Manor Court Of Princeton
Inspection history, citations, penalties and survey trends for this long-term care facility in Princeton, Illinois.
- Location
- 140 North Sixth Street, Princeton, Illinois 61356
- CMS Provider Number
- 146083
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Manor Court Of Princeton during CMS and state inspections, most recent first.
A resident’s HCPOA reported to an RN that the resident stated a man had touched her breast during the night, constituting an allegation of sexual abuse. Facility policy required the first nurse aware of alleged abuse to examine the resident, notify the attending physician, and ensure administration immediately contacted local law enforcement in cases of sexual abuse. The RN reported the allegation only to administration and did not notify the physician or police, and the Administrator later confirmed that neither the resident’s physician nor local law enforcement were notified of the allegation.
A resident was prescribed Risperidone for behavioral disturbance related to vascular dementia, but the facility did not document specific target behaviors or provide adequate justification for the medication's use. Staff confirmed the resident did not display harmful behaviors, and behavior tracking showed minimal incidents. After a failed gradual dose reduction, the medication was restarted due to insomnia and tearfulness, but without sufficient documentation or assessment to support this decision.
A resident with a history of diabetes, osteomyelitis, and peripheral vascular disease was admitted with a right heel wound. The care plan inaccurately described the wound as a diabetic ulcer instead of a pressure ulcer, despite confirmation from nursing staff and the DON that the diagnosis was incorrect and required revision.
A resident experienced significant weight loss over several months, dropping from 196 lbs to 171 lbs, without the facility updating the care plan or implementing new interventions. The resident, who had CHF and was on a diuretic, reported decreased appetite and depression, but these issues were not identified or addressed by staff until much later. The facility's weight monitoring system did not trigger an alert, and there was no documentation of physician or family notification or care plan changes.
A resident receiving tube feeding due to conditions such as cerebral infarction and dysphagia was found with dried material on the feeding pump, pole, floor, bed rails, and nightstand over two days. Despite staff presence, the equipment and surrounding area were not cleaned as required by facility policy, and a RN confirmed the debris should not have been there.
A nurse failed to maintain aseptic technique by using IV medication and tubing that had been dropped on the floor and did not perform a physician-ordered saline flush prior to administering IV antibiotics to a resident with a PICC line and multiple serious conditions. The nurse only flushed the line after starting the infusion, contrary to the prescribed protocol.
A resident with a diagnosis of vascular dementia did not have a care plan addressing dementia management, as required by facility policy. The care plan lacked goals and interventions specific to dementia care, and this deficiency was confirmed by the DON.
A resident was receiving daily Cephalexin for frequent UTIs without any documented rationale or justification for the continued antibiotic therapy in the medical record. The DON confirmed the absence of required documentation supporting the ongoing use of the antibiotic, contrary to the facility's Antibiotic Stewardship policy.
The facility failed to maintain a clean and sanitized kitchen floor, with built-up grease, grime, and debris observed during a tour. Despite nightly cleaning protocols, the floor remained dirty, requiring extra effort and abrasive pads to clean.
The facility failed to document a resident's Advanced Directives correctly, leading to a discrepancy between the resident's Face sheet, Physician Order Sheet (POS), and Shift Notes, which listed Full Code status, and the resident's POLST, which documented Do Not Resuscitate (DNR) status. This error was confirmed by an RN, who stated that CPR would have been initiated based on the incorrect Full Code status before checking the POLST.
The facility failed to include the care for an indwelling urinary catheter in the Baseline Care Plan for a resident within 48 hours of admission. The resident had a physician order for a 16F 30cc catheter due to urinary retention, but this information was not reflected in the Baseline Care Plan, despite being documented in the Care Plan Summary.
The facility failed to revise a Comprehensive Care Plan for a resident with a chronic, recurrent Stage 4 pressure wound on the coccyx. Despite the facility's policy requiring timely updates to care plans, the wound was not documented in the resident's care plan until a month after it was identified, leading to a delay in appropriate care planning.
