Loft Rehab & Nursing Of Normal
Inspection history, citations, penalties and survey trends for this long-term care facility in Normal, Illinois.
- Location
- 510 Broadway, Normal, Illinois 61761
- CMS Provider Number
- 145031
- Inspections on file
- 44
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Loft Rehab & Nursing Of Normal during CMS and state inspections, most recent first.
A resident with known swallowing difficulties and ongoing speech therapy, who safely tolerated only one pill at a time with applesauce, reported that an RN administered multiple medications at once and left the room while the resident was still swallowing. The resident’s preference and need for single-pill administration had been documented, and she attempted to signal the RN but was not heeded. A CNA then entered to provide incontinence care and lowered the head of the bed from elevated to flat while the resident was still trying to swallow, after which the resident began coughing, drooling, gasping, and choking. The RN returned to find the resident cyanotic with low O2 saturation, performed the Heimlich maneuver, and the resident expelled applesauce and undigested food, consistent with an esophageal obstruction that occurred during medication administration, contrary to facility policy requiring proper positioning and observation during medication administration.
A resident who was cognitively intact, used a mechanical lift, and had a pressure-relieving mattress activated the call light to request help retrieving food from the floor, but the call light reportedly remained unanswered for about 40 minutes. The resident then attempted to reach the item independently, rolled from a regular-height bed, and was found face down between the bed and the wall, complaining of pain. The resident was sent to the ED and diagnosed with multiple nondisplaced rib fractures. Staff, including CNAs, an LPN, rehab staff, and the DON, reported that call lights sometimes go unanswered for 20–40 minutes due to having only two CNAs on certain shifts, especially around dinner and bedtime, despite facility policies requiring call lights to be within reach and response times to be a priority.
A resident reported a missing cell phone and, after searching their room and common areas, staff notified the resident’s POA and management. Law enforcement was contacted, and location data suggested the phone had been taken off-site, but it was not recovered. The administrator told the POA the facility had no responsibility for the missing phone, did not report the incident to the state agency, and did not replace the phone. The POA ultimately purchased a replacement phone using the resident’s own funds, despite facility policy stating residents have the right to be free from misappropriation of property and to be informed of investigation conclusions.
A resident reported a missing cell phone to an RN, who then notified the resident’s POA and facility management. The POA later contacted local law enforcement and provided tracking information indicating the phone’s last known location off facility grounds, but the phone was not found. The Administrator told the POA the facility had no responsibility for the missing phone, did not reimburse the POA for a replacement, and acknowledged never reporting the allegation of misappropriated property to the state agency, despite a written abuse prevention policy requiring investigation and reporting of such allegations.
A resident reported a missing cell phone to a RN after unsuccessfully searching their room and a common area. The RN notified the resident’s POA and management, and the POA later involved local law enforcement, providing Life 360 data showing the phone’s last known location off-site. The police were unable to locate the phone. The Administrator told the POA the facility had no responsibility for the missing phone, did not report the incident to the state agency, did not identify who took the phone, and did not replace it, despite a written abuse prevention policy requiring investigation, state reporting, and keeping the resident informed regarding misappropriation of property.
Multiple residents experienced significant delays in call light response, with some waiting up to two hours for assistance. Grievance logs and resident council minutes documented ongoing concerns about slow staff response, and interviews confirmed that both cognitively impaired and intact residents were affected. Facility policy required call lights to be answered within 10-15 minutes, but this was not consistently achieved.
Three dependent residents did not consistently receive the required number of showers or bed baths, with some reporting long periods without bathing and issues with hot water availability. Staff confirmed that not all residents received two showers weekly and could not provide accurate documentation of bathing schedules, resulting in a deficiency related to inadequate ADL support and personal hygiene.
The facility failed to maintain complete and accurate medical records for several residents, including one who was not assessed by a nurse during a five-hour stay and others who did not receive adequate showers or bed baths. Documentation related to care was found to be inaccurate and altered, with inconsistencies in signatures and use of correction tape, in violation of facility policy.
Two residents with cognitive and behavioral issues engaged in a physical altercation in their shared room, exchanging hits and kicks after a verbal exchange. Staff intervened to separate them, but the incident demonstrated a failure to protect residents from physical abuse.
Staff and residents reported ongoing sightings of roaches in hallways and resident rooms over several months, with multiple rooms requiring pesticide treatment and restricted access. Despite a policy requiring effective pest control and prompt reporting, the facility did not adequately address the infestation, as confirmed by staff interviews, resident reports, and the need for an unscheduled pest control visit.
A resident with severe cognitive impairment and chronic eye conditions did not receive the prescribed Systane Complete Ophthalmic Solution as ordered by the physician. Instead, an LPN administered Ketotifen Fumarate eye drops, incorrectly assuming they were equivalent. The pharmacist confirmed these medications are not interchangeable, and the facility's policy requiring matching orders and prescriptions was not followed.
