La Bella Of Morrison
Inspection history, citations, penalties and survey trends for this long-term care facility in Morrison, Illinois.
- Location
- 500 North Jackson Street, Morrison, Illinois 61270
- CMS Provider Number
- 146084
- Inspections on file
- 25
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at La Bella Of Morrison during CMS and state inspections, most recent first.
A cognitively intact resident who was independent in self-care and mobility received an involuntary discharge notice for non-payment, while the ombudsman was actively assisting with an appeal and hearing. The resident chose to leave and was discharged home before the planned discharge date, but the facility did not notify the ombudsman of this discharge. The ombudsman learned of the discharge from an APS worker and confirmed that no discharge notice had been received, and the administrator acknowledged that required notification to the ombudsman, as outlined in facility policy, had not been provided.
Two residents were not safely transferred according to their assessed needs and facility policy, resulting in injuries requiring emergent hospital evaluation. One resident with severe anxiety, fear of falling, and a documented need for two-person assistance was transferred by a single CNA unfamiliar with her status, leading to a leg laceration when her leg likely caught on the wheelchair during a hurried transfer. Another resident with cognitive impairment, right-sided paralysis, and a fall history, who required a gait belt and one-person assist, was stood from the toilet without a gait belt and left unsupported when the CNA turned away, causing a fall with head impact and leg pain.
A resident was admitted from a hospital with discharge orders and a POLST indicating DNR status, and a POA document identified a healthcare representative. Despite this, a physician order listed the resident as Full Code, and the admission care plan omitted any reference to advance directives. The POA reported being told that the facility could not honor the POLST until the medical director signed it, even though the DON later confirmed that a physician-signed POLST should be honored without additional signatures. The facility’s policy requiring advance directives to be copied, charted, and communicated on admission was not followed, resulting in the resident’s DNR wishes not being implemented.
Two residents who were cognitively impaired and dependent on staff for toileting and incontinence care were not provided timely incontinence care consistent with their assessments, care plans, and facility policy. One resident’s brief was last changed early in the morning and was not changed again for over five hours while the resident remained in common areas and then in her room, after which she was found incontinent of urine with reddened buttocks. Another resident, care planned for q2h checks and assistance, was observed with a stool odor in the room and was found to have a brief unchanged since the night shift, containing a large amount of liquid stool and with bright pink buttocks. The DON stated residents needing assistance are to receive toileting and incontinence care every two hours and as needed.
A resident sustained a sutured left lower leg laceration and was discharged with orders for daily wound cleansing and specific dressings each day shift. Review of the TAR and interviews showed that daily wound treatments and dressing changes were not provided on multiple days, and the resident’s private caregiver reported that dressings were not changed on at least two of those days and that she frequently had to request dressing changes. On observation, the leg dressing was undated, appeared dirty, and had yellow drainage, and there was no documentation of wound care for the prior day. The DON later added initials to previously blank TAR entries for two dates, then admitted she had not performed the wound care and had documented after the fact because she had been told not to leave charting blank, contrary to the facility’s wound treatment policy and documentation expectations.
A resident with diabetes had physician orders for blood glucose checks before meals and at bedtime, scheduled insulin doses with meals, and Reglan to be given before meals. On an observed morning, the resident had already eaten part of breakfast and stated he was done when an LPN checked the blood glucose after the meal, then administered Humulin R and Reglan more than two hours past the ordered times and after the meal, instead of before as ordered. The DON stated that medications are considered late if given more than one hour after the scheduled time and that blood sugars should be checked prior to eating, and facility policies required adherence to physician orders and correct timing for blood glucose monitoring, insulin, and medication administration.
The facility did not develop or document discharge plans in the care plans or electronic medical records for two residents with complex medical needs. Both residents were unaware of their discharge plans, and staff confirmed that required discharge planning was missing, despite facility policy mandating comprehensive, person-centered discharge documentation.
Two residents in the facility suffered from inadequate pressure ulcer care due to failures in implementing necessary interventions and treatments. One resident was found on a deflated air mattress without heel protection, leading to a stage 3 pressure injury. Another resident's stage 2 pressure wound worsened to stage 3 without documented treatment. The facility did not follow its policy for assessing and treating skin alterations, resulting in inadequate care.