Two CNAs failed to perform hand hygiene and change gloves appropriately while providing catheter care to a resident with an indwelling urinary catheter. The CNAs did not follow the facility's infection control policy, which mandates hand hygiene and proper use of PPE.
The facility failed to obtain weekly weights for a resident with cerebral infarction, dysphagia, and gastrostomy status, as ordered by the physician. The Dietary Manager and a Registered Nurse confirmed that no weights had been recorded since an initial weight, despite the resident being on weekly weights due to tube feedings.
A resident with respiratory conditions was found using an oxygen concentrator with an empty humidifier bottle and without the required 'Oxygen in Use' sign on the door. The resident experienced difficulty breathing due to dry air, and staff confirmed the deficiencies.
The facility failed to document the appropriate use of an antipsychotic medication, identify target behaviors, and include non-pharmacological interventions for a resident. The resident's care plan lacked necessary details, and observations showed no inappropriate behaviors. The DON confirmed the absence of a care plan and lack of knowledge about the resident's behaviors since admission.
The facility failed to ensure Enhanced Barrier Precaution (EBP) signage was posted and PPE was available for two residents with indwelling medical devices and draining wounds. The Infection Control Nurse and Infection Preventionist confirmed the oversight during the survey.
Failure to Notify Physician and Law Enforcement After Allegation of Sexual Abuse
Penalty
Summary
The facility failed to follow its Abuse Prohibition and Reporting policy regarding notification of local law enforcement and the attending physician after an allegation of sexual abuse. The policy dated 11/28/19 states that administration shall immediately contact local law enforcement authorities in situations of sexual abuse by a staff member, another resident, or a visitor, and that the shift nurse who first becomes aware of alleged abuse shall immediately examine the resident and call the resident's attending physician. On 12/27/25 at approximately 1:15 p.m., the facility received a concern involving a resident when the resident’s HCPOA informed the on-duty RN (V6) that the resident reported a man had touched her breast during the night. The Administrator (V1) stated she was notified that same day by V6 of an allegation of sexual abuse by a resident, after V6 was approached by the resident’s HCPOA, who reported the resident said someone had touched her breast in the middle of the night. During interview, V6 confirmed that, after receiving the report from the HCPOA, she did not notify the resident’s physician or the local police department and believed her responsibility was limited to reporting the allegation to administration. The facility’s Regulatory Timeline showed the allegation was received on 12/27/25 and the investigation was completed on 12/29/25. On 1/8/26, V1 verified that the facility did not notify the resident’s physician or the local police department of the reported allegation of sexual abuse.
Failure to Document Justification for Antipsychotic Use and GDR
Penalty
Summary
The facility failed to document an appropriate diagnosis and identify target behaviors to justify the use of an antipsychotic medication for a resident. The resident, who had a diagnosis of vascular dementia with behavioral disturbance, was prescribed Risperidone 0.25 mg at bedtime. The care plan and physician orders referenced the use of Risperidone for behavioral symptoms, but there was no clear documentation of specific target behaviors warranting the medication. Staff interviews confirmed that the resident did not display behaviors such as aggression or harm to self or others, and behavior tracking indicated only two verbal behaviors in the past six months, both occurring before January. The resident's behaviors reportedly improved after moving to a private room, and no recent behaviors were documented that would support ongoing antipsychotic use. Additionally, the facility did not provide appropriate justification for a failed gradual dose reduction (GDR) of Risperidone. The medication was discontinued, but was restarted three days later due to symptoms of insomnia and tearfulness, as documented by the nurse practitioner. However, there was no evidence of a thorough assessment or documentation of behaviors that would necessitate resuming the antipsychotic. The facility's policy requires clear documentation of behaviors, rationale for medication use, and substantiation for unsuccessful GDRs, which was not met in this case.