A resident with significant mobility impairments and a history of falls was propelled in a wheelchair by staff without foot pedals attached, leading to a fall and head injury. Staff interviews and documentation confirmed that the resident was dependent on staff for wheelchair mobility and that foot pedals were not routinely used, despite the resident's risk factors and the facility's fall prevention protocols.
After a resident with multiple health conditions tested positive for COVID-19, the facility did not initiate required contact tracing or testing for other residents and staff, despite policy and staff acknowledgment that these steps should have been taken. This lapse in infection control had the potential to impact all residents.
A resident with multiple diagnoses, including COVID-19, was not provided with complete and accurate nursing assessments or documentation of respiratory status and transfer to the hospital. Progress notes showed the resident became symptomatic and tested positive for COVID-19, but there were missing head-to-toe and respiratory assessments, and no record of physician or family notification regarding the hospital transfer, contrary to facility policy.
A facility failed to provide timely laboratory services for a resident who underwent kidney stone surgery. The discharge instructions required a 48-hour urine collection two weeks post-operatively and a urine culture one month post-hospitalization. However, the medical record lacked documentation of these tests, and no results were found. The Director of Nursing confirmed the absence of test results, violating the facility's policy on timely laboratory services.
The facility failed to update care plans for two residents following status changes. One resident required a wheelchair modification to prevent sliding during transport, which was not documented in the care plan. Another resident began dialysis, but this was not reflected in their care plan. The Social Service Director acknowledged the oversight.
A facility failed to assess and document the elopement risk for a resident with severe cognitive impairment and a history of attempting to leave the building. The resident's medical record lacked an elopement assessment and justification for an elopement management bracelet. Upon readmission from the hospital, the resident did not receive a new assessment or bracelet, as confirmed by the SSD and an LPN.
The facility failed to maintain sanitary conditions in its dietary services, affecting all 87 residents. Observations included mildew in the ice machine, a leaking sink, soiled kitchen floors, and dirty can openers. These issues persisted over several days, indicating inadequate cleaning and maintenance.
The facility failed to permanently affix a narcotic lock box in the medication room, leading to improper storage of controlled substances. An LPN confirmed that the lock box, containing Morphine Sulfate and Hydrocodone/Acetaminophen for three residents, was not affixed and was used due to insufficient space in the medication cart. This practice violated the facility's policy requiring Schedule II medications to be stored in a permanently affixed compartment.
The facility did not ensure arbitration agreements allowed for a mutually convenient venue selection, affecting three residents. The agreements specified arbitration would occur in the facility's county unless mutually agreed otherwise.
A resident's room was found to have large areas of peeling and torn wallpaper, creating an unhomelike environment. The resident reported the disrepair had been present since their admission, and a CNA noted the damage was caused by the bed hitting the wall.
A facility failed to develop a comprehensive care plan for a hearing-impaired resident. The resident's hearing aid broke shortly after admission, and staff used a whiteboard for communication. However, the care plan did not document the hearing impairment or the communication method. The Care Plan Coordinator and DON confirmed the omission, despite policy requirements for care plan revisions.
The facility failed to provide proper pressure ulcer care and prevention for two residents. Both residents had orders for specific wound care treatments and pressure-relieving boots while in bed, but observations showed non-compliance. The treatments were not administered correctly, with medical honey not applied properly, and the residents were often without the required boots. The facility's policy on pressure injury prevention was not adhered to.
A resident with multiple medical conditions, including malnutrition and dysphagia, did not have their Gastrostomy tube placement verified before medication and feeding administration. On two occasions, a nurse and an LPN failed to check the tube placement as required by facility policy, despite clear orders to do so. This oversight occurred during the administration of water flushes, Jevity 1.5 feeding, and medications.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer. The resident had a pressure ulcer with serosanguineous drainage, but no EBP sign was posted on the door. Staff entered the room to change the dressing without donning gowns. The infection preventionist confirmed the need for EBP but did not implement it, as the ulcer was not deemed chronic.
A resident's financial affairs were mishandled when a facility withdrew funds from the resident's bank account without permission after discharge. The resident, who was cognitively intact, had authorized monthly withdrawals for billing, but the facility continued to charge for days beyond the discharge date. The error was due to a lack of communication and awareness of the discharge, causing stress for the resident's family. The facility eventually refunded the overcharged amount.
The facility failed to maintain a clean and homelike environment, affecting 36 residents. Observations revealed dirt and debris on floors, worn and slippery vinyl flooring, damaged walls, and rusted fixtures. Residents expressed concerns about these conditions, and previous complaints about cleanliness were documented. The facility administrator acknowledged the need for improvement.
A resident with a history of self-harm and suicide attempts was able to access self-harm items, leading to another attempt. Despite a care plan to remove corded accessories and replace the call light with a bell, the resident's room still contained hazardous items. Staff interviews revealed a lack of awareness and communication regarding the resident's precautions, and facility policies on behavioral health services and suicide prevention were not effectively implemented.
