La Bella Of Danville
Inspection history, citations, penalties and survey trends for this long-term care facility in Danville, Illinois.
- Location
- 1701 North Bowman, Danville, Illinois 61832
- CMS Provider Number
- 145753
- Inspections on file
- 64
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 8 (2 serious)
Citation history
Health deficiencies cited at La Bella Of Danville during CMS and state inspections, most recent first.
The facility failed to prevent sexual abuse by a resident with known sexually inappropriate behaviors and a documented criminal history, resulting in nonconsensual sexual contact with two cognitively impaired residents who lacked capacity to consent. One resident with dementia and multiple comorbidities was found in bed with her incontinence garment unfastened and a resident’s finger inside her vagina, shortly after staff had left her properly covered and fastened; she was observed to be tearful. Another resident with Alzheimer’s disease and prior documented abuse by the same perpetrator was later seen in the dining room when a visitor witnessed the same resident poking his finger into her genital area and intervened. The perpetrating resident’s care plan already identified wandering, inappropriate touching of residents and staff, and high-risk heterosexual behavior, yet he was still able to access and sexually touch these residents, contrary to the facility’s abuse-prevention policies.
A facility failed to protect residents from further sexual abuse after an initial allegation when staff did not immediately and effectively separate an alleged male perpetrator from other residents. A visiting family member reported seeing the man in a wheelchair intentionally touch a female resident’s genital area in the dining room and informed a CNA. The CNA told the man to go to his room but then left to remove her coat, leaving him unsupervised. During this time, a housekeeper found him in another female resident’s room, touching her genital area while she lay in bed with her incontinent brief unfastened and bed sheet pulled aside; an LPN removed him and observed his finger inside the resident’s vagina. Facility policy required immediate protection of alleged victims and separation of the alleged perpetrator, and leadership later confirmed that staff were expected to remove and monitor the perpetrator immediately, but this did not occur, resulting in a second sexual assault and an immediate jeopardy finding.
Staff failed to report a new allegation of sexual abuse to the facility Administrator/abuse coordinator as required by policy. A family member observed a resident in a wheelchair intentionally touching another resident’s private area in the dining room and reported this to a CNA, who had previously received abuse reporting training. The Administrator later confirmed he had not been informed of this allegation until notified by surveyors, despite a facility policy requiring immediate reporting of all abuse allegations and a documented history of prior sexual abuse incidents involving the same two residents.
The facility failed to maintain required licensed nurse coverage on multiple shifts, including the absence of an RN for at least 8 consecutive hours on several days and a complete lack of RN and LPN coverage on one overnight shift in one building while LPNs were present in another building. The facility’s own assessment specified that each shift should include an RN and that night shift should include multiple LPNs, yet staffing records and leadership interviews confirmed these requirements were not met for the building housing 54 residents.
The facility did not maintain required RN coverage for at least eight consecutive hours per day, seven days a week, despite its own assessment indicating that staffing should include one RN per shift. Review of nurse staffing records showed multiple days without adequate RN presence, and this was confirmed by the ADON, who reported that nursing management was only on-call on weekends if needed. Resident council minutes over several months documented ongoing concerns about short staffing, during a time when 138 residents were in the facility.
The facility did not submit required final investigation reports to the State Agency within five working days for three cases involving allegations of abuse and misappropriation of property. Although initial reports were made and investigations were started, the process was not completed as mandated by policy and regulation, due to residents recanting allegations or leaving the facility before investigations were finished.
The facility did not thoroughly investigate or document three separate allegations involving physical abuse and misappropriation of property. In each case, either the investigation was not completed or supporting documentation was missing, including situations where a resident recanted an abuse allegation against an LPN, another resident denied abuse by a CNA, and a third resident left AMA after reporting missing money.
A resident with severe cognitive impairment and a history of physical aggression struck another cognitively impaired resident, causing injury. Multiple prior incidents of aggression by the same resident were documented, but there was no consistent evidence that these behaviors were reported to a provider or addressed before the altercation occurred, resulting in a failure to protect residents from abuse.
A resident with dementia, known for a friendly and helpful demeanor and a history of working as a CNA, was not provided with a care plan that reflected their specific activity interests or behavioral patterns. This omission contributed to an incident where the resident startled another, resulting in a physical altercation and injury. Staff interviews confirmed the resident's activity preferences and behaviors, but these were not documented or addressed in the care plan.
Multiple residents with severe cognitive impairment and histories of aggression were involved in physical and verbal altercations, including one incident where a resident sustained a skin tear after being grabbed and another where a resident was struck in the face and subjected to a racial slur. Staff witnessed these events, and care plans documented the residents' behavioral risks, but the facility did not prevent the abuse.
A resident with a wound infection did not receive five consecutive doses of an ordered IV antibiotic, with the first dose delayed by over a day. Facility staff also failed to notify the prescribing provider about the missed doses, contrary to facility expectations.
A resident with severe cognitive impairment and a history of stroke experienced multiple falls from a wheelchair due to inadequate supervision and inconsistent implementation of care plan interventions. Staff provided conflicting accounts regarding who witnessed and responded to the falls, highlighting a lack of clear communication and supervision.
Two residents were involved in an alleged abuse incident, with one resident reportedly touching and kissing another who was severely cognitively impaired. Although the incident was reported internally and investigated by the administrator, it was not reported to the State Agency as required by facility policy.
A resident with a left above-the-knee amputation did not receive a physician-ordered referral to a prosthetic clinic. Although staff were aware of the order and discussed it among the interdisciplinary team, no appointment was made, and the resident did not receive the required service.
The facility did not employ a clinically qualified Director of Food and Nutrition Services, with the person in charge lacking required credentials and only holding a ServSafe certification. The dietician was present only one day per week. Additionally, the facility failed to maintain sanitary dishwashing areas and did not prevent flying insects in food service areas, leading to cross-contamination of dishes used by all residents.
Surveyors found that the facility did not maintain an effective pest control program in the kitchen, resulting in accumulations of decomposed food, soiled surfaces, and the presence of flies and other pests. Flies were observed landing on clean dishes near contaminated drain areas, and pest control reports documented ongoing issues with flies, cockroaches, and spiders. The kitchen prepares food for all residents in the facility.
A resident who was cognitively intact and dependent on staff for care was required to remain in bed for several hours until a wound physician arrived, despite expressing a desire to get up. Staff confirmed that the resident was not allowed out of bed, leading to distress and emotional upset. The DON acknowledged that this prolonged restriction violated the resident's rights to dignity and choice, as outlined in the facility's policy.
A resident's comprehensive assessment was marked as receiving an antibiotic, but review of medical records and order summaries showed no antibiotic was prescribed or administered during the assessment period. The MDS Coordinator confirmed the error, which was inconsistent with facility policy requiring accuracy in assessment documentation.
A resident with necrosis and peripheral vascular disease did not receive wound care in accordance with updated physician orders, as a wound nurse failed to enter new treatment instructions into the system and continued care under outdated orders. During a dressing change, the nurse also did not change gloves between cleaning the wound and applying a new dressing, contrary to professional standards.
