reassessment Policy did not specify a timeframe for conducting a speech therapy evaluation following a referral for choking.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
