Manor Court Of Rochelle
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochelle, Illinois.
- Location
- 2203 Flagg Road, Rochelle, Illinois 61068
- CMS Provider Number
- 146193
- Inspections on file
- 26
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Manor Court Of Rochelle during CMS and state inspections, most recent first.
Two residents did not receive appropriate incontinence and catheter care. One resident, fully dependent for ADLs and always incontinent of bowel and bladder, was found soaked with urine on his clothing, legs, and wheelchair pad during transfer, with a large reddened area on the buttock, despite a care plan and facility practice requiring incontinence care after each episode and rounding about every two hours. Another resident with an indwelling urinary catheter, ESBL colonization in the urine, and a history of UTIs was observed in the dining area with an uncovered drainage bag touching and dragging on the floor; a RN initially failed to notice this, and the DON later confirmed drainage bags should not touch the floor and should be covered, although the resident’s care plan lacked catheter-specific interventions and the catheter policy did not address bag positioning.
Surveyors found that staff failed to follow enhanced barrier precautions (EBP) and proper catheter handling for two residents with indwelling urinary catheters. One resident with colonized ESBL in the urine and a history of UTIs had an uncovered catheter drainage bag dragging on the floor in the dining area, and both an RN and a CNA handled the bag without PPE. Another resident with multiple comorbidities and a catheter had urine aspirated from the catheter tubing by an RN who wore only gloves, despite an EBP sign on the door and a care plan requiring EBP. The ADON and facility policy both specified that gown and gloves should be used for high-contact care involving catheters and other indwelling devices.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with severe dementia was not properly assessed or treated for pain following a fall that resulted in a hip fracture. Nursing staff failed to document pain assessments, administer ordered pain medications, or notify the physician of the resident's pain complaints, leading to a delay in pain management for several hours.
A resident with Parkinson's disease and dementia, who required assistance with oral care and dentures, experienced a delay in treatment after staff failed to notice and report a missing denture and did not adequately assess new gurgling sounds and diminished lung function. The resident was later hospitalized, where a dental appliance was found lodged in the hypopharynx and removed under anesthesia, and was also treated for pneumonia.
A resident who required assistance with oral care had their upper denture go missing, and the facility did not document any communication with the family or establish a plan for replacement or payment. The investigation into the missing denture did not result in a resolution or identification of a liable party, and facility policies regarding responsibility were not clearly applied or communicated.
The facility did not maintain adequate nursing staff to meet resident needs, leading to missed or delayed showers, incontinence care, and prolonged call light response times. Staff and residents reported frequent short-staffing, particularly on units with higher care needs, and documentation confirmed that scheduled care was not consistently provided. On one occasion, a resident with a fall history was left unsupervised and experienced a fall while the facility was short-staffed.
Several residents did not receive their scheduled showers as required, with staff and residents confirming that showers were missed due to inadequate CNA staffing. Documentation for missed or refused showers was incomplete or missing, and the facility's policy for daily hygiene care was not consistently followed.
A resident with severe dementia and a documented fall risk experienced multiple falls after being left unsupervised due to staffing shortages. Despite a care plan requiring supervision, the resident was found on the floor after attempting to go to the bathroom alone and later fell again in the common area when staff could not reach him in time. Staff interviews and facility records confirmed inadequate supervision and insufficient staffing at the time of both incidents.
The facility failed to complete comprehensive assessments for several residents in a timely manner. The assessments were overdue, with some being several months late. The Interim DON, who also served as the MDS Coordinator, acknowledged the backlog, citing the dual responsibilities taken on after the previous DON's departure as a contributing factor.
The facility failed to complete significant change assessments for four residents in a timely manner. The assessments were overdue by several weeks, and the Interim DON/MDS Coordinator acknowledged the delay, citing challenges in managing dual responsibilities and a backlog from when they assumed the role.
The facility failed to complete quarterly assessments for four residents on time, with assessments overdue and still 'In Process' as of early March. The Interim DON/MDS Coordinator cited the dual responsibilities and a backlog from being three months behind as reasons for the delay.
