Lincoln Village Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Illinois.
- Location
- 2202 North Kickapoo Street, Lincoln, Illinois 62656
- CMS Provider Number
- 145719
- Inspections on file
- 46
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Lincoln Village Healthcare during CMS and state inspections, most recent first.
A resident who was non-ambulatory, required extensive ADL assistance, had poor trunk control, and needed a mechanical lift and two-person assistance was turned onto their side in bed by a CNA, who then left the resident unattended to retrieve supplies. The resident rolled off the bed and fell to the floor, after which staff lifted the resident without a mechanical lift. Facility documentation initially noted only minor scratches, and over subsequent days the resident received PRN analgesics for discomfort and back pain without physician evaluation or diagnostic imaging. About a week later, the resident reported rib pain and was sent to the ED, where CT imaging showed multiple new rib fractures and an L2 compression fracture and scattered bruising. The resident’s care plan lacked ADL status, safe positioning, and staffing requirements, and leadership staff acknowledged that CNAs did not reliably access care plans and that the CNA involved was unfamiliar with the resident’s needs.
A resident experienced a fall from bed during care when a CNA turned the resident on their side and briefly left the room to retrieve supplies, during which time the resident rolled off the bed. The care plan revision completed afterward only added suctioning prior to care for coughing and did not include interventions to prevent rolling from bed, instructions to remain with the resident during care, reinforcement of two-person assistance for bed mobility, or accurate ADL status and assistance needs. Staff reported relying on a binder and verbal communication for care updates, and the CNA involved did not routinely work on that unit and was unfamiliar with the resident’s needs. The CNA supervisor confirmed the absence of ADL documentation in the care plan, and the DON and ADON acknowledged they did not directly communicate care plan updates to CNAs and were unaware of the missing ADL care instructions, while the Administrator stated nursing leadership was responsible for ensuring updated care plans and necessary information for staff.
A resident with schizoaffective and other psychiatric disorders, care planned to receive Depakote as a mood stabilizer, repeatedly refused this medication over several months, with dozens of doses missed. The MARs documented frequent refusals, but the EMR lacked documentation of these multiple refusals, and the physician reported not being informed of the ongoing problem. Facility policy required reporting medication refusals and notifying the prescriber when vital medications were repeatedly refused, yet the DON confirmed there was no documentation that the physician had been notified of the resident’s regular Depakote refusals.
The facility failed to prevent resident-to-resident physical abuse in two separate dining room incidents, despite having an abuse prevention policy. In one early-morning event, a cognitively intact male resident with psychiatric diagnoses used his mobility device and hands to shove another cognitively intact male resident with alcohol-induced dementia against a wall, causing the victim to drop a metal cup, sustain facial abrasions, and later describe the event as an act of violence. In a separate incident at mealtime, a female resident with Alzheimer’s disease, severe cognitive impairment, and significant functional limitations threw a salt or sugar container at another female resident with severe cognitive impairment and multiple comorbidities, striking her in the back and causing back pain; a witness resident believed the act was intentional. These incidents show that the facility did not adequately protect residents from physical abuse by other residents as required by its policy.
A resident with multiple chronic conditions developed a severe wound complication after staff failed to follow physician-ordered wound care protocols, resulting in maggot infestation. The wound was incorrectly covered with a dry dressing instead of being left open to air as ordered, and staff did not notify the physician of changes in the wound's condition. The resident was hospitalized for infected wounds and sepsis, ultimately requiring a right above-the-knee amputation.
A resident who required pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to inadequate pain control.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Three cognitively intact residents experienced multiple room moves without receiving the required written notice or explanation, as mandated by facility policy. Interviews confirmed that neither the residents nor their representatives were informed in writing or given reasons for the relocations, and the facility's leadership acknowledged unawareness of this requirement.
A resident with multiple complex medical conditions experienced a severe, unplanned weight loss over one month. Facility policy required prompt notification of such changes to the resident's legal representative and physician, but there was no documentation that the resident's guardian was informed. The guardian confirmed she was not notified, and the Regional Director acknowledged the lack of documentation regarding notification.
A resident, who was cognitively intact, reported that a CNA threatened to throw a trash can at them and used profane language, causing the resident to feel threatened. The incident was reported to the prior DON, but the facility was unable to confirm the identity of the CNA involved. This reflects a failure to protect a resident from staff verbal abuse as required by facility policy.
A resident with intellectual disabilities and epilepsy was administered Risperidone and Clobazam, both psychotropic medications, without documented informed consent. The resident's guardian confirmed that no verbal or written consent was provided, and facility staff could not produce any consent documentation, contrary to facility policy.
A resident reported that a CNA threatened them and used abusive language, but the incident was not immediately reported to the State Agency or the Administrator as required by facility policy. Staff interviews confirmed that the mandated reporting process was not followed.
A resident reported that a CNA cursed at them and threatened to throw a trash can, and stated they informed the prior DON, who allegedly fired the CNA. However, there was no documentation or evidence that the facility conducted an investigation into the abuse allegation, and facility leadership confirmed the incident was not reported or investigated.
Three residents transferred to the hospital did not receive required written notifications about bed hold policies or transfer/discharge, as confirmed by record review and staff interview. Facility policy mandates these notifications, but documentation was missing for each hospital transfer event reviewed.
A resident with lymphedema, diabetes, and chronic kidney disease did not receive physician-ordered consultations with a lymphedema specialist and a nephrologist. Despite staff attempts to arrange appointments, communication gaps and logistical barriers prevented the resident from receiving the required specialist care, in violation of facility policy and physician orders.
A resident with multiple comorbidities and high risk for pressure ulcers developed a stage 2 pressure ulcer on the right heel. The care plan was not updated to include the use of a pressure-relieving off-loading boot as recommended by the wound physician, and observations showed the resident's heel was not properly offloaded while in a wheelchair. The wound nurse acknowledged the lapse in both implementing and documenting necessary interventions, resulting in inadequate pressure ulcer care.
A resident with an indwelling urinary catheter did not receive required monitoring of urine output, color, and consistency, nor was catheter care performed every shift as per facility policy. Staff also failed to complete a physician-ordered voiding trial and follow-up with urology. Observation revealed dried debris at the catheter insertion site, and the resident reported that daily catheter cleaning was not performed.