A resident with severe cognitive impairment and a history of exit-seeking behaviors eloped from a facility during a fire drill, remaining missing for 17 hours. The resident's care plan did not address his high risk of elopement, and staff failed to provide adequate supervision or ensure exit doors were properly alarmed. The resident was found in a potentially dangerous area after crossing a busy street.
Esophageal Obstruction After Multiple Pills Given at Once and Improper Positioning
Penalty
Summary
The deficiency involves the facility’s failure to provide safe medication administration consistent with physician orders, speech therapy recommendations, the resident’s expressed preferences, and facility policy, resulting in an esophageal obstruction during medication administration. The resident involved was cognitively intact, dependent for transfers, turning, and repositioning, and required setup/supervision with eating. Speech therapy documentation showed the resident had swallowing difficulties, including mild lingual weakness and coughing several minutes after oral intake, and that she could safely swallow only one pill at a time with applesauce. The resident had been receiving speech therapy for swallowing difficulties since mid-2025, and therapy notes indicated she was specifically concerned about swallowing multiple pills when agency staff were present. On the date of the incident, the resident reported in writing that an RN administered multiple medications at once, despite her preference and need to take one pill at a time with applesauce. The resident stated she attempted to signal the RN by raising her hand to indicate she needed one pill at a time, but the RN left the room while the resident was still swallowing the medications. Shortly thereafter, a CNA entered the room to provide incontinence care and began to lay the resident’s head of bed from an elevated position to flat while the resident was still trying to swallow the pills. The resident then began coughing, drooling, gasping, and showing signs of choking. Nursing documentation shows that when the RN was called back to the room, the resident’s lips were cyanotic, her oxygen saturation was 64%, and she indicated she could not breathe and was choking. The RN assessed the airway, did not see a visible obstruction, and initiated the Heimlich maneuver. The resident became unresponsive briefly, then expelled applesauce and undigested food, and later vomited a second time after being repositioned. The facility’s medication administration policy required qualified staff to position the resident appropriately for medication administration and to observe the resident consuming medications, but the resident’s account and the sequence of events indicate that multiple pills were given at once, her expressed need for one pill at a time was not followed, and she was repositioned to a flat position while still swallowing, leading to the choking episode and esophageal obstruction.
Failure to Timely Respond to Call Light Resulting in Fall With Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to respond to a resident’s call light in a timely manner, resulting in a fall with injury. A cognitively intact resident (R1), who used a mechanical lift and had a pressure-relieving mattress, activated the call light to request assistance in retrieving popcorn from the floor. R1 and a family member reported that the call light remained on for approximately 40 minutes without response. During this time, R1 attempted to reach the popcorn independently, rolled out of the regular-height bed, and was found lying face down between the bed and the wall. R1’s roommate yelled for help, and a CNA entered the room and observed R1 on the floor. Progress notes document that R1 complained of pain “all over,” 911 was called, and R1 was transported to a local emergency department. Emergency department records document nondisplaced right lateral fifth through ninth rib fractures and nondisplaced acute fractures of the anterior left sixth, seventh, eighth, and tenth ribs. R1’s care plan included interventions to keep the bedside table next to the bed within reach and to keep the call light within reach at all times. Staff interviews revealed that call lights sometimes go unanswered for 20 to 40 minutes, particularly on evening, dinner, and bedtime shifts, and that there were often only two CNAs on duty for the unit, with one CNA occasionally off the unit accompanying another resident to appointments. Nursing and rehabilitation staff acknowledged that at times they could not get to residents soon enough after call lights were activated. The facility’s call light policy required that call lights be available at each bedside and that response times be a priority, and the incident/accident policy required appropriate and immediate interventions and corrective actions to prevent recurrences.
