Joliet Living & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Joliet, Illinois.
- Location
- 2230 Mcdonough, Joliet, Illinois 60436
- CMS Provider Number
- 14E247
- Inspections on file
- 28
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Joliet Living & Rehab Center during CMS and state inspections, most recent first.
The facility implemented new house rules that prohibited residents from visiting other residents’ rooms if they lived on different wings, directing them instead to visit only in the dining room and providing no alternative space for private visits. This change conflicted with the facility’s own Resident Rights document, which states that residents have the right to private visits unless limited by a physician. Multiple residents, including those with anxiety, depression, and chronic migraine headaches, reported that they could no longer have private time with friends or intimate partners, felt their rights were violated, and described feeling depressed, anxious, and like prisoners due to the loss of privacy. The Administrator confirmed the rule was added to address resident smoking in rooms and that most residents had signed the new agreement.
Two residents with behavioral health diagnoses were involved in a verbal and physical altercation after repeated complaints about one resident's disruptive behavior were not addressed by staff. Despite awareness of the issue, no interventions or care plan updates were made, resulting in both residents sustaining injuries and requiring hospital evaluation.
The facility did not identify water systems requiring Legionella control measures or assess the risk of hazardous conditions as outlined in its water management program. Staff could only provide water flushing logs and a general policy, with no documented risk assessment or system identification, affecting all 88 residents.
Several cognitively intact residents reported and were observed to have room windows without screens, leading to concerns about insects and other objects entering when windows were open. The Maintenance Director confirmed the absence of screens throughout the facility, and the Administrator stated there was no policy requiring window screens, with past screens having been removed or damaged and not replaced.
The facility did not provide written notification of its bed-hold and return policy to residents or their representatives before hospital transfers, as required by policy. This deficiency was identified for four residents with complex medical and psychiatric needs who were hospitalized for various acute events, with no documentation of the required notification found in their records.
Two residents with psychiatric conditions were involved in a physical altercation after one began punching the other, leading to retaliation and injury. Staff and witnesses confirmed a pattern of aggressive and intrusive behavior by one resident, and both individuals required hospital evaluation following the incident.
Two residents with severe mental illness did not receive the necessary behavioral health services as outlined in their PASRR assessments and care plans. Both attended only minimal group sessions, with no evidence of participation in key rehabilitative programs or one-on-one interventions, and the facility failed to document refusals or efforts to provide required behavioral health care.
A resident with multiple diagnoses and intact cognition had a large piece of plywood covering a hole in the wall next to their bed for about a year after accidentally kicking the wall. Despite being told the wall would be repaired, the fix was overlooked by maintenance staff, and the plywood remained in place for 14 months, contrary to facility policy requiring timely repairs and maintenance.
Three residents with psychiatric diagnoses and cognitive intactness were involved in incidents where one resident was sexually abused by another after consuming alcohol, and subsequently physically assaulted her boyfriend, believing he allowed the abuse. The facility failed to prevent these instances of sexual and physical abuse, contrary to its stated abuse prevention policy.
A resident with multiple medical conditions and a need for assistance with ADLs did not receive timely podiatry care, resulting in long, discolored, and curled toenails. Despite being on the podiatry list and requesting care, the resident was not seen by the podiatrist as scheduled, and there was no documentation of refusal or alternative arrangements for foot care, contrary to facility policy.
A resident with multiple medical and psychiatric diagnoses, who was cognitively intact and required supervision for ADLs, was denied a second cup of coffee by a CNA despite there being no facility rule limiting coffee servings. The resident observed another individual receiving a second cup and was not informed of any restrictions, leading to feelings of frustration and being singled out. Staff and administration confirmed that no such rule existed and that residents were generally allowed additional coffee.
Multiple incidents occurred in which residents engaged in physical altercations following staff discussions about resident behavior within earshot of others and insufficient supervision during smoke breaks. These events led to residents confronting and physically assaulting each other, in violation of the facility's policy prohibiting abuse.
A resident with multiple medical conditions did not receive a Nurse Practitioner's ordered Basic Metabolic Panel (BMP) lab test, despite the order being confirmed by an RN. The facility lacked documentation that the test was completed, even though prior labs showed abnormal sodium and bilirubin levels. The resident was later hospitalized with further abnormal lab findings, and staff confirmed the test should have been done according to facility policy.