Two residents with significant unplanned weight loss did not have their care plans updated to include new physician-ordered nutritional interventions, despite documented weight loss and existing orders for supplements and increased meal portions. The dietary manager confirmed that these updates were not made after the weight loss was identified.
A resident did not receive Basic Metabolic Panel (BMP) laboratory tests as ordered by the physician, with medical records showing missed intervals and incomplete compliance with the prescribed schedule. This was confirmed by facility staff during the survey.
A resident with a colostomy, pressure ulcer, and indwelling urinary catheter did not receive proper Enhanced Barrier Precautions during high-contact care when a CNA emptied the colostomy bag wearing gloves but not a gown, contrary to facility policy and posted instructions.
Two residents were involved in a physical altercation in the dining room when one resident, who is cognitively intact and uses a wheelchair, moved another resident's walker, prompting the latter, who has severe cognitive impairment, to strike him in the face. The facility did not effectively implement its abuse prevention policy, resulting in resident-to-resident physical abuse.
A facility did not thoroughly investigate an allegation of resident-to-resident abuse after an incident between two roommates. Although a skin assessment was performed and no injuries were found, there was a lack of documentation and no interviews with staff who were present. The administrator interviewed both residents but did not record these interviews or conduct a comprehensive investigation as required by facility policy.
A resident with a scabies diagnosis did not have a prescribed Permethrin treatment documented or administered, as confirmed by the DON. Additionally, two residents receiving wound care had dressings that were not labeled or dated after treatment, with an LPN stating that staff were told to document only in the TAR, not on the dressings, contrary to facility policy.
Two residents at high risk for falls were not provided with adequate supervision or timely assistance, resulting in preventable falls and injuries. One resident, dependent for bed mobility due to Parkinson's, was left unattended during care and fell from bed, sustaining an eyelid injury. Another resident, with multiple risk factors for falls, experienced repeated falls after waiting extended periods for staff to respond to call lights and not receiving frequent checks as required by her care plan. Staff did not consistently follow individualized fall prevention interventions.
The facility consistently scheduled only the minimum number of CNAs required by state regulations, resulting in frequent delays in call light responses and unmet care needs for residents, many of whom required full mechanical lifts and intensive assistance. Staff, residents, and family members reported long wait times for help, and surveyors observed call lights going unanswered for extended periods, confirming that the staffing levels were insufficient to meet the actual care needs of the resident population.
Multiple residents experienced significant delays in call light response, with some waiting over an hour for assistance after episodes of incontinence or for help with mobility. Staff interviews and grievances confirmed that inadequate CNA staffing led to these delays, and direct observation by surveyors documented call lights going unanswered for extended periods. The facility's policy requires prompt response, but both staff and residents reported that current staffing levels made this unachievable.
Surveyors observed that multiple medication carts contained unlabeled multi-dose insulin vials and delivery pens, which were not labeled with any resident's name. Nursing staff and the DON confirmed that such insulin should not be used or stored in the carts, as facility policy requires all medications to be labeled for specific residents.
A resident's allegation of physical abuse was investigated, but the facility did not follow its abuse policy by failing to interview other residents who received care from the same staff as the accused. The administrator confirmed that not all required investigation steps were completed.
A resident with severe cognitive impairment and a high risk for abuse was found with a significant bruise near the eye, and reported to his wife that a man had entered his room and caused the injury. The facility's investigation did not include interviews with other residents in the same hallway or those cared for by the same staff, despite policy requirements, and the DON confirmed the investigation was incomplete.
The facility failed to provide weekly showers for several residents, as required by their policy. Residents reported not receiving showers on scheduled days, with some having to wash themselves due to lack of assistance. The DON acknowledged issues with the shower schedule but could not provide documentation to support compliance.
The facility failed to provide sugar substitutes as per its dietary menu, affecting several residents with Diabetes Mellitus. Observations showed a lack of sugar substitutes on dining tables and trays, and residents reported having to buy their own due to shortages. The dietary manager admitted to not realizing the stock was depleted, despite the facility's policy for emergency purchases.
The facility failed to properly manage respiratory equipment for several residents, as oxygen tubing, humidification reservoirs, and other equipment were not dated, bagged, or stored correctly. An LPN confirmed these discrepancies, which were against the facility's procedures.
The facility failed to document or provide written notification to residents and/or their representatives for hospital transfers or discharges. The facility's policy requires verbal and written notifications, including details such as the reason for transfer and right to appeal. However, due to staff turnover, these notifications were not completed, potentially affecting all 73 residents.
The facility failed to employ a full-time DON, affecting 75 residents. The former DON resigned abruptly, leaving the ADON, an LPN, to fill in temporarily. The facility's assessment tool highlighted the need for a DON, but no replacement had been interviewed yet.
A resident experienced a fall resulting in a head injury, but the facility failed to notify the family until 29 hours later, contrary to its policy. The resident's PCP was informed over three hours after the incident. The facility administrator cited the resident's cognitive status as the reason for not notifying the family immediately, while the regional director confirmed the policy requires family notification.
A resident with a history of stroke and other health issues experienced an unwitnessed fall, resulting in a head injury. The facility failed to complete neurological assessments and delayed hospital transfer, leading to a late diagnosis of an occipital stroke. Initial monitoring was not continued as per protocol, and emergency services were only contacted after the resident reported vision loss and severe headache.
A resident with a high risk for falls fell from bed and sustained a femur fracture while receiving incontinence care. The CNA providing care turned away to find barrier cream, leaving the resident unsupervised, which led to the fall. The facility's investigation was inadequate as it did not include an interview with the cognitively intact resident.
An RN was caught on video misappropriating controlled substances from a medication cart, affecting eight residents. The RN was observed taking narcotic medications and placing them in her pocket. A fellow LPN suspected the RN of drug theft due to her behavior and reported it to the police, who confirmed the theft through surveillance footage. The RN was arrested and charged with related offenses.
The facility failed to obtain physician orders for catheter care, notify a physician of abnormal urine test results, and timely treat UTIs for two residents. One resident experienced severe complications, including septic shock, due to these failures. Another resident's ordered urinalysis and culture test were not completed.
The facility failed to designate a qualified Infection Preventionist to oversee the Infection Prevention and Control Program, leaving the role vacant after the previous IP nurse left. An LPN with a current IP certificate was identified as a backup but was not informed or assigned to the role, potentially affecting all 72 residents.
