La Bella Of Cahokia
Inspection history, citations, penalties and survey trends for this long-term care facility in Cahokia, Illinois.
- Location
- 2 Annable Court, Cahokia, Illinois 62206
- CMS Provider Number
- 145581
- Inspections on file
- 38
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 17 (2 serious)
Citation history
Health deficiencies cited at La Bella Of Cahokia during CMS and state inspections, most recent first.
Surveyors found that dietary staff failed to consistently monitor, calibrate, and document food temperatures, resulting in hot foods being served at inadequate temperatures and without proper verification. Temperature logs had not been completed for several weeks, a cook used a digital thermometer without calibrating it, a substitute fish entrée and a second pan of meatloaf were placed on the steam table without temperature checks, and no rechecks were done before service. A test tray showed some items, including vegetables, sweet potatoes, and fish, were cold to taste despite being intended as hot foods, while only the dessert fruit was at an appropriate cold temperature.
Surveyors identified multiple failures in dietary practices, including lack of documented food temperature checks for an extended period, absence of thermometers in the walk-in refrigerator and freezer, and uncovered, unlabeled food items stored in cold storage. Cooks were observed not calibrating thermometers before use, not checking temperatures on substitute menu items, not rechecking food temperatures before service, and touching plated food with bare hands while serving. Temperature logs for food, refrigerators, and freezers were incomplete or missing for several months, and logs did not clearly identify which equipment they referenced. These practices were inconsistent with facility policies requiring calibrated thermometer use, sanitary meal service, proper labeling and covering of food, and regular monitoring of refrigeration and freezer temperatures for all residents’ meals.
Two residents’ confidential medical records were compromised when the Social Service Director prepared discharge packets in unsealed envelopes for two simultaneous discharges and accidentally gave each resident the other’s paperwork. One resident, with multiple cardiopulmonary and other chronic conditions, took the envelope home, removed prescriptions, and discarded the remaining documents, later learning the contents were not theirs. The other resident’s daughter, who had declined a 30‑day medication supply and requested paper prescriptions, discovered at the pharmacy that the prescriptions in her mother’s discharge envelope belonged to another resident. Staff interviews confirmed that the envelopes were mixed up, the paperwork was not reviewed with one family before departure, and the facility did not retain copies of the discharge documents, resulting in an unauthorized disclosure of protected health information contrary to resident rights and HIPAA policies.
Two cognitively intact male residents with psychiatric and neurological diagnoses, both care planned for aggression and psychosocial risk, engaged in repeated conflicts that escalated into a physical altercation in the dining room and a separate incident involving a box-cutter type tool. During one event, staff and a manager found a resident on the floor after a fist fight, with witnesses reporting mutual hitting and a resulting bruise, yet one resident’s progress notes lacked documentation of the altercation. In another event, a resident used a box-cutter-like tool on dining tables, refused to surrender it when asked, and, according to multiple residents and interviews, threatened another resident with it and stated the tool was for him, leading several residents to report feeling unsafe. Staff acknowledged ongoing verbal conflicts between the two residents and confirmed the presence of the sharp tool in the dining room, despite existing abuse-prevention policies and care plan interventions intended to separate residents during conflict and maintain a safe environment.
Two residents experienced sexual and mental abuse from another resident with a known history of inappropriate behavior, including unwanted touching and sexually explicit propositions. Despite care plans and monitoring, staff failed to prevent these incidents or consistently investigate reports, resulting in emotional distress for the affected residents.
The facility did not properly implement its abuse prevention policy, failing to prevent, report, and investigate multiple allegations of sexual abuse and inappropriate behavior involving two residents with cognitive impairments. Staff did not conduct thorough investigations or interviews, and some abuse allegations were not reported to administration or external authorities as required by policy.
A resident with diabetes and muscle weakness, who was cognitively intact, reported that another resident grabbed her sweater and offered money for a sexual act. The incident was reported to staff but was not investigated or reported to authorities as required by the facility's abuse prevention policy. The administrator did not recognize the event as abuse due to lack of physical contact, despite policy definitions including verbal and nonverbal conduct.
A resident with intellectual disabilities reported being inappropriately touched by another resident with a traumatic brain injury. The facility's investigation into the abuse allegation was incomplete, as it did not include interviews with staff or residents, and there were inconsistencies in documentation regarding who was interviewed and who reported the incident, contrary to the facility's abuse prevention policy.
A resident with a recent below-the-knee amputation and high fall risk attempted to self-transfer when his bed, which had a malfunctioning locking mechanism, rolled away, causing him to fall and reopen his surgical wound. The care plan was not adequately individualized, and staff did not respond promptly to the resident's call light after the fall, resulting in significant injury and hospitalization.
A resident with a recent below-the-knee amputation, who required assistance with transfers, fell and reopened his surgical wound after his bed rolled away due to a malfunctioning locking mechanism. Despite complaints about the bed, the issue was not promptly addressed, and the resident did not receive immediate assistance after the fall, resulting in significant injury and the need for hospital treatment.
A resident with a recent below-the-knee amputation and high fall risk did not receive an individualized fall prevention plan. The care plan included only general interventions, and the resident experienced an unwitnessed fall while attempting to self-transfer, resulting in a reopened surgical wound and the need for urgent surgical intervention. Documentation and interviews confirmed that the facility did not implement an adequate, person-centered fall prevention plan as required by policy.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report notes insufficient safety measures and supervision but does not specify individual residents or detailed events.
A group of unauthorized men entered the facility by distracting the receptionist and bypassing visitor screening, then engaged in disruptive and abusive behavior, including smoking marijuana, shouting obscenities, and filming a music video that included two residents without their consent. The video was posted on social media, causing residents to feel unsafe and fearful. Staff and residents reported feeling uncomfortable and anxious due to the incident, which was not immediately addressed by facility staff.
A group of unauthorized individuals entered the facility, smoked marijuana, used obscene language, and filmed a music video that included two residents without their consent. Staff and residents reported feeling unsafe, and one resident, who is cognitively intact, expressed anxiety and fear following the event. The facility did not immediately recognize or report the incident as potential abuse, delaying notification to authorities for seven days, contrary to policy and federal requirements.
A group of unauthorized individuals entered the facility, engaged in disruptive behavior including smoking marijuana and using obscenities, and filmed a music video that included two residents without their consent. Staff and residents witnessed the incident, and at least one resident reported feeling unsafe. The facility's investigation was limited, as only alert and oriented residents on one hall were interviewed, despite the potential impact on all residents. The response did not meet the facility's abuse prevention policy requirements.
A group of unauthorized individuals entered the facility, smoked marijuana, used obscene language, and filmed a music video that included two residents without their consent. The video was posted on social media and viewed by thousands. Staff did not immediately intervene or notify authorities, and the residents involved reported distress and violation of their privacy rights.
A resident with a documented DNR order experienced a change in condition, and staff failed to verify and honor the advance directive, resulting in the administration of CPR, mechanical ventilation, and AED use. The resident was transferred to the hospital and expired after further resuscitative efforts, despite clear documentation of comfort-focused care preferences.
Multiple residents experienced significant changes in condition that were not promptly assessed or communicated to medical providers. In several cases, staff failed to document vital signs or notify practitioners in a timely manner, despite residents exhibiting symptoms such as refusal to eat, non-responsiveness, and unresponsiveness. These failures led to delays in medical intervention and contributed to adverse outcomes, including resident deaths.
Multiple residents experienced inadequate pressure ulcer prevention and care, including failure to use prescribed pressure-relieving devices, lapses in following wound care orders, and missed or delayed treatments. One resident developed new and worsening Stage IV pressure ulcers after being left on a malfunctioning low air loss mattress, while another was observed without required protective boots, resulting in a new pressure injury. Delays in obtaining wound cultures and starting IV antibiotics further contributed to the deterioration of wounds and infection management.
Multiple residents with significant fall risks, including those with stroke, epilepsy, and dementia, experienced repeated falls and injuries due to inadequate supervision and lack of progressive interventions. Despite documented care plans and repeated incidents, staff failed to update or escalate interventions, resulting in continued accidents and harm.
The facility did not provide adequate heating in the activity dining area, as reported by two residents, an LPN, and confirmed by the Maintenance Supervisor, who stated the heat had not worked for two years. The soiled utility rooms had malfunctioning hoppers and leaking faucets, and the roof had leaks causing water stains and ceiling damage. A resident's shower was nonfunctional since admission, as confirmed by a family member. The Administrator was aware of some issues, but no repairs had been made, and there was no policy on equipment functionality.
A resident with severe cognitive impairment was photographed and featured in a social media post by staff, with a sign displaying the resident's name and "Fall Risk" attached to a staff member. The resident and his POA were unaware of the photo or any consent being given, and the facility lacked a clear social media policy. Staff provided conflicting statements about the resident's ability to consent, and the consent form on file was illegible.
A resident with a history of pressure ulcers was not provided with their prescribed tilt and space wheelchair and ROHO cushion, despite repeated therapy and wound care recommendations. The resident was observed using a standard high back wheelchair while the specialized equipment remained in storage, and facility staff did not take action to locate or replace the necessary wheelchair and cushion.
A resident with mild cognitive impairment reported being inappropriately touched by another resident with a history of sexually inappropriate behavior. The facility's investigation was incomplete, lacking an interview with the alleged perpetrator and sufficient documentation of interviews with other staff or residents, resulting in an inadequate abuse investigation.