Two residents, both diagnosed with schizoaffective disorder and generalized anxiety disorder, were involved in a physical altercation when one resident slapped the other in a shared bathroom. The incident occurred due to a misunderstanding, as the resident who slapped perceived an insult. Despite the facility's abuse policy, the altercation was not prevented, highlighting a deficiency in protecting residents from abuse.
The facility failed to maintain cleanliness in the food preparation area and equipment storage, affecting all 92 residents. Staff were observed with improper hair restraints and inadequate hand hygiene. The kitchen had dust-covered vents, stained pans, and dusty storage racks. Facility policies on safe food preparation and cleaning schedules were not followed.
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies such as difficult-to-open bathroom doors, insufficient water pressure in showers, broken drawers, peeling paint, and wobbly toilets. These issues had been reported by residents but remained unresolved for extended periods, affecting their quality of life.
The facility failed to invite four residents to their care plan meetings, despite their cognitive abilities being intact or moderately impaired. Observations, interviews, and record reviews confirmed the absence of documentation for care plan meetings or invitations for these residents. The facility's policies require the development of a person-centered care plan with resident participation, but this was not adhered to, as evidenced by the lack of invitations and documentation.
The facility failed to prevent a resident from accessing unprescribed medications and did not adequately monitor smoking residents. One resident was found with five different pills, and multiple residents reported insufficient supervision during smoking breaks, contrary to facility policy.
The facility failed to maintain dignity and privacy for two residents with intact cognition. Staff entered rooms without waiting for permission, administered incontinence briefs in public areas, and shared dressers exposed personal belongings. The DON acknowledged these concerns, emphasizing the need for staff to knock and wait for permission before entering and to avoid public distribution of incontinence briefs.
The facility failed to maintain proper documentation for Advanced Directives for three residents, resulting in discrepancies between the residents' wishes and their medical records. The facility's policy mandates congruent documentation and timely updates, which were not followed.
The facility failed to follow physician orders for one resident by administering an incorrect dosage of Tylenol and did not monitor another resident's blood glucose levels despite her being on diabetic medications. The Director of Nursing confirmed these deficiencies, highlighting the need for proper medication administration and monitoring.
The facility failed to update the EMR to include a resident's medical diagnoses. The DON confirmed that the admitting nurse is responsible for entering the diagnoses and the MDS Coordinator should have reviewed them. The facility did not have a policy or procedure guide for updating resident records.
Restriction of In-Room Visitation and Loss of Resident Privacy Rights
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to private visits and a dignified existence when it implemented new house rules restricting in-room visitation between residents from different wings. The facility’s written Resident Rights document states that residents have the right to private visits unless limited by a physician for medical reasons. However, effective January 23, 2026, the facility implemented a new House Rules and Behavior Expectations agreement, including a rule that residents are prohibited from going onto another unit or floor where they do not reside and directing them to use the dining room if they wish to visit a co-resident. The Administrator confirmed that this rule was added to make it easier to identify residents who were smoking in their rooms and that it was implemented permanently, with 80 of 92 residents signing the new agreement. The Administrator also acknowledged that there is currently no place where residents from different wings can visit privately. Multiple residents reported that this new rule removed their ability to have private visits in their rooms, particularly with significant others and friends who live on different wings. One resident stated she could no longer have her boyfriend or friends in her room and that they could not be intimate due to lack of privacy. Another resident reported that the rule violated his rights, increased his depression, and that he does not like leaving his room. Other residents described the rules as unconstitutional, said they could no longer play video games with friends in private, and reported feeling annoyed, depressed, anxious, and like prisoners because they could not have private time with friends or partners. One resident with chronic migraine headaches stated she prefers to stay in her room and now has limited time with her boyfriend because she does not like to go to the dining area. Staff confirmed that the new rule prohibiting residents from entering rooms on other wings had recently started and that residents were complaining about it.
