Luther Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Illinois.
- Location
- 601 Lutz Road, Bloomington, Illinois 61704
- CMS Provider Number
- 146184
- Inspections on file
- 18
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Luther Oaks during CMS and state inspections, most recent first.
Two residents who experienced falls did not have complete or accurate documentation in their medical records. In one case, a fall and subsequent intervention were not recorded in the nursing notes or care plan. In another, a fall resulting in serious injury was not documented by the DON, and the care plan contained errors regarding the use of enabler side rails. These actions did not meet the facility's documentation standards.
A resident with Parkinson's disease, severe cognitive impairment, and a high risk for falls was transferred by a CNA without the use of a gait belt, despite facility policy and staff expectations requiring its use. Multiple staff confirmed the need for a gait belt during transfers for this resident, and the device was found unused in the room. This failure resulted in a deficiency related to accident hazard prevention and supervision.
The facility failed to employ a clinically qualified Director of Food and Nutrition, affecting all 16 residents. During a survey, deficiencies were noted, including unclean kitchen conditions, improper sanitation, and uncovered ice cream canisters. The Dietary Manager in Training had not started required certification courses.
The facility failed to maintain sanitary conditions in food service, affecting all 16 residents. Staff were observed preparing food without hairnets, and food debris was found on trays and tables. Ice cream containers were uncovered, risking cross-contamination. Sanitation practices were inadequate, with improper sanitizer concentration and incorrect cleaning solutions used, violating facility policy.
The facility lacked a comprehensive infection control program, with infection logging only starting recently. An RN failed to follow proper infection control practices by handling a contaminated pill without gloves and not performing hand hygiene before administering nasal spray to a resident.
A resident with severe cognitive impairment exhibited aggressive behaviors towards other residents, including physical and verbal abuse. Despite staff witnessing these behaviors, there was a failure in timely reporting and intervention, leading to continued risk of abuse. The facility's response was inadequate, as the aggressive resident remained in close proximity to the victims in the following days.
A facility failed to conduct a Level Two PASARR for a resident after a new diagnosis of Schizophrenia was added to their medical record. The facility lacked a specific policy for PASARRs, relying on regulations as guidelines. The resident's initial Level One PASARR in 2019 did not recommend further assessment, but the Director of Nursing admitted that a new PASARR should have been completed following the change in psychiatric diagnosis.
A facility failed to assess and track behaviors before diagnosing a resident with Schizophrenia and administering antipsychotic medication. Despite the facility's policy requiring behavior monitoring for residents on psychotropic medications, there was no documented evidence of behaviors justifying the diagnosis. Observations and interviews indicated the resident, with a history of Parkinson's and Dementia, did not exhibit behaviors consistent with Schizophrenia, and the family was unaware of the diagnosis.
A facility failed to provide an individual discharge plan for a resident discharged to Independent Living. The resident, who was cognitively impaired and required assistance with daily activities, had diagnoses of a urinary tract infection and an infection due to an indwelling urethral catheter. The care plan lacked discharge planning information, and the Social Service Designee was unaware of the discharge due to being on vacation. This was contrary to the facility's policy requiring a post-discharge plan to assist with transition.
The facility did not provide adequate shaving care for two residents who required assistance with activities of daily living. One resident, needing extensive help due to confusion and impaired balance, and another with dementia, were both observed with significant beard growth. Staff acknowledged the difficulty in meeting grooming needs due to heavy care demands.
The facility failed to maintain hygienic respiratory care for two residents, as observed with unbagged, undated nebulizer masks and tubing. One resident's mask was found wet and dusty, while another's had debris inside. The DON confirmed the absence of a policy for respiratory equipment maintenance, although it was expected to be rinsed, labeled, and bagged.
A facility failed to implement non-pharmacological interventions and conduct behavior monitoring before administering Seroquel to a resident with dementia. Despite the facility's policy emphasizing non-pharmacological approaches, there was no documentation of behavior tracking or interventions for the resident, who was diagnosed with schizoaffective disorder. Staff reported no recent behaviors, and a family member noted the resident's decline was due to falls related to Parkinson's and dementia.
A resident with Alzheimer's and GERD, requiring a mechanical soft diet excluding broccoli, was served broccoli, leading to a choking incident. Staff failed to adhere to dietary protocols, as the CNA was unaware of the diet book and the Dietary Aide did not regularly check it for updates, despite recent inservice training.