Care Plan Not Revised to Reflect Accurate Wound Diagnosis
Penalty
Summary
The facility failed to revise and accurately update a resident's care plan to reflect the correct wound condition. A resident with multiple diagnoses, including acute hematogenous osteomyelitis of the right ankle and foot, stage IV pressure ulcer of the right heel, diabetes mellitus, and peripheral vascular disease, was admitted with a wound on the right heel. Nursing staff and the DON confirmed that the care plan incorrectly identified the right heel wound as a diabetic ulcer, when in fact it was a pressure ulcer. The care plan had not been updated to reflect this change, despite the resident having a skin graft and current physician orders related to the wound. The inaccuracy was acknowledged by the DON, who stated the care plan was not correct and needed revision.
Failure to Address Significant Weight Loss in a Resident
Penalty
Summary
The facility failed to address and implement care plan interventions for a resident who experienced significant, ongoing weight loss. Despite the facility's policy requiring physician notification and care plan updates for significant weight changes, the resident's care plan did not address the weight loss. The resident's weight decreased from 196 lbs to 171 lbs over approximately six months, representing a 12.76% loss. The registered dietician documented the weight loss and noted that the resident's diet was regular, with variable meal intake, and that the weight loss could be related to fluid shifts due to diuretic use and a diagnosis of congestive heart failure. However, the only recommendations made were to continue the current diet and monitor weight, with no new interventions implemented. The resident reported feeling depressed and not eating much, but this decrease in appetite and mood was not identified or addressed by the facility until it was brought to the attention of the Director of Nursing, who confirmed being unaware of these issues. The facility's weight monitoring system did not trigger an alert for significant weight loss, and there was no documentation of physician or family notification, nor any evidence of care plan updates or new interventions to address the resident's ongoing weight loss.
Failure to Maintain Cleanliness of Tube Feeding Equipment
Penalty
Summary
Facility staff failed to maintain the cleanliness of tube feeding equipment for a resident with a gastronomy tube. The resident, who had diagnoses including cerebral infarction, hemiplegia, hemiparesis, and dysphagia, was receiving continuous tube feeding as ordered by the physician. Observations on two consecutive days revealed tan, dried material present on the feeding pump, pump pole, floor beneath the feeding pole, bed rails, and a nearby nightstand. This debris remained in place throughout the day, despite staff being present in the resident's room multiple times. The facility's policy required non-disposable tube feeding equipment to be wiped down daily and as needed with an approved disinfectant to maintain cleanliness, with licensed staff responsible for this task. However, the observed failure to clean the equipment and surrounding area was confirmed by a registered nurse, who acknowledged that the debris should not have been present. The deficiency was identified through direct observation, interview, and record review.
Failure to Follow Aseptic Technique and Physician Orders During IV Medication Administration
Penalty
Summary
A registered nurse failed to follow aseptic technique during the administration of intravenous medication to a resident with multiple serious diagnoses, including leukemia, malignant neoplasms, and infections requiring a PICC line for IV antibiotic therapy. The nurse dropped the IV bag and tubing on the floor before entering the resident's room, then picked them up and proceeded to use them for the medication administration without replacing them. The nurse donned appropriate personal protective equipment and swabbed the PICC port with alcohol before connecting the tubing and starting the infusion. Additionally, the nurse did not perform a physician-ordered saline flush of the PICC line prior to administering the IV medication, as required by the resident's orders. The flush was only performed after the medication had begun infusing, contrary to the specified protocol. These actions were observed and confirmed by the nurse, representing a failure to adhere to both infection control and medication administration policies.
Lack of Dementia-Specific Care Plan for Resident with Vascular Dementia
Penalty
Summary
The facility failed to develop and implement a care plan specific to the management of dementia for a resident diagnosed with vascular dementia. According to the facility's care plan policy, each resident is to have a comprehensive, person-centered care plan that addresses their medical, nursing, mental, and psychosocial needs, including measurable objectives and timeframes. Record review showed that the resident's current care plan did not include any goals or interventions related to dementia care, despite the resident's documented diagnosis. This omission was confirmed by the Director of Nursing during an interview.