Failure to Supervise, Safely Position, and Timely Evaluate a Resident After a Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, safe transfer and positioning practices, post-fall assessment, and timely medical evaluation for one resident. Facility policies on assisting with bed mobility require that residents not be left on the edge of the bed and that staff ensure the resident is in the middle of the bed with the bed lowered to reduce injury risk. The Falls and Fall Risk policy requires staff to identify and implement interventions to minimize serious consequences of falls. Despite these policies, the resident’s care plan did not include interventions for safe positioning during care, staff positioning, remaining with the resident during care, or documentation of the resident’s ADL abilities and required number of staff for care. The resident’s therapy records documented extensive assistance needs with ADLs, dependence on staff for transfers requiring a mechanical lift, poor trunk control, need for two-person assistance for sitting, and non-ambulatory status. On the date of the fall, a CNA reported turning the resident onto his side for care and then stepping away to retrieve supplies, leaving the resident unattended on his side. The CNA stated that upon returning, she observed the resident coughing and rolling off the bed, and although she attempted to stop the fall by grabbing the resident’s upper body, the resident fell completely to the floor. Staff then lifted the resident from the floor without using a mechanical lift because they reported being unable to get the lift into the area where the resident was lying. Following the fall, the facility’s incident note documented only minor scratches and no complaints of pain, and nursing notes over the next days recorded administration of PRN Tylenol and Tramadol for general discomfort and back pain. No physician evaluation or diagnostic imaging was obtained at that time. A week later, the resident complained of rib pain and was sent to the emergency room, where CT imaging revealed new rib fractures and an L2 compression fracture not present on prior studies, along with scattered bruising worse on the left side. Hospital staff documented that facility staff reported the fall had occurred a week earlier with no intervening physician evaluation or imaging. Interviews with the DON, ADON, and CNA supervisor revealed they did not ensure CNA access to or use of care plans, were unaware of an ADL care plan for the resident, and acknowledged that the care plan lacked ADL and safe care information, and that the CNA who provided care did not usually work on that unit and would not have been familiar with the resident’s needs.
Failure to Update and Communicate ADL Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess, document, and communicate a resident’s Activities of Daily Living (ADL) needs and to ensure the comprehensive, person-centered care plan was timely reviewed and revised after a fall. Facility policy required that care plans be revised as changes in condition dictate and that the interdisciplinary team maintain a comprehensive care plan identifying the highest level of function attainable. A resident (R1) experienced a fall from bed during care when left unattended; an incident note documented that R1 was found on the floor between the bed and the window after being turned on his side and left while the CNA retrieved supplies. The care plan revision completed the following day added an intervention to suction the resident prior to care due to coughing but did not include interventions to prevent rolling from bed during care, instructions for staff to remain with the resident during care, reinforcement of two-person assistance for bed mobility, or accurate documentation of R1’s ADL status and required level of assistance. During interviews, the CNA who provided care at the time of the fall stated that R1 rolled off the bed while she had stepped away and that she was unable to prevent the fall due to the resident’s weight; she also reported that staff lifted the resident from the floor without a mechanical lift because they could not get the lift into the area where the resident was lying. The CNA supervisor stated that staff relied on a binder and verbal communication for care updates and confirmed that R1’s care plan did not include documentation of ADL status, noting that staff unfamiliar with the resident would not know how to safely provide care. The CNA involved did not routinely work on that unit and would not have been familiar with R1’s care needs. The DON and ADON stated they did not directly communicate care plan updates to CNAs and relied on shift report and supervisory staff, and they were unaware that R1’s care plan lacked ADL care instructions. The Administrator stated that nursing leadership was responsible for ensuring care plans were updated and that staff had the information necessary to provide care.
Failure to Notify Physician of Repeated Refusals of Mood Stabilizer
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician in a timely manner about a resident’s frequent refusals of a prescribed mood stabilizer, Depakote, as required by facility policy. The facility’s Medication Administration Policy states that medication refusals must be reported to the prescriber after a specified number of doses are refused and that refusals of vital medications over a certain number of consecutive doses require physician notification and documentation of the response. One resident, admitted with diagnoses including Schizoaffective Disorder, Major Depressive Disorder, Panic Disorders, and Mild Intellectual Disabilities, had a care plan indicating use of Depakote as a mood stabilizer for aggressive mood and directing nursing staff to monitor for adverse reactions and report symptoms of schizoaffective disorder to the MD. The care plan also documented a change in the resident’s usual behavior, including increased restlessness, fidgetiness, lack of initiative, and irritability, with an intervention to evaluate whether behavior was attributable to organic causes or other risk factors. Review of the resident’s MARs showed repeated refusals of Depakote over several months: 23 refusals out of 90 doses in one month, 27 refusals out of 93 doses the following month, and 7 refusals out of 37 doses in the subsequent partial month, totaling 57 missed doses in the latter two periods alone. The electronic medical record did not contain documentation of these multiple refusals over the review period. The resident’s physician stated he was not aware of the missed doses and did not recall being notified of the ongoing problem, and affirmed he would want to be notified of regular medication refusals, especially for Depakote. The Administrator confirmed the policy did not specify the exact number of doses that could be missed before physician notification, and the DON verified that the resident was regularly refusing the noon dose of Depakote and that there was no documentation of physician notification regarding these refusals during the identified period.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room Incidents
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident physical abuse, contrary to its abuse prevention policy that affirms residents’ rights to be free from abuse, neglect, and mistreatment by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and includes deprivation of necessary goods or services. Despite this policy, two separate resident-to-resident altercations occurred, each involving physical contact and resulting in at least minor injury or pain to the residents involved. In the first incident, one cognitively intact male resident with diagnoses including mild intellectual disabilities, schizoaffective disorder, major depressive disorder, and panic disorder approached another cognitively intact male resident with alcohol-induced persisting dementia in the dining room early in the morning. Without provocation from the second resident, the first resident pushed him back against a wall using his hands and his mobility device, causing the second resident to drop his metal cup and spill its contents. Staff responded and separated the residents. The aggressor stated that the other resident was “in his business,” while the victim reported that the event happened quickly and that he had only gone to get ice and a straw. Documentation noted scratches on the victim’s face and an abrasion on his forehead, and the victim later described the event as an act of violence and showed a dented metal cup from the incident. In the second incident, a female resident with Alzheimer’s disease, dementia, anxiety, major depressive disorder, irritability, anger, severe cognitive impairment, and significant functional limitations, who used a wheelchair and was dependent for most ADLs, threw a salt and pepper caddy or plastic sugar container at another female resident. The target resident had severe cognitive impairment, polyarthritis, a history of transient cerebral ischemic attack, hypertension, and mild intellectual disabilities, and required supervision for ADLs. While both residents were seated in their usual dining room locations waiting for dinner, the aggressor became agitated and threw the container, which struck the other resident in the lower back. The struck resident later reported that the impact made her back hurt and that she did not like to be around the aggressor, and another resident witness stated that the throw appeared intentional. These events demonstrate that the facility did not effectively prevent abuse between residents as required by its own policy and regulatory standards.