Failure to Implement Interventions Following Behavioral Complaints Led to Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse by not implementing interventions in response to repeated behavioral concerns and a resident complaint. One resident, with a history of mood disorder, depression, anxiety, and chronic pain, exhibited verbally threatening behaviors almost daily and demonstrated depressive moods. Another resident, diagnosed with schizoaffective disorder, PTSD, anxiety disorder, and bipolar disorder, also experienced depressive moods. Despite ongoing complaints from residents and staff about one resident's behavior of placing meal trays on another table, no interventions or care strategies were documented or implemented to address the issue. An altercation occurred during dinner when one resident struck another after being verbally provoked, resulting in both sustaining injuries that required first aid and hospital evaluation. Multiple interviews confirmed that staff were aware of the ongoing behavioral issue and resident complaints but failed to act or document any interventions. The facility's abuse prevention policy requires timely response to consumer concerns, but records showed no evidence of such actions prior to the incident.
Failure to Implement Comprehensive Water Management and Legionella Risk Assessment
Penalty
Summary
The facility failed to follow its own water management program by not identifying building water systems that require Legionella control measures and not assessing the level of risk posed by hazardous conditions in those systems. During the survey, the facility was unable to provide documentation or evidence of a risk assessment or identification of specific water systems at risk for Legionella, as required by their policy. The only information provided consisted of a log for water flushing in unoccupied rooms, a general water management program policy, and screenshots of water flushing logs. The policy referenced a diagram (Figure A) for system identification, but no such diagram was attached or available. Interviews with the Administrator, Maintenance Director, and Regional Maintenance confirmed that no additional documentation or assessment existed beyond the flushing logs and policy. The staff stated that the water flushing logs constituted their assessment, but there was no written or otherwise documented evaluation of the facility's water systems or the risks associated with Legionella. This deficiency affected all 88 residents residing in the facility, as indicated by the facility census.
Failure to Provide Window Screens in Resident Rooms
Penalty
Summary
The facility failed to provide window screens in resident rooms, resulting in a lack of a safe, clean, and comfortable environment for residents. Multiple cognitively intact residents reported that their room windows did not have screens, and observations confirmed the absence of screens, as well as the presence of warped or damaged screens in several rooms. Residents expressed concerns about insects and other objects entering their rooms when windows were open for ventilation. In one instance, a resident reported that a maintenance staff member installed a wooden block to prevent the window from opening fully due to safety concerns, but did not address the missing screen despite being informed about it. Another resident's window screen was found lying outside on the grass, broken and ripped, and had not been replaced for over two weeks. The Maintenance Director confirmed that, to his knowledge, none of the facility's windows had screens since he began working there three years prior. The Administrator stated there was no facility policy regarding window screens and indicated that screens had previously been removed or damaged by residents, leading to the decision not to reinstall them. These actions and inactions resulted in the ongoing absence of window screens in resident rooms, despite residents' requests and concerns.
Failure to Provide Written Bed-Hold Policy Prior to Hospitalization
Penalty
Summary
The facility failed to provide written notification of its bed-hold and return policy to residents or their representatives prior to hospitalization, as required by its own policy. This deficiency was identified through record review and interviews, which revealed that four residents who were transferred to the hospital for various medical and behavioral reasons did not receive the required written documentation. The residents involved had complex medical and psychiatric diagnoses, including diabetes, schizoaffective disorder, bipolar disorder, PTSD, and intellectual disabilities. Each resident experienced an acute event necessitating hospital transfer, such as rib fractures with pneumothorax, abnormal diagnostic results, urinary tract infection, escalating aggressive behavior, or self-harm attempts. Despite multiple hospitalizations and clear documentation of the events leading to each transfer, there was no evidence in the residents' records that the facility provided the mandated written bed-hold and return policy prior to their departure. The facility administrator confirmed during the survey that the bed-hold forms were not being completed for residents transferred to the hospital, even though the facility's policy required this notification. The deficiency was found in all four cases reviewed for hospitalization in the sample.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with psychiatric diagnoses. One resident, who is cognitively intact and diagnosed with paranoid schizophrenia, was seated next to another resident with moderately impaired cognition, unspecified schizophrenia, and a history of aggressive and abusive behavior. While watching a movie in the dining/day room, the resident with a history of aggression began lightly punching the other resident's arm, escalating to harder punches. The recipient of the punches did not initially report the behavior, as it was consistent with the aggressor's known conduct, but eventually retaliated by grabbing the aggressor's hand and kneeing him in the abdomen. This resulted in the aggressor losing balance and falling to the floor. Multiple staff interviews confirmed that the aggressive resident had a pattern of socially inappropriate and intrusive behavior, including touching others without consent. Staff present at the time witnessed the escalation and responded after the physical altercation had already occurred. Both residents sustained injuries and were sent to the hospital for evaluation. The incident highlights a failure to adequately supervise and intervene to prevent physical abuse between residents, particularly given the known behavioral history of one of the individuals involved.