The facility failed to ensure a safe, clean, and comfortable environment, with deficiencies in the resident shower room and lack of hot water in bathrooms. The shower room had an uncovered drain, missing tiles, and exposed wood, while residents reported consistently cold water in their bathrooms. Staff acknowledged these issues, which were confirmed by temperature measurements and resident feedback.
The facility failed to maintain safe water temperatures and ensure call light accessibility. Hot water in resident areas exceeded the policy limit, and a resident at high fall risk had an unreachable call light. The Maintenance Director did not conduct additional checks or contact another plumber after identifying the issue. Staff confirmed call lights should be within reach, highlighting a lack of supervision and safety measures.
The facility failed to assess and authorize two residents to self-administer medications. One resident was found with lidocaine patches and an inhaler without proper orders, while another resident used an inhaler for shortness of breath without authorization. The facility's policy requires an assessment, physician's order, and care plan for self-administration, which were not completed for these residents.
A cognitively impaired female resident with autistic disorder and Down syndrome was observed wearing a restraint vest without a physician's order or a completed restraint assessment since admission. Staff provided conflicting accounts of the resident's ability to remove the harness, and the Director of Nursing confirmed the lack of assessment. The facility did not provide a restraint policy during the survey.
A facility failed to include necessary interventions for a chest harness restraint in a resident's care plan. The resident was observed using the harness multiple times, but no assessment had been completed since admission. The DON acknowledged the need for a restraint in the care plan, yet it was missing.
A facility failed to trim the nails of a resident with a hand contracture, resulting in indentations in the resident's palm. Despite the resident not refusing hygiene assistance, the nails remained untrimmed over consecutive days. Staff acknowledged the need for nail trimming, which is usually done during showers, but the facility's policy on grooming was not followed.
A resident with a history of lower extremity edema and congestive heart failure did not have elastic bandages applied as required by physician orders and care plan. Observations showed the resident without the bandages on multiple occasions, and staff interviews revealed a lack of awareness and adherence to the care plan. The resident's condition necessitates the use of these bandages to manage edema and circulation.
A facility failed to include a stop date in a psychotropic medication order for a resident with generalized anxiety disorder. The order for Lorazepam Oral Concentrate did not specify a duration, contrary to the facility's policy requiring PRN orders to be limited to 14 days. This was confirmed by the administrator.
The facility failed to assess and offer pneumococcal immunizations to two residents upon admission. The Director of Nursing acknowledged that the admitting nurse is responsible for screening and administering vaccines, but this process was not followed. The facility's policy requires assessment and offering of the vaccine upon admission, which was not adhered to.
The facility did not post daily staffing information for 35 residents as required. Staffing details were kept in a binder at the nurse's station, but not displayed near the front door for visitors. The CNA Supervisor was unaware of the requirement to visibly post staffing information.
The facility failed to test its water system for Legionella and did not prevent water from becoming sedentary in an unoccupied area. Maintenance staff were unsure if a water system assessment had been conducted, and there was no evidence of Legionella testing. Observations revealed a therapeutic bathtub with a continual slow drip and a long brown stain, and the facility's policies and procedures for Legionella management were not followed.
The facility failed to have a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The DON, who was identified as the IP, did not have the required certification. The Administrator acknowledged the requirement and mentioned that the DON was in the process of obtaining certification but was not currently certified. The facility's job description for the IP role specified that the individual must have completed specialty training in infection prevention and control through accredited continuing education such as the CDC or APIC.
The facility failed to update a resident's advanced directives as requested. Despite the resident opting to become a DNAR and signing the POLST form, the form lacked necessary signatures and was not processed correctly, leaving the resident still considered a full code.
The facility failed to ensure a resident received necessary post-amputation care, including follow-up with her surgeon, obtaining a properly fitted shrinker, and assisting in the process to obtain a prosthetic leg. The resident reported significant delays and improper fittings, and staff were unaware of the specific orders for her care.
The facility failed to implement pressure ulcer interventions and identify pressure injuries before they progressed to stage 2 for two residents. One resident's stage 2 pressure wound was not identified until it had been present for more than four days, and another resident was observed without a pressure-relieving device despite having a stage 2 pressure wound and orders for a pressure relief cushion.