Failure to Address Misappropriation of Resident’s Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of personal property and to respond appropriately when the resident’s belongings went missing. A cognitively intact resident (R6) discovered that their cellular phone was missing and searched their room and the dining room without success. A registered nurse (V9) notified the resident’s power of attorney (POA) and facility management about the missing phone. Later that day, a police officer (V11) documented taking a theft report by phone after speaking with the resident’s POA (V10), who reported that the resident’s phone, described as having a black case, was missing. The POA provided the Life 360 location data, which showed the phone’s last known location on a nearby road at a specific time, and the officer went to that location but was unable to locate the phone. The POA stated that after being notified by the facility of the missing phone, they contacted the police department and spoke with the facility administrator (V1), who indicated the facility had no responsibility for the missing phone. The POA then purchased and brought a new phone for the resident using the resident’s own personal funds. The administrator later confirmed that the missing phone was never reported to the state agency and that the facility did not replace the resident’s cellular phone, asserting that the facility was not liable for misappropriation of goods when residents are cognitively intact. The facility’s Abuse Prevention Policy, dated 1/24, affirms residents’ rights to be free from misappropriation of property and documents that the facility would keep residents informed of the conclusions of investigations, but the report indicates the facility failed to replace the misappropriated item in a reasonable time frame and failed to report the incident to the state agency.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of a resident’s property to the state agency. On 1/5/2026 at 2:40 PM, a resident (R6) informed an RN (V9) that the resident’s cellular phone could not be located after searching the resident’s room and the dining/common areas. Around 3:00 PM that same day, V9 notified the resident’s Power of Attorney (V10) and facility management that the phone was missing. Later that evening at 7:34 PM, a local police officer (V11) documented taking a theft report by phone after speaking with the resident’s Power of Attorney, who reported that the facility had called about the missing phone and provided Life 360 location data showing the phone in the roadway of a local street at approximately 2:13 PM, with no location updates for about five hours. V11 went to the indicated location but was unable to locate the phone. On 2/10/2026, the resident’s Power of Attorney stated receiving a call from the facility about the missing iPhone and reported contacting the police department and speaking with the facility Administrator (V1). According to the Power of Attorney, V1 stated the facility had no responsibility related to the missing phone. The Power of Attorney reported purchasing a replacement phone for the resident with personal funds and not being reimbursed by the facility. In an interview on 2/10/2026 at 2:15 PM, the Administrator acknowledged never reporting the missing phone to the state agency and stated the belief that the facility is not liable for misappropriation of goods when residents are cognitively intact, and that the facility did not replace the phone. The facility’s Abuse Prevention Policy dated 1/24 documents that residents have the right to be free from misappropriation of property and that the facility would investigate, report to the state agency, and keep residents informed of investigation conclusions, which was not followed in this case.
Failure to Investigate and Address Misappropriated Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and timely address an allegation of misappropriated property for one resident. On 1/5/2026 at 2:40 PM, the resident reported to a RN that the resident’s cellular phone could not be found after searching the resident’s room and the dining room. Around 3:00 PM that same day, the RN informed the resident’s power of attorney (POA) and facility management of the missing phone. Later that evening, a local police officer documented taking a theft report by phone after speaking with the resident’s POA, who reported that the facility had called about the missing phone. The POA provided the Life 360 location data, which showed the phone in the roadway of a local street at approximately 2:13 PM, with no location updates for about five hours. The officer went to that location but was unable to locate the phone. On 2/10/2026, the resident’s POA stated that after being notified by the facility of the missing phone, the POA contacted the police department and spoke with the facility Administrator, who stated the facility had no responsibility for the missing phone. The POA reported purchasing a replacement phone with personal funds and not being reimbursed by the facility. In an interview on 2/10/2026 at 2:15 PM, the Administrator stated that the missing phone was never reported to the state agency, that the facility was not liable for misappropriation of goods when residents are cognitively intact, and that the facility did not replace the phone or identify who took it, noting it could have been taken by staff, agency staff, or visitors. The Administrator also expressed a belief that facility staff would not have taken the phone. The facility’s Abuse Prevention Policy dated 1/24 documents that residents have the right to be free from misappropriation of property and that the facility would investigate, report to the state agency, and keep the resident informed of investigation conclusions, which was not followed in this case.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, as evidenced by grievance logs and resident council minutes documenting extended wait times for assistance. Grievance logs from October, November, and December 2025 recorded multiple instances where residents waited prolonged periods for help with various activities. Resident council minutes from December 2025 noted that staff needed to respond to call lights more quickly, with 13 residents present at the meeting. Interviews with residents and family members confirmed delays, including one resident who did not have a standard call light but instead used a bell that went unanswered several times. Medical records and interviews provided further details about the affected residents. One resident, admitted with multiple diagnoses including weakness, hemiparesis, cognitive decline, and multiple sclerosis, lacked an admission assessment or note from a licensed nurse during their stay. Another resident with cognitive impairment reported call light response times ranging from 30 minutes to two hours. A third resident, cognitively intact, also reported waiting up to two hours for assistance. Facility policy and statements from the corporate nurse and DON indicated that call lights should be answered within 10-15 minutes, but this standard was not met.
Failure to Provide Required Bathing Assistance and Maintain Hygiene
Penalty
Summary
The facility failed to provide adequate bathing assistance to three dependent residents who required help with activities of daily living (ADLs). One resident, admitted with acute osteomyelitis, weakness, chronic atrial fibrillation, and chronic kidney disease, reported not receiving a shower or bed bath for approximately two weeks prior to a recent bed bath, which was given with lukewarm water obtained from another area due to a lack of hot water in the resident's hall. The resident stated that the hot water issue had persisted for a couple of months and affected the entire hall. Another resident with chronic obstructive pulmonary disease, respiratory failure, and diabetes reported not consistently receiving the required two showers per week, though the showers received were warm. A third resident, admitted with a left fibula fracture and repeated falls, communicated that the lack of hot water on her hall had lasted over a month and that she was taken to another part of the facility for showers, but did not feel she received enough showers overall. Interview with the corporate nurse confirmed that not all residents were receiving the required two showers weekly and that accurate documentation of shower dates could not be provided. The facility's ADL policy requires that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene, including regular bathing. The failure to provide consistent bathing services and maintain proper documentation led to the deficiency identified during the survey.