A facility failed to provide oxygen therapy as ordered for a resident with COPD, OSA, and chronic respiratory failure during a power outage. The resident reported being without oxygen for hours and requested portable oxygen, which was not provided. The MAR lacked documentation of oxygen administration during the outage. Staff interviews revealed confusion about the resident's oxygen needs, and the administrator acknowledged the absence of a respiratory care policy.
A facility failed to prevent the recurrence of a pressure ulcer for a resident with risk factors and did not initiate timely treatment. A CNA observed a new open area on the resident's coccyx, but the resident was not listed as having a pressure ulcer. The resident's care plan noted the risk for pressure ulcers due to decreased mobility and incontinence. The DON confirmed the open area was identified on March 10, but treatment was delayed until March 13. The Pressure Wound Log initially excluded the resident, and the wound was not measured until March 13. A LPN applied treatment, but initially used only gauze and tape instead of the appropriate dressing.
A facility failed to perform ROM exercises for a resident with contractures, despite the resident's care plan indicating a need for such exercises. The resident, who has multiple diagnoses including diabetes and knee contractures, confirmed that no exercises were being performed. The facility lacked a restorative program and a policy for contracture prevention, and the CNAs were not performing the necessary exercises.
A resident with multiple health issues experienced severe knee pain and swelling over several weeks, which the LTC facility failed to adequately assess and treat. Despite reports of pain and swelling, the facility did not investigate or address the symptoms, leading to an undiagnosed femur fracture developing into an open fracture. The resident required hospitalization and surgery due to the facility's inaction.
A resident with multiple medical conditions suffered a femur fracture that went undiagnosed and untreated for weeks, leading to an open fracture and hospitalization. Despite reports of swelling and pain, the LTC facility failed to conduct further diagnostic testing or provide appropriate care, resulting in severe neglect.
A facility failed to monitor and report a resident's deteriorating condition, leading to a delay in medical intervention. The resident showed symptoms of discoloration and swelling in the foot and knee, which were not adequately addressed or communicated to the administration. The situation escalated when a bone was observed protruding from the knee, resulting in the resident's hospitalization with a femur fracture. This deficiency highlights a breakdown in communication and oversight within the facility's nursing department.
The facility did not hold a Quality Assessment and Assurance (QAA) meeting quarterly with all required members, potentially affecting all 88 residents. The last meeting was in January 2024, missing the medical director's attendance, contrary to the facility's QAPIC policy.
The facility failed to ensure CNAs completed the required 12 hours of education per year, potentially affecting all 88 residents. Several CNAs had not completed the necessary education hours, with some completing 0% of the required education. The facility had transitioned to an electronic education system, which has not been effective despite efforts by managers to encourage completion. The responsibility for monitoring CNA education lies with the Administrator, the Human Resource Director, and the CNA Supervisor.
A facility failed to investigate a resident's injury of unknown origin, leading to increased pain and swelling. The resident, who was non-ambulatory and dependent on staff for transfers, had a documented injury that was not investigated until weeks later, resulting in a serious femur fracture. The facility's policies on abuse prevention and reporting were not followed, contributing to the delay in addressing the resident's condition.
The facility failed to prevent resident-to-resident abuse involving three residents. One incident involved a cognitively intact resident pushing another resident's chair into a wall after an accidental bump. Despite being reported, no investigation was conducted. Another incident involved a moderately cognitively impaired resident being hit in the face by the same resident involved in the first incident. The facility's abuse prevention measures were not effectively implemented.
The facility failed to investigate an incident where a resident, who is cognitively intact, pushed the chair of another resident, who is moderately cognitively impaired, causing her to roll into a wall. The incident was reported by an activity aide to a nurse, who notified the DON, but there was uncertainty about whether the administrator was informed, and no investigation was conducted.
A resident in an LTC facility was physically abused by a CNA, resulting in a bloody lip. The incident was captured on video, showing the CNA making a punching motion towards the resident. The facility's response was delayed, with the CNA initially suspended but not immediately terminated, and the police were informed later. The resident, who had chronic health conditions and moderate cognitive impairment, was not adequately protected from abuse.
A resident alleged being hit in the mouth by a CNA, but the facility failed to immediately report the incident to the administrator and local law enforcement. The LPN informed of the incident did not assess the resident or notify the administrator, leading to a delay in addressing the allegation. The facility's investigation confirmed the likelihood of the incident, resulting in the CNA's termination.
A resident with severe cognitive impairment and acute infections missed multiple doses of IV antibiotics after pulling out their PICC line. The facility was unable to reinsert the line promptly, leading to a delay in treatment. The facility's policy required safe and accurate medication administration, which was not followed in this instance.
A resident with severe cognitive impairment and a complex medical history did not receive ordered medications due to a dislodged PICC line. The facility failed to administer critical intravenous antibiotics and several oral medications, as documented in the medication administration records. The facility's staff, including the DON, were aware of the situation, but the medications were not delivered in a timely manner, highlighting a deficiency in providing necessary treatment and care.
A resident with vascular dementia, identified as a high elopement risk, was inadequately supervised, leading to wandering into other residents' rooms. Despite a care plan and interventions like a wander guard, staff struggled to redirect the resident, causing discomfort among other residents. Interviews highlighted inconsistent supervision, contributing to the deficiency.
A resident with Type II diabetes did not receive scheduled doses of Humalog and Glargine insulin over several days, and his blood sugar was not checked as required. Despite the resident's willingness to receive insulin, the facility failed to administer it as ordered, leading to medication errors confirmed by the facility's pharmacist. The facility's policy mandates safe and accurate medication administration, but there was no documentation of physician notification for the missed doses.
The facility failed to serve food at the proper temperature for several residents, with test trays showing lukewarm turkey and gravy at 127°F and mixed vegetables at 115°F. Cognitively intact residents reported receiving cold meals, and staff acknowledged complaints, offering to reheat food. The facility lacked a specific policy for food preparation and temperature, relying on state guidelines.
The facility failed to store foods properly, with multiple instances of undated and unlabeled items in refrigerators and freezers, uncovered bowls near a toaster, and work boots in the dry storage area. The Dietary Manager and Administrator acknowledged the need for proper labeling and adherence to food storage policies.
The facility failed to prevent an elopement, investigate a fall, and follow fall precautions for four residents. One resident with dementia eloped and was found off-premises. Another resident with a history of falls was transferred alone despite requiring two-person assistance. A third resident's care plan for fall prevention was not followed, and a fourth resident's fall was not documented or investigated.
The facility failed to provide appropriate tracheostomy care for a resident with Acute and Chronic Respiratory Failure. The DON did not cleanse the tracheostomy site before applying a clean drain sponge, contrary to the facility's policy requiring aseptic technique. The resident's care plan indicated a risk for impaired oxygenation, and the physician's order required respiratory monitoring every shift.
The facility failed to follow infection control practices in the care of a resident with a tracheostomy. The DON did not change gloves or perform hand hygiene before changing the tracheostomy dressing, and the LPN did not maintain a sterile field while suctioning the tracheostomy, using a non-sterile container and failing to change gloves or perform hand hygiene when moving between clean and dirty fields.
Failure to Monitor and Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to consistently monitor, document, and maintain safe and appetizing food temperatures for all 84 residents. Surveyors observed that the Dietary Food Temperature Log had no recorded temperatures from the end of January through most of February, despite a facility policy requiring appropriate internal cooking temperatures and use of a properly calibrated thermometer. The cook reported that temperatures were taken but not written down, and the Dietary Manager stated they were unaware that temperatures were not being documented, though they expected staff to record them for each meal. The Administrator also stated an expectation that dietary staff check and document food temperatures for each meal and maintain a clean and sanitary kitchen environment. During direct observation of meal preparation and service, one cook was seen checking food temperatures with a digital thermometer but did not calibrate the thermometer before use, contrary to facility policy. A substitute fish entrée was placed on the steam table without any temperature check, and a second pan of meatloaf was placed on the steam table without a temperature check prior to plating. There was no rechecking of food temperatures before serving, and the cook was observed touching plated food with a bare hand while adjusting items on the plate. A test tray prepared and delivered with the last resident trays showed that while the meatloaf was at 163°F and warm with good appearance and taste, the corn was 120°F and cold to taste, the sweet potatoes were 102°F and cold to taste, and the fish was 108°F and cold to taste. Only the peaches were at an appropriate cold holding temperature of 46°F, with good appearance and taste.