Failure to Protect Wound from Insect Contamination and Provide Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's wound from insect contamination and did not provide appropriate, physician-ordered wound care. The resident, who had multiple comorbidities including chronic osteomyelitis, diabetes with skin complications, heart failure, and a history of alcohol dependence, had physician orders for specific wound care treatments. These included cleansing, application of topical medications, and either covering with a dry dressing or leaving the wound open to air, depending on the most recent orders. However, documentation and staff interviews revealed that the correct wound care orders were not consistently followed, and a dry dressing was applied to the resident's right foot wound when the current order was for betadine and open to air. During a routine skin sweep, a wound nurse discovered that the resident's right foot wound was covered with a dry dressing, contrary to the physician's most recent order. Upon removing the dressing, the nurse found the wound infested with over fifty maggots (myiasis) within necrotic tissue. The nurse, unfamiliar with treating maggot infestations and unable to reach the infection preventionist, contacted the physician and arranged for the resident's immediate transfer to the hospital. The resident reported that wound dressings were changed only about once a week, and that they were not informed about the condition of their feet. Hospital records confirmed the presence of maggots in the wound and documented subsequent treatment for infected wounds, sepsis, and osteomyelitis. The resident ultimately required a right above-the-knee amputation, was placed on a feeding tube and urinary catheter, and later became unresponsive, leading to a hospice recommendation. Staff interviews indicated a lack of communication regarding changes in the wound's condition and failure to notify the physician or follow up with appropriate wound care orders.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The deficiency was identified based on the failure to provide necessary pain management interventions for a resident in need.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notice of room changes to three cognitively intact residents who experienced multiple room moves. According to the facility's own policy, residents are to receive advance written notice, including the reason for the move, at least two days prior to relocation unless the move is medically necessary for safety and well-being. However, review of records and interviews revealed that no such written notices were issued to the residents or their representatives for any of the documented room changes. Interviews with the affected residents confirmed that they were not made aware of the reasons for their room moves and did not receive written notifications. One resident reported frequent room changes without explanation, while another stated he was never informed of the reason for his move. A family member of a third resident indicated she was only verbally notified of one move and was never given a reason or written notice for any of the moves. The Administrator in Training verified that the facility did not issue written notices for these room changes and was unaware of the requirement to do so.
Failure to Notify Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's responsible party after a significant weight loss was identified. According to facility policy, significant unplanned weight loss must be promptly communicated to the resident, their legal representative, and the attending physician. In this case, a male resident with multiple diagnoses, including cerebral palsy, epilepsy, intellectual disabilities, hypothyroidism, bradycardia, dysphagia, and gastrostomy status, experienced a severe weight loss of 13.2% in one month, as documented in the facility's records. The resident's Minimum Data Set (MDS) assessment also confirmed significant weight loss not associated with a physician-prescribed regimen. Despite these findings, there was no documentation in the electronic medical record that the resident's guardian was notified of the severe weight loss. The guardian confirmed during an interview that she was not informed of the weight loss and expressed a desire to be kept updated due to her involvement in the resident's care. The Regional Director acknowledged that it was the Director of Nursing's responsibility to notify the family and could not find any evidence that such notification occurred.
Failure to Protect Resident from Staff Verbal Abuse
Penalty
Summary
A facility failed to protect a resident from staff-to-resident verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who allegedly threatened to throw a trash can at a resident and used profane language. The resident, who was assessed as cognitively intact, reported feeling threatened by the CNA's actions and stated that the incident was reported to the prior Director of Nursing. The facility's Abuse Prevention Policy prohibits all forms of abuse, including verbal abuse, and defines it as the use of language that is disparaging, derogatory, or threatening toward residents. Despite the resident's report and the facility's policy, the identity of the CNA involved could not be confirmed by the current Administrator-In-Training, as the resident indicated the CNA no longer worked at the facility. The incident was not witnessed by others, and the facility was unable to determine the specific staff member responsible. The deficiency centers on the facility's failure to ensure the resident was protected from verbal abuse by staff.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to a resident diagnosed with unspecified intellectual disabilities and epilepsy. According to the facility's own policy, psychotropic medications should not be prescribed without the informed consent of the resident, guardian, or authorized representative. Despite this, the resident was receiving Risperidone 0.5 mg twice daily and Clobazam 5 mg twice daily without documented consent. The resident's guardian confirmed that she had never verbally given nor signed an informed consent for these medications. Facility staff, including the Administrator in Training and the Regional Nurse Consultant, were unable to produce any documentation of informed consent for the use of psychotropic medications for this resident.
Failure to Immediately Report Alleged Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to implement its Abuse Prevention Policy by not immediately reporting an allegation of resident abuse to the State Agency and the Administrator. A cognitively intact resident reported that about a month prior, a CNA threatened to throw a trash can at them and used abusive language. The resident stated they reported the incident to the prior DON, who allegedly terminated the CNA for abuse. However, there was no documentation in the resident's electronic health record or the facility's abuse investigations indicating that the administrator or the State Agency was notified of the allegation, as required by facility policy. Interviews with facility staff confirmed that the required reporting did not occur. The Administrator-in-Training stated they were on leave at the time, and the Regional Director confirmed that the prior DON did not report the allegation as mandated. The facility's policy requires immediate internal and external reporting of abuse allegations, but this process was not followed in this instance.