The facility failed to ensure proper catheter care for a resident, leading to deficiencies such as improper cleaning techniques and incorrect placement of the catheter drainage bag. The CNAs involved were unaware of the correct procedures, and the resident's care plan lacked specific interventions to prevent these issues.
Failure to Notify Ombudsman of Resident Discharge After Involuntary Discharge Notice
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the ombudsman of a resident’s discharge following an involuntary discharge notice for non-payment. The resident was admitted on an unspecified date and was documented as cognitively intact on a 3/3/26 assessment, with independence in self-care (with supervision) and mobility. On 2/13/26, the Administrator issued the resident an involuntary discharge notice due to non-payment, with a planned discharge date of 3/16/26. The ombudsman reported that she was actively working with the resident on the involuntary discharge case, including filing an appeal and arranging a hearing, and had obtained representation for the resident and notified the facility of these actions. Despite the pending appeal and scheduled hearing, the resident discharged to home on 3/11/26, which the Administrator stated was the resident’s choice. The ombudsman stated that she learned of the discharge from an APS care worker’s message and that, as of 3/19/26, the facility had not sent any discharge notification to her office. The Administrator acknowledged that either she or social services should have notified the ombudsman of the resident’s discharge and confirmed, after reviewing email communications, that no such notification had been sent. This failure occurred despite the facility’s transfer and discharge policy dated 10/13/25, which requires that notice of transfer or discharge, including any updated information, be provided to the resident, the resident’s representative if appropriate, and the ombudsman as soon as practicable, and that the facility maintain evidence that the notice was sent to the ombudsman.
Failure to Safely Transfer Residents and Use Required Gait Belts
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer residents in accordance with assessed needs and established procedures, resulting in resident injuries. One resident with severe anxiety, fear of falling, and a documented need for two-person assistance for transfers and standing was transferred by a single CNA who was unfamiliar with the resident’s transfer status. During a wheelchair-to-bed transfer, the CNA attempted to stand the resident, who became frantic and panicked. The CNA, feeling anxious, hurried to complete the transfer instead of stopping to seek additional help or allowing the resident time to calm down. The resident’s leg likely became caught on the wheelchair leg during this process, causing a large skin laceration that required emergent hospital evaluation and repair with nine sutures. Another resident with impaired cognition, right-sided paralysis from a prior stroke, nonverbal status, and a history of falls had a care plan requiring use of a gait belt and one-person assistance for transfers, standing, and ambulation. While assisting this resident from the toilet, a CNA did not use a gait belt as required. After helping the resident to stand, the CNA turned away to remove gloves and wash hands, leaving the resident unsupported. During this time, the resident fell and struck her head on the sink, later complaining of right leg pain and requiring emergent hospital evaluation. The facility’s policy required the use of gait belts for residents who could not independently ambulate or transfer, and restorative staff confirmed that a gait belt was to be used for this resident.
Failure to Honor Resident’s Documented DNR Status
Penalty
Summary
The deficiency involves the facility’s failure to honor and implement a resident’s documented DNR (do not resuscitate) status as indicated on a valid POLST (Physician Orders for Life-Sustaining Treatment) form. The resident was admitted from a hospital with discharge orders clearly indicating DNR status, and a POLST form dated later in the month also documented the resident as DNR. The resident’s healthcare POA was identified in a POA document, and the POA stated that the facility had a signed POLST form but reported being told by facility staff that they could not honor it until the facility’s medical director signed off on the DNR. Despite these existing documents, a physician order entered shortly after admission listed the resident as Full Code. The admission care plan documented that the resident was cognitively impaired but did not include any information related to advance directives. The facility’s DON confirmed that if a resident has a POLST form signed by a physician, the facility is supposed to honor it and that the medical director’s additional signature is not required for validity. Upon reviewing the POLST, hospital discharge orders, and current admission orders, the DON acknowledged not knowing why the resident was listed as Full Code and stated the resident should be DNR. The facility’s own policy on Residents’ Rights Regarding Treatment and Advance Directives states that upon admission, existing advance directives are to be copied, placed in the chart, documented in the medical record, and communicated to staff, but this was not carried out for this resident’s DNR status.
Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and toileting assistance to residents who were cognitively impaired and dependent on staff for these activities of daily living. One resident’s assessment showed cognitive impairment and dependence on staff for toileting and incontinence care. A private caregiver reported that staff did not toilet or change this resident’s brief unless prompted and that the resident would sit in the same brief for hours. On the survey day, the resident’s brief was last changed around 7:00 AM before being dressed and taken to breakfast. The resident remained in common areas and then in her room for several hours, during which time the private caregiver stated no staff offered toileting or incontinence care. When the resident was finally transferred to bed at 12:37 PM, staff confirmed the brief had not been changed since 7:00 AM, the resident was incontinent of urine, and her buttocks were red. Another resident’s assessment showed severe cognitive impairment, dependence on staff for toileting and incontinence care, and incontinence of stool and urine. The resident’s care plan directed staff to check the resident every two hours and assist with toileting as needed. On the survey day, the resident was observed seated in a wheelchair with an odor of stool in the room. A CNA stated the resident’s brief had last been changed by night staff sometime before 5:00 AM and that the resident was already up and dressed at the start of the CNA’s shift. When CNAs transferred the resident to bed and removed the brief, the resident was found incontinent of a large amount of liquid stool, and the buttocks appeared bright pink. The DON later stated that residents requiring assistance with toileting and/or incontinence care are to receive such care every two hours and as needed, and the facility’s incontinence policy indicated that all incontinent residents will receive appropriate treatment and services based on their comprehensive assessment.
Failure to Provide and Accurately Document Daily Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide daily wound treatments and dressing changes as ordered for a resident who sustained a left lower leg laceration requiring nine sutures after being injured during a transfer by facility staff. Hospital discharge instructions and a physician order dated 2/7/26 directed staff to cleanse the wound on the left lower extremity with wound cleanser and cover it with xeroform, maxorb, an abdominal pad, and kerlix dressing every day shift. Review of the February 2026 Treatment Administration Record (TAR) showed no documentation that wound treatments or dressing changes were provided on 2/11/26 or 2/12/26. The resident’s private caregiver reported that on those two days the dressing was not changed at all and stated that she had to ask staff every day to change the dressing. On subsequent observation, the resident was seen with a gauze dressing on the left lower leg that had no date and later appeared dirty with a moderate amount of yellow drainage, with the caregiver stating that no dressing change had been done the previous day. Review of the TAR on 2/24/26 showed no wound treatment or dressing change documented for 2/23/26. New entries had been added to the TAR indicating that the DON had provided wound care on 2/11/26 and 2/12/26, but in interview the DON admitted she had not performed the wound care on those dates and had entered her initials the previous night because she was told by corporate to never leave charting blank. The facility’s Wound Treatment Management policy required that wound treatments be provided in accordance with physician orders, including cleansing method, type of dressing, and frequency of dressing change.
Failure to Administer Insulin, Reglan, and Blood Glucose Monitoring at Ordered Times
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of pharmaceutical services related to medication and blood glucose administration for one resident with diabetes mellitus. The resident’s admission record documented a diagnosis of diabetes and physician orders for blood glucose (Accu-check) monitoring before meals and at bedtime, specifically at 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM. The resident also had orders for Humulin R insulin, 3 units SQ with meals at 7:30 AM, 12:00 PM, and 5:30 PM, and Reglan 10 mg to be given before meals at 6:30 AM, 11:30 AM, and 4:30 PM. The resident’s POA reported that staff were not checking the resident’s blood glucose levels as ordered and were administering medications late. On the morning observed, the resident was seated in the dining room with breakfast and had already consumed approximately 25% of the meal and stated to staff that he was done eating. At 8:33 AM, an LPN checked the resident’s blood glucose after he had eaten, obtaining a reading of 256, and then administered 3 units of Humulin R at 8:39 AM, more than two hours after the ordered 7:30 AM administration time. At 8:56 AM, the LPN administered 10 mg of Reglan, also more than two hours late and after the resident had eaten, contrary to the order for administration before meals. The DON confirmed that medications are to be given at the scheduled time per physician order, that medication is considered late if given more than one hour past the scheduled time, and that blood sugars are to be checked prior to eating. Facility policies on blood glucose monitoring, timely administration of insulin, and medication administration all required adherence to physician orders and correct timing, which was not followed in this case.