Failure to Maintain Safe Food Handling, Temperature Monitoring, and Storage Practices
Penalty
Summary
The deficiency involves the facility’s failure to follow proper sanitation, food handling, and food storage practices in the dietary department, affecting the safe procurement, preparation, and service of food for all 84 residents. During a kitchen observation with the Dietary Manager, a cook was seen removing meatloaf, sweet potatoes, cauliflower, and pineapple upside-down cake from the oven to the steam table, with review of the temperature logbook showing no food temperatures documented since 1/30/26. The cook stated that temperatures were taken but not written down. The stand-up refrigerator showed an internal digital temperature of 41°F, but the walk-in refrigerator and walk-in freezer had no thermometers or external temperature readings available, preventing verification of their temperatures. In the walk-in refrigerator, uncovered and unlabeled cups of fruit were observed on a tray, and in the freezer, an open bag containing crackers and an unlabeled container of dip, apparently brought from an outside facility, were found. The Dietary Manager stated thermometers had been present but was unsure what happened to them and reported being unaware that temperatures were not being documented, though she expected staff to document temperatures with each meal. Further observations showed that a cook checked food temperatures with a digital thermometer but did not calibrate it before use, only wiping it with an alcohol pad before proceeding. A substitute fish entrée was placed on the steam table by another cook without any temperature check, and the first plated meal was served without rechecking food temperatures. The cook was seen using a utensil to serve food and then using his other hand to adjust food on the plate, and a second pan of meatloaf was later placed on the steam table with no temperature check before plating. Review of the Dietary Food Temperature Logs showed incomplete documentation, with missing entries on specific days in January and no entries at all from 1/31/26 through 2/23/26. Refrigerator temperature logs did not specify which refrigerator they referred to and had missing months, including no checks for November and February, and freezer temperature logs lacked entries for February. The Administrator stated an expectation that dietary staff check and document food temperatures for each meal, maintain a clean and sanitary kitchen, and properly label and store foods. Facility policies required thorough cooking with properly calibrated thermometers, serving meals in a sanitary environment with proper food handling, and storing food at appropriate temperatures with labeling, covering, and regular temperature checks, including never leaving food uncovered and unlabeled and placing thermometers in the warmest part of refrigerators and checking freezer temperatures regularly.
Confidential Medical Records Misrouted in Discharge Paperwork Mix-Up
Penalty
Summary
The deficiency involves the facility’s failure to maintain confidentiality of personal and medical records for two residents during the discharge process. One resident (R4), who was cognitively intact, independent in ADLs, and diagnosed with COPD, chronic respiratory failure, anemia, obesity, hyperlipidemia, HTN, and a history of falls and smoking, was discharged home with medications and discharge instructions. The Social Service Director (V13) reported that on the day of discharge, she prepared discharge paperwork for R4 and another resident (R5) in large, unsealed yellow envelopes and accidentally gave each resident the other’s envelope. R4 later stated that she took the envelope home, removed the prescriptions and gave them to her daughter to take to the pharmacy, and then threw the remaining papers in the trash, indicating she had received paperwork that was not hers. The second resident (R5) was also cognitively intact, independent in ADLs, and had multiple diagnoses including diverticulitis, MRSA, morbid obesity, respiratory failure, COPD, emphysema, major depressive disorder, atrial fibrillation, carotid artery stenosis, cardiomegaly, lumbar disc degeneration, AAA, CHF, hyperlipidemia, HTN, cardiac pacemaker, hernia, and anxiety disorder. R5 was discharged home under the care of her daughter (V17), who declined home health services and stated she would care for her mother at home. At discharge, R5 and her daughter were given an envelope containing papers, medications, and prescriptions. V17 reported that when she took the envelope to the pharmacy, the pharmacist informed her that the prescriptions were not for her mother but for another resident (R4), revealing that R5’s discharge packet contained another resident’s protected health information. Interviews with staff clarified how the mix-up occurred and confirmed that confidential information was exchanged between the two residents. V13 stated that she had two residents leaving at the same time, gathered each resident’s discharge paperwork into unsealed yellow envelopes, and mistakenly handed each resident the other’s envelope. She also stated she had asked R5 and her daughter to review the paperwork with her before leaving, but the daughter refused, saying the paperwork was already in R5’s bag. The DON (V2) explained that the facility typically provides a 30‑day supply of medications rather than paper prescriptions, but R5’s daughter refused the 30‑day supply and insisted on paper prescriptions, which were then placed in R5’s discharge envelope. The Administrator (V1) confirmed that the facility did not retain copies of the discharge paperwork given to R4 and R5 and stated an expectation that staff maintain resident confidentiality and ensure residents receive the correct paperwork, consistent with the facility’s Resident Rights and HIPAA policies that require privacy and confidentiality of personal and medical records.
Failure to Prevent and Manage Resident-to-Resident Abuse and Threats Involving a Sharp Object
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident abuse and to adequately manage known behavioral risks between two cognitively intact male residents with significant psychiatric and neurological diagnoses. One resident (R3) had documented dementia, parkinsonism, bipolar disorder, and a history of being verbally and physically inappropriate and abusive with staff and other residents, including prior physical aggression and attempts to cut other residents’ hair with clippers. His care plan identified him as short-tempered with impaired cognition, at risk for being verbally/physically inappropriate and for psychosocial/mental abuse, and noted a recent altercation with another resident from whom he needed to be kept apart in common areas. The other resident (R2) had schizophrenia, diabetes, and a right below-knee amputation, and his care plan documented potential for verbal and physical aggression related to schizophrenia and potential to experience psychosocial/mental abuse, with interventions to analyze triggers and remove residents to a calm, safe environment when conflict arose. On one occasion, an altercation occurred between these two residents in the dining room. The state incident report documented that staff reported an alleged resident-to-resident altercation at approximately 7:35 AM, during which the residents were found in a physical confrontation. One account stated that R3 was propelling himself through the dining room and asked R2 to move; R2 allegedly yelled and pushed R3’s wheelchair, and R3 fell from his wheelchair while reaching out to stop it. Another account from a former Business Office Manager described staff running into the dining room and finding R3 on the floor after a fist fight, with witnesses stating that R3 was wiping off a table, R2 approached, words were exchanged, and both residents hit each other, resulting in R3 falling and sustaining a small bruise under his chin. R2’s progress note documented that staff heard arguing, entered the dining room, and found both residents with one on the floor, hitting and kicking each other before they were separated and taken to their rooms. Despite these events, R3’s progress notes contained no documentation of this altercation. A separate series of events involved R3’s possession and use of a box-cutter type tool in the dining room and threats made toward R2. The state incident report documented that R3 was observed using a box-cutter type tool to scrape dirt from dining room tables, and that he refused to relinquish the tool when asked by the Administrator and Social Services Director. Interviews documented that R3 stated he was scraping sticky tables and that R2 was cussing in front of visiting children; R3 admitted telling R2 he would “get him one way or another” and described hostile statements about wishing he could put R2 “back in the sewer” and ensure he did not come back up. Multiple residents reported that R3 had a box cutter, that he had threatened another resident with it, and that they did not feel safe living in the facility. R2 reported that R3 threatened him with the box cutter in the dining room, that R3 said the tool was for him, and that he did not feel safe and could not get away from R3 due to his mobility limitations. Another resident witness stated that R3 brought a razor knife to the dining room, used it on the tables, and, when asked why he had it, pointed to R2 and said it was for him. Staff interviews confirmed that R3 had a box-cutter-like object in the dining room and that R2 and R3 frequently did not get along, with escalating verbal exchanges. R2’s progress notes contained no documentation of the incident involving the box cutter and the reported threat. These events occurred despite the facility’s written Abuse Prevention Program, which prohibits abuse and defines physical abuse and willful actions, and despite care plan directives to separate residents during conflict and ensure a calm, safe environment.
Failure to Protect Residents from Sexual and Mental Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse and mental abuse, as evidenced by multiple incidents involving a resident with a known history of sexually inappropriate and aggressive behavior. This resident, who was moderately cognitively impaired and had a traumatic brain injury, was on 15-minute checks for inappropriate behavior and had a care plan addressing sexual inappropriateness. Despite these measures, the resident inappropriately touched another resident, who was also moderately cognitively impaired and at risk of abuse due to impaired cognition. The affected resident reported being touched in the genital area by the known perpetrator while at the nurse's station, resulting in emotional distress, crying, and being visibly shaken. Staff interviews confirmed the incident and acknowledged the perpetrator's history of similar behaviors toward both staff and residents. Another incident involved a cognitively intact resident who reported that the same perpetrator offered money for a sexual act and grabbed her sweater at the nurse's station. Although this incident did not involve physical touching of private areas, the resident reported the event to staff, but no abuse investigation was conducted. The administrator expressed uncertainty about whether the incident constituted sexual abuse, citing the lack of physical contact. The facility's abuse prevention policy defines abuse to include both unwanted intimate touching and verbal or nonverbal conduct causing humiliation, intimidation, or fear. The failure to recognize and investigate these incidents, despite clear policy definitions and resident reports, contributed to the deficiency.