Failure to Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to immediately investigate an allegation of resident abuse as required by its Abuse Prevention Policy. A cognitively intact resident reported that approximately one month prior, a CNA cursed at them and threatened to throw a trash can at them. The resident stated they reported the incident to the prior DON, who allegedly responded by firing the CNA. However, review of the resident's electronic health record and the facility's abuse investigation documentation revealed no evidence that an investigation was conducted regarding the allegation. Interviews with facility leadership confirmed that the allegation was not reported or investigated, resulting in a lack of documented follow-up on the reported abuse.
Failure to Provide Bed Hold and Transfer Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide required written notifications regarding bed hold policies and transfer notices to residents or their representatives when residents were transferred to the hospital. Specifically, three residents who were transferred to the hospital did not have documentation in their medical records indicating that they or their representatives received written notice of the facility's bed hold policy or a written notice of transfer/discharge at the time of their hospital transfer. The facility's own policies require that such notifications be provided both verbally and in writing, including information about the reason for transfer, effective date, location, appeal rights, and contact information for the state long-term care ombudsman and other advocacy agencies. Record review confirmed that for each of the three residents transferred to the hospital, there was no evidence that the required notifications were given on the dates of transfer. This was further verified by the Administrator in Training, who acknowledged that the notifications were not provided as required by facility policy. The deficiency was identified through interviews and review of census sheets and medical records, which consistently lacked the necessary documentation for each hospital transfer event reviewed.
Failure to Provide Physician-Ordered Specialist Consultations
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered consultations with a lymphedema specialist and a nephrologist. The resident, who had diagnoses including lymphedema, type 2 diabetes mellitus, stage 2 chronic kidney disease, and hyponatremia, had documented physician orders for follow-up with a nephrologist and an outpatient lymphedema clinic. Despite these orders, there was no evidence in the medical record that the resident received either consultation. Staff interviews revealed that attempts were made to schedule the lymphedema appointment, but the process was not completed due to referral requirements and the inability to locate a specialist within the facility's transportation radius. The nephrology appointment was not scheduled because the responsible staff were not informed of the need for the follow-up. The resident was observed with significant swelling and skin issues related to lymphedema and expressed that she had not received the specialist appointments she expected upon admission. Staff involved in scheduling and transportation confirmed communication gaps and incomplete follow-through on the physician's orders. The facility's policies required nursing staff to follow physician orders and assist with transportation for outside services, but these procedures were not effectively implemented for this resident, resulting in missed consultations.
Failure to Update Care Plan and Implement Pressure-Relieving Interventions for Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan and implement pressure-relieving interventions for a resident with a newly developed stage 2 pressure ulcer on the right heel. Despite the resident being identified as very high risk for pressure ulcer development due to conditions such as cerebral palsy, epilepsy, intellectual disabilities, and hypothyroidism, and being dependent on all activities of daily living, the care plan did not include the use of a pressure-relieving off-loading boot as recommended by the wound physician. Observations showed the resident's right heel was repeatedly resting on the wheelchair foot pedal, both with a sock and a tennis shoe, rather than being offloaded or protected as required. The wound nurse acknowledged that the resident should have been using a pressure-relieving boot to prevent further deterioration of the pressure ulcer, but this intervention was not implemented or communicated to the wound physician. The nurse also admitted responsibility for not updating the resident's care plan with new interventions to offload the heel, both in bed and while out of bed. The facility's own policies outlined the need for such preventative measures and equipment, but these were not followed, resulting in a failure to provide appropriate pressure ulcer care and prevention.
Failure to Monitor and Provide Care for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a resident with an indwelling urinary catheter. Specifically, staff did not monitor or document the resident's intake and output, assess urinary catheter drainage each shift, or perform catheter care every shift as required by facility policy and the resident's care plan. The resident's medical record lacked evidence of these essential assessments and interventions from the date of admission through the review period. Additionally, the facility did not complete a physician-ordered voiding trial or arrange for a follow-up with urology as directed in the hospital discharge orders. During observation, the resident was found in bed with an indwelling urinary catheter that had brown dried debris at the insertion site, and the resident reported that staff did not clean the catheter tubing daily. The Regional Nurse Consultant confirmed that the voiding trial and urology follow-up were not completed, and that monitoring of intake and output, urinary drainage, and catheter care every shift did not occur. These findings indicate a failure to follow physician orders, facility policy, and the resident's care plan regarding catheter management and infection prevention.
Failure to Update Care Plans with Weight Loss Interventions
Penalty
Summary
The facility failed to update the care plans with new weight loss interventions for two residents who experienced significant unplanned weight loss. For one resident with diagnoses including cerebral palsy, epilepsy, intellectual disabilities, hypothyroidism, bradycardia, dysphagia, and gastrostomy status, a significant weight loss of 13.2% in one month was documented. Although physician orders were in place for nutritional supplements, these interventions were not reflected in the resident's care plan after the weight loss was identified. Similarly, another resident with quadriplegia, cerebral infarction, Alzheimer's, type 2 diabetes, and major depressive disorder experienced a 16.6% weight loss over six months and 5.2% in one month. This resident also had physician orders for nutritional supplements and double meal portions, but the care plan was not updated to include these interventions after the significant weight loss was identified. The facility's policy requires individualized care plans to address causes of weight loss, set goals, and include interventions and monitoring parameters. However, the dietary manager confirmed that the care plans for both residents were not updated with the new physician-ordered interventions following the identification of significant weight loss. This omission was acknowledged during interviews, with the dietary manager stating that the updates had not yet been made.