Lack of Documentation for Continued Antibiotic Use
Penalty
Summary
The facility failed to document a rationale for the continued use of antibiotic therapy for one resident who was receiving Cephalexin 250 milligrams daily as a prophylactic antibiotic for frequent urinary tract infections (UTIs). The resident's physician order sheet indicated a diagnosis of long-term use of antibiotics, but the medical record lacked any documentation or explanation justifying the ongoing antibiotic treatment. During an interview, the Director of Nursing confirmed that there was no documentation or rationale present in the resident's record to support the continued use of the antibiotic, as required by the facility's Antibiotic Stewardship policy.
Failure to Maintain Clean and Sanitized Kitchen Floor
Penalty
Summary
The facility failed to provide a clean and sanitized floor in the kitchen, potentially affecting all 99 residents who receive food from the kitchen. During a tour of the kitchen, built-up brown/black discolored grease, grime, and debris were observed on the floor in front of both sides of the food preparation table, stove, and other areas. The Dietary Manager acknowledged that the floor had been cleaned that morning but still appeared dirty. A posted kitchen sign indicated that floors should be swept and mopped nightly. The following day, the floor was free of grime and debris, but stains remained where the build-up had been. The Custodian/Floors stated that they had to spend extra time and use a more abrasive pad to remove the built-up grease and grime.
Failure to Document Advanced Directives Correctly
Penalty
Summary
The facility failed to ensure that Advanced Directives were documented correctly in the resident's clinical record for one resident. The resident's Face sheet, Physician Order Sheet (POS), and Shift Notes all documented the resident as Full Code, while the resident's Practitioner Orders for Life-Sustaining Treatment (POLST) documented Do Not Resuscitate (DNR) status. This discrepancy was confirmed by a Registered Nurse (RN), who stated that in the event of a code, they would initially follow the Full Code status listed on the report sheet and Face sheet before checking the POLST. The RN acknowledged that if the resident had coded, CPR would have been initiated based on the incorrect Full Code status, only to be stopped upon later review of the POLST indicating DNR status.
Failure to Include Indwelling Catheter Care in Baseline Care Plan
Penalty
Summary
The facility failed to include the care for an indwelling urinary catheter in the Baseline Care Plan for one resident within 48 hours of admission. The resident, who was observed lying in bed with an indwelling catheter draining clear amber urine, had been admitted to the facility, transferred to the hospital, and then returned with the catheter in place. The resident's Physician Order Sheet included an order for a 16F 30cc catheter with a diagnosis of urinary retention, but this information was not reflected in the Baseline Care Plan. The Care Plan Coordinator acknowledged that catheters were not included in the template that nurses could pull up, but confirmed that it should have been part of the Baseline Care Plan. The Care Plan Summary, which was printed during the review, documented the presence of the catheter and the associated physician and nursing orders. However, this critical information was missing from the Baseline Care Plan, indicating a lapse in the facility's adherence to its own Care Plan Policy, which mandates the inclusion of all necessary healthcare information within 48 hours of a resident's admission.
Failure to Revise Comprehensive Care Plan for Resident with Chronic Wound
Penalty
Summary
The facility failed to revise a Comprehensive Care Plan for one resident (R7) of 21 residents reviewed for Care Plan revision in a sample of 40. The facility's Care Plan Policy mandates the development and implementation of a Comprehensive Person-Centered Care Plan that includes measurable objectives and timeframes to meet a resident's needs as identified in the comprehensive assessment. Despite this policy, R7's care plan did not document the presence of a wound on her coccyx, which was identified on 4/26/24 and required specific wound care treatment. The wound was described as a Stage 4 pressure wound with specific dimensions and treatment orders, but this information was not incorporated into R7's care plan in a timely manner. On 5/29/24, an observation of R7's coccyx area confirmed the presence of a small opening, and the LPN providing wound care treatment noted that R7's wound was chronic and recurrent. The RN/MDS/Care Plan Coordinator acknowledged that the wound issue should have been included in R7's care plan and admitted to being unaware of the wound's recurrence until that day. The RN subsequently added the wound information to the care plan, but this delay in updating the care plan represents a failure to adhere to the facility's policy and ensure comprehensive care for the resident.
