La Bella Of Freeburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Freeburg, Illinois.
- Location
- 746 Urbanna Drive, Freeburg, Illinois 62243
- CMS Provider Number
- 145515
- Inspections on file
- 20
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at La Bella Of Freeburg during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and documented fall risk had care plan interventions that included use of bed and chair pad alarms. Facility policy and staff statements indicated that these alarms were to be functioning and checked each shift. However, the resident was found ambulating unassisted to the bathroom with a pad alarm in place that was not sounding, became unsteady, struck the back of the head on a bathroom door, and slid to the floor, demonstrating the facility’s failure to ensure the alarm was in working order.
A resident with moderate cognitive impairment was injured when another resident, who had no documented cognitive deficits but required neurological monitoring, attacked with a butter knife in the dining room. The altercation lasted over half a minute before staff intervened, resulting in a facial laceration and a fall from a wheelchair that required hospital evaluation. The incident occurred despite facility policies prohibiting abuse and requiring a secure environment.
A resident with a comfort-focused POLST and advanced directives was mistakenly transferred to the hospital due to staff confusion, despite no documented symptoms or need for outside intervention. The error resulted in unnecessary diagnostic testing before the mistake was identified, and staff interviews confirmed the transfer was not warranted.
Two residents experienced lapses in care when one was mistakenly sent to the ER without physician order or hospice notification, and another was not transferred to the hospital as ordered by the medical director. Staff confusion and failure to follow established protocols led to these deficiencies, with family and hospice not properly notified prior to transfers.
The facility did not properly notify the designated representatives and physicians for two residents regarding significant changes in their status, including a mistaken hospital transfer and a planned transfer that did not occur. Documentation indicated notifications were made, but interviews revealed delays and failures in communication, contrary to facility policy.
A resident with severe cognitive impairment was transferred to the hospital without prior notification or consent from her healthcare power of attorney. Facility records did not document any preparation or notification for the transfer, contrary to facility policy requiring such communication and documentation.
A resident in a LTC facility sustained a fracture after her leg was accidentally bumped by another resident's wheelchair. Despite showing signs of pain and increased bruising, an x-ray was not ordered until two days later, revealing the fracture. The facility failed to adhere to its policy for immediate notification of acute symptoms, resulting in delayed treatment.
A resident with severe cognitive impairment and multiple diagnoses was injured during meal service when her leg was bumped by another resident's wheelchair, resulting in a fracture. The incident was not immediately documented, and the facility's investigation was criticized for poor documentation and lack of clarity on the injury's cause.
The facility failed to store and prepare food properly, risking contamination for all 99 residents. Surveyors found improperly thawed chicken, undated and uncovered food items, and greasy kitchen hoods. The Dietary Manager was absent, and staff were unsure about the spoilage and cleaning schedules, violating facility policies and FDA guidelines.
The facility failed to follow infection control guidelines for six residents. CNAs were observed feeding residents without proper hand hygiene, and an LPN provided wound care without wearing the required gown under Enhanced Barrier Precautions. These actions violated the facility's infection control policies.
A resident with cognitive impairments and on blood thinners was found with a large bruise on her arm after a transfer. The facility failed to report this injury of unknown origin to the appropriate authorities, as required by their policy. The DON and ADON concluded the bruise was due to the resident's combative behavior, but inconsistencies in staff accounts and lack of proper documentation led to a deficiency in reporting suspected abuse or neglect.
A resident with severe cognitive impairment and mobility limitations was found with a bruise of unknown origin, which was not thoroughly investigated by the LTC facility. The incident report lacked details, and the investigation was poorly documented, resulting in a delayed diagnosis of a leg fracture. The facility's failure to adhere to its abuse policy led to a deficiency in care.
