Lakeland Rehab & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Effingham, Illinois.
- Location
- 800 West Temple Street, Effingham, Illinois 62401
- CMS Provider Number
- 145256
- Inspections on file
- 24
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Lakeland Rehab & Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow its standardized recipe and cooking procedures for potato au gratin, resulting in potatoes that were hard and not tender, as reported by multiple cognitively intact residents. A resident with a history of CVA and dysphagia, on a regular diet under AMA, choked in the dining room on a large, hard piece of potato that could not be cut with a fork and required multiple Heimlich maneuvers by an LPN to expel. Documentation showed no recorded food temperatures for the meal, and the Dietary Manager stated the potatoes should have been soft enough to break apart with a fork, indicating the menu and recipe requirements for proper preparation and consistency were not met.
A cognitively impaired resident was subjected to inappropriate sexual touching and comments by another resident in an LTC facility. Despite staff awareness of the situation and the perpetrator's history of inappropriate behavior, the facility failed to implement adequate measures to prevent further incidents. The deficiency highlights a lack of effective enforcement of abuse prevention policies and insufficient intervention to protect vulnerable residents.
A facility failed to report a peer-to-peer sexual abuse incident involving two residents. One resident, with severe cognitive impairment, was inappropriately touched by another resident with a history of inappropriate behavior. Despite observations by an LPN, the incident was not reported to the facility's Abuse Coordinator, and no investigation was initiated, violating the facility's abuse prevention policy.
A facility failed to report and investigate peer-to-peer sexual abuse involving two residents. One resident with severe cognitive impairment was inappropriately touched by another resident with a history of inappropriate behavior. Staff observed and documented the interactions but did not report them as abuse, leading to a lack of immediate investigation and intervention.
A resident under hospice care in an LTC facility did not receive a scheduled dose of morphine due to the medication going missing. The nurse responsible claimed to have locked the medication in the cart after administering the previous dose, but no narcotic count was conducted between shifts. Despite an investigation and interviews with staff, the facility could not determine what happened to the morphine, and the incident remains unresolved.
A resident with diabetes experienced a hypoglycemic event, and an LPN attempted to start an IV without a physician's order. The facility lacked specific protocols for managing low blood sugar, and there was no documentation of further action or glucagon administration.
A facility failed to provide adequate supervision for two residents with dementia, resulting in an inappropriate sexual interaction. Both residents, diagnosed with Alzheimer's and severe cognitive impairment, were found in a compromising situation. The facility lacked specific supervision plans and did not follow its policy on consent, as there was no documentation of discussions or education regarding consent in the residents' records.
A facility failed to reconcile narcotic medication counts, leading to a missing morphine dose for a resident. An LPN did not perform a narcotic count when transferring the medication cart to another nurse. Interviews confirmed that narcotic counts should occur during such transitions, as per facility policy.
A resident with severe cognitive impairment was verbally abused by an RN, who threatened to kick him in the forehead. The incident was witnessed by a CNA and reported to the Director of Nursing, leading to an investigation. The facility substantiated the allegation of verbal abuse based on the CNA's account.
A resident with severe cognitive deficits and multiple diagnoses experienced an infection due to the facility's failure to remove surgical staples and obtain an x-ray as ordered after hip fracture surgery. The discharge instructions were not followed, leading to a delay in care and subsequent infection at the surgical site. The facility lacked policies for surgical wound care and did not communicate effectively with the orthopedic surgeon's office.
The facility failed to provide adequate daily denture and oral hygiene care for four residents, leading to grievances and reports of unclean dentures. Residents with cognitive and physical impairments were not consistently assisted with oral care, and the facility lacked a formal policy and documentation system for tracking care. Interviews with CNAs revealed inconsistencies in care routines, contributing to the deficiency.
A resident experienced frustration, embarrassment, and neck pain due to prolonged wait times for toileting assistance, with staff confirming delays were due to high demand from heavy care residents.