Incomplete and Inaccurate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents reviewed. One resident was admitted from a hospital with multiple diagnoses, including weakness, hemiparesis, cognitive decline, and multiple chronic conditions. There was no admission assessment or nursing note documenting the time of arrival or any assessment by a licensed nurse during the five hours the resident was in the facility before being transferred to another facility. Both the family member and facility staff confirmed that the resident was not assessed by a nurse during this period, and the medical record lacked any documentation of an assessment or admission note. Additionally, three other residents reported not receiving adequate showers or bed baths, with one stating they had not received a shower or bed bath for approximately two weeks. Review of the facility's shower documentation revealed inaccuracies and alterations, including the use of correction tape and inconsistent signatures compared to staff assignment sheets. The facility's own policy requires that each resident's medical record accurately reflect the care and services provided, with documentation completed at the time of service or by the end of the shift, which was not followed in these cases.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. An incident occurred between two roommates, one with diagnoses including metabolic encephalopathy, dementia with agitation, and a history of wandering, and the other with cognitive impairment and behavioral symptoms. The incident was documented in an investigation file, which noted that staff responded immediately to intervene and separate the residents after a physical altercation took place in their shared room. Staff statements indicated that the two residents exchanged words, engaged in hitting and kicking, and that yelling was heard from the room. One resident reported being hit and responding by hitting back. The care plans for both residents documented behavioral concerns, including wandering and behavioral symptoms, but the altercation still occurred, resulting in a failure to ensure the residents' right to be free from physical abuse.
Failure to Follow Pest Control Policy Resulting in Ongoing Roach Infestation
Penalty
Summary
The facility failed to follow its pest control policy for four residents, as evidenced by multiple observations and staff interviews. Housekeeping and CNA staff reported seeing roaches in hallways and resident rooms, particularly in the downtown west hallway, with sightings beginning as early as March or April. On the day of the survey, several resident rooms had been recently sprayed for pests, with doors closed and signs posted requiring ventilation. One resident attempted to enter his room but was redirected by an LPN due to recent pesticide application. Residents also reported seeing roaches in their rooms, and a resident pointed out a roach-like bug to the surveyor, which was confirmed by staff. The pest control technician was called to the facility on the day of the survey in response to a work order for bugs in resident rooms, which had been submitted earlier that morning. The facility's pest control policy requires maintaining an effective program to eradicate and contain pests, including regular treatment of the facility's exterior and prompt reporting of issues between scheduled visits. Despite this policy, staff and residents reported ongoing pest sightings over several months, indicating the facility did not effectively implement its pest control measures.
Failure to Follow Physician's Order for Eye Drop Administration
Penalty
Summary
The facility failed to follow a physician's order for the administration of eye drops for one resident with severe cognitive impairment and chronic eye conditions, including ectropion and chronic blepharitis. The resident was observed with red eyes and yellow/white matter on the lower lids, and was seen rubbing his eyes. The physician's order specified Systane Complete Ophthalmic Solution, one drop to each eye twice daily, but only Ketotifen Fumarate eye drops were available and administered. The LPN stated that Ketotifen was being used in place of Systane, believing them to be the same, although the pharmacist later clarified that these medications serve different purposes and are not interchangeable. A review of the medication cart confirmed that only Ketotifen eye drops were present for the resident, with no Systane available. The pharmacist also noted that Ketotifen was not on the resident's order profile and that any substitution would require a physician's order and pharmacy notification, which had not occurred. The facility's policy requires that physician orders and prescriptions match and that any discrepancies be resolved with a valid prescription, but this protocol was not followed in this case.
Failure to Use Wheelchair Foot Pedals Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that wheelchair foot pedals were in place prior to propelling a resident in a wheelchair, resulting in a fall and serious injury. A resident with multiple diagnoses, including hemiplegia, muscle weakness, unsteadiness, and a history of falls, was being transported by an activity aide without foot pedals attached to the wheelchair. The resident, who was dependent on staff for wheelchair mobility and did not self-propel, placed her feet on the floor while being moved and subsequently fell forward from the wheelchair, striking her head on the tile floor. This incident led to a subarachnoid hemorrhage and required an overnight hospital stay. Interviews and record reviews confirmed that staff routinely propelled the resident without foot pedals, despite the resident's care plan identifying her as at risk for falls and requiring substantial assistance for mobility. Occupational therapy staff noted that while the resident had foot pedals available, they were not often used, and the resident was known to refuse them on occasion. Multiple CNAs confirmed the absence of foot pedals prior to the fall and acknowledged the risk of falling due to their non-use. The facility's fall prevention program required individualized interventions and the use of assistive devices for residents at risk, but these measures were not implemented for this resident at the time of the incident.