A resident with a suprapubic catheter and multiple medical conditions received catheter care from an LPN who failed to change gloves or perform hand hygiene after cleaning a contaminated insertion site, then applied a new dressing with the same gloves. The resident reported that daily site cleaning was not performed as ordered. The DON confirmed that such contamination could lead to infection, and facility policy requiring glove removal and hand hygiene was not followed.
Two residents with severe cognitive impairment were not offered, administered, or documented for Influenza and Pneumococcal vaccinations as required by facility policy. Review of their medical records showed no evidence of consent, administration, or refusal of these vaccines, and the Infection Preventionist confirmed the lack of documentation.
A resident's bathroom ventilation fan remained inoperable despite repeated requests to staff for repairs. The fan had not worked since the resident's admission, and no corrective action was taken by facility staff.
A resident with a history of falls and assessed as a fall risk experienced a preventable fall resulting in a forehead laceration requiring emergency treatment. The facility failed to implement and monitor resident-centered fall interventions, such as ensuring the bed was in a low position and call light accessibility. Staff were unaware of the resident's care plan, leading to inadequate supervision and intervention.
A resident with severe cognitive impairment and a history of elopement exited a facility through a deactivated alarmed door, walking 0.4 miles in cold weather before being found. The facility failed to update the care plan for elopement risks, ensure functional exit alarms, and conduct a post-elopement assessment, leading to significant safety lapses.
The facility failed to maintain a clean and comfortable environment as a resident's disruptive behavior, involving hacking and spitting up mucous, went unaddressed. This behavior, which included throwing tissues on the floor, was observed to affect the dining experience of other residents, leading to complaints. Despite being aware of the issue, the facility did not take action to manage the behavior, resulting in a deficiency.
Two residents reported dissatisfaction with another resident's disruptive behavior, involving hacking and spitting in the dining room, to the staff, including the Assistant Administrator. Despite the facility's grievance policy requiring prompt investigation and resolution, no grievance was filed, and the issue remained unaddressed, as the Assistant Administrator did not recognize it as a grievance-worthy complaint.
The facility failed to provide necessary medications to three residents, resulting in missed doses due to unavailability. One resident did not receive Duloxetine and Lorazepam as ordered, another missed Alendronate-Cholecalciferol due to billing issues, and a third did not receive Aripiprazole because it was not in the backup supply. The facility's policies for handling unavailable medications were not followed, and there was no documentation of physician notification for the missed doses.
A resident in the facility did not receive insulin on time, leading to significant medication errors. The resident, who is cognitively intact, reported delays in receiving medications, including insulin, which affected blood sugar levels. The MAR showed that Lispro insulin was scheduled at specific times but was often administered hours late. The DON confirmed that medications should be given within an hour of the scheduled time, as per the facility's policy.
A facility failed to administer medications correctly, resulting in a 12% error rate. An LPN did not give a resident their prescribed Ferrous Sulfate, another resident received the wrong dosage of Breo Ellipta and was not instructed to rinse their mouth, and a third resident missed a dose of Aripiprazole due to unavailability. The facility's policy mandates correct administration according to physician orders.
A resident with multiple diagnoses, including wounds, experienced maggot infestation due to the facility's failure to perform wound dressing changes as ordered. The resident's wounds deteriorated, causing significant pain. The DON acknowledged the unacceptable care, and the wound physician raised concerns about infection.
The facility's ineffective pest control program led to a fly infestation affecting all 141 residents. Despite a policy requiring regular pest control, reports from April to August 2024 did not address flies. Observations revealed numerous fly strips in resident rooms, with one room having over 50 flies on a strip. A resident reported using fly strips for months, and an LPN confirmed widespread use among residents. The Maintenance Director dismissed flies as pests, while the pest control representative identified entry points and breeding sites but was unaware of the issue until the survey. The DON confirmed a resident had maggots in wounds, highlighting the infestation's severity.
The facility failed to provide prescribed low concentrated sweets diets to diabetic residents, serving the same meals to all residents regardless of dietary needs. This oversight was confirmed by staff interviews and could lead to health issues such as elevated blood sugar levels and poor wound healing.
A resident was physically abused by another resident, resulting in facial swelling and fear. The incident occurred after an argument over borrowed money, with staff witnessing aggressive behavior and racial remarks. The facility's abuse prevention policy was not effectively enforced.
A facility failed to ensure resident safety by not accurately screening a new resident with a criminal background, leading to an incident where the resident physically assaulted a roommate. The facility's background check process was flawed, and necessary safety interventions were not implemented, resulting in harm to the assaulted resident.
A facility failed to create a comprehensive care plan for a resident identified as an offender, as required by their policy. The resident, with a history of criminal offenses and assessed as a moderate risk, did not have their offender status or risk level documented in their care plan. This oversight was confirmed by the Social Service Director.
A resident's breakfast meal preferences were not honored, as they were served only one fried egg on two consecutive days, despite requesting two fried eggs, two pieces of toast, and two sausages. The Dietary Manager confirmed the resident's request but was unaware of the deviation.
A resident reported an incident where a CNA made a derogatory comment about the resident's weight after the resident was unable to clean himself following an episode of loose stools. The incident was reported to the Activity Director and led to an investigation by the Administrator and DON, resulting in the CNA's suspension.
The facility failed to include the resident, their guardian, and other required staff in a care plan meeting, resulting in incomplete documentation and lack of interdisciplinary input. The Care Plan Coordinator held the meeting alone without ensuring the guardian received an invitation.
A resident dependent on staff for all activities of daily living was found in a soiled state with long toenails and unshaven hair. The facility's policies on bathing and nail care were not followed, and there was no documentation of when the resident last received these services. The Administrator and DON acknowledged the neglect but could not explain the oversight.
The facility failed to protect a resident from sexual abuse and another resident from physical abuse. One resident with Alzheimer's was sexually abused by another resident with a history of inappropriate behavior. In a separate incident, a resident with dementia was physically abused by another resident with aggressive behaviors. Both incidents were witnessed and confirmed by staff.
The facility failed to thoroughly investigate an allegation of sexual abuse between two residents. The incident was witnessed by a dietary aide and a CNA, but the facility did not document interviews with the IDT or other staff and residents who might have had knowledge of the behavior. The administrator confirmed the lack of documentation and interviews.