The facility failed to implement an antibiotic stewardship program for two residents, as required by their policy. Antibiotics were prescribed prophylactically without obtaining cultures or sensitivities, and there was a lack of documentation and communication between the Infection Preventionist and physicians. The IP acknowledged the absence of antibiotic logs and expressed concerns about the prophylactic use of antibiotics without cultures.
Failure to Maintain Accurate and Complete Medical Records for Residents with Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two of three residents reviewed for falls. In one instance, a resident experienced an unwitnessed fall while transferring from a wheelchair to a recliner. Although an incident report was completed and a non-skid device was added to the recliner as an intervention, there were no corresponding nursing notes in the resident's electronic medical record documenting the fall or the intervention. The Director of Nursing confirmed the absence of documentation and acknowledged that the intervention was not added to the resident's care plan. In another case, a resident fell from her bed, resulting in a subarachnoid hemorrhage and nasal fractures. The fall investigation was completed and signed by the Director of Nursing, but this documentation was not included in the resident's clinical medical record. The nurse on duty at the time of the fall was on break, and upon returning, only documented what she observed, omitting details of the incident that occurred during her absence. The Director of Nursing, who was present during the fall, did not document the event in the resident's chart, despite being the responsible nurse at the time. Additionally, there were inconsistencies in the documentation of the resident's use of enabler side rails. The care plan erroneously indicated the use of enabler bars for bed mobility, while assessments and therapy notes confirmed that the resident did not use such devices. The Care Plan Coordinator admitted to adding the intervention in error, attributing it to standard practices at another facility. These documentation errors are contrary to the facility's own policies, which require accurate and timely documentation of resident status, incidents, and interventions.
Failure to Use Gait Belt During Transfer for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with a progressive neurological condition, Parkinson's disease, muscle weakness, gait abnormalities, and severe cognitive impairment. The resident was identified as high risk for falls and required partial to moderate assistance with transfers, as documented in the Minimum Data Set and care plan. Despite these documented needs and facility policy, a Certified Nurse Assistant (CNA) assisted the resident in transferring from a recliner to a wheelchair without using a gait belt. The CNA acknowledged not using the gait belt and stated that its use depended on the resident's anxiety level, even though the expectation was to always use it for this resident. Multiple staff, including a Registered Nurse, Physical Therapist, and the Director of Nursing, confirmed that all staff are expected to use a gait belt when transferring or walking with this resident. During observation, the gait belt was found unused and rolled up on the counter in the resident's room. The facility's Falls Prevention and Post-Falls Management Policy requires staff to identify fall risks and implement resident-centered prevention plans, which includes the use of assistive devices like gait belts. The failure to use the gait belt as required led to a deficiency in providing adequate supervision and accident hazard prevention.
Failure to Employ Qualified Director of Food and Nutrition
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition, which has the potential to affect all 16 residents residing in the facility. During the survey conducted from July 30, 2024, to August 1, 2024, several deficiencies were observed in the food and nutrition services. The facility did not maintain cleanliness in the kitchen, with debris present in preparation and storage areas. Additionally, the facility did not sanitize food preparation areas according to its sanitation policy and failed to properly cover and contain ice cream canisters in the freezer. Kitchen staff also did not contain their hair while in the kitchen and food preparation areas. On July 30, 2024, the Dietary Manager in Training stated that she had enrolled in Certified Dietary Manager courses in April 2024 but had not yet started the modules. The facility administrator confirmed that the Dietary Manager in Training had not begun the Certified Dietary Manager training.
Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, which could potentially affect all 16 residents. Observations revealed that kitchen staff were preparing food without wearing hairnets, and one dietary aide was unsure of their location. Additionally, food crumbs and debris were found on a food tray and soup table, and two large ice cream containers in the freezer were uncovered, posing a risk of cross-contamination. Further inspection showed that the sanitation practices were inadequate. The dietary manager tested the sanitation solution and found it insufficient, with a pH level of 3.0 instead of the required 5.5, indicating a lack of proper sanitizer concentration. Another staff member cleaned the food prep area with a degreaser instead of the appropriate sanitation solution, as she was unaware of its location. These actions were not in compliance with the facility's policy, which mandates the use of approved cleaning solutions and proper sanitation procedures.