The facility failed to respond to resident call lights in a timely manner, with residents reporting wait times ranging from 15 minutes to 2 hours. Staff attributed the delays to the high care needs of residents, particularly on the 200 hall. Despite attempts to address the issue, the problem persisted, leading to significant delays in care.
The facility failed to notify resident representatives in writing of hospital transfers for two residents with cognitive impairments. The administrator confirmed that while phone calls are made to the family or POA, written documentation regarding the transport, reasons, and bed hold policy is not provided.
The facility failed to notify resident representatives in writing of the bed hold policy during resident transfer for two residents with cognitive impairments. The administrator confirmed that only phone calls were made to the family or POA, without providing written documentation regarding the reasons for transport and the bed hold policy.
The facility failed to revise a care plan to include antibiotics ordered for a UTI for a resident with multiple diagnoses. Despite a urine culture indicating a bacterial infection and a subsequent prescription for Bactrim, the care plan did not document the antibiotic treatment. The Regional Nurse confirmed the expectation to include all medications in care plans, and it was noted that the facility lacks a specific care plan policy.
The facility failed to ensure that as-needed psychotropic medications were ordered for a specific duration for two residents. Both residents had orders for Lorazepam without a specified duration, contrary to the facility's policy requiring PRN psychotropic medications to be limited to 14 days unless otherwise specified by a physician.
The facility failed to protect two residents from abuse. One resident with severe cognitive impairment had clothing placed over his mouth by a CNA to quiet him, while another resident was pushed by a fellow resident, causing her to fall. Both incidents were reported and investigated, leading to the termination of the abusive staff member and the removal of the aggressive resident.
The facility failed to provide a resident with written notification of discharge, including the reason and appeal rights, after the resident exhibited aggressive behavior. The family was only verbally informed, and no emergency discharge paperwork was completed, violating the facility's policy and regulatory requirements.
Improper Preparation of Potato Au Gratin Leading to Choking Incident
Penalty
Summary
The deficiency involves the facility’s failure to prepare potato au gratin according to the standardized recipe and to ensure the potatoes were cooked to a tender consistency before service. The facility’s Fall/Winter menu listed potato au gratin for the dinner meal, and the kitchen production report for that meal contained no documented temperatures to verify that the food items were cooked thoroughly. The facility’s standardized recipe for potato au gratin required potatoes to be peeled, sliced, boiled or steamed until softened, then baked until tender and soft enough to break apart with a fork. The Dietary Manager stated that the potatoes should be soft after baking and easily broken with a fork, but acknowledged that the cook responsible for the meal left the facility and did not participate in an interview. One resident with cerebrovascular disease, aphasia, dysphagia, and hemiplegia had a care plan identifying swallowing problems and interventions such as staff education on special dietary and safety needs, upright positioning, slow eating, and thorough chewing. This resident had a physician order for a regular diet under an AMA agreement despite the dysphagia. On the evening in question, the resident choked while eating potato au gratin in the main dining room. Nursing documentation described the resident turning blue, having difficulty breathing with no notable breaths, and requiring multiple abdominal thrusts (Heimlich maneuver) before expelling a large, hard piece of potato that could not be cut with a fork. A subsequent health status note recorded that the resident declined hospital transfer and that a STAT chest X-ray was ordered. Two other cognitively intact residents reported that the potatoes served at that meal were hard and not tender. One resident stated the potatoes were “hard like they were still raw” and reported this to staff but said nothing was done to correct the issue. Another resident, who had a care plan for nutritional risk and monitoring for dysphagia signs, stated she was present when the choking incident occurred and observed the affected resident place a large piece of potato in his mouth. She reported that the potatoes were “not so good” and “not tender,” and commented that sometimes the food is cooked well and sometimes it is not. These resident interviews, combined with the lack of documented cooking temperatures and the description of the expelled potato piece as hard and not cuttable with a fork, demonstrate that the potatoes were not prepared and cooked according to the facility’s standardized recipe and menu requirements.