Failure to Document and Implement Discharge Planning in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a discharge planning process and include this process in the electronic medical record and comprehensive care plan for two of three residents reviewed for discharge planning. One resident expressed uncertainty about his discharge date and reported not being informed about his discharge plans, aside from being told he would be discharged. Staff interviews revealed that discharge planning was not documented in the electronic medical record or care plan, and communication about discharges was primarily through dashboard alerts. The care plan for this resident did not include any discharge planning, and there were no physician orders for discharge at the time of review. The facility's policy requires that the comprehensive, person-centered care plan contain the resident's goals for admission and desired outcomes aligned with discharge, with supporting documentation of the resident's intent to leave and documented discussions, which was not present in this case. Another resident also did not have a discharge plan documented in her care plan, despite her goal to return to the community being noted in the Minimum Data Set. She was unaware of her discharge plan and only knew she would be receiving cancer treatment. The care plan lacked any information related to discharge, and staff confirmed that a discharge plan should have been in place. Both residents had complex medical histories, including chronic conditions and recent treatments, but the required discharge planning and documentation were not completed as per facility policy.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement necessary interventions and treatments for pressure injuries for two residents, leading to a deficiency in care. Resident R33 was found with a deflated air mattress and without heel protection boots, which are essential for pressure relief. The air mattress was turned off, and the heel boots were not in use, contrary to the care plan. The Director of Nursing (V2) was unaware of the pressure injury until it was reported on 2/27/25, although it was initially noted on 2/17/25. The wound physician (V6) confirmed the injury as a stage 3 pressure injury, indicating it had been present for more than three days without appropriate treatment or pressure-relieving interventions. Resident R21 also experienced a lapse in care, as her stage 2 pressure wound progressed to a stage 3 wound without documented treatment. The Treatment Administration Record for January 2025 did not show any scheduled treatment for her pressure ulcer, and there were no orders for wound treatment from 1/23/25 to 2/5/25. The Director of Nursing (V2) acknowledged the oversight, noting that treatment orders were not entered into the system until the day after the wound physician's rounds. The facility's failure to adhere to its Assessment of Skin Alteration Policy, which mandates assessment and treatment of skin alterations as ordered by a physician, contributed to the worsening of pressure injuries for both residents. The lack of timely intervention and communication among staff members resulted in inadequate care and management of the residents' pressure injuries.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the condition of the resident shower room and the lack of hot water in resident bathrooms. Observations revealed that the shower room had an uncovered drain, missing tiles, exposed wood framing, and tiles held in place with duct tape. A Certified Nursing Assistant reported that a wheelchair wheel got stuck in the drain, and a resident who had been at the facility for nine years expressed ongoing dissatisfaction with the shower room's condition. The facility's administrator acknowledged awareness of the issues, and the Resident Council Minutes from June 2024 indicated that updates to the shower room were needed. Additionally, the facility failed to provide hot water in resident bathrooms, with temperatures recorded significantly below acceptable levels. Residents reported that the water never got warm, even after running for extended periods. A staff member indicated that the north wing had issues with hot water, possibly due to a lack of a return circuit. Temperature measurements taken during the investigation confirmed that the hot water in several residents' bathrooms was consistently below 61 degrees Fahrenheit, failing to meet the residents' rights to a safe and comfortable environment.