A facility failed to provide timely incontinence care to a cognitively impaired resident requiring maximum assistance. The resident was found with saturated briefs and wet clothing, indicating a lapse in the protocol of providing care every two hours. CNAs were unsure of the last time the resident received care, leading to prolonged exposure to moisture.
A facility failed to ensure accurate narcotic reconciliation for a resident's Tramadol 50mg medication. An LPN found a discrepancy in the count due to a nurse not signing out a dose given during a shift. The DON confirmed the issue, noting no misappropriation occurred. Facility procedures require controlled substances to be documented and verified by nurses during shift changes.
A facility failed to label a resident's Humalog insulin pen with an opened date, as observed by an LPN and confirmed by the DON. The facility's procedure requires insulin vials to be dated when opened to prevent potency loss after 30 days.
The facility failed to provide smooth puree diets for three residents, as observed during a lunch meal. The cook did not achieve a smooth texture for the Swiss steak, resulting in a gritty consistency with small chunks of meat. Similarly, the creamed corn was not pureed to a smooth texture, containing hulls. The Dietary Manager confirmed the issue, noting that the puree should have been smooth according to the facility's procedure.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection control. A nurse provided wound care without a gown, a resident with ESBL lacked EBP signage and PPE, and a student nurse assisted a resident without proper PPE. These actions violated the facility's EBP policy, which requires gown and glove use during high-contact care for residents with wounds or indwelling devices.
A resident with a history of falls and medical conditions experienced an unwitnessed fall resulting in a head injury. The facility failed to perform necessary neurological assessments following the incident. The Director of Nurses acknowledged the oversight, citing unfamiliarity with protocols by agency nurses.
A resident with hemiplegia and hemiparesis, identified as a high fall risk, fell in the bathroom after being left unattended by a CNA. The resident sustained a hematoma and bruising. The care plan indicated the resident should not be left alone, but the facility lacked a fall prevention policy.
A resident with a UTI did not receive prescribed levofloxacin for two days due to unavailability, despite the medication being in the facility's stat safe. Staff were unaware of the missed doses and did not contact the pharmacy or use the stat safe. The pharmacist confirmed delivery, and the physician was not informed of the missed doses.
A resident left the facility against medical advice with their significant other, and the RN on duty failed to notify the resident's POA, contrary to facility protocol. The DON and another RN confirmed that notifying the POA is standard procedure. The POA had been involved in prior medical decisions for the resident.
Failure to Provide Timely Incontinence Care and Proper Catheter Management
Penalty
Summary
The deficiency involves failure to provide timely incontinence care and appropriate catheter management for two residents. For one resident with extensive medical conditions including right-sided hemiplegia, Parkinson’s disease, cerebrovascular disease, chronic kidney disease, heart failure, and bowel and bladder incontinence, surveyors observed that when CNAs and a shift coordinator transferred him from a padded wheelchair to bed using a mechanical lift, the back of his pants, his buttocks, and his legs were soaked with urine. The pad and sling in his wheelchair were also wet, and staff verbally acknowledged that both the pad and sling were wet and needed replacement. The resident had a large reddened area on his right buttock. The DON stated that staff are expected to round on residents every two hours and provide toileting or incontinence care as close to every two hours as possible, and the resident’s care plan directed staff to provide incontinence care after each incontinent episode, consistent with the facility’s personal care policy requiring proper daily personal attention and care. The deficiency also includes improper catheter care and infection control practices for another resident with an indwelling urinary catheter and a history of UTI, acute cystitis, and colonization with ESBL in the urine. Surveyors observed this resident seated in a wheelchair in the dining room with the urinary drainage bag under the chair, uncovered by a dignity bag and touching the floor. A RN later moved the resident’s wheelchair without noticing that the drainage bag was dragging on the floor, and upon being informed, acknowledged that the bag should have a cover and should not be touching the floor for infection control reasons. The DON confirmed that catheter drainage bags should not touch the floor and that dignity bags are supposed to be used, with extras available. The resident’s care plan noted enhanced barrier precautions and a history of UTIs but did not include that she had an indwelling urinary catheter or any catheter-related interventions, and the facility’s catheter care policy did not address keeping drainage bags off the floor.