Failure to Prevent Peer-to-Peer Sexual Abuse
Penalty
Summary
The facility failed to prevent peer-to-peer sexual abuse involving a cognitively impaired resident, R1, who was unable to give informed consent. R1, diagnosed with Alzheimer's Disease and severe cognitive impairment, was subjected to inappropriate sexual touching and unsolicited sexual comments by another resident, R2. R2, who is cognitively intact but exhibits variable cognitive function and confusion, was observed engaging in inappropriate behavior towards R1 on multiple occasions, including touching R1's leg and breast without consent. Staff members, including a Licensed Practical Nurse and Certified Nursing Assistants, witnessed and reported R2's inappropriate actions towards R1. Despite being aware of R2's history of sexually inappropriate behavior towards staff, the facility did not implement adequate measures to prevent R2 from seeking out and interacting with R1. The facility's response to the incidents was insufficient, as R2 continued to have access to R1 and other female residents, raising concerns about the safety and well-being of residents. The facility's policies on abuse prevention and resident consent were not effectively enforced, leading to a failure in protecting R1 from abuse. The staff's actions, such as separating the residents and monitoring R2, were reactive rather than proactive, allowing the inappropriate behavior to persist. The facility's lack of timely and effective intervention contributed to the deficiency, as R1 was repeatedly exposed to unwanted and inappropriate interactions with R2.
Failure to Report Peer-to-Peer Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of peer-to-peer sexual abuse involving two residents, R1 and R2, to the facility Administrator or designated representative. R1, who has severe cognitive impairment due to Alzheimer's Disease, was involved in an incident with R2, who is cognitively intact but has a history of inappropriate sexual behavior. On a specific date, R2 was observed by a Licensed Practical Nurse (LPN) engaging in inappropriate touching of R1 in a common area and later in a dining area. Despite these observations, the interactions were not reported to the facility's Abuse Coordinator, and no abuse investigation was initiated. R1's care plan documented a behavior problem related to a resident-to-resident touching incident, and interventions were put in place, such as changing R1's room and implementing 15-minute checks. R2's care plan also noted a problem area regarding inappropriate sexual behavior, with interventions to ensure the safety of others and to separate R2 from the environment when necessary. However, the LPN who observed the incidents did not perceive them as sexual abuse and only reported them to the Director of Nurses or Assistant Director of Nurses, who were the Weekend Managers on Duty, rather than directly to the Administrator. The facility's policy requires immediate reporting of any abuse or neglect to the Administrator, who is the designated Abuse Coordinator. The Administrator confirmed that she was not made aware of the interactions between R1 and R2, and no investigation was conducted. The Assistant Director of Nurses recalled being informed of R2's behavior but did not consider it to be progressing into sexual abuse, despite R2's history of inappropriate behavior with staff. This lack of reporting and investigation constitutes a deficiency in the facility's handling of abuse prevention and response.
Failure to Report and Investigate Peer-to-Peer Sexual Abuse
Penalty
Summary
The facility failed to report, investigate, and prevent further peer-to-peer sexual abuse involving two residents. One resident, with severe cognitive impairment due to Alzheimer's Disease, was involved in inappropriate interactions with another resident who was cognitively intact but had a history of inappropriate sexual behavior. The interactions included the cognitively intact resident touching the impaired resident's leg and arm, and later, more inappropriate touching occurred, which was not immediately reported to the facility's Abuse Coordinator. The nursing staff, including an LPN, observed and documented these interactions but did not classify them as sexual abuse, leading to a lack of immediate reporting and investigation. The facility's Assistant Director of Nurses was informed of the interactions but did not perceive them as potentially escalating to sexual abuse, given the history of the resident's behavior. The Director of Nurses was not informed of the ongoing interactions until a more severe incident occurred, and the facility's Abuse Coordinator was not notified at all until much later. The facility's policy required immediate reporting of abuse to the Administrator, who is also the Abuse Coordinator, but this protocol was not followed. The lack of immediate action and investigation allowed the inappropriate behavior to continue without adequate intervention, highlighting a significant deficiency in the facility's abuse prevention and reporting procedures.