Failure to Implement Abuse Prevention Policy and Investigate Allegations
Penalty
Summary
The facility failed to implement its abuse prevention policy through adequate prevention, reporting, and investigation of abuse allegations involving two residents. One resident with a history of traumatic brain injury and moderate cognitive impairment was known to display sexually inappropriate behaviors and was on 15-minute checks for monitoring. Despite this, staff interviews revealed ongoing incidents of inappropriate touching involving both staff and other residents. Another resident, also moderately cognitively impaired, reported being touched in the genital area by the first resident near the nurse's station. This allegation was corroborated by staff observations and the resident's emotional distress following the incident. The facility's investigation into the reported abuse was incomplete, lacking interviews with relevant staff and residents. Although documentation indicated that certain residents were interviewed, direct interviews with those residents revealed that some had not actually been questioned about the incident. Additionally, the staff member listed as having reported the abuse denied knowledge of the allegation and did not report it to the administrator. The administrator acknowledged that it was problematic for residents to claim they were not interviewed as part of the investigation. A third resident, who was cognitively intact, reported a separate incident in which the same resident with a history of inappropriate behavior grabbed her sweater and offered money for sexual favors. This allegation was reported to staff at the time but was not investigated or reported by the administrator, who did not consider the incident to be sexual abuse due to the lack of physical contact. The facility's abuse prevention policy defines abuse broadly, including both physical and mental abuse, and requires all allegations to be reported and investigated within required timeframes.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who was admitted with diagnoses including diabetes mellitus type 2 and muscle weakness, and who was cognitively intact and required partial assistance with transfers. Shortly after admission, the resident reported that another resident grabbed her sweater and offered her money for a sexual act while she was at the nurse's station. The resident stated she reported the incident to staff at the time, but could not recall their names. The facility's care plan for the resident did not address risk of sexual abuse. Upon review, the facility administrator confirmed that there were no abuse investigations documented for the individuals involved and acknowledged that the allegation had not been reported to the appropriate authorities. The administrator expressed a lack of understanding regarding the incident being considered abuse, citing the absence of physical contact. The facility's Abuse Prevention Program Policy defines abuse to include both physical and mental injury or sexual assault, and requires that all allegations of abuse be reported within federally mandated timeframes. Despite this policy, the incident was not reported as required.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with intellectual disabilities who reported being inappropriately touched by another resident with a traumatic brain injury. The initial report was sent to the state surveying agency, but the facility's investigation did not include any staff or resident interviews. Documentation provided by the administrator listed residents who were supposedly interviewed, but upon further inquiry, some of these residents stated they were not interviewed about the incident. Additionally, the staff member who was documented as having reported the incident denied any knowledge of the allegation and stated she did not report it. The facility's abuse prevention policy requires that all allegations of abuse be investigated within the timeframes required by federal law. Despite this, the investigation was incomplete, lacking interviews with key individuals and containing inconsistencies in the documentation of who was interviewed and who reported the incident. The administrator maintained that the investigation was complete, even though evidence showed otherwise.
Failure to Prevent Fall Due to Inadequate Care Planning and Faulty Equipment
Penalty
Summary
The facility failed to develop and implement a person-centered plan of care for fall prevention and did not ensure that a resident's bed was in proper working order. The resident in question had a recent below-the-knee amputation, was identified as high risk for falls, and required assistance with transfers. Despite these known risks, the care plan interventions were not adequately tailored to the resident's needs, and the environment was not maintained to prevent accidents. The resident attempted to self-transfer from bed to wheelchair due to an urgent need to use the bathroom. During this attempt, the bed rolled away because its locking mechanism was malfunctioning, causing the resident to fall. The fall resulted in the reopening of the surgical incision at the amputation site, leading to significant bleeding and requiring urgent hospital treatment and surgical revision. The resident reported that after the fall, he used his call light for assistance, but no staff responded in a timely manner, prompting him to crawl into the hallway to seek help. Interviews with maintenance and administrative staff confirmed that the bed's locking mechanism was not functioning and that the bed was replaced only after the incident. There was uncertainty among staff regarding when the issue was first reported and when corrective action was taken. The facility's fall prevention protocol required comprehensive risk assessments and individualized care plans, but these measures were not effectively implemented for this resident, contributing to the accident and subsequent injury.
Failure to Maintain Resident Bed in Safe Working Condition Resulting in Fall and Injury
Penalty
Summary
The facility failed to ensure that essential resident equipment was in good working condition, specifically for a resident who had a recent below-the-knee amputation and required assistance with transfers. The resident's bed had a malfunctioning locking mechanism, which allowed the bed to roll. Despite the resident's complaints about the bed not locking, the issue was not addressed in a timely manner. The resident attempted to self-transfer from the bed to a wheelchair, and the bed rolled away, causing the resident to fall to the floor. This fall resulted in the reopening of the surgical incision site on the amputated limb, leading to significant bleeding and the need for urgent hospital treatment and surgical revision. Interviews and record reviews confirmed that the resident had reported the bed's malfunction to staff, and maintenance staff were aware of the issue. However, there was confusion among staff regarding when the problem was reported and when action was taken. The resident stated that after the fall, he activated his call light but did not receive immediate assistance, leading him to crawl into the hallway to seek help. Staff eventually responded and provided care, but the delay and the equipment failure directly contributed to the resident's injury.
Failure to Develop and Implement Person-Centered Fall Prevention Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for fall prevention for a resident who was at high risk for falls following a right below-the-knee amputation. The resident had multiple diagnoses, including peripheral vascular disease, Type II diabetes mellitus, and required assistance with personal care and transfers. Despite being identified as a high fall risk on the Morse Fall Scale, the care plan for falls included only general interventions such as anticipating needs, ensuring the call light was within reach, and following the facility's fall protocol, without specific, measurable actions tailored to the resident's unique risks. The resident experienced an unwitnessed fall while attempting to self-transfer, which resulted in the reopening of the surgical incision at the amputation site. The incident required urgent hospital treatment and surgical revision due to the severity of the wound dehiscence and associated complications, including a hematoma and exposed bone. Documentation indicated that the resident's call light was not answered and there were issues with the bed, contributing to the resident's attempt to self-transfer. Interviews and record reviews confirmed that the facility did not have an adequate fall prevention plan in place for this resident, despite clear risk factors and previous incidents. The facility's own policies required comprehensive, individualized care plans and timely risk assessments, but these were not effectively implemented for this resident, as acknowledged by the medical director and supported by the facility's documentation.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential accidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or incidents described.
Failure to Prevent Mental Abuse and Unauthorized Access
Penalty
Summary
The facility failed to prevent mental abuse by allowing a group of unauthorized men to enter the building, where they engaged in disruptive and abusive behavior, including smoking marijuana, shouting obscenities, and swinging a leather belt while filming a music video. The men entered the facility by distracting the receptionist and bypassing visitor screening procedures. Staff members, including CNAs and dietary staff, observed the men in the hallways and common areas, but did not immediately intervene to stop the intrusion or prevent the filming. The video, which included footage of two residents without their consent, was later posted on social media and viewed by tens of thousands of people. One resident, who was cognitively intact and required assistance with daily care, reported being awoken by the commotion and expressed feeling unsafe and fearful, noting that neither he nor other residents could defend themselves. Another resident, with moderate cognitive impairment and multiple medical conditions, also appeared in the video without permission. Both residents stated they did not consent to being filmed or having their images shared online. Additional residents and staff reported feeling unsafe and uncomfortable as a result of the incident, with some residents expressing ongoing fear and anxiety about their safety in the facility. The facility's own investigation confirmed that the men were not affiliated with any staff or residents and had gained entry by providing false information to the receptionist. Staff and residents witnessed the men recording themselves, but there was a lack of immediate and effective response to remove the intruders or protect residents' privacy and well-being. The facility's abuse prevention policy was not effectively implemented, as the incident resulted in mental and psychosocial harm to residents, who reported feeling unsafe in their home environment.
Failure to Immediately Report and Recognize Potential Abuse Incident
Penalty
Summary
The facility failed to recognize and immediately report a potential abuse incident involving unauthorized individuals entering the building and interacting with residents. On the evening of 6/18/25, a group of men entered the facility by following employees, smoked marijuana, used obscene language, and filmed a music video in the hallway. Two residents were included in the video without their permission, and the video was later posted on social media, where it was viewed by over 67,000 people. Staff members, including the receptionist and dietary aides, observed the men in the facility and noted that they felt unsafe during the incident. The receptionist did not attempt to stop the men or call the police, citing fear for her own safety. Instead, one of the residents called the police after witnessing the commotion and feeling threatened by the group’s behavior. One of the residents involved, who is cognitively intact according to his most recent MDS assessment, reported being awoken by loud noises and witnessing the group cursing and smelling of marijuana. He expressed feeling unsafe and anxious, stating that neither he nor other residents could defend themselves. Staff interviews confirmed that several employees and residents felt uncomfortable and unsafe during the incident, and that the men were not known to staff or residents. Despite these observations and the clear distress caused to at least one resident, the facility did not immediately recognize the situation as a potential abuse incident or report it to the Department as required by policy and federal law. The facility’s final investigation report indicates that the initial report to authorities was not made until seven days after the incident, after the video surfaced on social media. The facility’s abuse prevention policy requires immediate reporting of any allegations or events that may constitute abuse, neglect, or exploitation. However, the delay in reporting and the failure to recognize the incident as potential abuse resulted in noncompliance with regulatory requirements. The incident had the potential to affect all 91 residents in the facility.
Failure to Investigate Alleged Abuse After Unauthorized Intrusion and Filming
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse after a group of unauthorized men entered the building, engaged in disruptive and inappropriate behavior, and included two residents in a music video without their consent. The men entered the facility by distracting the receptionist and proceeded to walk through the halls, smoking marijuana, using obscene language, and filming. Staff and residents witnessed the incident, and at least one resident reported feeling unsafe and fearful as a result. The video was later posted on social media and viewed by thousands. Interviews revealed that staff, including CNAs, dietary aides, and the receptionist, observed the men in the facility and felt unsafe but did not take immediate action to stop the intrusion or protect the residents. The receptionist did not call the police due to fear for her own safety, and it was a resident who ultimately contacted law enforcement. The Director of Nursing and the police arrived after the men had exited the building. The incident was reported to the administrator only after the video surfaced online, and the administrator confirmed that no staff or residents knew the men or had given permission for filming. The facility's investigation was limited in scope, as only alert and oriented residents on one hall were interviewed, despite the potential impact on all 91 residents. The facility's abuse prevention policy requires thorough investigation and reporting of all allegations of abuse, but the response to this incident did not meet those standards. The investigation did not include all potentially affected residents, and the initial response by staff did not adequately address the safety and well-being of residents during or after the event.