Failure to Follow Enhanced Barrier Precautions for Residents With Indwelling Urinary Catheters
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not following enhanced barrier precautions (EBP) and proper catheter handling for residents with indwelling urinary catheters. One resident with an indwelling urinary catheter and a history of urinary tract infections, colonized ESBL in the urine, and multiple comorbidities including Alzheimer disease and morbid obesity was observed sitting in the dining room with an uncovered catheter drainage bag under the wheelchair, dragging on and touching the floor. A RN moved the resident’s wheelchair without noticing the drainage bag on the floor, and when it was pointed out, the RN and a CNA attempted to adjust the drainage bag without wearing any PPE, despite the resident’s care plan indicating EBP due to colonized ESBL and the facility policy requiring gown and gloves for high-contact care involving indwelling devices. In a separate incident, another resident with an indwelling urinary catheter and multiple diagnoses including congestive heart failure, deep venous thrombosis, urinary tract infection, and obesity was observed in her room while a RN, wearing only gloves, aspirated urine from the catheter tubing using a syringe. The RN had clamped the catheter tubing distally to prevent drainage into the bag and was unsure whether the resident was on EBP, even though there was an EBP sign on the resident’s door and the care plan documented enhanced barrier precautions per facility protocol. The ADON confirmed that EBP required gown and gloves when handling catheters, consistent with the facility’s EBP policy stating that residents with indwelling medical devices, including urinary catheters, require targeted gown and glove use during high-contact care activities.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Monitor and Manage Post-Fall Pain
Penalty
Summary
The facility failed to monitor and manage post-fall pain for a resident who sustained a left hip fracture. After the resident, who had severe dementia and other comorbidities, fell in the early morning hours, the nurse on duty assessed her and noted complaints of back and side pain but did not document any pain assessment or administer pain medication. There was no documentation of pain intensity or descriptors, and the resident's care plan did not address pain management either before or after the fall. The nurse also failed to notify the physician of the resident's pain complaints at that time. The following shift, an LPN was alerted by CNAs that the resident was in severe pain and refused to get out of bed, which was unusual for her. The LPN immediately contacted the physician, arranged for the resident to be sent to the hospital, and later learned the resident had a left hip fracture. Review of medication administration records showed no pain medication was given post-fall, despite orders for as-needed analgesics. The facility's pain management policy required regular pain assessments and physician notification for pain indicators, but these procedures were not followed.
Failure to Identify and Respond to Change in Condition Resulting in Delayed Treatment
Penalty
Summary
A deficiency occurred when staff failed to identify and respond to a resident's change in condition, resulting in a delay in treatment. The resident, an elderly male with Parkinson's disease, tremor, and vascular dementia, required assistance with oral care and dentures. On the morning of 5/11/2025, a CNA noticed the resident did not have his dentures but did not report this to anyone, assuming they were misplaced. Other CNAs who assisted the resident over the weekend either did not notice the missing dentures or did not check the care report, and one reported hearing gurgling sounds but attributed it to oral care. The resident's family also reported gurgling noises, which prompted a nurse to assess the resident and order a non-urgent chest x-ray, but no immediate action was taken. Nursing staff noted diminished lung sounds and audible congestion, but the x-ray was not performed until the following day. The resident was found to be lethargic and had further diminished lung sounds, leading to a decision to transfer him to the hospital for evaluation. Paramedics documented difficulty breathing, decreased oxygen saturation, and a Glasgow Coma Scale of 10, indicating moderate impairment. Hospital evaluation revealed a dental appliance lodged in the hypopharynx, which required removal under anesthesia. The resident was also diagnosed with pneumonia and started on antibiotics. The facility's care plan indicated that the resident required staff assistance with oral care and had both upper and lower dentures. Despite this, staff failed to report the missing denture and did not adequately assess or escalate the resident's change in condition, resulting in a delay in identifying the foreign body aspiration. This delay contributed to the resident's hospitalization and the need for surgical intervention.