Inadequate Infection Control Program and Medication Administration Practices
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, as evidenced by the absence of a complete infection control log and inadequate surveillance of infections. The Infection Preventionist (IP) admitted that logging and surveillance of infections only began in July 2024, and prior to that, there was no record-keeping of resident or employee illnesses, nor adherence to McGreer's protocol for antibiotic use. This lack of structured surveillance and documentation has the potential to affect all 16 residents in the facility. Additionally, there was a specific incident involving a registered nurse (RN) who failed to adhere to proper infection control practices while administering medications to a resident. The RN picked up a contaminated pill from a dining room table with bare hands and returned it to the resident, who then ingested it. Furthermore, the RN administered nasal spray to the resident without wearing gloves and did not perform hand hygiene between handling the contaminated medication and administering the nasal spray. The Director of Nurses confirmed that the RN should have used appropriate hand hygiene, as outlined in the facility's handwashing policy.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by another resident, affecting three residents in the sample. The facility's policy on abuse and neglect emphasizes the residents' right to be free from abuse, including physical harm and intimidation. However, the report details incidents where a resident, identified as R4, who is severely cognitively impaired, exhibited aggressive behaviors towards other residents, including R16 and R271. R4 was noted to have been verbally aggressive and physically abusive, including squeezing R16's hand and pulling her hair, as well as attempting to trip R271 and throwing objects at her. The incidents occurred over two consecutive days, with staff witnessing R4's escalating behaviors. Despite these observations, there was a failure in communication and reporting among the staff. The Social Service Director (SSD) and the Director of Nurses (DON) were not informed of R4's aggressive behavior on the first day, which included throwing a fork and ketchup bottle at R271. This lack of timely reporting prevented appropriate interventions from being implemented to prevent further incidents. The facility's response to the incidents was inadequate, as R4 continued to be in close proximity to R16 in the days following the incidents, despite the previous aggressive interactions. The staff's failure to report and address R4's behavior in a timely manner contributed to the ongoing risk of abuse, highlighting a deficiency in the facility's ability to protect residents from harm.
Failure to Complete Level Two PASARR After New Diagnosis
Penalty
Summary
The facility failed to complete a Level Two Pre-Admission Screening and Resident Review (PASARR) for a resident after a new mental health diagnosis was added to their electronic medical record. This deficiency was identified during an interview and record review, where it was found that the facility did not have a specific policy for PASARRs and instead followed regulations as guidelines. The resident in question had a Level One PASARR completed in 2019, which did not recommend a Level Two assessment. However, a diagnosis of Schizophrenia was added to the resident's medical record in May 2023, and no subsequent PASARR was conducted. The Director of Nursing acknowledged that a PASARR should be completed whenever there is a change in psychiatric diagnosis, indicating that the facility failed to adhere to this requirement.
Failure to Assess Behaviors Before Diagnosing Schizophrenia
Penalty
Summary
The facility failed to properly assess and track behaviors before diagnosing a resident with Schizophrenia and administering antipsychotic medications. The facility's policy on psychotropic medication management emphasizes the use of person-centered, non-pharmacological approaches and requires behavior monitoring for residents on psychotropic medications. However, the facility did not adhere to this policy for one resident, who was diagnosed with Schizophrenia without documented evidence of behaviors warranting such a diagnosis. Observations and interviews with staff and family members revealed that the resident did not exhibit behaviors or hallucinations consistent with Schizophrenia, and the family was unaware of the diagnosis. The resident, who had a history of Parkinson's and Dementia, was initially prescribed Seroquel for delusional disorder while on hospice care in 2022. After being discharged from hospice in January 2023, the resident was diagnosed with Schizoaffective Disorder in May 2023 due to crying, anger, falling, and exit-seeking behaviors. However, these behaviors were also consistent with the resident's existing Dementia diagnosis, and there were no documented behaviors since 2022. The facility's failure to document and assess the resident's behaviors before diagnosing Schizophrenia and administering antipsychotic medication constitutes a deficiency in meeting professional standards of quality care.
Failure to Provide Individual Discharge Plan for Resident
Penalty
Summary
The facility failed to provide an individual discharge plan for a resident, identified as R18, who was discharged to Independent Living. R18 had diagnoses of a urinary tract infection and an infection and inflammatory reaction due to an indwelling urethral catheter. The resident was cognitively impaired and required assistance with activities of daily living, as documented in the Minimum Data Set (MDS) assessment. Despite these needs, R18's care plan did not include any information regarding discharge planning. The Social Service Designee, identified as V19, stated that they were unaware of the discharge due to being on vacation and confirmed that no discharge planning was conducted for R18 in the care plan. The facility's policy on discharge planning and summary, dated April 2024, requires a post-discharge plan and summary to assist residents with their transition, which was not adhered to in this case.