Failure to Initiate Contact Tracing and Testing After COVID-19 Case
Penalty
Summary
The facility failed to follow its infection prevention, response, and reporting policy after a resident tested positive for COVID-19. The resident, who had multiple diagnoses including COVID-19, was identified as positive on 4/14/2025, with documentation showing that the Power of Attorney was notified and COVID isolation precautions were initiated. However, the Infection Preventionist (RN) stated that she was not aware that contact tracing and testing were required following the positive result and confirmed that these steps were not taken. The Director of Nursing verified that contact tracing and testing should have been initiated immediately after the positive case was identified. The facility's policy, reviewed on 10/1/2024, requires evaluation of potential exposures and either contact tracing or a broad-based testing approach for all residents and health care providers identified as close contacts or on the affected unit. Despite this, no contact tracing or testing was performed after the resident's positive COVID-19 result, and staff were noted to work throughout the facility, increasing the potential for exposure. The failure to implement these required infection control measures had the potential to affect all 108 residents in the facility.
Incomplete Documentation of Assessments and Transfer for Resident with COVID-19
Penalty
Summary
The facility failed to document complete and accurate assessments for one resident who had multiple diagnoses, including repeated falls, malignant neoplasm of the prostate, COVID-19, and chronic atrial fibrillation. After being admitted from the hospital emergency room following a fall, the resident's nursing assessments on the first two days did not indicate any respiratory symptoms and documented the resident as negative for respiratory signs. However, there were no head-to-toe or respiratory assessments documented for the following three days, despite the resident testing positive for COVID-19 and exhibiting symptoms such as chest congestion and cough. Progress notes indicated that COVID-19 isolation precautions were initiated and that the resident's power of attorney was notified. However, there was no documentation regarding subsequent assessments, the resident's transfer to the hospital, the rationale for the transfer, or whether the physician or family were informed of the transfer. The Director of Nursing acknowledged the lack of documentation and stated that it was expected for respiratory assessments and transfer documentation to be completed when a resident becomes symptomatic and is sent to the hospital. The facility's policy also requires physician notification in the event of a transfer or discharge.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident who was diagnosed with a kidney stone and underwent bilateral percutaneous nephrolithotomy. The After Visit Summary (AVS) from the hospital discharge on July 25, 2024, included instructions for a 48-hour urine collection to be conducted two weeks post-operatively, and a urine culture to be collected one month post-hospitalization and then monthly for two more months. However, the resident's medical record did not document the completion of these urine tests, and no laboratory results were found in the record. On March 10, 2025, the Director of Nursing confirmed the absence of urine test results in the medical record, despite the discharge instructions. The facility's Laboratory Services and Reporting policy mandates the provision of laboratory services when ordered by a physician and emphasizes the timeliness of these services. The policy also requires that all laboratory reports be dated, contain the name and address of the testing laboratory, and be filed in the resident's clinical record. The failure to adhere to these policies resulted in a deficiency in providing timely laboratory services as ordered by the physician.
Failure to Revise Care Plans Following Status Changes
Penalty
Summary
The facility failed to revise care plans for two residents, R4 and R7, following changes in their status, as required by their policy. R4, who is cognitively intact and requires a wheelchair for mobility, experienced issues during transport due to her inability to keep her feet on the pedals of the transport wheelchair. This led to her sliding down in the wheelchair. On January 19, 2024, a Physical Therapy Assistant applied a footboard and non-slip material to R4's transport chair to prevent this issue. However, R4's care plan was not updated to document this intervention. Similarly, R7, who is also cognitively intact and requires dialysis, had a care plan that did not document the dialysis services. R7 was referred to dialysis on December 6, 2024, and began receiving dialysis three times a week starting December 25, 2024. Despite this significant change in R7's care needs, the care plan was not revised to include dialysis services. The Social Service Director/Care Plan Coordinator acknowledged that these updates should have been made but were not completed.
Failure to Assess and Document Elopement Risk for Resident
Penalty
Summary
The facility failed to properly assess and document the elopement risk for a resident, identified as R6, who was severely cognitively impaired and had a history of attempting to leave the building. Despite the facility's policy requiring a systematic approach to managing residents at risk for elopement, R6's medical record lacked an elopement assessment or documentation justifying the application of an elopement management bracelet on November 25, 2024. The Social Services Director (SSD) mistakenly believed that nursing staff were responsible for completing elopement assessments, leading to a lack of documentation and assessment for R6. Upon readmission from the hospital on January 30, 2025, R6 did not receive a new elopement assessment, nor was the elopement management bracelet reapplied, as confirmed by both the SSD and a Licensed Practical Nurse (LPN). The SSD acknowledged that R6 continued to attempt to exit the building and required an elopement management bracelet, but was unaware that the necessary assessments and interventions had not been completed following R6's readmission.