Failure to Prevent Sexual Abuse by Resident With Known Inappropriate Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by another resident with known sexually inappropriate behaviors. One resident with Alzheimer’s disease, prior transient ischemic attacks, altered mental status, muscle weakness, difficulty walking, and a documented risk for abuse had previously been identified as an alleged victim of sexual abuse by the same perpetrating resident, who had touched her breasts in past incidents. This prior incident was serious enough to have been cited on a previous CMS Form 2567, and the resident’s care plan had been revised to reflect her status as an alleged victim of abuse. Despite this history and the resident’s inability to formulate relevant responses to questions, the facility did not prevent further sexual contact from occurring. Another resident with dementia, depression, pseudobulbar affect, reduced mobility, anxiety, lack of coordination, bipolar disorder, and a care plan indicating risk of abuse was also involved. This resident’s diagnoses list later included confirmed adult sexual abuse. On the day of the incident, a housekeeper observed that this resident, who resided alone, had a second wheelchair in her room. Upon entering, the housekeeper saw the perpetrating resident with his hand in the resident’s diaper area while the resident lay on the bed without a diaper. A CNA who had provided care 15–20 minutes earlier reported that at that earlier time the resident’s undergarment had been fastened and she was covered with a sheet, but when she returned after the report, the sheet was pulled aside, the undergarment was unfastened exposing the genital area, and the resident was tearful. A nurse who responded to the report stated she observed the perpetrating resident’s finger inside the resident’s vagina. The perpetrating resident had a documented history of sexually inappropriate behavior and criminal offenses. His care plan noted that he wandered aimlessly throughout the facility, inappropriately touched other residents and staff, and made inappropriate comments. His diagnoses included high-risk heterosexual behavior, schizoaffective disorder bipolar type, and moderate vascular dementia with agitation. During an interview, he admitted to touching a woman’s vagina in her room and stated he believed she wanted him to touch her. A family member of another resident reported witnessing this same resident poking his finger into the private area of the first cognitively impaired resident while both were in wheelchairs in the dining room and intervened by moving his wheelchair. Facility leadership, including the DON and Administrator, confirmed that the two victim residents did not have the cognitive capacity to consent to sexual activity. The facility’s own policies defined sexual abuse as any nonconsensual sexual contact of any kind with a resident, including unwanted touching of the perineal area and all types of sexual assault, and committed the facility to implement policies to prevent all types of abuse. Despite these policies and the known history and care plan information, the facility did not prevent the resident with known sexual behaviors from making sexual contact with the two cognitively impaired residents.
Removal Plan
- R5 was placed on one-to-one continuous supervision.
- R5 was assessed by an emergency room provider, Social Services V4, and a psychotherapy provider.
- R4 received a head-to-toe nursing assessment by Registered Nurse V22.
- R6 received physician notification and medical evaluation by Nurse Practitioner V9.
- R5 received physician notification and medical evaluation by Nurse Practitioner V9.
- R5 received a psychosocial assessment and emotional support by Social Services V4.
- R4 received a psychosocial assessment and emotional support by Social Services V4.
- R6 received a psychosocial assessment and emotional support by Social Services V4.
- Families/responsible parties for R5 and R6 were notified by Social Services V4.
- R4's family/responsible party was notified by Social Services V4.
- Law enforcement and state reporting requirements were completed for R5 and R6 by Administrator V1.
- Law enforcement and state reporting requirements were completed for R4 and R5 by Administrator V1.
- R6 was transferred to the hospital for evaluation and relocated to the south building upon return.
- A facility-wide resident assessment for abuse risk was conducted by Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3.
- All-staff in-service training for abuse prevention was conducted by Administrator V1, Director of Nursing V2, Assistant Director of Nursing V3, and Social Services V4.
- The Abuse Prevention Policy was reviewed by Administrator V1, Director of Nursing V2, and President of Clinical Operations V33 to ensure inclusion of defined staff response steps and immediate Director of Nursing and Administrator notification.
Failure to Separate Alleged Perpetrator After Initial Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to separate an alleged perpetrator of sexual abuse from other residents after an initial allegation, resulting in a second sexual assault. A family member visiting a resident in the dining room reported witnessing a male resident in a wheelchair intentionally poking his finger into the private area of a female resident who was also in a wheelchair. The family member stated she had to move the male resident’s wheelchair to stop the contact and then informed a CNA when the CNA entered the dining room. The family member reported that, because both residents were in wheelchairs, the contact could not have been accidental and she believed the act was intentional. After receiving the report from the family member, the CNA stated she directed the alleged perpetrator to go down the hall to his room and then left the area to remove her coat. During this time, the male resident was not supervised. While the CNA was away, a housekeeper observed the same male resident in a female resident’s room, with the female resident lying in bed and the male resident touching her in her diaper area; the housekeeper clarified that the female resident was not wearing her diaper. The housekeeper reported this to the CNA and an LPN. When the CNA arrived at the second resident’s room after this report, she observed that the LPN was already removing the male resident from the room and that the female resident’s bed sheet was pulled to the side, her incontinent undergarment was unfastened exposing her genital area, and she was tearful. The LPN who responded to the second incident stated she observed the female resident in bed with her bed sheet pulled to the side, her incontinent undergarment unfastened, and the male resident’s finger inside the female resident’s vagina. The facility’s Abuse, Neglect and Exploitation policy required immediate steps to protect alleged victims, including room and staffing changes to protect residents from an alleged perpetrator, and mandated that staff respond immediately to protect alleged victims. The administrator stated he expected staff to take steps to prevent further abuse, including immediately removing the resident from the incident and not contacting him until the situation was under control, and confirmed that facility policy required staff to remove the perpetrator from the incident. Despite prior abuse prevention in-service training for the involved staff, the male resident was left unsupervised after the first allegation and was able to access and sexually assault another resident, leading to a determination of immediate jeopardy.
Removal Plan
- R5 was placed on one-to-one continuous supervision pending full investigation.
- R5 was assessed by an emergency room physician.
- R5 was assessed by Social Services V4.
- A psychiatric evaluation was requested by Assistant Director of Nursing V3 and completed by Psychotherapist V49.
- R6 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4.
- R4 was assessed for injury, trauma, and psychosocial needs by Registered Nurse V22 and Social Services V4.
- Families and responsible parties of R5 and R6 were notified by Social Services V4.
- R4's family/responsible party was notified by Social Services V4.
- Law enforcement and required state agencies were notified per mandatory reporting requirements by Administrator V1.
- A room change was completed to ensure separation of R5 and R6, and R6 was later moved to the south building upon return from emergency room evaluation.
- All-staff in-service training for abuse prevention was conducted by Administrator V1, Director of Nursing V2, and Assistant Director of Nursing V3.
- Administrator V1, Director of Nursing V2, and President of Clinical Operations V33 reviewed the Abuse Prevention Policy to ensure inclusion of a clear step-by-step response protocol following any allegation, mandatory immediate separation of the alleged perpetrator, and immediate notification of the Administrator and Director of Nursing.
- A facility-wide risk assessment for abuse involving Social Services V15, Care Plan Coordinator V37, Director of Nursing V2, and Assistant Director of Nursing V3 was completed.
Failure to Report Allegation of Sexual Abuse to Administrator
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving one resident (R5) allegedly touching another resident (R4) to the Administrator/abuse coordinator as required by facility policy. The Administrator (V1) stated he is the abuse coordinator and that all staff are trained to report all allegations of abuse to him, but he confirmed he had no active investigation regarding an allegation of sexual abuse involving R5 touching R4 until the surveyor informed him on 2/5/26. The facility’s abuse policy dated 10/1/25 requires all alleged violations to be reported to the Administrator immediately, but not more than two hours if the allegation involves abuse or bodily harm. Training records dated 8/29/25 show that the CNA (V13) had received abuse prevention and reporting training. Interview and record review showed that on 2/2/26, a family member (V21) witnessed R5 in a wheelchair intentionally poking a finger into the private area of R4, who was also in a wheelchair, in the dining room. V21 reported this incident to CNA V13 at the time and stated she had to move R5’s wheelchair to prevent further inappropriate contact. Despite this report, V1 did not receive any report of this allegation from staff. The record also documents a prior allegation on 5/7/25 that R5 had touched R4’s breasts, and a previous CMS-2567 dated 4/17/24 citing an incident in which R5 (then R205) was identified as the perpetrator of sexual abuse toward R4 (then R206) by touching her breasts. These prior documented incidents further establish that R5 had a known history of sexually inappropriate contact toward R4, yet the new allegation reported to staff on 2/2/26 was not reported to the Administrator as required.