Failure to Obtain Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain a physician-ordered Basic Metabolic Panel (BMP) for one resident as required. According to the facility's policy, nursing staff are expected to follow physician orders. The resident had an active order for a BMP to be performed every two weeks starting from a specified date. However, medical record review showed that the BMP was not obtained at the prescribed intervals, with only a few tests documented and significant gaps between them. This deficiency was confirmed by the Regional Nurse Consultant, who verified that the laboratory tests were not performed as ordered.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during direct care for a resident with multiple risk factors for infection. According to the facility's policy, EBP, including the use of gown and gloves, is required during high-contact care activities for residents with wounds, indwelling devices, or known colonization or infection with multi-drug-resistant organisms (MDROs). One resident had a colostomy, a pressure ulcer on the right buttock, and an indwelling urinary catheter, all of which necessitated EBP as documented in the care plan and physician orders. During observation, a CNA was seen emptying stool from the resident's colostomy bag while wearing gloves but not a gown, despite a posted EBP sign on the resident's door. The CNA later acknowledged forgetting to wear a gown, and the facility's Infection Preventionist confirmed that a gown should have been worn during this care activity. This lapse in following established infection control protocols constituted a failure to implement the facility's EBP policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy, resulting in a physical altercation between two residents. One resident, who uses a walker and has a BIMS score indicating severe cognitive impairment, was seated in the dining room when another resident, who propels himself in a wheelchair and is cognitively intact, moved the first resident's walker to create more space. In response, the resident with the walker struck the other resident in the face. Staff observed the incident, but the altercation occurred before they could intervene. Both residents were assessed after the incident, and no injuries were found. The resident who initiated the physical contact has a history of behavioral symptoms, including physical aggression and verbal outbursts when agitated, as documented in his care plan. His diagnoses include mild intellectual disabilities, schizoaffective disorder, and major depressive disorder. The other resident involved has significant medical conditions, including mantle cell lymphoma and generalized anxiety disorder, and was unable to recall the incident. The facility's policy affirms residents' rights to be free from abuse, but the policy was not effectively implemented to prevent this resident-to-resident physical abuse.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two roommates. According to progress notes, an incident occurred between the two residents, resulting in one being moved to another room. Documentation indicated that a skin assessment was performed and no injuries were noted, but there was no further documentation in the electronic health records regarding the incident for either resident. The facility's abuse policy requires prompt and aggressive investigation and documentation of all reports and allegations of abuse, neglect, or mistreatment, but this was not followed in this case. Interviews revealed that the administrator interviewed both residents about the incident but did not document these interviews in the health records. Additionally, the administrator did not interview staff who were aware of the incident, including the LPN on duty at the time. The administrator stated that she believed she had enough information and did not pursue a further investigation, and there was no other documentation or investigation record regarding the incident.
Failure to Document and Implement Treatment Orders and Label Wound Dressings
Penalty
Summary
The facility failed to document and implement a prescribed treatment order for one resident diagnosed with scabies. Although a specialty physician ordered Permethrin (Elimite) 5% cream to be applied to the resident's whole body for 12 hours and repeated in seven days, there was no evidence in the electronic health record or treatment administration record that the order was documented or carried out. The Director of Nursing confirmed that the treatment order was not entered into the resident's records and that the resident was apparently not treated as prescribed. Additionally, the facility did not follow its own policy regarding the labeling and dating of wound dressings after treatment for two other residents. Observations showed that dressings on these residents were clean and intact but lacked required labeling and dating. The wound nurse acknowledged that staff were instructed to document wound care only in the treatment administration record and not to label or date the dressings, contrary to facility policy. These actions resulted in a failure to ensure proper documentation and implementation of wound care treatments as ordered.
Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for two residents identified as high risk for falls. One resident, with a history of polyneuropathy, generalized muscle weakness, cognitive deficits related to Parkinson's, and requiring extensive assistance with bed mobility, was left unattended in bed by a CNA who walked away to obtain supplies during care. This resulted in the resident rolling out of bed and sustaining a right eyelid injury. The resident's care plan specified that they should never be left in an unsafe or uncomfortable position, and assessments documented the need for extensive assistance for all bed-related activities. Another resident, also identified as high risk for falls due to spinal stenosis, generalized edema, muscle weakness, poor safety awareness, and a history of falls, experienced multiple falls. The care plan required frequent checks and assistance with bathroom needs. On one occasion, the resident attempted to get up alone after waiting an extended period for staff to respond to a call light, resulting in a fall to her knees. The resident reported frequent long waits for assistance, especially at night, sometimes resulting in accidents. On another occasion, the resident fell while trying to use the bathroom, and investigation revealed that staff did not follow the care plan intervention for frequent checks. Interviews with the Director of Nursing confirmed that in both cases, staff failed to provide the required supervision and did not adhere to individualized care plan interventions. The facility's Fall Reduction Program policy required individualized interventions and supervision based on assessed risks, but these were not consistently implemented, leading to preventable falls and injuries.
Inadequate Staffing Leads to Delayed Resident Care and Unanswered Call Lights
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by consistent understaffing on both day and night shifts. Staffing assignment sheets showed that although extra CNAs were scheduled, they were routinely sent home if the state minimum staffing was met, leaving only six CNAs on day shift and four on night shift for a census of 72 to 76 residents. Staff, residents, and family members reported frequent delays in call light responses, with some residents waiting up to an hour or more for assistance with incontinence care, transfers, or other needs. Multiple grievances were filed regarding slow response times, and direct observations by surveyors confirmed call lights going unanswered for extended periods, including one instance where a resident's call light was not answered for 21 minutes until the surveyor intervened. Several residents required high levels of care, including 31 out of 72 residents needing full mechanical lifts for transfers, which require two CNAs to operate safely. Staff interviews revealed that the reduction in CNA staffing made it difficult to provide timely care, complete showers, and respond to call lights, especially on halls with residents requiring more intensive assistance. The facility's own assessment acknowledged the need for sufficient nursing staff with appropriate competencies to ensure resident safety and well-being, but staffing decisions were based solely on meeting state minimum requirements rather than the actual acuity and needs of the resident population. Specific incidents included a resident who waited over an hour to be changed after incontinence, another who attempted to transfer herself after waiting too long for help and subsequently fell, and multiple reports from residents and family members about long waits and unmet care needs. The Director of Nursing and other staff confirmed that staffing was determined by census and state minimums, despite the heavy care needs of many residents. The facility's grievance log, staff, and resident interviews, as well as direct observations, all supported the finding that inadequate staffing led to delays in care and unmet resident needs.
Failure to Respond Timely to Resident Call Lights Due to Insufficient Staffing
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner for seven residents, as evidenced by direct observations, interviews, and review of facility records. The facility's own policy requires call lights to be answered as soon as possible, and the facility assessment states that sufficient nursing staff must be available to meet resident needs. Multiple grievances were filed by residents regarding slow call light response times, and staff interviews confirmed that inadequate staffing contributed to delays. Certified Nursing Assistants (CNAs) reported being overwhelmed and unable to answer all call lights promptly due to insufficient staffing levels. Residents described waiting extended periods for assistance, with one resident reporting a wait of an hour and a half after an episode of incontinence, and another stating that call lights could go unanswered for over an hour. Direct observation by the surveyor confirmed call lights going unanswered for 10 to 21 minutes. Family members also reported long waits for call light responses. The administrator acknowledged that call lights should be answered within five to ten minutes and that it was unacceptable for them to go unanswered for 20 minutes or more.