Deficiencies in Water Temperature Monitoring and Call Light Accessibility
Penalty
Summary
The facility failed to ensure that water temperatures in resident care areas were monitored and maintained within safe limits, as well as failed to ensure a resident's call light was within reach. Observations revealed that the hot water temperature in a shared resident bathroom was measured at 121.5 degrees Fahrenheit, exceeding the facility's policy limit of 110 degrees Fahrenheit. The Maintenance Director, V9, acknowledged the high temperatures and stated that the hot water heater was turned down to 125 degrees Fahrenheit a week prior, but no further action was taken to address the issue. Despite identifying the problem, V9 did not conduct additional water temperature checks beyond the regular Friday rounds, nor did he contact another plumber after the initial one was unavailable. Additionally, a resident identified as R4, who was at high risk for falls due to dementia and required assistance with personal care, was found with her call light coiled and out of reach on the floor. This was contrary to the facility's Call Light Policy, which mandates that call lights be within reach and secured as needed. The Director of Nursing and a Certified Nursing Assistant confirmed that call lights should be accessible to residents. These deficiencies indicate a lack of adequate supervision and environmental safety measures to prevent accidents and ensure resident safety.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to assess, care plan, and obtain physician orders for two residents to self-administer medications. Resident 27, who is [AGE] years old, was found with a box of lidocaine patches and an inhaler in her bedside stand, which she used for pain and respiratory issues, respectively. Despite having an order for the lidocaine patch, there was no order for her to self-administer any medications. The Director of Nursing confirmed that no residents had orders or assessments to self-administer medications, and the facility could not provide a medication self-administration assessment for Resident 27. Similarly, Resident 22, a [AGE] year old cognitively intact resident with chronic obstructive pulmonary disease and congestive heart failure, was observed with an inhaler on her bedside table, which she used as needed for shortness of breath. Her physician order sheet included an order for an Albuterol Sulfate inhaler but did not authorize self-administration. The facility's policy requires an assessment, physician's order, and care plan for residents to self-administer medications, none of which were completed for Resident 22.
Failure to Assess Resident for Restraint Use
Penalty
Summary
The facility failed to ensure a resident was properly assessed for the use of a physical restraint. A cognitively impaired female resident with diagnoses of autistic disorder and Down syndrome was observed wearing a restraint vest while seated in a wheelchair near the nurse's station. The vest was secured with straps and clips, but there was no physician order for its use, nor was there a restraint assessment completed since the resident's admission. Staff members provided conflicting accounts of the resident's ability to remove the harness independently, with one CNA stating the resident could move the top straps over her head, while another CNA indicated that staff were responsible for undoing the harness. The Director of Nursing confirmed that no restraint assessment had been conducted since the resident's admission. The facility did not provide a restraint policy during the survey.
Failure to Include Restraint in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for a resident included necessary interventions for a chest harness restraint. This deficiency was identified during a survey where the resident was observed wearing a restraint harness while in her wheelchair on multiple occasions. Despite the use of the harness, the resident's medical record showed no assessment had been completed since her admission. Additionally, the Director of Nursing acknowledged that a restraint should be included in a resident's care plan, yet the current care plan for the resident lacked any focus area or interventions related to the restraint.
Failure to Trim Nails for Resident with Hand Contracture
Penalty
Summary
The facility failed to ensure proper grooming for a resident with a hand contracture, leading to a deficiency in providing activities of daily living (ADL) assistance. The resident, a male with a history of stroke affecting his left side, was observed with fingernails approximately 1/4 inch long, causing indentations in his palm due to the contracture. Despite the resident not refusing hygiene assistance, his nails remained untrimmed over consecutive days. A Certified Nursing Assistant and a Certified Nursing Supervisor both acknowledged the need for nail trimming, which is typically performed during a resident's shower. The resident's care plan indicated a need for ADL assistance, but the facility's policy on providing resident care, including grooming, was not adequately followed.
Failure to Apply Elastic Bandages for Resident with Edema
Penalty
Summary
The facility failed to ensure that elastic bandages, known as tubi grips, were applied to a resident with a history of lower extremity edema. This deficiency was observed in one of the twelve residents reviewed for quality of care. On multiple occasions, the resident was seen in the activity room without the required elastic wraps on her legs, despite having physician orders to wear them daily from her toes to her knees. The resident's care plan also specified the need for these bandages to manage her condition, which includes congestive heart failure and a history of cellulitis. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan. A CNA assigned to the resident admitted to not applying the elastic bandages, stating she was unaware of the requirement. A Licensed Practical Nurse confirmed that the resident was supposed to wear the bandages to aid circulation and prevent edema. The Director of Nursing acknowledged the resident's history of edema and cellulitis, emphasizing the importance of the bandages in managing her condition, especially since the resident prefers to remain active and upright.