Insufficient RN and LPN Coverage on Multiple Shifts
Penalty
Summary
The facility failed to ensure sufficient licensed nursing staff were present for each shift in each building, including required RN coverage, affecting the South Building where 54 residents resided. The Facility Assessment Tool for 12/2024 through 12/2025 documented that staffing for licensed nurses (RNs and LPNs) should follow the facility assessment and CMS minimum staffing rule and specified that staffing should include one RN on each shift and three LPNs on the night shift. Daily Nurse Staffing Sheets from 1/1/2026 through 1/20/2026 showed there was no RN coverage for at least 8 consecutive hours on four separate days (1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026). On 1/17/2026, the same records documented that there were no RNs or LPNs working the 11 p.m. to 7 a.m. shift in the South Building, while two LPNs were working the night shift in the North Building. The Assistant DON confirmed the lack of RN coverage for at least 8 consecutive hours on the identified dates and stated that nursing management staff are on-call on weekends if needed. The DON reported being notified by the Administrator at 8 p.m. on 1/17/2026 that there was no nursing coverage for the 11 p.m. to 7 a.m. shift in the South Building and stated that the DON personally worked from 3 a.m. to 5 a.m. during that shift.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) provided services for at least eight consecutive hours a day, seven days a week, as required. The Facility Assessment Tool for 12/2024 through 12/2025 documented that staffing for licensed nurses, including RNs, should follow the facility assessment and CMS minimum staffing rule and further specified that staffing should include one RN per shift. However, review of the Daily Nurse Staffing Sheets from 1/1/2026 through 1/20/2026 showed there was no RN coverage for at least eight consecutive hours on 1/3/2026, 1/4/2026, 1/11/2026, and 1/17/2026. On 1/21/2026 at 9:16 a.m., the Assistant Director of Nursing confirmed that there was no RN coverage for eight consecutive hours on those dates and stated that nursing management staff are on-call on weekends if needed. Resident Council Meeting Minutes from October, November, and December 2025 documented short staffing and staffing concerns, and the facility’s Midnight Census Report dated 1/15/2026 showed that 138 residents resided in the facility during this period. No specific resident medical histories or conditions were described in the report, but the deficiency was identified as having the potential to affect all 138 residents currently residing in the facility.
Failure to Submit Final Investigation Reports for Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to submit the results of investigations into allegations of abuse and misappropriation of resident property to the State Agency within five working days, as required by federal and state regulations. Specifically, for three residents who made allegations—two of physical abuse and one of misappropriation of property—initial reports were sent to the Illinois Department of Public Health, but the final investigation reports were not submitted. The Director of Nursing confirmed that no five-day final reports were sent for these cases. The previous administrator explained that in two cases, the residents recanted their allegations or clarified that no abuse occurred, and in the third case, the resident left the facility against medical advice before the investigation was completed, leading to the omission of the required final reports. Facility policy and federal regulations mandate that all allegations of abuse, neglect, or misappropriation must be promptly investigated and the results reported to the appropriate authorities within specified timeframes. Documentation reviewed showed that initial reports were made for each incident, but the process was not completed as required. The failure to submit final investigation reports occurred despite the facility's written policies outlining the obligation to report and investigate such incidents thoroughly and within the required timeframe.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse and misappropriation of resident property were thoroughly investigated for three residents. The Director of Nursing was unable to locate investigation files for allegations of physical abuse and misappropriation of property involving three residents, and could not confirm that thorough investigations were conducted due to the absence of supporting documentation. The previous administrator acknowledged being informed of the allegations but did not complete final reports or thorough investigations for any of the cases. In one instance, after a resident recanted an allegation of physical abuse against an LPN, no final report or investigation was completed. In another case, after a resident stated that a CNA was not abusive, the investigation was not completed or reported. For the third resident, who alleged misappropriation of property and subsequently left the facility against medical advice, no investigation was completed.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On 6/2/25, a certified nursing assistant (CNA) witnessed one resident physically striking another with a closed fist, resulting in a skin tear and bruising. The resident who was struck had severe cognitive impairment and was unable to provide detailed information about the incident. The aggressor also had severe cognitive impairment, a history of delusions, physical aggression, and was receiving psychiatric services and antipsychotic medication, which had recently been reduced. Prior to the incident, there were multiple documented episodes of physical and verbal aggression by the aggressor toward both staff and other residents, including swinging at residents and physically assaulting staff during care. These behaviors were noted in nursing and medication administration records. Despite these documented behaviors, there was no evidence that the physical aggression incidents were consistently reported to a physician or provider prior to the altercation. Staff interviews revealed uncertainty about whether such behaviors were communicated to psychiatric providers, and documentation of these reports was lacking. The facility's policy states that residents have the right to be free from abuse, including abuse from other residents, but the failure to report and address escalating behaviors contributed to the incident of resident-to-resident abuse.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement person-centered activities and interventions for a resident diagnosed with dementia. Specifically, the care plan for a resident with severe cognitive impairment did not identify individualized activities of interest or account for the resident's history of working as a CNA, friendly personality, or tendency to enter other residents' personal space. Despite staff interviews confirming that the resident enjoyed helping others, participating in crafts, going outside, and engaging in activities such as manicures and music, these preferences and behaviors were not reflected in the care plan prior to a documented incident. An incident occurred in which the resident, known for patting and rubbing other residents in a non-aggressive manner, startled another resident by patting him on the head. This led to the second resident, who was drowsy and leaning forward, reacting by striking the first resident, resulting in a skin tear. Staff confirmed that the resident had a pattern of getting into others' personal space and that not all residents liked to be touched. The lack of individualized, person-centered interventions and failure to address the resident's specific behaviors and preferences in the care plan contributed to the incident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents, as evidenced by multiple altercations involving three residents with severe cognitive impairments and histories of behavioral issues. In one incident, a resident with dementia and violent behavior attempted to touch another resident's watch, resulting in the second resident, who also has dementia and a history of physical aggression, grabbing the first resident's wrist and causing a skin tear. Both residents were identified as being at moderate risk for abuse, and their care plans documented behavioral problems and tendencies toward aggression. In a separate incident, another resident with dementia and a history of aggressive behaviors attempted to move a wheelchair occupied by a resident with dementia and agitation. This led to a physical altercation where the resident in the wheelchair swung her arms, and the other resident responded by striking her in the face. The altercation escalated further when the resident who was struck used a racial slur. These events demonstrate that the facility did not adequately prevent or intervene in resident-to-resident abuse, despite documented risks and behavioral histories.