Failure to Protect Resident Privacy During Unauthorized Filming Incident
Penalty
Summary
The facility failed to protect the privacy and confidentiality of two residents when a group of unauthorized individuals entered the building, smoked marijuana, used obscene language, and filmed a music video that included the residents without their consent. The video was subsequently posted on social media, where it was viewed by over 67,000 people. One resident, who is cognitively intact and has multiple medical conditions including Type 1 Diabetes and heart disease, reported being awoken by the commotion and expressed feeling anxious, nervous, and fearful as a result of the incident. Another resident, with moderate cognitive impairment and several health issues, also stated he did not give permission to be videotaped or have the video posted online. Staff interviews revealed that the receptionist was distracted by one of the men and did not immediately call the police due to personal safety concerns. Certified Nursing Assistants were observed in the video but did not intervene. The Director of Nursing and Administrator confirmed that the men were not affiliated with the facility and that staff did eventually ask them to leave. The facility's Resident Rights Policy states that residents have the right to privacy and confidentiality, which was not upheld in this incident.
Failure to Honor Resident's DNR Order Resulting in Unwanted Resuscitation
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's documented Do Not Resuscitate (DNR) order, resulting in the resident receiving life-saving interventions against his expressed wishes. The resident, who was cognitively intact and had clearly indicated his preference for DNR status on a signed POLST form, experienced a change in condition. Multiple staff members, including CNAs and nurses, observed and reported the resident's declining status, but there was confusion and lack of clarity regarding his code status at the time of the emergency. Despite the resident's POLST form being uploaded to the electronic medical record, staff reported difficulty accessing or reading the code status during the critical event. As the resident became unresponsive, staff initiated CPR, used mechanical ventilation, and applied an AED, all of which were specifically prohibited by the resident's advance directive. Several staff members admitted they were unaware of the resident's DNR status and proceeded with resuscitation efforts based on assumptions or instructions from other staff, rather than verifying the resident's documented wishes. After the event, it was confirmed through interviews and record review that the resident's DNR status was known to some staff but not effectively communicated or accessible to those providing care during the emergency. The failure to follow the resident's advance directive led to the resident being transferred to the hospital, where he ultimately expired after further resuscitative measures were performed. The deficiency was identified as Immediate Jeopardy due to the facility's failure to ensure that the resident's right to refuse life-sustaining treatment was honored.
Failure to Assess and Notify Medical Providers During Resident Change in Condition
Penalty
Summary
The facility failed to properly assess and monitor residents experiencing a change in condition, resulting in significant deficiencies for multiple residents. In one case, a resident with multiple comorbidities, including acute kidney failure, diabetes, and congestive heart failure, was documented as having a Do Not Resuscitate (DNR) order with comfort-focused measures. Despite clear changes in the resident's condition, such as refusal to eat, drink, or take medications, and increased non-responsiveness, there was no documentation that the medical practitioner was notified in a timely manner. Vital signs were inconsistently recorded, and when the resident's condition further declined, the medical provider was still not notified until after the resident was sent to the hospital, where he later expired. Another resident experienced a change in condition that was reported by CNAs to the assigned nurse, but there was a delay in assessment and documentation. Staff reported the resident was not acting himself, was dizzy, and eventually became unresponsive. Despite these reports, there was no documentation of vital signs or a thorough assessment prior to the resident being transferred to the hospital, where he was pronounced deceased. Interviews with staff revealed inconsistencies in communication and documentation, with some staff stating they reported changes while others did not recall being notified. The medical record lacked evidence of timely notification to the physician and appropriate documentation of assessments. A third resident was found unresponsive during wound care, and while CPR was initiated and emergency services were called, there was no documentation of vital signs or a thorough assessment prior to the intervention. The facility's policy required immediate assessment and physician notification upon identification of a change in condition, but this was not consistently followed. The lack of timely assessment, documentation, and communication with medical providers contributed to delays in medical intervention and ultimately resulted in adverse outcomes for the residents involved.
Failure to Prevent and Treat Pressure Ulcers and Timely Manage Wound Infections
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents, as evidenced by direct observations, interviews, and record reviews. One resident with Alzheimer's disease and muscle weakness was observed multiple times without the prescribed pressure-relieving boot on her left foot, despite care plan interventions requiring its use at all times. Her left heel was later found to be darkened and sore, indicating the development of a pressure injury. Staff only applied the pressure-relieving boot after the injury was identified, and the wound nurse confirmed that the boot and skin prep were necessary to prevent breakdown. Another resident, who was severely contracted, cognitively impaired, and at high risk for pressure injuries, experienced multiple failures in pressure ulcer prevention and treatment. This resident's low air loss mattress malfunctioned, causing him to lie directly on the metal bed frame without adequate pressure relief. Despite physician orders for pressure-relieving devices and frequent repositioning, the resident developed new deep tissue injuries that progressed to Stage IV pressure ulcers, exposing tendon and hardware. Documentation revealed lapses in following wound care orders, inconsistent application of prescribed treatments, and incomplete or missing documentation of wound care and medication administration. The facility also failed to obtain and process wound cultures in a timely manner, resulting in delays in identifying and treating wound infections. There were significant delays in starting IV antibiotics due to issues with venous access and lack of timely PICC line placement. Medication administration records showed missed doses of prescribed antibiotics, and there was no documentation explaining these omissions. Additionally, maintenance and nursing staff were unable to provide accurate records of when pressure-relieving equipment was malfunctioning or replaced, further contributing to the inadequate care and worsening of pressure ulcers.
Failure to Prevent Accidents and Implement Progressive Fall Interventions
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision or implement progressive interventions to prevent accidents for multiple residents. For one resident with a history of stroke and significant left-sided weakness, the care plan required extensive assistance with transfers and toileting. However, a CNA was observed directing the resident to stand and transfer with only verbal cues, resulting in the resident struggling to pivot and falling heavily onto the toilet seat. The Director of Nursing was also unsure of the resident's transfer status, indicating a lack of clear communication and supervision regarding the resident's needs. Another resident with epilepsy, a history of falls, and poor safety awareness experienced at least 24 falls over a one-year period, many of which resulted in injuries such as a closed nondisplaced fracture of the right ilium, lacerations, and bruising. Despite repeated falls, there was a consistent lack of documentation of new or progressive interventions on the care plan following each incident. The resident continued to fall in various locations, including the dining room, bedroom, and smoking area, often during or after seizure activity. Staff responses were limited to immediate care and education, with no evidence of systematic changes to the care plan to address the ongoing risk. A third resident with dementia, muscle weakness, and a history of falls also experienced multiple falls in different settings, including the bathroom, dining area, and bedroom. The care plan identified the resident as at risk for falls, but after each fall, interventions were limited to verbal reminders and education about using the call light, which were repeated without modification or escalation. There was no documentation of new or progressive interventions on the care plan after repeated incidents, and the resident continued to attempt transfers and ambulation without assistance, leading to further falls and injuries.
Failure to Maintain Safe, Functional, and Comfortable Environment
Penalty
Summary
The facility failed to provide adequate heating in the activity dining area, as multiple residents and staff reported the room was consistently cool in the mornings. The Maintenance Supervisor confirmed that the heat in the activity dining room had not worked at all during his two-year tenure, and the room temperature only reached about 60°F even when outside temperatures were extremely low. The Administrator was aware of the heating issue but was not informed of its duration. Additionally, the facility did not have a policy regarding the functionality of equipment. Further deficiencies were observed in the maintenance of the building and utilities. The soiled utility room between two halls had a hopper that did not fully flush, and another utility room had a leaking faucet. The Maintenance Supervisor acknowledged both issues and stated repairs were needed. There were also leaks in the roof, with visible water stains and peeling ceiling material, and the Maintenance Supervisor indicated the roof was out of warranty and required replacement. In one resident's room, the shower was nonfunctional, lacking a shower head and water flow, and a family member confirmed it had never worked since admission. No corrective actions had been taken for these issues at the time of the survey.
Failure to Respect Resident Dignity and Privacy in Social Media Post
Penalty
Summary
The facility failed to respect a resident's privacy and dignity by posting a photo of a resident with severe cognitive impairment on social media without clear, valid consent. The resident, who has diagnoses including Parkinson's Disease with Dyskinesia, a history of falls, hypertension, and aphasia, was documented as severely cognitively impaired on the Minimum Data Set. The consent form for photography had an illegible signature, and both the resident and his power of attorney (POA) denied knowledge of or consent for the photo to be taken or posted. The POA stated she was never contacted for consent and expressed that the resident would not want his photo posted. The resident himself was unable to recall giving consent and expressed discomfort with the photo being posted, requesting its removal. The photo in question depicted the resident in his wheelchair with a staff member, who had a sign taped to her buttock displaying the resident's first initial, last name, and the phrase "Fall Risk." Staff interviews revealed conflicting accounts regarding the resident's awareness and consent, with some staff asserting the resident was alert and oriented, while documentation and interviews indicated otherwise. The facility did not have a specific social media policy, relying instead on a general consent form included in admission paperwork, and could not confirm who took or posted the photo. The incident was found to be inconsistent with the requirement to treat residents with dignity and respect, as outlined in the Illinois Long Term Care Ombudsman Program Resident Rights pamphlet.