Failure to Include Duration in Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that psychotropic medication orders included a duration for one of the six residents reviewed for psychotropic medications. Specifically, a resident with a diagnosis of generalized anxiety disorder had a physician's order for Lorazepam Oral Concentrate 2 MG/ML to be administered 0.25 ml by mouth every 2 hours as needed for anxiety. This order, dated 1/13/25, did not include a stop date or duration, which is a requirement according to the facility's policy. The policy, dated 3/2025, mandates that PRN orders for psychotropic medications, excluding antipsychotics, should be limited to no more than 14 days. This oversight was confirmed during an interview with the facility's administrator, who acknowledged that all psychotropic as-needed medications should have a stop date.
Failure to Assess and Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that residents were assessed and offered pneumococcal immunizations upon admission, as evidenced by the cases of two residents. Resident 15's admission record indicated no historical or current record of having had or being offered a pneumococcal immunization. Similarly, Resident 21's records showed no evidence of being assessed or offered the vaccine. The Director of Nursing/Infection Prevention Nurse acknowledged that the admitting nurse is responsible for screening residents for vaccination status and administering vaccines, but noted that the previous Director of Nursing failed to ensure this process was followed. The facility's policy, reviewed in January 2025, mandates that each resident be assessed for pneumococcal immunization upon admission and offered the vaccine, which was not adhered to in these cases.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post the daily staffing information for all 35 residents reviewed for staffing. During the survey conducted from March 3 to March 5, 2025, it was observed that there were no staffing postings near the front door on the entry table or bulletin boards. The facility's Long Term Care Facility Application for Medicare and Medicaid indicated a resident census of 35. On March 5, 2025, at 1:25 PM, the Certified Nursing Assistant (CNA) Supervisor stated that staffing information was kept in a binder at the nurse's station, which included monthly and daily schedules for nursing and CNA staff. The CNA Supervisor admitted that staffing was not posted near the front door for visitors to see and was unaware that it needed to be visibly posted.
Failure to Test Water System for Legionella and Prevent Water Stagnation
Penalty
Summary
The facility failed to ensure its water system was tested for Legionella and did not prevent water from becoming sedentary in an unoccupied area. The maintenance staff admitted to flushing toilets and running water weekly but was unsure if a water system assessment had been conducted to identify potential problem areas conducive to waterborne pathogen growth. There was no evidence of Legionella testing being done, and the Business Office Manager confirmed that the city only tested for chlorine and fluoride, not Legionella. Additionally, there were no logs to show any flushing or water temperature checks were done on the south hall, which had been unoccupied since 2018-2019. Observations revealed a large therapeutic bathtub with a lift system in a common bathroom near the north nurse's station, which had a continual slow dripping of water and a long brown stained area. Staff were observed toileting residents in the room, and the door was wide open when not in use. The south end of the facility, which was unoccupied, also had a large therapeutic soaking tub that was inoperable. Despite this, the maintenance staff confirmed that water did come from the faucet when turned on. The facility's Legionella Environmental Assessment Form and Management Procedure showed no evidence of maintenance, disinfecting, or monitoring of the tubs. The facility's policies and procedures for Legionella management were not followed. The Legionella Environmental Assessment Form completed by a Corporate Administrator inaccurately marked the presence of hot tubs, whirlpool, or hydrotherapy spas as not applicable. The facility's Legionella Management Procedure required staff to be informed of good practices and for approved contractors to undertake surveys and risk assessments, but there was no evidence of such actions being taken. The Illinois Compiled Statutes require facilities to develop a policy for testing water supply for Legionella bacteria, including a risk assessment, water management program, and documentation of results and corrective actions, none of which were evident in the facility's practices.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to have a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The Director of Nursing (DON), who has been at the facility since January 29, 2024, was identified as the IP but did not have the required certification. The facility's application for Medicare and Medicaid indicated there were 28 residents. The Administrator acknowledged the requirement for a certified IP and mentioned that the DON was in the process of obtaining certification but was not currently certified. The facility's job description for the IP role specified that the individual must have completed specialty training in infection prevention and control through accredited continuing education such as the CDC or APIC. The facility's QAPI team roster also identified the DON as the IP.