Failure to Provide Shaving Care for Residents
Penalty
Summary
The facility failed to provide adequate shaving care for two residents who were dependent on staff assistance for activities of daily living. Resident 12, who requires extensive assistance due to confusion, disease processes, and impaired balance, was observed with beard hair approximately one half inch in length. Similarly, Resident 13, who requires assistance due to dementia, was also observed with beard growth of the same length. The facility's General Nursing and Personal Care Policy mandates proper daily personal attention, including grooming and personal hygiene for residents unable to perform these tasks independently. Despite this policy, staff members indicated that it was challenging to meet the grooming needs of all residents due to the heavy care demands in the facility.
Deficiency in Hygienic Respiratory Care Practices
Penalty
Summary
The facility failed to provide hygienic respiratory care for two residents, leading to deficiencies in the maintenance and care of nebulizer masks and tubing. For one resident, physician orders required the use of Albuterol Sulfate via nebulizer for respiratory issues such as wheezing and shortness of breath. However, the resident's nebulizer mask was observed on the bedside table, unbagged, undated, and appeared wet and dusty over two consecutive days. The Director of Nursing acknowledged the absence of a policy for respiratory equipment maintenance, although it was expected that such equipment should be rinsed, labeled, and bagged. Another resident, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), had a physician order for Albuterol Sulfate nebulization as needed. The resident's nebulizer tubing and mask were found undated and unbagged on the bedside dresser, with visible debris inside the mask. These observations indicate a lack of proper hygiene and labeling practices for respiratory equipment, contributing to the deficiency.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions and conduct behavior monitoring before administering psychotropic medication to a resident. The facility's policy on psychotropic medication management emphasizes the use of person-centered, non-pharmacological approaches to care. However, for one resident, identified as R6, there was no documentation of behavior tracking or non-pharmacological interventions prior to the administration of Seroquel, an antipsychotic medication. The resident's care plan did not document targeted behaviors or non-pharmacological interventions, which is a deviation from the facility's policy. R6's medical history includes a diagnosis of dementia and a previous diagnosis of delusional disorder while on hospice care. The resident was later diagnosed with schizoaffective disorder due to behaviors such as crying, anger, falling, and exit-seeking, which are also common in dementia. Despite these diagnoses, staff members, including a CNA and an RN, reported not observing any recent behaviors in R6. Additionally, a family member stated that R6 had no history of mental health issues and had declined following falls related to Parkinson's and dementia. The lack of documented behaviors and non-pharmacological interventions prior to the use of psychotropic medication constitutes a deficiency in the facility's care practices.
Failure to Honor Resident's Dietary Preferences Leads to Choking Incident
Penalty
Summary
The facility failed to honor a resident's food preferences, leading to a choking incident. The resident, who has Alzheimer's Disease, Failure to Thrive, and Gastroesophageal Reflux Disease (GERD), was documented to require a mechanical soft textured diet with specific exclusions, including broccoli. Despite this, the resident was served broccoli during a meal, which resulted in a choking episode. The Hospice Certified Nurse Aide assisting the resident was unable to cut the broccoli properly, and the resident began coughing and spitting up pieces of broccoli, indicating a failure to adhere to the prescribed dietary restrictions. The deficiency was further compounded by a lack of communication and adherence to dietary protocols among the staff. The Hospice CNA was unaware of the diet book that contained the resident's dietary restrictions, and the Dietary Aide admitted to not regularly checking the diet book for updates. Although the staff had been inserviced on serving accurate diets, the Dietician confirmed that the dietary staff did not consistently follow the protocol of checking the diet book before serving meals. This oversight led to the resident receiving food that was not in accordance with their dietary needs.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for two of the six residents reviewed for antibiotic use. The facility's Antimicrobial Stewardship Policy, dated 7/31/24, outlines the importance of measuring and improving antibiotic prescriptions and usage to treat infections effectively and combat antibiotic resistance. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and monitoring of antibiotic use for residents R9 and R12. R9 was prescribed Sulfa/Trimethoprim for a wound infection and Methenamine prophylactically for urinary symptoms without obtaining cultures. Similarly, R12 was on Nitrofurantoin prophylactically for urinary symptoms without culture and sensitivity tests. The Infection Preventionist (IP) acknowledged the absence of antibiotic logs, including types of infections, antibiotic usage, cultures, and sensitivities, prior to July 2024. The IP expressed concerns about the prophylactic use of antibiotics without cultures but noted that the prescribing doctors did not agree with her stance. The lack of documentation and communication between the IP and the physicians regarding antibiotic stewardship was evident, as no records of McGreer's criteria or communication with prescribers were found during the survey.
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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