Misappropriation of Morphine in LTC Facility
Penalty
Summary
The facility failed to protect a resident from the misappropriation of a controlled substance, specifically morphine, which was intended for pain management. The incident involved a resident who was under hospice care and had a prescription for Morphine Sulfate to be administered every two hours. On the day of the incident, the resident received the 8 am dose, but when the nurse attempted to administer the 10 am dose, the morphine bottle was missing from the medication cart. Despite a thorough search of the facility and grounds, the medication was not located. The investigation revealed that the nurse responsible for administering the medication, identified as V4, claimed to have followed standard procedures by placing the morphine back in the cart and locking it after the 8 am dose. However, there was no narcotic count conducted between shifts, which could have verified the presence of the medication. Interviews with staff, including the night shift nurse V11, indicated that the medication cart was in front of the nurse's station, but no one observed the morphine being misplaced or taken. V4 was the only staff member suspended and investigated, although he denied taking the medication and passed a drug test. The facility's policy on abuse prevention and prohibition was referenced, highlighting the prohibition of misappropriation of resident property. Despite the investigation, the facility was unable to determine the fate of the missing morphine, and the incident remains unresolved. The resident involved had multiple health conditions, including chronic pain, and was being assessed for pain management during the investigation.
Unauthorized Medical Treatment Without Physician's Order
Penalty
Summary
The facility failed to prevent a resident from receiving medical treatment without a doctor's order. A resident, who was admitted with diagnoses including type II diabetes mellitus with hypoglycemia, had an order for ACCUCHECK every two hours due to hypoglycemia. On a specific date, the resident's blood sugar was recorded at a hypoglycemic level of 46, but there was no documentation of further action or administration of glucagon, which was ordered for low blood sugar. Additionally, an LPN attempted to start an IV on the resident without a physician's order, which was not successful, and no medications were administered. The Director of Nursing (DON) confirmed that the LPN had spoken with a nurse at the doctor's office about the resident's condition, but no standing order for IV dextrose was given. The facility lacked a specific policy or protocol for managing low blood sugars, and the resident did not have standing orders for such situations. The incident was documented as a failure to follow departmental policies and procedures, with no order obtained from a physician prior to initiating a medical procedure or medication.
Inadequate Supervision Leads to Inappropriate Resident Interaction
Penalty
Summary
The facility failed to provide adequate supervision for residents with dementia, leading to an incident involving inappropriate sexual behavior between two residents, identified as R3 and R4. Both residents were found in a compromising situation, with R4 having his pants down and R3 providing oral sex. The incident was witnessed by a housekeeper, and both residents were immediately separated. R3 believed R4 was her husband, while R4 did not recognize R3, indicating a lack of cognitive ability to consent to the interaction. R4's medical records show a diagnosis of Alzheimer's disease and a severely impaired cognitive status, with a Brief Interview for Mental Status (BIMS) score of 3. His care plan included a focus on inappropriate sexual behavior, but there was no specific supervision plan in place. R4 had a history of wandering into female residents' rooms and displaying inappropriate sexual conduct, yet the facility did not have a clear protocol for monitoring his behavior or ensuring his safety and the safety of others. Similarly, R3 was diagnosed with Alzheimer's and dementia, with a BIMS score of 7, indicating severe cognitive impairment. Her care plan also addressed inappropriate sexual behavior, but like R4, there was no documentation of discussions or education regarding consent. The facility's policy on abuse prevention and resident capacity to consent was not followed, as there was no evidence of one-on-one discussions or consent documentation in the clinical records of R3 and R4.