Failure to Address and Replace Lost Denture
Penalty
Summary
The facility failed to address the loss of a resident's upper denture and did not formulate a plan for its replacement. The resident, who required assistance with oral care and was not responsible for managing their own dentures, had their upper denture reported missing on 4/13/2025. The Social Services Director investigated the missing denture the following day, but the denture was not found. There was no documentation of any conversation with the resident's family regarding the lost denture or any agreement about replacement or payment prior to the survey initiation. The facility's records, including the Loss Control/Damage Report, indicated that the investigation began promptly after the denture was reported missing and was signed off two days later. However, the report did not specify a resolution or identify a liable party for the missing denture. Facility policies stated that the facility would not be responsible for lost or damaged dentures unless negligence by staff was determined or if the dentures were given to the facility for safekeeping. Despite these policies, there was no evidence that the facility communicated with the family or made a determination regarding responsibility or replacement.
Failure to Provide Adequate Staffing Resulting in Missed Care and Delayed Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple staff and resident interviews, record reviews, and staffing schedules. Certified Nursing Assistants (CNAs) reported that staffing levels were frequently below the facility's recommended numbers, particularly on the Liberty Lane unit, which has a high number of residents requiring heavy care and mechanical lifts. Staff described situations where only two CNAs were available for 27 residents, making it difficult to provide timely care, including showers, toileting, and feeding assistance. Staff also reported that when short-staffed, they had to prioritize care, resulting in missed or delayed showers and incontinence care, and longer wait times for call lights to be answered. Residents corroborated these accounts, with one resident documenting long periods between being checked or changed and waiting over 30 minutes for call lights to be answered. This resident also reported missing scheduled showers and feeling dismissed by staff when raising concerns. Another resident stated that it was common to wait 40-45 minutes for call lights to be answered and was told that showers could not be provided due to insufficient staffing. Review of shower sheets confirmed that some residents did not receive the facility's policy of two showers per week, and there were days with no documentation of showers or bed baths for certain residents. The facility's staffing schedules and logs showed multiple days within a two-week period where the number of CNAs on duty did not meet the facility's own recommended levels. On one such day, a resident with a history of falls was left unsupervised and experienced a fall resulting in a hospital visit. Staff and the Director of Nursing acknowledged ongoing staffing challenges, especially during call-ins, and confirmed that these shortages impacted the ability to provide timely and complete care to residents, including supervision, showers, and incontinence care.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to provide scheduled showers for five out of eight residents reviewed for Activities of Daily Living (ADLs). Multiple residents reported not receiving their scheduled showers, with one resident stating that she is supposed to receive showers twice a week but this does not always occur. Staff interviews confirmed that on days with insufficient staffing, showers could not be provided as scheduled. One CNA reported being unable to provide showers, incontinence care, or feeding to all residents due to low staffing levels. Another CNA stated that when a shower is missed or refused, it should be documented and attempted again, but documentation was missing for several residents on scheduled shower days. Review of facility records and shower sheets revealed that several residents did not receive the required two showers per week, and in some cases, there was no documentation of showers or bed baths for extended periods. The facility's policy requires proper daily attention and care, including as many baths as necessary for hygiene needs. However, the lack of documentation and missed showers indicate that this standard was not consistently met for the residents involved.
Failure to Provide Adequate Supervision for Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as a fall risk, resulting in multiple falls. The resident, an elderly male with severe unspecified dementia, anxiety, and altered mental status, was admitted with a care plan indicating a risk for falls due to weakness and a new environment. On two separate occasions, the resident was left unsupervised or insufficiently supervised due to staffing shortages. On one occasion, the resident attempted to go to the bathroom alone, fell, and hit his head, requiring hospital evaluation. Staff interviews confirmed that the resident should not have been left alone and that the unit was short-staffed at the time of the incident. On another occasion, the resident, who was supposed to be kept in the common area for supervision, was able to stand up and fall before staff could intervene, again resulting in a head injury and hospital evaluation. Documentation and staff statements consistently indicated that the resident was not provided the necessary supervision as outlined in his care plan, and that staffing levels were below normal on both days when the falls occurred. The facility's records confirmed the occurrence of both falls within a short period.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for residents in a timely manner, as required. This deficiency was identified for four residents who were part of a sample of 18. Specifically, the Minimum Data Set (MDS) Assessment Tracking indicated that the comprehensive assessments for these residents were overdue, with some assessments being several months late. The Interim Director of Nursing (DON) and MDS Coordinator acknowledged the backlog, attributing it to the dual responsibilities taken on after the departure of the previous DON in September. The interim DON stated that the facility was initially three months behind on assessments, and despite efforts to catch up, the assessments remained incomplete at the time of the survey.