Failure to Update Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure a resident's advanced directives were updated as requested. Resident R18, who was admitted to the facility on an unspecified date, had a Practitioner Order for Life-Sustaining Treatment (POLST) form dated 12/16/21 indicating he opted to be a full code. However, a new undated POLST form on the front of R18's chart showed he opted to become a Do Not Attempt Resuscitation (DNAR). This new form was signed by R18 but lacked a witness signature and the required signature by a healthcare practitioner. Despite R18 being cognitively intact and having expressed his wishes, the form was not properly processed, leaving him still considered a full code according to the April 2024 Physician Order Sheet (POS). The facility's policy requires that no order for DNAR be effective until the POLST form is signed by both the resident and the physician, which was not adhered to in this case. Interviews with staff revealed that the form had not been sent to the physician for signature, as confirmed by the Registered Nurse (RN) and the Director of Nursing (DON). The DON stated that the procedure on admission involves having residents fill out and sign the POLST form, which should then be sent out for the physician's signature. The failure to follow this procedure resulted in the resident's advanced directives not being updated as requested, thereby not honoring the resident's right to refuse treatment as per his wishes.
Failure to Provide Necessary Post-Amputation Care
Penalty
Summary
The facility failed to ensure a resident received necessary treatment and services for her amputated leg, including following up with her surgeon, obtaining a sleeve for her stump, and assisting in the process to prepare and obtain a prosthetic leg. The resident, who had been at the facility for 9 months following a house fire that resulted in numerous injuries including a left above-the-knee amputation, reported that it took 4.5 months to get a shrinker, which was too large and not measured properly. The resident also stated that she never followed up with the surgeon after being transferred to the facility, and the facility did not arrange for the necessary follow-up appointments or fittings for a prosthetic leg as indicated in her hospital discharge documents and physician orders. The Director of Nursing (DON) and Social Services staff were unaware of the orders for the resident's follow-up care and the need for a properly fitted shrinker. The facility's records did not show any follow-up appointments with the surgeon or any fitting of a sleeve for the resident's stump. The DON and Social Services staff acknowledged the importance of having the correct measurements for the shrinker to reduce swelling and prepare for a prosthetic leg but admitted to not being aware of the specific orders or the resident's needs. The facility also lacked a policy for quality of care, post-surgical care, or current standards of practice related to the care of a resident after an amputation, which contributed to the oversight in the resident's care.
Failure to Implement Pressure Ulcer Interventions and Identify Pressure Injuries
Penalty
Summary
The facility failed to ensure pressure injury interventions were in place as ordered and did not identify a pressure injury before it progressed to a stage 2 pressure injury for two residents. One resident, admitted to the facility and documented as being at risk for pressure injuries, had a stage 2 pressure wound to the sacrum that was not identified until it had been present for more than four days. The resident's treatment record did not show any skin checks ordered or completed, and the care plan required weekly skin checks, which were not documented. The RN and DON confirmed that the pressure injury should have been identified earlier and documented in the nursing progress notes. Another resident was observed in a wheelchair without a pressure-relieving device, despite having a stage 2 pressure wound and orders for a pressure relief cushion. The resident's care plan did not include interventions for offloading and repositioning, which were necessary to prevent the wound from worsening. The DON confirmed that the resident should have had a pressure relief cushion to relieve pressure and prevent the wound from getting worse. The facility's policy required additional interventions to be established and noted on the care plan when a pressure ulcer is identified, which was not done in this case.
Deficient Catheter Care Practices
Penalty
Summary
The facility failed to ensure proper catheter care for a resident, leading to several deficiencies. The resident was observed with a catheter drainage bag attached to the lower bed frame and without a secure device for the catheter tubing. During catheter care, a CNA used a wet washcloth to clean the resident's groin and vaginal area, then wiped down the catheter tubing without changing the washcloth, which is against proper infection control practices. Additionally, the catheter drainage bag was placed on the resident's bed during repositioning, which is not allowed for infection control reasons. The CNAs involved were unaware of these requirements. The Director of Nursing confirmed that the catheter drainage bag should not be on the bed and that the washcloth should be folded differently or changed before cleaning the catheter tubing. The resident had a history of multiple medical conditions, including neurogenic bladder and a wound infection requiring antibiotics. The care plan indicated catheter care every shift and weekly changes, but did not include specific interventions to prevent the observed deficiencies. The facility's catheter care policy did not specify the need to use a clean washcloth or turn an existing one before cleaning the tubing, and the catheter insertion policy required securing the catheter to the thigh, which was not done in this case.
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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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