Failure to Reconcile Narcotic Medication Counts
Penalty
Summary
The facility failed to consistently and accurately reconcile narcotic medication counts in accordance with professional standards of practice for a resident. The incident involved a resident who was supposed to receive a dose of morphine at 10 am, but the medication could not be located. An investigation was initiated following the discovery of the missing narcotic. Interviews with staff revealed that the narcotic count was not performed when the responsibility of the medication cart was transferred between nurses. Specifically, an LPN who stayed over from the midnight shift did not count the narcotics with the oncoming nurse, as she was still using the cart to pass medications. The keys for the cart were handed over without performing a count. Further interviews with other nursing staff, including another LPN and an RN, confirmed that narcotic counts should be conducted whenever a nurse assumes responsibility for a medication cart. The Director of Nursing also stated that narcotics should be counted any time a nurse takes over responsibility for the cart and before anyone leaves. The facility's controlled substance policy requires that all controlled substances be counted every shift, with the oncoming and off-going licensed nurses signing to verify the inventory. Employee corrective action forms for the involved LPNs documented their failure to follow departmental policies and procedures regarding narcotic counts.
Verbal Abuse Incident Involving RN and Resident
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a registered nurse (RN) and a resident. The RN, identified as V21, verbally abused a resident, R3, by telling him to go away and threatening to kick him in the forehead. This incident was reported by a certified nursing assistant (CNA), V4, who witnessed the exchange at the nurse's station. The CNA described the RN's demeanor as aggressive and threatening, which she perceived as abusive. The incident occurred when R3, who has severe cognitive impairment and a history of heart disease, dementia, and anxiety disorder, approached the nurse's station and asked about small motors. The RN, V21, responded in a dismissive and threatening manner, which was reported to the Director of Nursing and led to an investigation. Despite R3 not recalling the incident due to his cognitive condition, the facility substantiated the allegation of verbal abuse based on the CNA's account. The facility's policy on abuse prevention and prohibition emphasizes the right of residents to be free from abuse, including verbal abuse. The RN involved in the incident was immediately suspended, and the facility notified relevant authorities and initiated an investigation. The facility's failure to protect R3 from verbal abuse by a staff member constitutes a deficiency in maintaining a safe and respectful environment for residents.
Failure to Follow Post-Surgical Care Orders
Penalty
Summary
The facility failed to remove surgical staples and obtain an x-ray as ordered for a resident who had been readmitted after a hip fracture surgery. The resident, who had severe cognitive deficits and multiple diagnoses including congestive heart failure and chronic kidney disease, was supposed to have the staples removed and an x-ray done on a specific date as per the discharge instructions from the hospital. However, the facility did not remove the staples on the scheduled date, and the x-ray was delayed due to issues with the portable x-ray provider. The nursing progress notes indicated that the resident experienced severe pain in the right hip and leg, which led to an emergency room visit where a hip fracture was diagnosed. After readmission to the facility, the discharge instructions were not followed correctly. The x-ray was delayed, and the staples were not removed until much later, which resulted in the surgical site becoming infected. The infection was identified when a wound care nurse assessed the incision, which was red, warm, swollen, and had purulent drainage. The Director of Nurses and other staff members were not familiar with the resident's care and did not clarify the discharge orders or report the delay in obtaining the x-ray to the orthopedic surgeon. The facility lacked policies for surgical wound care and following physician's orders, which contributed to the oversight. The orthopedic surgeon's office confirmed that the staples should have been removed and the x-ray obtained on the specified date, and the failure to do so led to the infection at the staple sites.
Inadequate Denture and Oral Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate daily denture and oral hygiene care for four residents, as evidenced by interviews and record reviews. Resident 1, who has severe cognitive deficits and requires moderate assistance, was reported by a family member to have dentures that were yellow, odorous, and covered with food particles. Resident 7, with minimal cognitive deficits and range of motion impairment, stated that staff do not offer or remind her to clean her dentures, and assistance is only provided upon request. Resident 5, who also has minimal cognitive deficits, reported losing her dentures two weeks prior and stated that staff only assist with oral care when CNA students are present. Resident 6, with severe cognitive deficits and restricted range of motion, had a grievance filed by her power of attorney due to inadequate denture care, as evidenced by a calendar in her room that was rarely initialed by staff. The facility lacks a formal policy for denture care and oral hygiene, and there is no documentation in the electronic medical records to track when care is provided. Interviews with CNAs revealed inconsistencies in the care routine, with some reporting that dentures are not always cleaned and soaked overnight as required. The administrator acknowledged the grievance filed regarding Resident 6's care but believed that staff were performing the care without documenting it. The absence of a structured policy and documentation system contributed to the deficiency in providing necessary oral hygiene care for the residents.