Failure to Provide Required Behavioral Health Services to Residents with SMI
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with severe mental illness (SMI), as required by their PASRR Level II recommendations and care plans. Both residents had diagnoses including schizoaffective disorder and schizophrenia, and their PASRR assessments specified the need for rehabilitative supports such as life skills programs, psychotherapy, and regular meetings with mental health professionals. Despite these documented needs, the facility did not ensure that the recommended behavioral health services were consistently offered or provided. For the first resident, documentation showed only two group sessions attended over a five-month period, totaling one hour of behavioral health services. The resident was not listed as a participant in key groups such as symptom management, home and self-care, or social skills, despite being assessed as able to benefit from them. Facility staff stated that the resident refused both group and one-on-one sessions, but there was no documentation of these refusals or of efforts to offer one-on-one interventions as required by the care plan and PASRR recommendations. The second resident also had a history of SMI and substance use, with PASRR recommendations for multiple rehabilitative services and psychotherapy. This resident attended only three money management group sessions and one sexual health group session over several months, with no participation in other recommended groups. Staff confirmed that the resident refused additional groups and one-on-one sessions, but again, there was no documentation of refusals or of attempts to provide individualized behavioral health interventions. Both cases demonstrate a lack of implementation and documentation of required behavioral health services for residents with SMI.
Failure to Repair Resident Room Wall in Timely Manner
Penalty
Summary
A deficiency was identified when a resident's room was not maintained in good repair, as required by facility policy. The resident, who was cognitively intact and had multiple diagnoses including schizoaffective disorder and obesity, had a large piece of plywood covering a hole in the wall next to his bed. The hole was created when the resident accidentally kicked the wall while sleeping, and the plywood had been in place for approximately a year. The resident reported that he was told the wall would be repaired, but no timeline was provided, and the repair was not completed. Interviews with facility staff confirmed that the plywood had been covering the hole for 14 months due to an oversight by the Maintenance Director. The Administrator acknowledged that the hole should have been fixed and that leaving plywood on the wall for such an extended period was inappropriate. Facility policy states that the Maintenance Department is responsible for keeping the building in good repair and free from hazards, but this was not followed in this instance.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect three residents from sexual and physical abuse. One resident, who was cognitively intact and had diagnoses including PTSD, schizoaffective disorder, anxiety, and borderline personality disorder, reported that another resident with similar psychiatric diagnoses and a history of substance use entered her room and touched her inappropriately by grabbing her breast. The incident occurred after the residents had consumed alcohol together. The resident responded by kicking the perpetrator and later reported the incident to facility staff, after which the police were called. Additionally, the same resident slapped her boyfriend, another resident, because she believed he allowed the inappropriate contact to occur. The boyfriend confirmed being slapped but denied injury or pain and declined police intervention. Both incidents were reported to the Illinois Department of Public Health. The facility's abuse policy states a commitment to protecting residents from abuse by anyone, but the events described demonstrate a failure to uphold this policy, resulting in residents being subjected to both sexual and physical abuse by peers.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including schizoaffective disorder, attention deficit hyperactivity disorder, obesity, and tinea unguium, did not receive appropriate podiatry care. The resident was cognitively intact and required supervision or assistance with activities of daily living. During observation, the resident was found to have long, black, and curled toenails on the left foot and long toenails on the right foot. The resident reported that the last podiatry visit for toenail clipping was six months prior and that, despite being on the list to see the podiatrist, was not seen during the most recent visit. The resident also stated that he had informed the program manager of his need for toenail care. Interviews with facility staff confirmed that the resident should have received podiatry care and that there was no documentation of the resident refusing services. The facility's records showed the resident was added to the podiatry list for toenail trimming, but there was no documentation of the resident being seen by the podiatrist as scheduled. The facility's policy requires podiatry services, including toenail trimming, to be made available to all residents, but this was not provided in this case.