Delayed Completion of Significant Change Assessments
Penalty
Summary
The facility failed to complete significant change assessments for four residents in a timely manner. Resident 24's assessment was due on January 30, 2025, Resident 25's on January 29, 2025, Resident 48's on January 22, 2025, and Resident 49's on February 20, 2025. As of March 4, 2025, all these assessments were still listed as 'In Process.' The Interim Director of Nursing (DON) and MDS Coordinator, identified as V2, acknowledged the delay, stating that they had been behind since taking over the role in September after the previous DON left. V2 mentioned that they had sent emails indicating that their part of the assessments was completed, but the remaining parts were pending completion by others. V2 also expressed difficulty in managing both the interim DON responsibilities and keeping up with the MDS assessments.
Delayed Completion of Quarterly Assessments
Penalty
Summary
The facility failed to complete quarterly assessments for four residents in a timely manner, as required by regulations. Specifically, the Minimum Data Set (MDS) Assessment Tracking for these residents showed that their assessments were overdue and still listed as 'In Process' as of March 4, 2025. The assessments for these residents were due between January 1 and January 15, 2025. The Interim Director of Nursing (DON) and MDS Coordinator, identified as V2, acknowledged the delay, attributing it to the dual responsibilities of managing both the DON and MDS roles after the departure of the previous DON in September. V2 mentioned that the facility was initially three months behind on assessments, which contributed to the current backlog.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care and toileting assistance to a resident who required maximum staff assistance for these activities. The resident, who was cognitively impaired and had a history of incontinence, was observed seated in a wheelchair with a strong smell of urine in the room. Upon being transferred to the toilet by two CNAs, it was noted that the resident's sweatpants were wet with urine, and the brief was saturated with urine and contained a moderate amount of soft stool. The resident's buttocks appeared red, indicating prolonged exposure to moisture. One of the CNAs admitted it was their first time changing or toileting the resident that day and was unsure when the resident was last changed, suggesting a lapse in the facility's protocol of providing incontinence care every two hours.
Narcotic Reconciliation Count Inaccuracy
Penalty
Summary
The facility failed to ensure the accuracy of the narcotic reconciliation count for a resident, identified as R274, who was part of a sample reviewed for narcotics. On the morning of March 4, 2025, an LPN discovered that the narcotic count for R274's Tramadol 50mg was incorrect. The resident had two cards of Tramadol, one with 30 tablets and another with 19 tablets, totaling 49 tablets. The discrepancy arose because a nurse did not sign out a dose of Tramadol administered during the 7:00 AM to 10:00 AM shift on March 3, 2025. The Director of Nursing was informed of the issue and confirmed that the count was off due to the nurse's failure to document the administered dose. The facility's pharmaceutical procedures require that controlled substances be documented on individual resident control sheets, with shift counts verified by both off-going and on-coming nurses.
Failure to Date Insulin Pen Upon Opening
Penalty
Summary
The facility failed to label an insulin pen with an opened date, which is a requirement for ensuring the proper management of medications. During an observation on March 4, 2025, at 8:00 AM, it was noted that a resident's Humalog insulin pen was stored in the medication cart without an opened date. This was confirmed by an LPN who acknowledged that the insulin pen should have been dated when opened. Later that day, the Director of Nursing also confirmed that insulin pens should be dated upon opening. The resident's Physician Order Report indicated that the Humalog KwikPen Insulin was started on September 22, 2025. The facility's Insulin Administration Procedure, revised in February 2004, states that insulin vials should be dated when opened to prevent loss of potency after 30 days of use.