Failure to Provide Timely Assistance for Toileting Needs
Penalty
Summary
The facility failed to provide timely assistance for toileting needs for a resident, resulting in undue feelings of frustration, embarrassment, and neck pain. The resident, a cognitively intact [AGE] year old female with diagnoses including Secondary Parkinsonism and End Stage Renal Disease, reported that it often took staff between 30 minutes to 2 hours to respond to her call light, leading to incontinence episodes and neck pain from prolonged periods on the commode. The resident expressed that these delays were particularly problematic in the morning, after lunch, and around 2 PM, causing her significant discomfort and emotional distress. Certified Nurse Assistants (CNAs) working on the 200 hall confirmed that the resident frequently experienced incontinence by the time staff responded to her call light. They acknowledged that the 200 hall had heavy care residents requiring significant staff time, which contributed to the delays. Despite the facility having what some staff considered adequate staffing levels, the high demand for assistance from multiple heavy care residents often led to prolonged wait times for individual residents. The facility administrator acknowledged that there had been ongoing concerns about call light response times, which had been discussed in resident council meetings. The administrator stated that the facility had explored various options to improve response times, such as redistributing heavy care residents and evaluating staffing needs and productivity. However, the issue persisted, with the administrator and medical director both emphasizing the importance of timely responses to call lights to address residents' needs and discomfort promptly.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner for four residents, leading to significant delays in care. Resident R32, a [AGE] year-old male with chronic conditions including COPD and diabetes, reported an average wait time of 15 minutes, with instances extending up to 45 minutes. Similarly, Resident R92, a [AGE] year-old female with heart failure and hip pain, experienced an average wait time of 15 minutes, but reported a recent instance where she waited for 2 hours. Both residents confirmed these times by observing the clock in their rooms. Resident R103, an [AGE] year-old male with dementia and anxiety, had his family member report that call lights typically took 20 minutes to be answered. Resident R56, a [AGE] year-old female with Parkinsonism and end-stage renal disease, reported waiting up to 2 hours for assistance, particularly during peak times such as mornings and after lunch. This delay led to incontinence episodes and physical discomfort. Staff members acknowledged the delays, attributing them to the high care needs of residents on the 200 hall, which often required the assistance of two staff members. The facility's administrator admitted that there have been ongoing concerns about call light response times, as documented in resident council meeting minutes and grievance forms. Despite attempts to address the issue, such as redistributing heavy care residents and evaluating staffing needs, the problem persisted. The administrator stated that the expectation is for call lights to be acknowledged within 5 minutes, but this standard was not consistently met, as evidenced by the residents' complaints and staff testimonies.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to notify resident representatives in writing of hospital transfers for two residents who were reviewed for hospitalization. Resident 36, who had a cognitive impairment as indicated by a BIMS score of 7, was transported to the emergency room due to a change in condition. Similarly, Resident 71, with a BIMS score of 9 indicating cognitive impairment, was also transported to the emergency room for a change in condition. The facility's administrator confirmed that while they call the resident's family or POA via phone during transfers, they do not provide written documentation regarding the hospital transport, reasons for the transport, or the bed hold policy to the POA or family members.
Failure to Notify Resident Representatives of Bed Hold Policy
Penalty
Summary
The facility failed to notify resident representatives in writing of the bed hold policy during resident transfer for two residents reviewed for hospitalization. Resident 36, who had a cognitive impairment as indicated by a BIMS score of 7, was transported to the emergency room after a change in condition. Similarly, Resident 71, with a BIMS score of 9 indicating cognitive impairment, was also transported to the emergency room due to a change in condition. The facility's administrator confirmed that while they call the resident's family or POA via phone during transfers, they do not provide written documentation regarding the reasons for transport and the bed hold policy to the POA or family member.