Unsanitary Conditions in Dietary Services
Penalty
Summary
The facility failed to maintain sanitary conditions in its dietary services, which could potentially affect all 87 residents. Observations revealed dark-colored mildew growth inside the dietary service ice machine, specifically on the plastic evaporator skirt. The Regional Dietary Manager indicated that the facility's maintenance department was responsible for cleaning the machine, but the issue persisted over multiple days. Additionally, the kitchen's three-basin sink had a continuously dripping sewer pipe, with discolored and opaque water collecting in a pan on the floor. The kitchen floors were sticky and soiled with food debris and other waste materials, and two can openers were found to be soiled with food debris and metal shavings. The pantry floor was also littered with various debris. These unsanitary conditions were observed over several days, indicating a lack of proper cleaning and maintenance.
Improper Storage of Narcotics in Medication Room
Penalty
Summary
The facility failed to comply with medication storage regulations by not permanently affixing a narcotic lock box in the medication room. During an inspection, it was observed that a lock box containing narcotics was placed loosely on a shelf in the medication storage room. The lock box contained medications for three residents, including Morphine Sulfate for two residents and Hydrocodone/Acetaminophen for one resident. The Licensed Practical Nurse (LPN) confirmed that the lock box was not affixed to anything and was used because there was insufficient space in the medication cart lock box. The facility's Medication Storage policy, which was reviewed and revised in December 2023, requires Schedule II controlled medications to be stored in a separately locked, permanently affixed compartment when other medications are stored in the same area. The Administrator acknowledged providing the lock box to the nurses for storing extra medications. This practice was not in alignment with the facility's policy, leading to the deficiency noted during the survey.
Arbitration Venue Selection Deficiency
Penalty
Summary
The facility failed to ensure that arbitration agreements included provisions for selecting an arbitration venue convenient to both parties. This deficiency was identified during interviews and record reviews, which revealed that three residents had signed arbitration agreements upon admission that did not contain language allowing for the selection of a mutually convenient arbitration venue. Instead, the agreements stipulated that arbitration would occur in the county where the facility is located unless both parties agreed otherwise. This oversight has the potential to affect three residents out of the five reviewed for arbitration agreements.
Failure to Maintain Homelike Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a homelike environment in a resident's room, specifically for a resident identified as R61. During an observation on October 6, 2024, it was noted that large areas of wallpaper above R61's headboard were peeling and torn, with sections dangling from the wall. A significant portion of the wallpaper, approximately four feet tall, was curling away from the wall. This condition persisted as of a follow-up observation on October 9, 2024. R61, who was present during the observations, reported that the wall had been in disrepair since their admission to the facility on March 23, 2023. A Certified Nurse Aide (V18) indicated that the damage was due to R61's bed being positioned too high and hitting the wall.
Failure to Address Hearing Impairment in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a hearing-impaired resident, identified as R73. Observations and interviews revealed that R73 was sitting in his room without his hearing aids and expressed difficulty in hearing. Staff members confirmed that R73's hearing aid broke shortly after his admission, and a whiteboard was being used as an alternative communication method. However, the care plan for R73 did not address his hearing impairment or the use of the whiteboard for communication. The Care Plan Coordinator and the Director of Nursing acknowledged that the care plan lacked documentation of a hearing assessment or a plan to address the hearing deficit, despite the facility's policy requiring care plans to be reviewed and revised as necessary when a resident experiences a status change.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and implement pressure-relieving interventions for two residents, R138 and R142, who were reviewed for pressure ulcers. R138 had multiple diagnoses, including a pressure ulcer of the sacral region, with an order for treatment involving cleansing with normal saline, drying, applying medical honey, and covering with a bordered gauze dressing. Additionally, R138 was ordered to have pressure-relieving boots on while in bed. However, observations revealed that R138 was frequently without the boots, and the treatment was improperly administered as the medical honey was not applied correctly, sliding off the wound and onto healthy skin. Similarly, R142, who had a coccyx wound, was ordered to receive a similar treatment regimen and to wear pressure-relieving boots while in bed. Observations showed that R142 was also without the boots, and the treatment was not executed as ordered. The medical honey was not applied correctly, as it slid off the pressure ulcer, and the dressing was applied without the honey being on the open area of the ulcer. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of proper implementation of the care plan and interventions for these residents.