Failure to Provide Resident with Prescribed Specialty Wheelchair and Cushion
Penalty
Summary
The facility failed to ensure the availability and working order of a personal tilt and space wheelchair with a specialized ROHO cushion for a resident with a history of pressure ulcers and specific seating needs. Occupational therapy documentation over multiple periods indicated that the resident was unable to use their prescribed wheelchair due to it being in disrepair and missing the required cushion. Despite repeated assessments and recommendations from occupational therapy and wound care staff for the use of a tilt and space wheelchair with a pressure-relieving cushion, the resident continued to be observed sitting in a standard high back wheelchair, while the prescribed wheelchair was found stored away and not in use. Interviews with therapy and wound care staff revealed that the resident's specialized wheelchair was not returned after a hospice discharge, and efforts to locate or replace the equipment were not made by facility management. The occupational therapist reported making multiple requests to the former therapy manager regarding the wheelchair, but these were not addressed. Additionally, the facility was unable to provide a policy regarding accommodation of needs when requested by surveyors during the survey period.
Failure to Thoroughly Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct a complete investigation into an allegation of sexual abuse involving a resident with mild cognitive impairment who reported being touched inappropriately by another resident. The resident, who was alert and oriented, stated that the incident occurred a few weeks prior and was reported to a nurse, but she could not recall specific details or witnesses. Documentation showed that the resident had a history of making accusations, but also that she felt safe and was not afraid of the alleged perpetrator. The facility's records indicated that the incident was reported to the nurse, who then notified the administrator, local police, the resident's family, and the medical doctor. The alleged perpetrator, a resident with moderate cognitive impairment and a documented history of sexually inappropriate behaviors toward staff, denied any inappropriate contact with the reporting resident. Progress notes detailed multiple prior incidents of sexual and physical aggression by this resident toward staff, including attempts to touch private areas and making inappropriate comments. Despite these documented behaviors, the facility's abuse investigation did not include an interview with the alleged perpetrator, and there was insufficient documentation of interviews with other staff or residents who may have had relevant information. The final abuse investigation report concluded there was insufficient evidence to declare intentional abuse, but lacked comprehensive documentation of the investigative process. Only a limited number of individuals were interviewed, and there were no notes specifying who was interviewed, when, or by whom, beyond a few named staff and residents. The investigation file provided by the administrator did not validate that a thorough and complete investigation was conducted, as required.
Failure to Provide Ordered Oxygen Therapy During Power Outage
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for a resident with chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and chronic respiratory failure with hypoxia. The resident reported that during a power outage, she was without oxygen for a couple of hours and requested portable oxygen, which was not provided. The resident began to feel short of breath before the power was restored. The resident's physician order required oxygen at 2 liters/minute per nasal cannula continuously and as needed for chest pain or shortness of breath, but the medication administration record (MAR) for the evening shift on the day of the power outage did not document that oxygen was provided. Interviews with facility staff revealed a lack of clarity regarding the resident's oxygen needs. A registered nurse stated that the resident only uses oxygen as needed, while a nurse practitioner confirmed that the resident is cognitively intact and can determine when she needs supplemental oxygen. The facility administrator acknowledged the absence of a policy regarding respiratory care but expected oxygen to be provided as ordered and documented in the MAR. The failure to provide oxygen therapy as ordered and the lack of documentation in the MAR contributed to the deficiency identified by the surveyors.
Failure to Prevent and Timely Treat Pressure Ulcer
Penalty
Summary
The facility failed to prevent the recurrence of a pressure ulcer for a resident with a history of wounds and risk factors, and did not initiate timely and appropriate treatment. On March 13, 2025, a CNA observed a new open area on the resident's coccyx, which was confirmed by the resident. However, the facility's Resident Matrix did not list the resident as having a pressure ulcer. The resident's medical history includes diabetes mellitus, atherosclerosis, mixed incontinence, muscle weakness, and knee contractures, which increase the risk of pressure ulcers. The resident's care plan noted the risk for pressure ulcers due to decreased mobility and incontinence, with a goal of preventing new ulcers. The facility's Director of Nursing, who assumed wound care responsibilities, confirmed that the open area was first identified on March 10, 2025, but treatment was not initiated until March 13, 2025. The Pressure Wound Log did not initially include the resident, and the wound was not measured until March 13, 2025. A Licensed Practical Nurse was observed applying a treatment to the resident's left buttock, but initially, only gauze and tape were used instead of the appropriate dressing. The facility's policy requires immediate measurement and physician-approved orders within 24 hours for any skin issues, which was not followed in this case.
Failure to Perform ROM Exercises for Resident with Contractures
Penalty
Summary
The facility failed to perform Range of Motion (ROM) exercises for a resident with contractures, identified as R3, who was part of a sample of seven residents reviewed for Restorative Programs/Physical Therapy. R3 has multiple diagnoses, including diabetes mellitus, atherosclerosis of bilateral legs, mixed incontinence, muscle weakness, and contractures of the knees. The resident's care plan indicated a need for ROM exercises to prevent pain, stiffness, edema, and decreased mobility, but these exercises were not being performed. Observations and interviews revealed that the Certified Nursing Assistant (CNA) responsible for R3 was not performing any exercises, and the resident confirmed the lack of exercises. The Director of Nursing (DON) acknowledged that the facility was without a restorative program for a month or two and that residents with contractures should be receiving ROM exercises. The facility did not have a restorative nurse at the time, and the CNAs were expected to perform ROM exercises, but this was not happening. The facility also lacked a policy for contracture prevention/ROM, contributing to the deficiency. The administrator confirmed that the facility did not have a restorative program in place and that residents with contractures could be referred to therapy services, but R3 was not enrolled in any therapy services at the time of the survey.
Failure to Assess and Treat Resident's Knee Pain Leads to Severe Injury
Penalty
Summary
The facility failed to assess, monitor, and provide timely treatment for a resident's knee pain, which resulted in a severe medical condition. The resident, who had multiple diagnoses including Alzheimer's disease, osteoporosis, and functional quadriplegia, experienced continued pain and swelling in her knee from mid-November until early December. Despite multiple observations and reports of swelling, bruising, and pain, the facility did not adequately investigate or address the resident's symptoms. This lack of action led to the resident's undiagnosed femur fracture developing into an open fracture, with the bone protruding through the skin, necessitating hospitalization and surgical intervention. The resident's medical records and interviews with staff revealed a series of missed opportunities for intervention. Initial signs of injury were noted in mid-November, with reports of discoloration and swelling in the resident's foot and knee. Despite these observations, the facility's response was limited to notifying hospice and ordering x-rays, which did not reveal a fracture. Over the following weeks, the resident's condition worsened, with increased swelling and pain, yet there was no comprehensive assessment or follow-up to determine the cause of these symptoms. Staff interviews indicated a lack of communication and coordination in addressing the resident's condition, with some staff members expressing concerns about potential mishandling during transfers. The facility's failure to investigate the resident's injury and provide appropriate care was compounded by inadequate documentation and communication. The incident report from mid-November was not properly investigated, and there were gaps in the resident's medical records regarding the ongoing assessment of her condition. The facility's policies for reporting and investigating changes in condition were not followed, leading to a delay in identifying the severity of the resident's injury. This deficiency in care resulted in significant pain and suffering for the resident and raised concerns about the facility's ability to manage and respond to changes in residents' health conditions.
Removal Plan
- The facility has conducted an ongoing investigation into R2's injuries.
- V2, Director of Nursing, or designee has assessed all residents to identify any pain or injury of unknown origin not previously identified, assessed, reported, and treated. For any findings identified, the facility would follow its policy to ensure the pain/injury is reported, assessed, monitored, and treated timely. No residents with unreported/untreated pain or injuries identified.
- V1 Administrator, V2 Director of Nursing, and V20 Regional Director and Facility Governing Body reviewed the facility's policies for Incidents/Accidents and Significant change to confirm policies provide a system for identifying, assessing, monitoring, and treating injuries and pain, as well as investigating the cause. Governing Body recommended retraining on policy requirements.
- V2, Director of Nursing, or designee have provided in-service training to all direct care staff and nursing staff on facility policy for: Significant changes, with an emphasis on ensuring timely reporting, assessment, and follow-up when a resident demonstrates a significant change; and Incidents and Accidents, with an emphasis on policy section addressing injuries of unknown origin including the process for identifying, reporting, assessing, and facilitating treatment, as well as investigating the cause of any unknown injury. Any staff or agency who have not received the in-service training(s) by the Removal/Abatement date will receive the training before starting their next shift.
- V2, Director of Nursing or designee will conduct random observations of at least 5 residents to determine if there is any pain or injuries of unknown origin that have been addressed per policy. V1, Administrator/designee will conduct review of PCC 24-hour Communication and Incident reports to ensure any change of condition/injury is monitored, assessed, investigated, reported, and treated. Any identified failures will be immediately addressed. Results will be documented and shared with QAPI for review, analysis and follow-up as needed.