Resident Denied Second Cup of Coffee Without Justification
Penalty
Summary
A resident with multiple diagnoses, including cocaine dependence with cocaine-induced anxiety disorder, major depressive disorder, COPD, cardiac arrhythmia, back pain, and suicidal ideations, was admitted to the facility and assessed as cognitively intact and requiring supervision with all ADLs. On the day in question, the resident requested a second cup of coffee during a meal service. The CNA serving coffee refused the request, instructing the resident to wait until all others had received their first cup. The resident expressed frustration, noting that he was not informed of any such rule and observed another resident receiving a second cup. The resident attempted to obtain a second cup through his roommate, but the CNA recognized the attempt and did not provide the coffee. Interviews with staff confirmed that there were no facility rules limiting residents to one cup of coffee, and the administrator stated there had been no issues with coffee supply or restrictions on second helpings. The Psychiatric Rehabilitation Services Coordinator noted that the resident was particularly distressed that day and that a second cup of coffee could have helped. Observations on a subsequent day showed residents freely receiving additional cups of coffee, and no rules regarding coffee service were posted. The incident resulted in the resident feeling singled out and denied a personal preference without justification.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving altercations between residents. In one incident, a resident with a history of cocaine dependence, major depressive disorder, and other medical conditions requested a second cup of coffee and was denied by a CNA, leading to a verbal exchange. The CNA later discussed the incident within earshot of other residents, who then confronted the resident in his room. This confrontation escalated into a physical altercation, with one resident striking another in the face. Staff interviews confirmed that the CNA's conversation was overheard by residents, which directly contributed to the escalation of the situation. Another incident involved two residents with cognitive impairments and multiple medical diagnoses who became involved in a physical altercation during a smoke break. One resident cut in line, leading to an argument and a physical push. Staff and other residents intervened to prevent further escalation, but the initial lack of supervision allowed the altercation to occur. Documentation and staff interviews confirmed that the altercation was witnessed and that the residents were able to physically engage before being separated. In both cases, the facility's failure to prevent staff from discussing resident-related issues in the presence of other residents, as well as insufficient supervision during high-risk times such as smoke breaks, contributed to the occurrence of physical abuse. The facility's own policy affirms the right of residents to be free from abuse, yet these incidents demonstrate lapses in maintaining a safe environment and protecting residents from harm.
Failure to Complete Ordered Laboratory Test for Resident
Penalty
Summary
The facility failed to follow a Nurse Practitioner's order to obtain a Basic Metabolic Panel (BMP) laboratory test for a resident who had multiple complex medical diagnoses, including schizoaffective disorder, UTI, abnormal gait, muscle weakness, heart failure, COPD, diabetes, and others. The order to check the BMP was placed on August 31 and confirmed by a Registered Nurse on September 2, but there is no documentation that the laboratory test was ever completed. The facility's own policy requires that laboratory and diagnostic testing be performed according to provider orders, with oversight and coordination by the Director of Nursing or designee, and that requisitions be completed and filed appropriately. The resident's previous laboratory results had already shown abnormal sodium and bilirubin levels. Later, the resident was sent to the hospital, where further testing revealed a significantly low sodium level and elevated bilirubin, leading to diagnoses of hyponatremia and acute kidney injury. Interviews with facility staff confirmed that the ordered BMP should have been completed, but it was not carried out as required.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to prevent a physical altercation between two residents, R1 and R2, which occurred on October 13, 2024. R1 reported to the Administrator that R2 slapped him when he entered the shared bathroom while R2 was using it. Both residents are diagnosed with schizoaffective disorder and generalized anxiety disorder, and are cognitively intact according to their respective MDS assessments. R1 also has Parkinson's disease and experiences delusional thoughts and maladaptive behaviors, while R2 has a history of aggressive behavior and ineffective coping mechanisms. The incident was reported to have occurred because R2 was surprised and upset by R1's entry into the bathroom, which R2 perceived as an insult. The facility's abuse policy, effective since March 2022, prohibits any form of abuse, including physical abuse, which is defined as the infliction of injury that requires medical attention. Despite this policy, the facility's investigation concluded that R2 did not intend to abuse R1, attributing the incident to R2's response to internal stimuli. The Administrator confirmed the incident and noted that R2 had no previous episodes of aggression or violence, while R1 is hard of hearing and hears voices, which can lead to annoyance. The facility's failure to prevent this altercation indicates a deficiency in protecting residents from abuse, as outlined in their policy.