Failure to Verify Gastrostomy Tube Placement Before Administration
Penalty
Summary
The facility failed to adhere to its policies regarding the verification of Gastrostomy tube (g-tube) placement before administering medications and feedings for a resident. The resident, identified as R138, had multiple medical conditions including Unspecified Protein-Calorie Malnutrition, Dysphagia, and several malignant neoplasms. The resident's care plan included orders for nothing by mouth and specific instructions for flushing the enteral tube with water before and after medication administration and feedings. Additionally, there was an order to check the g-tube placement before administering medications and feedings every shift. On two separate occasions, staff members did not verify the g-tube placement as required. A Registered Nurse administered a water flush and a Jevity 1.5 feeding without checking the tube placement, stating that she had checked it earlier in the day. Similarly, a Licensed Practical Nurse administered medications via the g-tube without verifying its placement, acknowledging afterward that she should have done so. The facility's policies clearly state that tube placement must be verified prior to administering any fluids or medications, which was not followed in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer, as observed during a survey. The resident, identified as R142, had a pressure ulcer on the coccyx with serosanguineous drainage, documented in the nurse's notes. Despite this condition, there was no EBP sign posted on or near the resident's door on multiple occasions. On one occasion, a registered nurse and a certified nursing assistant entered the resident's room to change the dressing without donning gowns, which is a necessary precaution for handling open pressure ulcers. The infection preventionist confirmed that residents with pressure ulcers should be placed in EBP but did not do so because the ulcer was not considered chronic.
Unauthorized Withdrawal from Resident's Bank Account
Penalty
Summary
The facility failed to safeguard a resident's financial affairs by withdrawing funds from the resident's personal bank account without permission. The resident, who was cognitively intact, had authorized the facility to withdraw a specific amount monthly for billing purposes. However, after the resident was discharged, the facility continued to withdraw funds for days beyond the discharge date. This unauthorized withdrawal was acknowledged by the facility's Regional Corporate Business Office Manager, who stated that the funds were removed due to a lack of awareness of the resident's discharge. The resident's Durable Power of Attorney (DPOA) confirmed that the facility overcharged the resident for days not spent at the facility, causing stress and confusion for the resident's family. Although the facility eventually refunded the overcharged amount, the incident highlighted a lack of communication and proper billing procedures. The facility's administrator admitted that there was no policy in place for such situations and acknowledged the error in billing the resident for days past the discharge date.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for its residents, affecting 36 out of 39 residents reviewed for environmental cleanliness. During an environmental tour, several deficiencies were observed, including heavy accumulations of dirt and debris on bathroom floors, worn and slippery vinyl flooring, and damaged walls and bulletin boards. Residents expressed concerns about these conditions, with one resident noting a broken wall and another mentioning the need for new walls due to noise issues. Additionally, rusted fixtures, cracked ceilings, and detached baseboards were noted in various rooms, contributing to the overall unclean and unsafe environment. Further observations included a black ring around a toilet, heavily soiled floor-to-wall junctions in multiple rooms, and a dirty entry threshold into the main dining room. The facility's Concern Log documented previous complaints from residents about sticky floors, unpleasant odors, and dirty conditions, indicating ongoing issues with cleanliness. The facility administrator acknowledged these deficiencies, agreeing that residents deserve a better environment.
Failure to Prevent Self-Harm in Resident with Known History
Penalty
Summary
The facility failed to ensure the safety and supervision of a resident with a history of self-harm and suicide attempts. This deficiency was identified when the resident, who had previously been found with a call light cord wrapped around their neck, was able to access self-harm items again, leading to another suicide attempt. The resident was found with a plastic bag over their head, resulting in emergency transport to the hospital. Despite the resident's known history of self-harm, the facility did not implement adequate interventions or update the care plan to prevent further incidents. The resident's medical records indicated a history of self-harm attempts and suicidal ideations, with documented incidents of using a call light cord and a plastic bag to attempt self-harm. The care plan had been updated to remove corded accessories and replace the call light with a bell, but these interventions were not consistently implemented. Observations during the survey revealed that the resident's room still contained corded items and plastic bags, which were accessible to the resident, indicating a lack of adherence to the care plan. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's precautions and interventions. Some staff members were not informed of the resident's history of self-harm or the necessary precautions, and there was no documentation of staff education on these matters. The facility's policies on behavioral health services and suicide prevention were not effectively implemented, as evidenced by the continued presence of self-harm hazards in the resident's environment.
Failure to Prevent Resident Elopement During Fire Drill
Penalty
Summary
The facility failed to prevent the elopement of a severely cognitively impaired resident, who exited the facility unnoticed during a fire alarm drill. The resident, who had a known history of exit-seeking behaviors and was at high risk for elopement, was not adequately supervised or reassessed for his care plan. This oversight led to the resident being missing for 17 hours, during which he was found in a potentially dangerous environment, having crossed a busy street and ended up in a grassy area next to a creek. The resident's medical history included severe cognitive impairment, dementia, and other health conditions, which increased his vulnerability. Despite previous incidents of wandering and exit-seeking behaviors documented in his progress notes, the resident's care plan did not address these risks. On the day of the incident, staff observed the resident near exit doors and attempted to redirect him, but there was a lack of consistent supervision, especially during the fire alarm when no nurses were present at the nurse's station. The facility's policies on elopement and wandering were not effectively implemented, as evidenced by the failure to ensure that exit doors were properly alarmed and monitored. The resident's personal alarm system was only functional at the front door, which did not prevent his exit through other doors. The lack of a comprehensive plan to address the resident's high risk of elopement and the absence of adequate supervision during emergency procedures contributed to the incident.
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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