Failure to Maintain Functioning Pad Alarm Resulting in Unassisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning chair/bed pad alarm for a resident identified as being at risk for falls. The resident was admitted with multiple significant diagnoses, including chronic kidney disease, shortness of breath, anxiety disorder, torsades de pointes, sepsis, atrial fibrillation, heart failure, acute respiratory failure with hypoxia, restlessness and agitation, muscle weakness, unsteadiness on feet, cerebral infarction, and osteoarthritis. The resident’s MDS documented a severely impaired BIMS score of 4, and the care plan identified the resident as at risk for falls due to a history of falls on admission and weakness, with interventions including a chair pad alarm and bed pad alarm. The facility’s fall prevention policy required confirmation that bed/chair alarms are functioning when ordered, and staff reported that bed and chair alarms are to be checked for working status every shift. Despite these identified risks and interventions, an incident note documented that the resident was found ambulating unassisted to the bathroom, with the bed pad alarm in place but not sounding. During this unassisted ambulation, the resident became unsteady, turned, and hit the back of the head on a closed bathroom door, then slid to the floor and landed on the back. An LPN immediately assessed the resident, noting range of motion within normal limits, usual confusion, and a raised area developing on the posterior head. The administrator later confirmed that when the resident fell, the pad alarm was not sounding and that it should have been, indicating that the alarm was not functioning as required at the time of the fall.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent abuse for one of three residents reviewed for abuse, resulting in a resident being cut on the face with a butter knife and falling from a wheelchair, which required hospital evaluation and treatment. The incident occurred in the dining room, where two residents were seated at separate tables. One resident, who had diagnoses including anxiety disorder, dementia, and chronic atrial fibrillation, stood up, took a butter knife, and stabbed another resident in the cheek. The altercation lasted approximately 35 to 40 seconds, during which the injured resident slid from the wheelchair and landed on the floor. The resident who was attacked had a history of sepsis, dementia, contractures, and chronic pain syndrome, and was documented as moderately cognitively impaired. The care plan for this resident noted behavioral issues such as attention-seeking and fixation due to anxiety and depressive disorders. The attacking resident had no cognitive deficits documented but was noted to have an alteration in neurological status requiring cueing and reorientation. Staff in the vicinity responded after hearing the injured resident scream, and immediate assessment and first aid were provided. The incident was captured on video surveillance, confirming the sequence of events. Staff interviews indicated that the attacking resident had not previously exhibited such behavior and that staff were present in the dining room but did not prevent the incident. The facility's abuse policy affirms residents' rights to be free from abuse and outlines the facility's responsibility to prevent such occurrences. Despite these policies, the incident occurred, resulting in physical harm to a resident and the need for hospital transfer.
Failure to Honor Advanced Directives Leads to Unnecessary Hospital Transfer
Penalty
Summary
A resident with a diagnosis of cerebral infarction and facial weakness, who had a care plan and POLST indicating a preference for comfort-focused treatment and limited hospital transfers, was mistakenly sent to the hospital. The resident's care plan specifically directed that hospital transfer should only occur if comfort could not be achieved in the facility. On the date of the incident, there were no documented vital signs or medical symptoms for the resident, and no nurse's progress notes indicated any concerns. A late entry in the nurse's notes later clarified that the resident was sent to the emergency room due to low blood pressure and low oxygen saturation, but this was a case of mistaken identity; another resident was actually intended to be transferred. Interviews with facility staff confirmed that the resident did not require outside intervention and that the transfer was not medically necessary. The Director of Nursing was unable to explain how the resident was taken by emergency medical technicians without the duty nurses' knowledge. The resident underwent unnecessary diagnostic testing at the hospital before the error was discovered. Facility policy requires that services be provided to maintain residents' physical and mental health and satisfaction, but in this case, the resident's advanced directives and care preferences were not honored.
Failure to Follow Physician Orders and Hospice Agreements During Resident Transfers
Penalty
Summary
The facility failed to follow physician orders and hospice agreements for two residents, resulting in significant lapses in care. One resident, who had a diagnosis of cerebral infarction and was on hospice care with a DNR/DNI status, was mistakenly sent to the emergency room for evaluation and treatment of low blood pressure and low oxygen saturation. The hospital identified that the wrong patient had been sent, and the resident was returned to the facility without receiving treatment. The family was not notified prior to the transfer, and the hospice provider was only informed after the incident. The facility did not have a physician order to send this resident to the hospital, and the hospice agreement specifically required prior approval before any transfer, which was not obtained. Another resident, who had been admitted with diagnoses including Human Metapneumovirus and SIRS, experienced a temperature elevation, abnormal lung sounds, and a significant drop in blood pressure. The medical director ordered this resident to be transferred to the hospital for further evaluation. However, due to an error, the resident was not sent to the hospital as ordered. The oncoming nurse reassessed the resident and decided to manage the symptoms at the facility without consulting the medical director or following the original transfer order. The resident's family was notified after the decision not to transfer was made. Interviews with staff revealed confusion and lack of clarity regarding the transfer process, with agency CNAs unfamiliar with resident names and roles. The facility's own policies and the hospice agreement required notification and coordination with hospice and family prior to any transfer, which did not occur in these cases. Documentation confirmed that the wrong resident was sent to the hospital and that a resident who should have been transferred was not, both in direct violation of physician orders and established protocols.