Failure to Administer Ordered IV Antibiotic and Notify Provider
Penalty
Summary
Facility staff failed to administer five consecutive doses of an ordered intravenous antibiotic (Unasyn, 1.5 grams every eight hours) to a resident with a history of wound infection and a current diagnosis of cutaneous abscess of the buttock. The resident was scheduled to begin antibiotic treatment on the morning of 4/19/2025, but did not receive the first dose until 4:00PM on 4/20/2025, as documented in the medication administration record. Additionally, staff did not notify the resident's wound care medical provider about the missed doses, as confirmed by a handwritten note and staff interview. The facility's assistant administrator reported that staff are expected to contact the prescribing provider within a day's time if unable to provide an ordered medication. These actions and inactions resulted in the resident not receiving timely antibiotic therapy as ordered, and the medical provider was not informed of the missed doses.
Failure to Supervise High-Risk Resident Resulting in Multiple Falls
Penalty
Summary
The facility failed to provide effective supervision to prevent falls for a resident with severe cognitive impairment, a history of stroke, and Alzheimer's disease. The resident, who was dependent on staff for mobility and transfers, experienced multiple falls from their wheelchair in their room. Despite being identified as high risk for falls and having care plan interventions in place, such as placing the resident in bed after meals and frequent checks, the resident continued to experience falls, including unwitnessed incidents. Documentation indicated that staff were to keep the resident in a common area or under monitoring when in the wheelchair, but these interventions were not consistently implemented. There was confusion and inconsistency among staff regarding who witnessed the resident's falls and who assisted after the incidents. Multiple staff members, including the DON, CNAs, and MDS Coordinator, provided conflicting accounts about their presence and actions during the falls. This lack of clear supervision and communication contributed to the resident's repeated falls, demonstrating a failure to ensure the area was free from accident hazards and that adequate supervision was provided.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents, one of whom was severely cognitively impaired and dependent on staff for most activities of daily living, while the other was cognitively intact and able to self-propel in a wheelchair. According to the facility's abuse summary report, a certified nurse aide reported to the administrator that the cognitively intact resident had put his hand on the inner thighs of the cognitively impaired resident and kissed her on the side of her neck. The aide immediately removed the resident from the area, and the administrator subsequently reviewed camera footage and interviewed staff and other residents present at the time of the incident. Despite the facility's policy requiring that any allegation of abuse be reported to the State Agency unless it can be immediately refuted, the administrator did not report the incident to the State Agency. The administrator acknowledged that an investigation was initiated but confirmed that no report was made to the required authorities, as stipulated by facility policy. This failure to report the allegation constituted a deficiency in the facility's abuse reporting procedures.
Failure to Arrange Physician-Ordered Prosthetic Clinic Referral
Penalty
Summary
The facility failed to follow a physician's order to arrange a referral to a prosthetic clinic for a resident with a pre-existing left above-the-knee amputation. The resident, who was cognitively intact and required supervision with daily activities, had a physician order documented for a prosthetic clinic referral. Nursing progress notes confirmed the order, but there was no documentation of an appointment being made. Multiple staff members, including the Social Service Director, Physical Therapy Assistant, and Transportation Director, were aware of the referral but did not ensure the appointment was scheduled. The Social Service Director informed the Interdisciplinary Team, but no follow-up occurred, and the Transportation Director was told not to make the appointment. The Nurse Practitioner who wrote the order expected it to be carried out, and the facility administrator confirmed that staff are expected to follow provider orders, although there was no formal policy in place. The lack of action resulted in the resident not receiving the necessary referral to the prosthetic clinic as ordered by the physician.
Lack of Qualified Food Service Director and Sanitation Failures
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, as required by federal and state regulations. The individual identified as the full-time manager of the food service, V10, was observed supervising dietary operations but did not possess the necessary credentials such as being a certified dietary manager, a dietician, or having an associate's or higher degree in food service management or hospitality. V10 only completed a one-day ServSafe food service sanitation course, which did not include clinical nutrition instruction, and held a Certified Food Protection Manager certificate, not a Certified Dietary Manager or equivalent. V10 confirmed not meeting the Illinois standards for a food service or dietary manager and reported that the facility dietician only worked one day per week. Additionally, during the survey period, the facility failed to maintain sanitary conditions in the dishwashing areas and did not prevent or exclude flying insects from the food service areas, resulting in direct cross-contamination of resident dishes. The food prepared in the kitchen was available to all 146 residents in the facility, potentially exposing all residents to the effects of these deficiencies.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain an effective pest control program in the kitchen and food service areas, resulting in the presence of flying insects and unsanitary conditions. On multiple occasions, accumulations of decomposed food were found under the kitchen dishwasher drainboards, on surrounding walls, floors, and plumbing surfaces. The dishwasher drain pipe discharged into a floor-level trough that was soiled with food debris and emitted a fetid odor. Containers beneath the dishwasher and three-basin sink were partially filled with dirty water and food debris, and winged insects resembling fruit flies were seen flying around these areas. The disposal basin attached to the dishwasher, which was designed to empty into a food grinder/disposal, was instead draining into a metal pan in the floor trough, further contributing to the accumulation of food debris and the presence of flies. Pest control reports documented ongoing issues, including fly problems, potential harborage, and sightings of German cockroaches and spiders in the kitchen. Despite recommendations to clean the affected areas, conditions persisted, with flies observed landing on food contact surfaces of clean resident dishes stored near the contaminated drain trough and sewer pipe. The kitchen prepares food for all residents in the facility, and at the time of the survey, 146 residents resided in the facility.
Resident Rights Not Honored During Wound Care Scheduling
Penalty
Summary
A resident with multiple medical diagnoses, including muscle wasting, morbid obesity, end stage renal disease, and moderate protein calorie malnutrition, was documented as cognitively intact and dependent on staff for most activities of daily living. The resident's care plan instructed staff to provide opportunities for choice during care. However, on the day in question, the resident expressed a desire to get out of bed but was told by staff that he had to remain in bed until the wound physician arrived, which could be several hours. The resident became visibly upset and teary-eyed, stating he could not get up by himself and staff would not assist him. Staff interviews confirmed that the resident was not allowed to get up until seen by the wound physician, and that he had been crying all morning due to this restriction. Further interviews revealed that the wound nurse instructed staff not to assist the resident out of bed until the physician arrived, and that the resident refused wound care because he wanted to get up. The resident reported that he was not opposed to wound care but objected to being made to stay in bed for extended periods. The DON acknowledged that requiring the resident to remain in bed for hours was a violation of his rights, stating that a short wait would be acceptable but not a prolonged one. The facility's policy affirms residents' rights to a dignified existence and to be treated with respect, which was not upheld in this instance.
Inaccurate Completion of Resident Assessment
Penalty
Summary
A comprehensive assessment for one resident was inaccurately completed when the medication section indicated the resident was taking an antibiotic during the assessment period. However, a review of the resident's February 2025 Order Summary Report and Electronic Medical Record showed no documentation of any antibiotic orders or administration during that time. The MDS Coordinator, who completed the assessment, confirmed that the resident was not prescribed or given any antibiotics during the look-back period. The facility's policy requires all individuals completing any portion of the MDS assessment to attest to the accuracy of the information provided.