Neglect Leads to Severe Injury in Resident
Penalty
Summary
The facility failed to provide adequate care and monitoring for a resident, resulting in a severe case of neglect. The resident, who had multiple medical conditions including Alzheimer's disease, osteoporosis, and functional quadriplegia, sustained a femur fracture that went undiagnosed and untreated for an extended period. Despite numerous reports of swelling, pain, and abnormal presentation of the resident's right leg, the facility did not conduct further diagnostic testing or provide appropriate medical intervention. The resident's condition was first noted on a hospice aide visit when swelling and bruising were observed on the right foot. Over the following weeks, the resident's leg continued to swell, and pain persisted, yet the facility's response was limited to administering pain medication and ordering an x-ray, which failed to identify the fracture. Staff members, including CNAs and LPNs, repeatedly reported the resident's worsening condition, but the facility did not take decisive action to address the underlying issue. Ultimately, the resident's condition deteriorated to the point where the bone penetrated the skin, causing an open fracture that required emergency hospitalization and surgical intervention. The facility's lack of timely investigation and failure to communicate effectively with the resident's physician and hospice team contributed to the neglect. The facility's policies on abuse prevention and neglect were not adhered to, resulting in significant pain and suffering for the resident.
Failure to Monitor and Report Resident's Condition
Penalty
Summary
Facility administration failed to effectively direct and monitor the nursing department managers, resulting in a lack of timely identification and response to a resident's medical condition. The resident, identified as R2, exhibited a series of concerning symptoms starting with slight discoloration and edema in the right foot, which was noted on 11/15/24. Despite the notification of the Nurse Practitioner and hospice nurse, the condition was not adequately monitored or escalated. Over the following weeks, R2's condition worsened, with swelling and pain in the right knee being documented on multiple occasions. However, there was a significant gap in communication and follow-up, as the Director of Nursing (DON) was not informed of any changes or worsening of R2's condition until 12/7/24, when a bone was observed protruding from the knee, prompting emergency services to be contacted. The Administrator and DON both stated they were not informed of the ongoing issues with R2's condition until the critical incident on 12/7/24. The Administrator noted that if she had been aware of the initial injury, she would have investigated it. The DON mentioned that the nursing staff did not notify him of any changes or concerns from 11/15/24 until the emergency on 12/7/24. This lack of communication and oversight led to a delay in appropriate medical intervention, culminating in R2 being admitted to the hospital with a right femur fracture. The facility's failure to adhere to its own policies and procedures for monitoring and reporting changes in residents' conditions contributed to this deficiency, potentially affecting all 88 residents in the facility.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to conduct a Quality Assessment and Assurance (QAA) meeting quarterly with the required members in attendance, which has the potential to affect all 88 residents residing in the facility. The last documented QAA meeting was held on January 25, 2024, with the MDS/CPC, treatment nurse, restorative nurse, infection control nurse, DON, and administrator present. However, there was no documentation indicating that the medical director attended this meeting. The facility's QAPIC policy outlines the necessity of having key administrative staff, including the medical director, as part of the QAA committee. The administrator confirmed that the last meeting was held in January 2024, acknowledging that these meetings are supposed to occur quarterly.
Failure to Ensure CNA Education Compliance
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required 12 hours of education per year, which has the potential to affect all 88 residents residing in the facility. The Learner Status report provided by the Administrator on December 17, 2024, revealed that several CNAs had not completed the necessary education hours. Specifically, one CNA hired on May 30, 2023, and another hired on April 5, 2023, had completed 0% of their required education for the past year. Another CNA, hired on February 8, 2017, had completed only 34.62% of the required education, and a CNA hired on October 3, 2018, had also completed 0% of the required education. The Administrator stated that CNAs are supposed to have 15 hours of education per year, and the facility had previously held education blitzes twice a year to facilitate this. However, they transitioned to an electronic education system, which has not been effective despite efforts by managers to encourage completion. The responsibility for monitoring CNA education lies with the Administrator, the Human Resource Director, and the CNA Supervisor. The facility's policy, dated March 15, 2023, mandates that CNAs attend all mandatory in-services and maintain 12 hours of continuing education each year.
Failure to Investigate Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately investigate a resident's injury of unknown origin, which resulted in the resident experiencing increased pain and swelling over a period of time. The resident, who was non-ambulatory and dependent on staff for transfers, was first noted to have a slight discoloration and edema on the right foot, with no incident reported. Despite the documentation of this injury, no investigation was initiated until several weeks later, after the resident's condition had significantly worsened. The resident's medical history included severe protein-calorie malnutrition, Alzheimer's disease, osteoporosis, and functional quadriplegia, among other conditions. The resident's care plan required the use of a mechanical lift for transfers, yet the resident care flow sheet indicated assistance of one for transfers. The facility's failure to investigate the initial injury and monitor the resident's condition led to a delay in identifying a serious injury, as the resident was eventually found with a femur fracture that had penetrated the skin. The facility's administrator acknowledged the oversight, stating that the injury should have been investigated when first noted. The facility's policies on abuse prevention and reporting require immediate investigation and reporting of injuries of unknown origin, but these procedures were not followed. The lack of timely investigation and communication with the resident's physician contributed to the delay in addressing the resident's injury, which was eventually reported to the appropriate authorities only after the resident was admitted to the hospital.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving three residents. One incident involved a cognitively intact resident with multiple health issues, including cerebrovascular disease and chronic kidney disease, who pushed another resident's chair into a wall. The second resident, who is moderately cognitively impaired and has a history of severe abuse and mental health issues, accidentally bumped into the first resident's chair, prompting the aggressive response. Despite the incident being reported to the nurse and the Director of Nursing, the facility did not conduct an investigation into this altercation. Another incident involved a moderately cognitively impaired resident with cerebral infarction and hemiparesis, who was hit in the face by the same resident involved in the first incident. This resident was unclear about the reason for the attack and did not sustain any injuries. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of a thorough investigation into the first incident, although an investigation was conducted for the second incident. The facility's failure to prevent these incidents and ensure the safety of its residents highlights a deficiency in their abuse prevention measures.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an incident of resident-to-resident abuse involving two residents. Resident R2, who is cognitively intact, pushed the chair of Resident R3, who is moderately cognitively impaired, causing R3 to roll into a wall. This incident was reported by an activity aide who witnessed the event during an activity session. The aide informed a nurse, who then notified the Director of Nursing (DON). However, there was uncertainty about whether the administrator was informed, and no investigation was conducted for this altercation. The facility's policy on abuse prevention affirms residents' rights to be free from abuse, including physical assault. Despite this policy, the incident involving R2 and R3 was not investigated, as confirmed by the administrator. The lack of investigation into the altercation between R2 and R3 represents a failure to adhere to the facility's abuse prevention program, which requires a thorough investigation of all alleged violations.
Failure to Prevent Resident Abuse by CNA
Penalty
Summary
The facility failed to prevent physical abuse of a resident by a staff member, specifically a CNA, which resulted in the resident sustaining a bloody lip. The incident occurred when the CNA allegedly hit the resident in the mouth with her fist during a verbal altercation. The resident reported the incident to a family member, who then informed the facility. The facility's video footage corroborated the resident's account, showing the CNA making a punching motion towards the resident. The facility's response to the incident was delayed and inadequate. The CNA was initially suspended but not immediately terminated, and the police were not informed until later. The facility's staff, including a Licensed Practical Nurse, failed to promptly assess the resident's injuries or report the incident to the appropriate authorities. The Director of Nursing was informed of the incident by the resident's niece, but there was confusion about whether the message was received earlier in the evening. The resident involved in the incident had a history of chronic health conditions, including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Schizophrenia, and was on a blood thinner medication. The resident was also noted to have moderate cognitive impairment and required substantial assistance with daily activities. Despite these vulnerabilities, the facility did not adequately protect the resident from abuse, as evidenced by the failure to prevent the incident and the delayed response in addressing it.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to immediately report an allegation of physical abuse involving a resident, R2, who claimed to have been hit in the mouth by a CNA, V4. The incident was first reported by R2 to his family member, who then informed the staff. However, the staff did not immediately notify the administrator or local law enforcement as required by the facility's policy. The initial report was made to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) via tele-message, which was not monitored in real-time, leading to a delay in addressing the allegation. The Licensed Practical Nurse (LPN), V8, who was informed of the incident by R2's sister, did not assess the resident immediately or report the incident to the administrator, as she was unaware of the reporting protocol. The DON, V2, was informed of the incident by R2's niece later in the evening but did not take immediate action to investigate or report the incident to the administrator. The administrator, V1, was not informed until the following day, and the police were only notified after the investigation was completed, which was not in compliance with the facility's abuse prevention policy. The facility's investigation, including a review of camera footage, provided substantial evidence that the incident likely occurred, leading to the termination of the CNA, V4. The facility's policy requires immediate reporting of any potential abuse to the administrator and local law enforcement, especially in cases of serious bodily injury. The delay in reporting and investigating the incident resulted in a deficiency in the facility's handling of abuse allegations, as the proper authorities were not notified in a timely manner.