Unlabeled Insulin Vials and Pens Found in Medication Carts
Penalty
Summary
Surveyors found that the facility failed to remove and discard unlabeled multi-dose insulin vials and insulin delivery pens from four active medication carts. This deficiency affected 17 residents who were reviewed for insulin usage. During observations, multiple instances were noted where unlabeled insulin vials and pens were stored in the insulin compartments of medication carts across several halls, including Harmony I, Harmony II, and the respiratory unit. Interviews with nursing staff confirmed that these insulin vials and pens were not labeled with resident names and should not be used or stored in the carts. The facility's policies require that all medications be stored in containers with pharmacy labels and be prepared and administered only to the residents for whom they were ordered. The Director of Nursing and nursing staff acknowledged that insulin vials and pens not labeled with a resident's name should be immediately discarded and never used for any resident. Despite these policies, the presence of unlabeled insulin in active medication carts was observed for all residents in the facility who regularly utilize insulin.
Failure to Follow Abuse Investigation Procedures
Penalty
Summary
The facility failed to fully implement its Abuse Prevention Policy during an investigation into an allegation of physical abuse made by a resident. According to the policy, the appointed investigator is required to interview the person who reported the incident, anyone likely to have direct knowledge, the resident if possible, and other residents who receive care from the same staff member accused, as well as employees who regularly work with the accused. In this case, the investigation did not include interviews with other residents who received care from the same caretakers as the resident who made the allegation. The administrator confirmed that these required interviews were not conducted during the investigation, as the investigation was handled by another appointed individual in her absence.
Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with significant cognitive deficits, as evidenced by a BIMS score of 00 and a care plan noting risk factors for abuse. The incident began when the resident's wife, a retired nurse and mandated reporter, observed a severe bruise near the resident's eye and reported that the resident claimed a man had entered his room and caused the injury. The facility's abuse prevention policy requires interviews with the person reporting the incident, anyone with direct knowledge, the resident if possible, and other residents and staff who may have relevant information. During the investigation, staff who worked the night of the alleged incident were interviewed and reported not seeing any male enter the resident's room. However, the investigation did not include interviews with other residents residing near the affected resident's room or those who received care from the same staff. The Director of Nursing confirmed that some interviewable residents in the hallway should have been included in the investigation, acknowledging that the process was not thorough and did not meet the facility's own policy requirements.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide weekly showers for seven out of eight residents reviewed in a sample of nine. The facility's policy requires that showers be documented weekly, but records show that residents did not receive showers as scheduled. The facility's shower schedule indicates bi-weekly showers for the residents, but documentation was missing for several weeks, indicating a failure to adhere to the schedule. Residents expressed dissatisfaction with the shower schedule, with some stating they were not receiving showers on their scheduled days. One resident, who is the Resident Council President, reported that staff often claimed they did not have time to provide showers or promised to return but did not. Another resident on hospice care expressed discomfort with the way showers were administered and noted that they often had to wash themselves due to lack of assistance. The Director of Nursing acknowledged the issues with the shower schedule, stating that improvements were being made but could not provide additional documentation to support compliance with the shower policy. This lack of documentation and adherence to the shower schedule led to the deficiency identified in the report.
Failure to Provide Sugar Substitutes for Diabetic Residents
Penalty
Summary
The facility failed to adhere to its dietary menu by not providing necessary condiments, specifically sugar substitutes, for residents with dietary preferences and needs. The facility's Week at a Glance Dietary Menu indicated that condiments should be served with all meals, but observations on multiple occasions revealed the absence of sugar substitutes on dining room tables, individual serving trays, and the main dining room condiment cart. This deficiency affected six out of nine residents reviewed, all of whom had a diagnosis of Diabetes Mellitus, necessitating the use of sugar substitutes. Interviews with residents and the dietary manager highlighted the ongoing issue of insufficient sugar substitute supplies. Residents reported having to purchase their own sweeteners due to frequent shortages, and the dietary manager acknowledged the high demand and occasional hoarding of sweetener packets by residents. Despite the facility's policy allowing for emergency purchases from local stores, the dietary manager admitted to not realizing the stock had been depleted, resulting in a lack of sugar substitutes available for residents from March 10 to March 27.
Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to adhere to its own respiratory therapy procedures and professional standards, resulting in deficiencies in the management of respiratory equipment for several residents. Specifically, the facility did not ensure that oxygen tubing, humidification reservoirs, and other respiratory equipment were properly dated, bagged, and stored off the floor. For instance, one resident's nasal cannula tubing was not dated, and the humidification reservoir was improperly dated, with a new date written over an old one. Another resident's oxygen tubing and humidification reservoir were also undated, and a nebulizer mask was found hanging uncovered and close to the ground. Additionally, other residents were observed with undated nasal cannulas and humidification reservoirs, and one resident had a CPAP mask with undated tubing. A gallon of distilled water, used for humidification, was found sitting on the floor without a date, and later dated incorrectly. These observations were confirmed by the facility's LPN/Infection Preventionist, who acknowledged the discrepancies and the failure to follow the facility's respiratory therapy procedures.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to document in the residents' medical records or provide written notification to residents and/or their representatives regarding hospital transfers or discharges. This deficiency was identified through record review and interviews, revealing that the facility did not issue written notifications for any resident when they were discharged to the hospital. The facility's Transfer and Discharge Policy requires that residents or their authorized legal representatives be notified both verbally and in writing in emergent situations, including details such as the reason for transfer, effective date, location, right to appeal, and contact information for the state Ombudsman. However, the Regional Director of Operations admitted that these notifications were not being completed due to staff turnover, despite previous compliance following a similar issue identified a couple of years ago. This oversight has the potential to affect all 73 residents residing in the facility.