Failure to Update Care Plan for UTI Medication
Penalty
Summary
The facility failed to revise a care plan to include medications ordered for a Urinary Tract Infection (UTI) for one resident. The resident, who has multiple diagnoses including Type 2 Diabetes Mellitus, Parkinsonism, and obstructive uropathy, was admitted to the facility on 03/29/2024. A urine culture from a local hospital dated 05/15/2024 showed a bacterial infection sensitive to Bactrim, and the resident was subsequently prescribed Bactrim 800-160 mg twice a day starting 05/20/2024. However, the resident's care plan, which included monitoring for UTI symptoms, did not document the antibiotic treatment for the UTI. On 05/24/2024, the Regional Nurse confirmed that it is her expectation that any medication should be included in the care plan. Additionally, it was noted that the facility does not have a specific policy on care plans and follows state guidelines. This oversight in updating the care plan to reflect the prescribed antibiotic treatment for the UTI constitutes a deficiency in the facility's care planning process.
Failure to Specify Duration for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were ordered for a specific duration for two residents. One resident, a male with diagnoses including Generalized Anxiety Disorder and Unspecified Dementia with Agitation, had an order for Lorazepam without a specified duration. Another resident, a female with Generalized Anxiety Disorder, also had an order for Lorazepam without a specified duration. Both orders were for as-needed use every 12 hours for anxiety or behaviors. The Regional Nurse stated that she believed no end date was necessary if there was clinical rationale for continued use. However, the facility's policy requires that PRN psychotropic medications be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or prescribing practitioner. This discrepancy between practice and policy led to the deficiency noted in the report.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents are free from abuse, resulting in two incidents involving residents R2 and R6. R6, who has severe cognitive impairment and is dependent on assistance for daily activities, experienced abuse when a CNA placed clothing over his mouth twice to quiet him. This incident was reported by another CNA, leading to the immediate removal and termination of the abusive staff member. Despite R6's inability to recall the event due to his cognitive condition, the incident was substantiated by the facility's investigation and witness statements. In another incident, R2, who has cognitive impairment and multiple diagnoses including vascular dementia, was pushed by another resident, R5, causing her to fall and hit her back on the bed. This incident was witnessed by a CNA and documented in nursing progress notes. Although R2 did not sustain any physical injuries, the facility substantiated the abuse and took steps to prevent R5 from returning to the facility due to his behavioral issues. Both incidents highlight the facility's failure to protect residents from abuse, as required by their abuse prevention policy. The facility's policy mandates that residents must not be subjected to abuse by anyone, including staff and other residents. The incidents were reported and investigated, but the initial failure to prevent these abusive actions resulted in emotional and physical distress for the affected residents.
Failure to Provide Written Notification of Discharge
Penalty
Summary
The facility failed to notify a resident in writing of the reason for transfer/discharge. The resident, who had severe cognitive impairments and a history of behavioral issues, was involved in an incident where he shoved another resident, causing her to fall. Following this, the resident exhibited further aggressive behavior, including attempting to punch a door and rearing his fist at another resident. The facility decided to send the resident to the emergency room and informed the hospital that the resident would not be allowed to return. However, the facility did not provide the required written notice of discharge to the resident or his family at that time. The resident's family member was initially notified of a potential discharge in January, but no further written notice was given after the recent incidents. The facility's administrator believed that the initial notice from January was sufficient and did not complete any emergency discharge paperwork. The family member was only verbally informed that the resident would not be allowed to return after being sent to the hospital. The facility's policy requires written notice to be provided at least 30 days in advance or as soon as practicable in emergency situations, but this was not done. The facility's failure to provide timely written notification of the discharge, including the reason for the discharge and the resident's right to appeal, constitutes a deficiency. The facility's policy mandates that such notice must be given to the resident and their family or legal representative, but this procedure was not followed in this case. The lack of proper documentation and communication led to a violation of the resident's rights and regulatory requirements.
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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