Infection Control Lapse During Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the care of a resident with an indwelling urinary catheter. Specifically, two CNAs did not perform hand hygiene or change gloves appropriately while providing catheter care. The CNAs were observed lowering the resident's shorts and soiled incontinence brief, cleansing the meatus and catheter tubing, and then changing gloves without performing hand hygiene. They continued to touch the resident's bare skin and handle the soiled incontinence brief without changing gloves or sanitizing their hands in between these actions. The resident involved had a diagnosis of urinary retention and was using a 16F 30cc indwelling catheter. The CNAs' failure to follow proper infection control protocols was confirmed by their own admissions and the Director of Nursing's expectations for hand hygiene and glove changes. The facility's infection control policy mandates hand hygiene and proper use of PPE, including changing gloves after direct contact with a resident's secretions or excretions, which was not followed in this instance.
Failure to Obtain Weekly Weights as Ordered
Penalty
Summary
The facility failed to obtain weekly weights as ordered by the physician for a resident with diagnoses including cerebral infarction, dysphagia, and gastrostomy status. The facility's Weight Monitoring Policy requires weekly and monthly weights to be recorded in the resident's electronic medical record. The resident's physician orders included weekly weights, but the Vitals Weight Summary showed no weights recorded after an initial weight on 5/8/24. The Dietary Manager was unaware of the weekly weight order and confirmed that no further weights had been documented. A Registered Nurse also verified that the resident had not been weighed since 5/8/24, despite being on weekly weights due to tube feedings.
Failure to Maintain Oxygen Humidifier and Post Required Signage
Penalty
Summary
The facility failed to ensure a resident's oxygen humidifier bottle was not empty while in use. The resident, who has diagnoses including Shortness of Breath, Other Pulmonary Embolism without Acute Cor Pulmonale, Panlobular Emphysema, and Acute Respiratory Failure with Hypoxia, was observed using an oxygen concentrator with an empty, undated humidifier bottle. The resident reported difficulty breathing due to dry air and informed a CNA, who then alerted a nurse. The nurse confirmed the humidifier bottle was empty and replaced it. Additionally, the resident's room did not have an 'Oxygen in Use' sign posted at the door as required by the facility's policy. On subsequent observations, the resident was again found using oxygen without the required 'Oxygen in Use' sign on the door. Staff confirmed the absence of the sign and acknowledged that it should have been posted. The facility's failure to maintain the humidifier bottle and post the necessary signage represents a deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Document and Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to provide an appropriate indication for the use of an antipsychotic medication, failed to identify target behaviors, and failed to identify non-pharmacological interventions for one resident. The facility's policy requires documentation of behaviors and conditions necessitating the use of psychopharmacological medications, as well as the medication's response and potential adverse consequences. The resident's physician's orders indicated the use of Risperidone for Vascular Dementia with Other Behavioral Disturbance, but behavior monitoring records did not specify behaviors to be monitored. Additionally, the resident's care plan did not include the administration of the antipsychotic medication, goals, side effects, or interventions. Observations of the resident showed no inappropriate, disruptive, or psychotic behaviors, and the Director of Nursing confirmed the absence of a care plan and lack of knowledge regarding the resident's behaviors since admission.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precaution (EBP) signage was posted and Personal Protective Equipment (PPE) was available for two residents reviewed for infection control. One resident had an indwelling urinary catheter and a midline intravenous catheter but did not have EBP signage or an infectious linen trash bin in the room. The Infection Control Nurse confirmed that the resident should have been under Enhanced Barrier Precautions upon returning from the hospital but was not. This oversight was observed during a survey on two separate dates. Another resident with an ileostomy and multiple fistulas also did not have EBP signage posted outside the room, nor was there quick access to gowns before entering the room. The resident's condition included chronic drainage from the fistula sites, which required regular ostomy bag changes. The Infection Preventionist acknowledged that the resident should have been placed under Enhanced Barrier Precautions due to the draining wounds but was not initially considered for EBP. This deficiency was confirmed through interviews with nursing staff and direct observation 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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