Failure to Notify Representatives and Physicians of Resident Status Changes
Penalty
Summary
The facility failed to notify the designated representatives and physicians of two residents regarding significant changes in their status, specifically related to hospital transfers. One resident, who was severely cognitively impaired and had a diagnosis of cerebral infarction and facial weakness, was mistakenly sent to the emergency room due to low blood pressure and low oxygen saturation. Although documentation indicated that the resident's power of attorney and the medical director were notified, interviews revealed that the power of attorney was not informed until two days later by a hospice nurse, and the medical director was not notified at all. The hospice nurse also confirmed delayed notification. In a separate incident, another resident, who was cognitively intact and had diagnoses including Human Metapneumovirus and SIRS, was reportedly not transferred to the hospital as initially planned. The resident's daughter was not informed by the facility about the transfer status and only learned through a hospital inquiry that her mother was not at the hospital. The medical director was also not informed that the resident had not been sent out as ordered and only discovered this during a routine visit. Facility policies require timely notification of residents, families, and physicians regarding transfers, but these procedures were not followed in these cases.
Failure to Notify Resident Representative Prior to Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident or their representative received adequate preparation and notification prior to a hospital transfer. Specifically, a resident with a diagnosis of cerebral infarction and severe cognitive impairment was transferred to the hospital without the knowledge or consent of her designated healthcare power of attorney, her daughter. The daughter reported that she was not informed of the transfer, and the resident was unable to speak or make decisions for herself due to her condition. Review of the resident's records, including the face sheet, MDS, and nurse progress notes, revealed no documentation that either the resident or her representative was prepared for or notified about the hospital transfer. The facility's policy requires that all discharge decisions, including reasons for discharge and discussions with the resident and family, be documented, and that required notices and appeals information be provided. This policy was not followed in this instance, resulting in a lack of proper documentation and notification.
Delayed Medical Intervention for Resident's Fracture
Penalty
Summary
The facility failed to seek timely medical intervention for a resident who sustained a fracture. The incident began when a bruise was noted on the resident's left shin during routine care, and the nurse practitioner was notified. Despite the resident showing signs of pain and increased bruising the following day, an x-ray was not ordered until two days after the initial incident. The x-ray revealed a fracture, and the resident was then sent to the emergency room for evaluation and treatment. Interviews with staff revealed that the resident, who was unable to propel herself in a wheelchair, was likely injured when her leg was accidentally bumped by another resident's wheelchair. The documentation of the incident was poor, and there was a delay in recognizing the severity of the resident's condition. The facility's policy required immediate notification of the nurse practitioner for acute symptoms, but this was not adhered to, resulting in a delay in treatment.
Resident Injury Due to Inadequate Supervision During Meal Service
Penalty
Summary
The facility failed to ensure a resident was not injured while being pushed in their wheelchair during meal service, resulting in the resident sustaining a fracture to her left leg. The resident, who had a diagnosis of major depression disorder, severe with psychotic symptoms, Alzheimer's disease, and dementia, was severely impaired for cognition and dependent on staff for daily activities. She was in a manual wheelchair and unable to propel herself. During a meal service, the resident's leg was bumped by another resident's wheelchair, leading to a bruise that later developed into a fracture. The incident was initially noted when staff observed a bruise on the resident's leg during routine care. The bruise was reported to the nurse, who monitored it and later ordered an x-ray when the bruise worsened. The x-ray revealed a fracture, and the resident was sent to the emergency room for evaluation and treatment. Interviews with staff indicated that the resident was sliding down in her wheelchair and was repositioned by staff when her leg was accidentally bumped by another resident's wheelchair pedal. The facility's documentation and investigation into the incident were criticized for being poor and lacking immediate and thorough reporting. The nurse practitioner expressed concerns about the late entry in the documentation and the lack of clarity on how the injury occurred. The facility's policies on abuse and accident/incident reporting require timely and thorough investigations, but the documentation in this case was found lacking, contributing to the deficiency.