Facility Lacks Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON), which is a requirement for providing adequate support and care for residents. This deficiency was identified through observation, interviews, and record reviews. The facility's daily census report documented 75 residents, and the facility assessment tool highlighted the necessity of a DON for the facility's operations, including infection control and compliance with state and federal regulations. However, the assessment did not document a current DON, and the job summary for the DON position outlined critical responsibilities that were not being fulfilled due to the vacancy. The deficiency arose when the former DON resigned abruptly, leaving the facility without a DON for several weeks. During this period, the Assistant Director of Nursing (ADON), who is a Licensed Practical Nurse (LPN), was temporarily filling in for the DON role. The Administrator in Training acknowledged the absence of a DON and mentioned efforts to interview a potential candidate, although no interviews had been conducted at the time of the report. This lack of a full-time DON has the potential to affect all 75 residents in the facility.
Failure to Notify Family of Resident Fall
Penalty
Summary
The facility failed to notify a family member of a resident's fall, which was a deficiency identified during the survey. The facility's policy requires prompt notification of the resident, their attending physician, and their representative in the event of a change in the resident's condition or status, including falls. In this case, a resident self-reported a fall in their room, resulting in a head injury. The fall was documented, but there was no record of the family being notified until 29 hours later, despite the facility's policy. The resident's primary care physician was informed of the fall over three hours after it was reported, but the family was not notified until the following day. The delay in communication led to the family requesting the resident be sent to the hospital for further evaluation. The facility administrator confirmed that the family was not notified initially because the resident was cognitively intact and their own power of attorney. However, the regional director confirmed that the facility's policy is to notify family members or emergency contacts of such incidents.
Failure to Complete Neurological Assessments and Timely Hospital Transfer
Penalty
Summary
The facility failed to implement complete neurological assessments, provide continuous monitoring, and ensure timely hospital transfer for a resident who experienced an unwitnessed fall. The resident, who had a history of cerebral infarction, chronic respiratory failure, and other significant health conditions, fell in their room and hit their head, resulting in a knot on the occipital region. Initial assessments were conducted, and neurological checks were initiated but not completed as per the facility's protocol. The resident self-reported the fall and was noted to have a knot on the head with no loss of consciousness. Despite the initial assessment and the initiation of neurological checks, the monitoring was not continued beyond a certain point, and the resident later complained of complete vision loss in one eye and severe headache. It was only after these symptoms were reported that the facility contacted emergency services for hospital transfer. The hospital evaluation revealed that the resident had suffered an occipital stroke, which was not immediately identified due to the incomplete neurological assessments and delayed response. The facility's failure to adhere to its own policy for monitoring and timely intervention contributed to the delay in the resident receiving appropriate medical care.
Resident Fall Due to Inadequate Supervision During Care
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R6, during incontinence care, which resulted in a fall and subsequent injury. R6, who has a history of falls and is at high risk for falls due to conditions such as contractures, dementia, and a traumatic brain injury, was being assisted by a CNA when the incident occurred. The CNA was providing care and turned away from R6 to find barrier cream, during which time R6 fell from the bed and hit her head, leading to a fracture of the left femur. The facility's policies require that CNAs ensure resident safety during care, including keeping necessary supplies within reach and maintaining a hazard-free environment. However, during the incident, the CNA did not maintain physical contact with R6 and turned away, which contributed to the fall. The CNA was unaware if R6 was reaching for something or trying to grab onto something due to falling, indicating a lack of adequate supervision and safety measures during the care process. The investigation into the fall was insufficient, as the facility administrator only interviewed the CNA involved and did not speak with R6, who was cognitively intact and could have provided valuable information about the incident. The Regional Director later educated the administrator on the importance of interviewing the resident involved in such incidents. The facility's failure to conduct a thorough investigation and ensure proper supervision during care led to the deficiency noted in the report.
Misappropriation of Controlled Substances by RN
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substance medications for eight residents. The incident involved a Registered Nurse (RN), identified as V8, who was observed on video surveillance taking controlled substances from the medication cart and placing them into her pocket. This occurred on the Respiratory Care Unit, where V8 had access to the medications of residents R2, R7, R9, R10, R11, R12, R13, and R14. The facility's video footage showed V8 unlocking the medication box, flipping through the narcotic count book, and discreetly removing narcotic medications over a span of two minutes. The report also includes statements from a Licensed Practical Nurse (LPN), identified as V10, who suspected V8 of stealing medications due to her behavior and appearance, which reminded V10 of someone with a pill addiction. V10 reported these suspicions to the police, who confirmed the theft after reviewing the surveillance footage. V8 was subsequently arrested and charged with forgery, possession of a controlled substance, and theft. The facility's administrator verified the theft after reviewing the surveillance footage, which clearly showed V8's actions.
Failure to Obtain Physician Orders and Timely Treat UTIs
Penalty
Summary
The facility failed to obtain physician orders for the use and care of an indwelling urinary catheter for a resident, failed to notify a physician of abnormal urine laboratory test results, and failed to timely treat a urinary tract infection (UTI). These failures resulted in the resident experiencing lower abdominal pain, urine with increased sediment in the catheter tubing and bag, and abnormal urine laboratory test results with a delay in physician notification and treatment. The resident was subsequently transferred to two different hospitals and admitted to the intensive care unit with a diagnosis of UTI with septic shock. The resident's medical records did not contain documentation that the indwelling catheter care was completed daily. The resident's urine laboratory results indicated a UTI, but the results were not promptly communicated to the physician, and no treatment orders were obtained. The resident's spouse reported that the resident had been complaining about lower abdominal pain and not feeling well for almost a week, and the staff did not take appropriate action despite the spouse's concerns. Another resident also had a physician-ordered urinalysis and culture and sensitivity test that was not completed. The Director of Nursing verified that the test should have been collected but was not done. This indicates a pattern of failure to follow through with physician orders and proper documentation, leading to significant health risks for the residents.
Failure to Designate Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to oversee the Infection Prevention and Control Program (IPCP). The job summary for the IP role, dated 2/13/20, outlines responsibilities such as tracking infections, updating electronic medical records, and conducting staff in-service training on infection control. However, the Key Personnel List provided on 4/23/24 was blank in the section for the Infection Preventionist, indicating no staff member was designated for this role. Interviews revealed that the previous IP nurse left the facility on 4/2/24, and although a Licensed Practical Nurse (LPN) with a current IP certificate was identified as a backup, this LPN had not been informed or assigned to the IP role. The LPN confirmed not having worked in the IP capacity since the previous IP nurse's departure. This lack of a designated IP has the potential to affect all 72 residents currently residing in the facility.
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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