Failure to Provide Smooth Puree Diets
Penalty
Summary
The facility failed to ensure that puree diet textures were smooth for three residents on puree diets. During the lunch meal on March 3, 2025, the cook responsible for pureeing the Swiss steak did not achieve a smooth texture, resulting in a gritty consistency with small chunks of meat. Similarly, the creamed corn was not pureed to a smooth texture, as it contained hulls. The Dietary Manager confirmed that the puree served at the noon meal was gritty and identified the three residents receiving these diets. The facility's procedure for pureeing food, dated July 2020, specifies that pureed foods should have a smooth, mashed potato consistency with no lumps or particles visible, which was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow Enhanced Barrier Precautions (EBP) for three residents, leading to deficiencies in infection control. For one resident with wounds on her left calf and mid-back, a registered nurse provided wound care without wearing a protective gown, despite the presence of an EBP sign on the door. Another resident with a history of ESBL infection and urinary incontinence did not have an EBP sign or PPE cart outside his room until the day after the infection preventionist was notified of his condition. This delay in implementing EBP precautions highlights a lapse in communication and adherence to infection control protocols. Additionally, a student nurse assisted a resident with wounds in the bathroom without wearing a gown and gloves, despite the presence of an EBP sign on the door. The facility's policy requires gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices. These incidents demonstrate a failure to consistently apply the facility's EBP policy, potentially increasing the risk of transmission of multi-drug resistant organisms.
Failure to Conduct Neurological Assessments After Resident Fall
Penalty
Summary
The facility failed to perform neurological assessments after an unwitnessed fall involving a resident with a history of falls and medical conditions including right lower leg amputation, dementia, and urinary retention. The resident was found on the bathroom floor with a head injury and was sent to the local hospital for treatment. Despite the presence of a head injury, the facility did not conduct the required neurological checks, which are crucial for monitoring potential changes in the resident's condition following a fall. The incident occurred in the early hours of the morning, and the documentation of the event was completed approximately three hours after the fall. The Director of Nurses acknowledged the oversight and attributed it to the use of agency nurses who may not be familiar with the facility's protocols for post-fall assessments. The lack of immediate and ongoing neurological assessments was identified as a deficiency in the standard nursing care provided to the resident, particularly given the presence of a head injury.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure resident safety by not implementing fall interventions for a resident identified as a high fall risk. The resident, who has a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was found with a hematoma on her forehead and bruising on her left wrist and hand after falling in the bathroom. The resident reported that she was on the toilet and fell while trying to wipe, with no one present in the bathroom at the time. This incident was the second time the resident had fallen in the bathroom. The Certified Nursing Assistant (CNA) involved admitted to stepping out of the bathroom to retrieve clothes, leaving the resident unattended, which led to the fall. The facility's administrator confirmed that the CNA should not have left the resident alone, as per the care plan intervention dated 10/7/24, which explicitly stated not to leave the resident alone in the bathroom. Additionally, the facility lacked a policy on falls or fall prevention, which contributed to the failure to provide adequate supervision and prevent the accident.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to ensure that physician-prescribed medication was obtained and administered to a resident diagnosed with a urinary tract infection (UTI). The resident, who was admitted with conditions including adult failure to thrive, urinary retention, unspecified dementia, and protein-calorie malnutrition, was discharged from a local hospital with a prescription for levofloxacin, an antibiotic, to be taken daily for five days. However, the Medication Administration Record indicated that the resident did not receive the scheduled doses on the first two days due to the medication being unavailable. Interviews with facility staff revealed that the medication was available in the facility's onsite medication distribution system, known as stat safe, but was not administered. The Licensed Practical Nurse and Registered Nurse were unaware of the missed doses and did not take action to obtain the medication from the stat safe or contact the pharmacy. The facility's pharmacist confirmed that the order was received and delivered, but the medication was not administered as scheduled. The resident's physician was not informed of the missed doses, which were ordered by the hospital physician and should have been followed as scheduled.
Failure to Notify POA After Resident Leaves AMA
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) after the resident left the facility against medical advice (AMA). On September 10, 2024, a resident expressed a desire to leave the facility and subsequently left with their significant other in a car, despite being advised by staff to remain. The Registered Nurse (RN) on duty did not contact the resident's POA, although it was standard procedure to do so. The Director of Nursing (DON) and another RN confirmed that the facility's protocol requires notifying the POA when a resident discharges. The resident's POA had previously been involved in medical decisions, as evidenced by a surgical consent completed via telephone on September 5, 2024. The POA had been in place since April 2, 2018.
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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