Improper Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored and prepared in a manner that prevents potential contamination, affecting all 99 residents. During a tour of the kitchen, surveyors observed five large industrial bags of frozen chicken in a sink, with only one bag under running water at 100 degrees Fahrenheit, contrary to the facility's policy and FDA guidelines which require water temperatures below 70 degrees Fahrenheit for thawing. Additionally, the chicken was not fully submerged, and the water was not agitating the bags as required. In the walk-in refrigerator, uncovered and undated orange substance cups were found, along with a leaking box of glazed chicken, and a container of pineapple past its use-by date. A large container of corn kernels was also found without a date or label. The facility's Dietary Manager was not present during the inspection, and staff were unsure about the spoilage of the chicken and the cleaning schedule for the kitchen hoods, which were observed to be greasy and in need of cleaning. The facility's policies on meat defrosting and food labeling were not adhered to, as evidenced by the improper thawing of chicken and the presence of undated and expired food items. The FDA code requires proper thawing methods and clean ventilation systems to prevent contamination, which were not followed in this instance.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control guidelines for six residents, as observed during a survey. A Certified Nursing Assistant (CNA) was seen feeding a resident without washing or disinfecting her hands after touching her face and the resident's bib. This CNA then proceeded to feed another resident without performing hand hygiene. Similarly, another CNA was observed feeding two residents alternately without using hand sanitizer between feedings, and no hand sanitizer was available nearby. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of handwashing to prevent infection spread. Additionally, a Licensed Practical Nurse (LPN) provided wound care to a resident under Enhanced Barrier Precautions (EBP) without wearing the required gown, despite a sign on the resident's door indicating the need for personal protective equipment (PPE) including masks, gloves, and gowns. The Director of Nursing confirmed that staff are expected to wear the appropriate PPE for residents on EBP. The facility's policies on infection control and EBP were not followed, leading to these deficiencies in infection prevention and control practices.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R23, who was reviewed for abuse. R23, who has diagnoses including generalized anxiety, major depressive disorder, dementia, unsteadiness on feet, and muscle weakness, was found to have a large bruise on her right upper arm. The bruise was discovered by CNAs during a transfer from a wheelchair to bed, and the resident complained of pain during the process. Despite the severity of the bruise and the resident's cognitive impairment, the facility did not report the injury as required. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were informed of the bruise and conducted an investigation. They concluded that the bruise was likely caused by the resident being combative during care, a behavior noted as common for R23. However, there was no documentation that the Administrator was notified, and the investigation report lacked details on the exact statements from the CNAs involved. The facility's policy requires immediate notification to the Illinois Department of Public Health (IDPH) for potential mistreatment, but this was not done. Interviews with staff revealed inconsistencies in the accounts of the incident. The CNAs involved in the transfer did not report any unusual behavior from R23 that day, and one CNA stated that R23 was not combative or resistive to care. Despite these discrepancies, the facility did not follow its policy to report the injury to the appropriate authorities, resulting in a deficiency in handling suspected abuse or neglect cases.
Incomplete Investigation of Resident's Bruise Leads to Deficiency
Penalty
Summary
The facility failed to thoroughly investigate a bruise of unknown origin for a resident with multiple medical conditions, including severe cognitive impairment and mobility limitations. The resident, who was dependent on staff for most activities of daily living and used a manual wheelchair, was found to have an 11 x 6 cm bruise on her left shin during routine care. The incident report noted that the bruise was allegedly caused by another resident's wheelchair, but it lacked critical details such as the identity of the staff member present during the incident and the other resident involved. The investigation into the bruise was incomplete and poorly documented. The Skin Injury Investigation Checklist did not include the resident's name, and there were no documented interviews or statements from staff members involved in the incident. The Director of Nursing, who was new to the position, admitted to not documenting interviews or obtaining statements, which contributed to the lack of clarity regarding the incident. The Licensed Practical Nurse who initially assessed the bruise did not know the identities of the staff or resident involved in the collision. The facility's failure to conduct a timely and thorough investigation resulted in a delayed diagnosis of a fracture in the resident's leg. The Nurse Practitioner expressed concerns about the poor documentation and the lack of immediate reporting, which hindered the ability to determine the cause of the fracture. The facility's abuse policy emphasizes the importance of timely and thorough investigations, but this was not adhered to in this case, leading to a deficiency in the standard of care provided to the resident.
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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