Failure to Update Wound Care Orders and Follow Sterile Technique
Penalty
Summary
A deficiency occurred when staff failed to enter new wound dressing change orders and did not provide wound care in accordance with professional standards for a resident diagnosed with Idiopathic Aseptic Necrosis of both feet and Peripheral Vascular Disease. The wound nurse performed a dressing change on the resident's right foot, cleansing the wound with Betadine and then, without changing gloves, applied a new clean dressing. The nurse later confirmed that she should have removed her dirty gloves before handling the clean dressing, as per the facility's wound care policy, which requires the use of sterile technique and glove changes to prevent contamination. Additionally, the wound nurse did not update the resident's wound care orders in the computer system after the wound doctor changed the treatment plan. As a result, wound care continued to be provided and documented under the previous orders, which differed from the new physician's instructions. The nurse acknowledged that the new orders should have been entered into the system on the same day they were received, but this was not done, leading to a failure to provide care according to the most current physician orders.
Failure to Prevent Cross Contamination During Catheter Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow proper infection control procedures during catheter care for a resident with multiple complex medical conditions, including hereditary spastic paraplegia, morbid obesity, neuromuscular dysfunction of the bladder, and a suprapubic catheter. The LPN removed a contaminated split gauze from the resident’s suprapubic catheter insertion site, which had yellow/pink drainage, and cleansed the area by wiping the gauze back and forth multiple times over the same area. Without changing gloves or performing hand hygiene, the LPN then placed a new split gauze over the insertion site using the same contaminated gloves. The resident’s medical records indicated a physician’s order for twice-daily cleansing of the suprapubic catheter site, but the resident reported that staff never clean the site daily, only during monthly catheter changes. The LPN acknowledged contaminating the site by not changing gloves between cleaning and dressing application. The Director of Nursing confirmed that contaminating an open wound could lead to infection. Facility policy required staff to discard gloves and perform hand hygiene after cleansing around the catheter site, which was not followed in this instance.
Failure to Document and Offer Required Vaccinations
Penalty
Summary
The facility failed to offer, administer, or obtain consent or declination for Influenza and Pneumococcal vaccinations for two residents out of five reviewed for immunizations. Both residents had been admitted to the facility and were documented as severely cognitively impaired according to their Minimum Data Set (MDS) assessments. Review of their electronic medical records revealed no documentation of consent, administration, or refusal of the required vaccinations since their admission. During an interview, the facility's Registered Nurse/Infection Preventionist confirmed that there was no documentation available to show that the two residents had been offered or had received the Influenza or Pneumococcal vaccines, nor was there evidence of refusal. Facility policy requires that Influenza vaccines be offered to all residents between October 1 and March 31, and that Pneumococcal vaccination status be assessed within five working days of admission, with all actions documented in the resident's medical record. These procedures were not followed for the two residents in question.
Failure to Maintain Functional Bathroom Ventilation Fan
Penalty
Summary
The facility failed to maintain a functional bathroom ventilation fan for one resident. On two separate occasions, it was observed that the bathroom ventilation fan in the resident's room was inoperable, with the fan blades not moving when the switch was turned on. The resident reported that the fan had not worked since admission in June 2024 and expressed a desire for it to be operational. The resident also stated that multiple requests had been made to various staff members over time to repair the fan, but no action had been taken to address the issue.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safety of a resident by not implementing resident-centered fall interventions and not thoroughly investigating a fall incident. The resident, who had a history of falls and was assessed as a fall risk, experienced a fall resulting in a forehead laceration that required emergency room treatment and sutures. The resident's care plan included interventions such as wearing non-skid socks and ensuring the bed was in a low position, but these were not adequately implemented or monitored. Observations revealed that the resident's bed was positioned against a wall with multiple pillows, which crowded the resident and forced her to sleep close to the edge, increasing the risk of falling. The resident's call light was not within reach, and staff were not aware of the resident's fall risk status or specific care plan interventions. Interviews with staff indicated a lack of awareness and understanding of the resident's care plan and fall interventions, with some staff relying on visual cues like floor mats to identify fall risks rather than documented care plans. The interdisciplinary team reviewed the fall incident but failed to address the root cause effectively. The resident's sleeping patterns and the inappropriate use of pillows were not included in the care plan, leading to confusion among agency staff. The facility's policy on falls required continuous evaluation and identification of fall causes, but this was not adequately followed, resulting in the resident's preventable fall and injury.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to provide adequate supervision for a severely cognitively impaired resident, who was known to exit seek and had a history of elopement. This resident, who was at high risk of falls and was receiving anticoagulation therapy, managed to exit the facility through a deactivated alarmed exit door without staff knowledge or supervision. The resident walked approximately 0.4 miles in extreme cold weather, down a busy street, before being found by a passerby who alerted the facility. Staff were unaware of the resident's absence for approximately one-half to one hour. The resident's medical history included severe dementia with mood disturbance, delirium, restlessness, agitation, hypertension, paroxysmal atrial fibrillation, muscle weakness, and gait abnormalities. Despite these conditions and a documented history of falls, the facility did not update the resident's care plan to address elopement risks in a timely manner. The resident had been observed wandering and exit-seeking prior to the incident, yet no effective interventions were implemented to prevent the elopement. Additionally, after the resident was returned to the facility, staff failed to conduct a full body assessment to check for injuries or hypothermia. The facility also did not ensure that exit door alarms were functional, contributing to the resident's ability to leave the premises unnoticed. These failures highlight significant lapses in supervision and safety measures, which placed the resident at risk of serious harm.
Removal Plan
- Confirmed the facility identified residents affected or likely to be affected by completing resident elopement assessments and reassessments and updating care plans.
- Confirmed elopement binder was updated and at the nurses' stations, and the reception desk.
- Confirmed Accidents and Incidents- Investigating and Reporting Policies including documentation of the condition of the affected person, including vital signs was revised and updated.
- Staff training was initiated and is ongoing. In-service training on elopement protocol and retention quiz were not provided prior to start of shift for several staff.
- Confirmed V1, V2 and V28 Assistant Director of Nurses initiated education relating to immediate head to toe assessments following unusual occurrences.
- Confirmed V12, Maintenance Director assessed all doors, exit alarms, and the departure alert system to ensure proper working order and observed during survey. Ad-Hoc QAPI meeting was completed discussing event and evaluating the current elopement program including conducting daily assessments of exits, and routinely scheduled elopement drills to be ongoing. One mock drill was completed during survey.
- Confirmed V1, provided training to the IDT regarding development of care plans to address residents who are newly identified with exit-seeking /wandering behaviors and elopement risk.
- Confirmed Ad-Hoc QAPI meeting, including the Medical Director by phone, to discuss the incident and the corrective actions to prevent similar events.
- Confirmed in interviews, Daily IDT meetings were conducted to discuss new or worsening wandering/exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring appropriate clinical interventions are implemented to prevent an incident of elopement.