Failure to Maintain Cleanliness in Food Preparation Area
Penalty
Summary
The facility failed to maintain cleanliness in the food preparation area and equipment storage, affecting all 92 residents. During an initial kitchen tour, it was observed that a cook was wearing a hair restraint improperly, with hair dangling to the earlobes, and did not change gloves or perform hand hygiene after retrieving additional vegetables from the cooler. Another dietary aide was also observed with hair dangling to the earlobes while preparing food. The air vent in the food preparation area was covered with black dust, and the floor behind the shelving had a black substance. During lunch service, five of the six pans used were stained with black grease, and the ceiling above the steam table had dust particles and food stains. The storage racks for clean equipment were covered with dust and cobwebs. A cook was also observed with an improperly covered beard while serving food from the steam table. The facility's policies on safe food preparation and handling, as well as cleaning schedules, were not followed. The policies required proper hand washing techniques and suitable hair restraints, which were not adhered to by the staff. The dietary manager confirmed that the vents above the stove are cleaned every six months by an outside company, but there was uncertainty about how to ensure full beard coverage for staff. The deficiencies in cleanliness and hygiene practices in the kitchen were evident, as staff continued to use dusty and stained equipment for food preparation and storage.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies observed and reported by residents. Resident R34 reported that his bathroom door was difficult to open and close, requiring significant physical effort, and had been in this condition for 3-4 months despite notifying the Maintenance Director. Similarly, R72, who shares the bathroom with R34, confirmed the issue and added that the doorknob was loose and missing screws, making it even more challenging to use the door. The Maintenance Director acknowledged being aware of the problem but had not yet addressed it adequately. Resident R53 reported that the water pressure in his shower was insufficient to rinse soap off his body, a problem that had persisted for six months since the shower head was replaced. Despite informing the Maintenance Director, the issue remained unresolved. Resident R193 expressed concerns about her room's condition, including a piece of gum stuck under her bedside table, a falling baseboard, and broken or missing drawers in her built-in closet. These issues had been reported to staff but had not been addressed, making her feel unsafe and uncomfortable in the facility. Residents R75, R42, R59, and R71 also reported various maintenance issues in their rooms, such as broken drawers, peeling paint, and wobbly toilets. These problems had been ongoing for extended periods, with some residents reporting issues that had persisted for years. The Maintenance Director admitted to being unaware of some of these concerns and acknowledged that the facility was not homelike for the residents when their rooms were in disrepair. The Administrator and Director of Nursing also recognized the deficiencies and agreed that the facility should provide a more homelike environment for its residents.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite four residents (R55, R65, R76, and R31) to their care plan meetings, despite their cognitive abilities being intact or moderately impaired. Observations and interviews revealed that these residents had never been invited to or attended any care plan meetings. Record reviews confirmed the absence of documentation for care plan meetings or invitations for these residents. Specifically, R55, R65, and R76, all with intact cognition, reported never being invited to care plan meetings, and their electronic health records corroborated this lack of documentation. R31, with moderate cognitive impairment, also reported not being invited to a care plan meeting in over a year, and there was no documentation to show his participation or invitation to any care plan meetings. The facility's Administrator and Director of Nursing confirmed the lack of documentation and stated that the facility had only recently started documenting residents' acceptance or refusal to participate in these meetings. The facility's Care Plan policy requires the interdisciplinary team to develop and implement a person-centered care plan in consultation with the resident and their representative, with appropriate documentation of any refusals to participate. The facility's Care Planning - Interdisciplinary Team (IDT) policy mandates the development of a comprehensive care plan within seven days of the resident's assessment, encouraging the participation of the resident, their family, and/or legal representative. However, the facility failed to adhere to this policy, as evidenced by the lack of invitations and documentation for the care plan meetings of the four residents reviewed. The Psych Rehab Services Director, responsible for inviting residents and their families to care plan meetings, also confirmed the absence of documentation for R31's participation or invitation to any care plan meetings. This deficiency highlights a significant lapse in the facility's adherence to its own policies and regulatory requirements for resident care planning and documentation.