Failure to Administer IV Antibiotics Due to Dislodged PICC Line
Penalty
Summary
The facility failed to administer ordered intravenous (IV) antibiotics to a resident, resulting in missed doses and a prolonged antibiotic course. The resident, who was admitted with acute and subacute infective endocarditis, bacteremia, and other conditions, was dependent on staff for mobility and transfers and was severely cognitively impaired. The resident's care plan indicated a full code status, requiring all indicated treatments to prevent cardiac arrest. On 9/15/2024, the resident pulled out their peripherally inserted central catheter (PICC) line, which was necessary for administering the IV antibiotics. The facility notified the physician and the resident's power of attorney, but the hospital was unable to reinsert the PICC line until the following day. As a result, the resident missed multiple doses of Ampicillin Sodium and Ceftriaxone Sodium, as documented in the medication administration records (MARS). The facility's Director of Nursing and other staff were aware of the situation, but the lack of available registered nurses to administer IV medications contributed to the delay in treatment. Interviews with the resident's power of attorney and facility staff revealed concerns about the missed antibiotic doses and the facility's inability to promptly address the dislodged PICC line. The facility's policy, updated in 2020, stated that medications should be administered safely and accurately as ordered by the physician, but this was not adhered to in this case. The pharmacist emphasized the significance of missing IV antibiotics, especially given the resident's condition.
Failure to Administer Ordered Medications Due to Dislodged PICC Line
Penalty
Summary
The facility failed to administer ordered medications to a resident, identified as R2, who was severely cognitively impaired and dependent on staff for mobility and transfers. R2 had a complex medical history, including acute and subacute infective endocarditis, bacteremia, and dementia. The deficiency occurred when R2's peripherally inserted central catheter (PICC) line was dislodged on 9/15/2024, preventing the administration of critical intravenous antibiotics, Ceftriaxone Sodium and Ampicillin Sodium, as ordered by the physician. The facility was unable to reinsert the PICC line immediately, resulting in missed doses of antibiotics. The facility's medication administration records (MARS) documented that the antibiotics were not administered on several occasions due to the dislodged PICC line and subsequent hospitalization for its replacement. Additionally, on 9/28/2024, several oral medications were not administered due to unavailability, despite attempts to contact the pharmacy for a STAT delivery. The Director of Nursing (DON) and the resident's Power of Attorney (POA) were aware of the situation, but the medications were still not delivered in a timely manner. Interviews with the facility's staff, including the Administrator and DON, revealed that the facility lacked sufficient registered nurses to administer intravenous medications, and the procedure for a dislodged PICC line involved sending the resident to the hospital for reinsertion. The facility's policy stated that medications should be administered safely and accurately, but this was not adhered to in R2's case, leading to a failure in providing the necessary treatment and care according to the physician's orders and the resident's needs.
Inadequate Supervision of Wandering Resident with Dementia
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident diagnosed with vascular dementia from wandering into other residents' rooms. The resident, who is severely cognitively impaired and requires assistance with all activities of daily living, was identified as a high elopement risk. Despite having a care plan that included interventions such as frequent face checks, structured activities, and a wander guard, the resident was observed wandering aimlessly within the facility, entering other residents' rooms, and attempting to get into bed with them. Staff were noted to have difficulty redirecting the resident, who was unresponsive to verbal and physical cues. Interviews with staff and other residents revealed inconsistencies in supervision, with some residents expressing discomfort and concern over the wandering behavior. The facility's policy on behavioral assessment and monitoring emphasizes the need for interventions to be adjusted based on their impact on behavior, yet the resident continued to wander without effective redirection. The facility's administration acknowledged the expectation for staff to safely redirect wandering residents, but the report indicates that this was not consistently achieved, leading to the deficiency.
Failure to Administer Insulin and Monitor Blood Sugar
Penalty
Summary
The facility failed to monitor blood sugars regularly and administer insulin as ordered for a resident with multiple health conditions, including Type II diabetes mellitus. The resident, who is cognitively intact and requires a wheelchair, was supposed to receive Humalog Insulin 5 units subcutaneously three times a day, along with additional doses per a sliding scale, and 24 units of Glargine Insulin at bedtime. However, the Medication Administration Record (MAR) documented multiple instances where the resident did not receive the scheduled doses of both Humalog and Glargine insulin over a period of several days. The resident reported that his blood sugar was not checked as required over a weekend, and he expressed concerns about the staff's knowledge of his medications. Despite the resident's refusal of other medications, he stated he did not refuse insulin or blood glucose checks. The facility's pharmacist confirmed that the missed insulin doses constituted medication errors. The facility's policy requires medications to be administered safely and efficiently, with vital signs obtained when necessary, but there was no documentation of physician notification regarding the missed insulin doses.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at the proper temperature for three of the eight residents reviewed in the sample. During an observation on July 23, 2024, a test tray was obtained after all residents had been served, revealing that the turkey and gravy were lukewarm at 127 degrees Fahrenheit, the scalloped potatoes were hot at 163 degrees Fahrenheit, and the mixed vegetables were lukewarm at 115 degrees Fahrenheit. Residents R1, R2, and R6, all cognitively intact with a BIMS score of 15, reported that their food was sometimes cold. Staff members, including a CNA and the Dietary Manager, acknowledged receiving complaints from residents about cold food, with the Dietary Manager offering to reheat meals or provide new trays. The facility's Administrator admitted that there was no specific policy for food preparation and temperature, stating that they follow state guidelines. The resident council meeting minutes from April 29, 2024, also documented complaints about the taste of the food. The lack of a formal policy and the acknowledgment of food temperature issues by both residents and staff highlight the deficiency in maintaining food at safe and appetizing temperatures, as required by regulations.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure foods were stored in a manner that prevents foodborne illness, potentially affecting all 81 residents. Observations revealed multiple instances of improper food storage, including undated and unlabeled pitchers, cups, sandwiches, and individual cups with clear liquid in the standing refrigerator. Additionally, bowls were stored uncovered next to a toaster, and work boots were found in the dry storage area. In the walk-in refrigerator, a plastic container with a white creamy substance and loaves of processed and unprocessed meat were not labeled. The walk-in freezer contained trays of rainbow sherbet and chocolate ice cream, as well as plastic bags with meat patties and ground meat, all of which were not labeled or dated. The Dietary Manager confirmed the identity of some of the unlabeled items and acknowledged the need for proper labeling. The Administrator stated that the facility is expected to follow its food storage policies, which require all foods to be covered, labeled, and dated. The facility's policies on food receiving, storage, and refrigerator/freezer maintenance emphasize the importance of safe food handling practices and proper labeling to ensure food safety. Despite these policies, the facility did not comply, leading to the observed deficiencies.
Failure to Prevent Elopement and Follow Fall Precautions
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement, investigate a fall, and follow fall precautions for four residents. One resident, diagnosed with vascular dementia and severe cognitive impairment, eloped from the facility. The resident was found off the premises by a CNA on her break and returned to the facility. The resident's care plan did not document the elopement risk or interventions to prevent elopement prior to the incident, despite previous assessments indicating a high risk for elopement. Another resident, with a history of hemiplegia, diabetes, and falls, experienced a fall during a transfer. The care plan required two-person assistance for transfers, but a CNA was observed transferring the resident alone. This discrepancy indicates a failure to follow the care plan's fall precautions. Additionally, the resident's fall investigation recommended two-person assistance, which was not consistently implemented. A third resident, with diagnoses including paranoid schizophrenia and Alzheimer's dementia, was identified as a fall risk. The care plan included the use of floor mats beside the bed, but the mats were not in place during multiple observations. CNAs were unaware of the requirement for floor mats, indicating a lack of communication and adherence to the care plan. Lastly, a resident with chronic respiratory failure and morbid obesity experienced a fall that was not documented in the progress notes, and no fall investigation was completed, contrary to the facility's policy on accidents and incidents.
Failure to Provide Appropriate Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident diagnosed with Acute and Chronic Respiratory Failure and Tracheostomy Status. During an observation, the resident was found with light yellow drainage on the drain sponge around the tracheostomy site. A CNA requested the Director of Nurses (DON) to change the tracheostomy dressing. The DON removed the soiled dressing but did not cleanse the tracheostomy site before applying a clean drain sponge. This action was contrary to the facility's Tracheostomy Care policy, which mandates the use of aseptic technique, including cleaning the stoma with peroxide and saline-soaked gauze pads before applying a new dressing. The resident's care plan indicated a risk for impaired oxygenation and difficulty breathing due to the tracheostomy. The physician's order required tracheotomy/respiratory monitoring every shift. The DON acknowledged that tracheostomy care should utilize sterile technique, including proper hand hygiene and glove use. However, the observed care did not adhere to these standards, leading to a deficiency in providing safe and appropriate respiratory care for the resident.
Infection Control Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to follow infection control practices in the care of a resident with a tracheostomy. On one occasion, the Director of Nurses (DON) did not change gloves or perform hand hygiene before changing the tracheostomy dressing, and placed a new drain sponge on the resident's bed without maintaining sterility. Additionally, the Licensed Practical Nurse (LPN) did not maintain a sterile field while suctioning the resident's tracheostomy, using a container that was not sterile and failing to change gloves or perform hand hygiene when moving between clean and dirty fields. The resident involved had a diagnosis of Acute and Chronic Respiratory Failure and required tracheostomy care. The facility's policies for suctioning the lower airway and tracheostomy care, as well as hand hygiene, were not followed. These policies require the use of sterile equipment and aseptic techniques to prevent infection, which were not adhered to during the observed procedures.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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