- Confirmed QAPI team will review results of the audits, posttests, door and window checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for several residents, as observed during a survey. On multiple occasions, a resident was seen sitting at a dining room table covered with napkins, tissues, condiments, and personal items, including mucous-filled tissues. This behavior was noted to be disruptive and unpleasant for other residents, leading to complaints. One resident expressed discomfort and a loss of appetite due to another resident's habit of hacking and spitting up mucous, which was also thrown onto the floor. This resident reported having complained to the staff about the issue, but no action was taken to address the behavior. The administrative assistant acknowledged awareness of the disruptive behavior, which continued to occur daily. The care plan for the resident exhibiting the behavior documented the need for supervision and reminders to refrain from such actions during meal times. Despite this, the behavior persisted, affecting the dining experience and comfort of other residents. The facility's inaction in managing the situation and ensuring a clean and comfortable environment for all residents led to the deficiency noted in the report.
Failure to Address Resident Grievances Regarding Disruptive Behavior
Penalty
Summary
The facility failed to honor the residents' right to voice grievances without discrimination or reprisal, as evidenced by the lack of a filed grievance for a known complaint. Two residents expressed dissatisfaction with another resident's behavior, which involved hacking, spitting up mucous, and discarding tissues on the floor in the dining room. These actions were reported to staff, including the Assistant Administrator, but no grievance was filed, and the issue remained unaddressed. The facility's grievance policy, dated April 2017, mandates that grievances be investigated and resolved promptly, with a written response provided within five working days. Despite this policy, the Assistant Administrator acknowledged awareness of the disruptive behavior but did not file a grievance, mistakenly attributing the issue to the resident's behavior rather than recognizing it as a grievance-worthy complaint. This oversight resulted in the residents' complaints not being documented or addressed according to the facility's established procedures.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered, resulting in multiple missed doses for three residents. One resident, who was cognitively intact, reported that the facility had run out of their medications, including Duloxetine and Lorazepam, on several occasions. The Medication Administration Records (MARs) and nursing notes documented that these medications were unavailable on specific dates, and there was no evidence that the resident's physician was notified of the missed doses. Another resident, also cognitively intact, stated that their bone medication was unavailable for several weeks. The MARs indicated that Alendronate-Cholecalciferol was not administered as scheduled due to a billing issue and lack of prior authorization. Despite multiple attempts to resolve the issue, the medication remained unavailable, and there was no documentation that the physician was informed of the missed doses until a later date. A third resident did not receive their prescribed Aripiprazole because the medication was not found in the facility's backup supply. The LPN responsible for administering the medication confirmed its unavailability and reordered it from the pharmacy. However, there was no documentation of follow-up with the pharmacy or physician regarding the medication's unavailability. The facility's policies outlined procedures for handling unavailable medications, but these were not followed, contributing to the deficiency.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to administer insulin timely, resulting in significant medication errors for one resident. The resident, who is cognitively intact, reported not receiving medications on time, including insulin, which led to fluctuations in blood sugar levels. The resident's Medication Administration Record (MAR) indicated that Lispro insulin was scheduled to be administered three times daily at specific times. However, the Medication Administration Audit Report showed multiple instances where the insulin was administered hours later than scheduled. The Director of Nursing confirmed that medication administration times should be documented accurately and that medications should be given within an hour of the scheduled time unless specified otherwise. The facility's policy on administering medications, dated April 2019, also states that medications should be administered according to physician's orders and within one hour of the prescribed time. Despite these guidelines, the facility repeatedly failed to administer insulin within the required timeframe, leading to significant medication errors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered for three residents, resulting in a 12% medication error rate. For one resident, the Licensed Practical Nurse (LPN) did not administer Ferrous Sulfate 325 mg as scheduled during the morning medication pass, despite confirming that the medication administration was complete. The facility's medication pass times indicated that the medication should have been administered between 6:00 AM and 11:00 AM. Another resident received an incorrect dosage of Breo Ellipta inhaler, which was intended for a different resident, and was not instructed to rinse their mouth after administration as required. The inhalers were stored incorrectly, leading to the administration error. Additionally, a third resident did not receive their prescribed Aripiprazole due to the medication being unavailable in the facility, and there was no documentation of the physician being notified of the missed dose. The facility's policy requires medications to be administered according to physician orders, ensuring the right resident, medication, dosage, time, and method.
Failure to Perform Wound Care Leads to Maggot Infestation
Penalty
Summary
The facility failed to complete wound dressing changes as ordered by the wound care physician for a resident, resulting in the resident's wounds becoming infested with maggots. The resident, who was admitted with multiple diagnoses including wounds and dementia, had specific wound care orders that were not followed. The wound care physician had prescribed the application of Triamcinolone cream and compression wraps twice a week, but these were not consistently documented or performed. On one occasion, a nurse admitted to not performing a dressing change due to being busy, despite having charted it as completed. The resident experienced significant pain and deterioration of the wounds, which were found to be infested with maggots on two separate occasions. The room was noted to have a strong smell of urine and fly strips with flies, indicating poor sanitation. The Director of Nursing acknowledged the unacceptable care, and the wound physician expressed concerns about infection due to the maggot infestation. The resident's condition worsened, with new wounds developing and existing wounds declining in size and condition.
Fly Infestation Due to Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest management program, resulting in a significant fly infestation affecting all 141 residents. The facility's pest control policy, dated March 2024, assigns the Environmental Services Director the responsibility for coordinating pest control, which should be conducted regularly and as needed. However, pest control service reports from April to August 2024 did not document flies as an area of concern. Observations on August 19 and 20, 2024, revealed numerous fly strips with flies attached in several resident rooms, including one room with over 50 flies on a strip. A resident reported having to use fly strips for the past 2-3 months due to the fly problem, and an LPN confirmed that many residents were using fly strips to keep flies away. The Maintenance Director acknowledged the presence of fly traps and a fly light at the courtyard door but dismissed flies as pests. The contracted pest control representative was not informed of the fly issue until the survey and identified entry points for flies through air conditioning units and standing water outside the building as breeding sites. The representative recommended fly lights and noted that the fly strips in use were not provided by their company, indicating a lack of communication and coordination in addressing the pest issue. Additionally, the Director of Nursing confirmed that a resident had maggots found in wounds on two occasions in the past week, further highlighting the severity of the infestation.
Failure to Provide Prescribed Diabetic Diets
Penalty
Summary
The facility failed to provide a diet as ordered for five residents with diabetes, resulting in a deficiency. The facility's Physician Order Policy requires that after an order is received and confirmed, it should be completed as directed by the prescriber. However, the facility provided only one meal option for all residents, regardless of their dietary needs. Specifically, residents with orders for a low concentrated sweets diet were not given meals that adhered to these dietary restrictions. Instead, they were served the same meals as other residents, which included items not suitable for a diabetic diet, such as ravioli and sauce for lunch, and a breakfast of biscuit, sausage gravy, and a banana. The deficiency was confirmed through observations and interviews with facility staff. The Dietary Assistant Manager and the Director of Nursing both acknowledged that there were no different menus or portion sizes for diabetic residents. The Registered Dietician was unaware that the staff were not serving a low concentrated sweets diet to diabetic residents, which could lead to health issues such as elevated blood sugar levels, weight gain, and poor circulation and wound healing. The failure to provide the prescribed diet as ordered for diabetic residents was a significant oversight in the facility's dietary management.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in an incident where one resident (R1) struck another resident (R2) in the face. This incident occurred after R1 became aggressive upon returning to the facility. Multiple staff members, including CNAs and an LPN, witnessed the altercation and reported that R1 was yelling profanities and making racial remarks towards the staff. The police were called to manage the situation, and R2 was moved to a different room for safety. R2 experienced discomfort and swelling on the left side of the face near the eye as a result of the altercation. The facility's investigation revealed that R1 had borrowed money from R2 and failed to repay it, leading to the confrontation. R2 expressed fear of R1 following the incident and was relieved to be moved to a different room. The facility's Abuse Prevention and Reporting Policy, dated October 2022, explicitly prohibits abuse, neglect, and mistreatment of residents, yet this policy was not effectively enforced in this case, resulting in a failure to protect R2 from physical harm.