Medication Mismanagement and Inadequate Smoking Supervision
Penalty
Summary
The facility failed to prevent a resident from accessing medications that were not prescribed to them and did not adequately monitor smoking residents. One resident, who had a history of self-harm and substance abuse, was found in possession of five different pills that were not prescribed to him. The facility's staff admitted that the medications should have been disposed of properly and that the resident should not have had access to them. This lapse in supervision could have led to serious health risks for the resident and others who missed their medications. Additionally, the facility did not properly monitor residents during smoking breaks. Multiple residents reported that staff were either not present or only monitored from inside the building, leaving lighters unattended and allowing residents to light their own cigarettes. This was against the facility's smoking policy, which required staff to be present and to light cigarettes for the residents. The lack of supervision during smoking breaks posed a significant safety hazard, especially for residents with cognitive impairments or those who were not safe smokers. The facility's staff acknowledged the deficiencies in both medication management and smoking supervision. The Director of Nursing and other staff members admitted that the current practices were not in line with the facility's policies and posed risks to the residents. The facility's failure to adhere to its own policies and ensure proper supervision contributed to the identified deficiencies.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain dignity and privacy for two residents, R17 and R71, whose cognition is intact. R17 reported that staff would knock on her door and enter without waiting for permission, which made her feel disrespected and invaded. This was observed when a CNA knocked while opening the door and entered R17's room without waiting for permission. Similarly, R71 reported that some staff would enter her room without knocking, especially at night, leaving her exposed. This was confirmed when a nurse entered R71's room without knocking to administer medication. Additionally, R71 expressed discomfort with staff giving her incontinence briefs in the dining hall and the shared dresser that allowed her roommate to see her belongings, causing her anxiety. The DON acknowledged these concerns, stating that staff should knock and wait for permission before entering and that residents should not receive incontinence briefs in public areas for dignity reasons. The facility's Resident Rights information and policies from the Illinois Department of Aging and the facility itself emphasize the residents' right to privacy and a dignified existence. The facility's policies, dated 3/2021 and 4/2020, respectively, state that residents have a right to privacy and should be treated with respect, kindness, and dignity. The observations and interviews indicate that the facility did not adhere to these policies, leading to the reported deficiencies in maintaining resident dignity and privacy.
Failure to Maintain Proper Documentation for Advanced Directives
Penalty
Summary
The facility failed to maintain proper documentation for Advanced Directives for three residents in a sample of 26. For one resident, the health records showed conflicting information between the Advanced Directives book and the electronic health record regarding the resident's code status. The Director of Nursing confirmed that staff would follow the electronic health record, which could result in actions against the resident's wishes. The facility's policy requires congruent documentation and periodic reviews, which were not adhered to in this case. Another resident did not have an Advanced Directive care plan or a POLST form uploaded into the electronic medical record upon admission. It was only after a significant delay that the POLST form was completed and uploaded. Similarly, a third resident did not have a code status order entered until much later after admission, and there was a discrepancy between the resident's stated wishes and the documentation. The facility's policy mandates that code status orders be obtained upon admission, which was not followed in these instances.
Failure to Follow Physician Orders and Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to follow physician orders for one resident and did not monitor another resident's blood glucose levels as required. For the first resident, who had diagnoses including spinal stenosis and muscle weakness, the physician had ordered 1000 mg of Tylenol for pain management. However, the nurse administered only 650 mg, substituting two 325 mg tablets for the prescribed 500 mg tablets. The resident reported that this discrepancy occurred frequently, and the Director of Nursing confirmed that the nurse should have administered the correct dosage as per the physician's order to manage the resident's pain effectively. For the second resident, who had multiple diagnoses including schizophrenia and congestive heart failure, the facility failed to monitor her blood glucose levels despite her being on diabetic medications. The resident reported that her blood sugar was not being checked daily, as it had been in her previous facility. The nurse confirmed that there were no orders for blood glucose monitoring or an A1C test, and the resident's electronic medical record did not include a diabetes diagnosis. The Director of Nursing acknowledged that the resident's blood sugar levels should be monitored to prevent potential complications, given her diabetic medication regimen.
Failure to Update Resident's Medical Diagnoses in EMR
Penalty
Summary
The facility failed to update the EMR to include a resident's medical diagnoses. The resident was admitted to the facility, but during a review of the medical record, no diagnoses were listed in the EMR. The Director of Nursing confirmed that the admitting nurse is responsible for entering the diagnoses and the MDS Coordinator should have reviewed them. The diagnoses list is typically obtained from the discharge summary or admission packet received from the hospital. The facility did not have a policy or procedure guide for updating resident records.
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.