Failure to Implement Safety Measures for Resident with Criminal Background
Penalty
Summary
The facility failed to ensure the safety of its residents by not accurately screening and assessing a newly admitted resident, identified as R1, who had a history of felony offenses and was assessed as a moderate risk to others. Upon admission, R1 was placed in a room with another resident, R2, without implementing necessary safety interventions or an individualized plan of care that considered R1's criminal background. This oversight led to an incident where R1 physically assaulted R2, causing facial discomfort, swelling, and psychosocial harm to R2. The facility's policy required a thorough review of criminal history and the development of a care plan tailored to the needs of identified offenders. However, R1's care plan did not document any offender information, and an abuse risk assessment was not completed until after the incident occurred. The facility's background check process was flawed, as the initial check was conducted with an incorrect date of birth, delaying the identification of R1's criminal history. Despite R1's background indicating a need for a private room, the facility placed R1 in shared accommodations, which contributed to the incident. Interviews with facility staff revealed a lack of awareness and preparedness regarding R1's background and the necessary precautions to protect other residents. The Social Service Director acknowledged the error in the background check process and the absence of safety measures for R1. The Regional Director of Operations was unaware of R1's aggravated battery conviction, and the facility administrator denied being informed by R1 of the need for a private room. This series of inactions and miscommunications led to the failure to protect R2 from harm.
Failure to Develop Comprehensive Care Plan for Identified Offender
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as an offender, which is a requirement according to their policy. The policy mandates that upon admission of an identified offender, the facility must create an individualized plan of care that includes security measures to protect other residents. This plan should be developed in consultation with a medical doctor and law enforcement. However, the resident's care plan did not document their status as an identified offender, their risk level, or any specific interventions to address these concerns. The resident in question has a significant criminal history, including several arrests and convictions for offenses such as aggravated battery, burglary, and resisting a peace officer. Despite this history and the moderate risk assessment from the referring facility, the resident's care plan lacked necessary details to ensure the safety of other residents. The Social Service Director confirmed that the resident's offender status and risk level were not included in the care plan, acknowledging that this was an oversight.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to honor a resident's breakfast meal preferences, affecting one of the three residents reviewed for meal preferences in the sample list of nine. On June 9 and June 10, 2024, the resident was served only one fried egg for breakfast, despite having previously requested two fried eggs, two pieces of toast, and two sausages every day. The resident had communicated these preferences to the Dietary Manager about a month prior, and the facility initially complied for a few days. However, the resident reported that the facility subsequently reduced the meal to one slice of toast and, on the past two days, only one fried egg. On June 11, 2024, the resident's breakfast tray included two fried eggs, one slice of toast, oatmeal, and a four-ounce drink. The Dietary Manager confirmed the resident's request and was unaware of the deviation from the requested meal on the previous days.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
The facility failed to ensure a resident's right to be free from verbal abuse by staff. This deficiency was identified when a resident, who is cognitively intact and requires assistance with grooming and toileting, reported an incident where a Certified Nursing Assistant (CNA) made a derogatory comment. The resident had an episode of loose stools and was unable to reach to clean himself. When the CNA handed him wipes and the resident demonstrated his inability to reach, the CNA responded with a comment about the resident's weight, making him feel ashamed and embarrassed. This incident was reported to the Activity Director and subsequently led to an interview with the Administrator, Director of Nursing, and a local police officer. The facility's abuse policy, dated August 2023, emphasizes the right of residents to be free from abuse, neglect, and mistreatment. Despite this policy, the incident occurred, and the CNA involved was suspended pending an abuse investigation. The Administrator confirmed that based on the gathered information, the incident would be considered verbal abuse. This failure to protect the resident from verbal abuse by staff highlights a significant deficiency in the facility's adherence to its own policies and procedures designed to prevent such occurrences.
Failure to Facilitate Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to facilitate interdisciplinary care plan meetings including residents for one of three residents reviewed for care plan meetings. The facility's Care Plan Meeting Procedure requires invitations to be extended to the resident or their representative and for various staff members to participate. However, for one resident, the quarterly care plan meeting was attended only by the Care Plan Coordinator, with no documentation regarding falls, injuries, behaviors, cares, or weight loss. The Care Plan Coordinator admitted to not knowing if the resident's guardian received the invitation and held the meeting alone. The Director of Nursing and the Regional Nurse Consultant acknowledged the issue, noting that the resident, family, and other staff should be present and that communication with the guardian was lacking.
Failure to Provide Basic Hygiene Care
Penalty
Summary
The facility failed to provide adequate bathing, shaving, and nail care for a resident who was dependent on staff for all activities of daily living. The resident, who was severely cognitively impaired, was observed in a soiled state with long toenails and unshaven hair. The facility's policies on bathing and nail care were not followed, and there was no documentation indicating when the resident last received these essential care services. Both the Administrator and the Director of Nursing acknowledged the resident's neglected state but could not explain why the care needs had not been addressed by the CNAs or the Podiatrist.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse and another resident's right to be free from physical abuse. In the first incident, a resident with Alzheimer's Disease and severe cognitive impairment was sexually abused by another resident who was moderately cognitively impaired and had a history of inappropriate sexual behavior. The incident occurred in the dining room where the perpetrator grabbed the victim's chest and refused to let go despite the victim's attempts to pull away. This was witnessed by a dietary aide and confirmed by video evidence. The perpetrator later admitted to the act, stating they knew it was wrong but acted on an urge. In the second incident, a resident with dementia and moderate cognitive impairment was physically abused by another resident with severe cognitive impairment and a history of aggressive behaviors. The perpetrator accused the victim of stealing and struck them with a closed fist, leading to a physical altercation where both residents fell to the floor. This incident was witnessed by a nurse practitioner and a certified nurse assistant, both of whom confirmed the aggressive behavior and the physical altercation. The perpetrator was placed on one-on-one supervision following the incident.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents, R205 and R206. The incident occurred in the dining room where R205, in a wheelchair, touched R206's chest over the clothes. The investigation included statements from a dietary aide who witnessed the event and a certified nurse assistant who assisted in separating the residents. However, the facility did not document interviews with the Interdisciplinary Team (IDT) or other staff and residents who might have had knowledge of R205's inappropriate behavior. The administrator confirmed that no other residents were in the dining room during the incident and acknowledged the lack of documented interviews with the IDT and other potential witnesses.
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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