Marshall Rehab & Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshall, Illinois.
- Location
- 410 North Second Street, Marshall, Illinois 62441
- CMS Provider Number
- 146046
- Inspections on file
- 36
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Marshall Rehab & Nursing during CMS and state inspections, most recent first.
The facility failed to ensure meals were palatable and served at an appetizing temperature for all 58 residents. A grievance documented complaints of cold food, and surveyors twice observed numerous trays in the main dining room with more than half of the food uneaten. A test tray showed beef stew at 132°F, and the stew and mixed vegetables did not taste warm. A resident reported meals being cold, unappetizing in appearance, and often overcooked, burned, or dried out. Another resident reported usually receiving cold food, including inedible pancakes, and stated that although heating “pucks” were purchased to keep plates warm, they were sometimes not heated or not used by staff. The Administrator acknowledged multiple complaints about cold and poor-tasting food.
Surveyors observed that an in‑kitchen air conditioning unit was leaking water onto the dishwashing area and splashing into the food service area during meal service. During the same meal service, a CDM accidentally knocked multiple paper meal tickets onto the kitchen floor over a several‑foot area, then, with another staff member, picked them up and placed them back on the counter and onto resident meal trays. The CDM later acknowledged that the air conditioner had broken and was dripping condensate in the kitchen and that the meal tickets were contaminated when they touched the floor, yet they were still used on trays for residents.
A resident who was moderately cognitively intact and incontinent, requiring assistance with toileting and personal hygiene, did not receive incontinence care for several hours while seated in a wheelchair, despite having physician orders for regular coccyx wound treatment. During observed wound care, an LPN collected wound supplies by holding them against her jacket and placed them on an un-disinfected bedside table, later acknowledging this contaminated the supplies. The resident’s coccyx wound, previously smaller, was observed as an open, red area about the size of a quarter with non-blanchable peri-wound tissue and an additional line-shaped open wound, while the wound nurse reported not being aware of the wound’s worsening or the new area. The DON stated that staff are expected to provide incontinence care every two hours and as needed, along with preventative measures such as repositioning and toileting.
A cognitively intact resident who required assistance with toileting and personal hygiene received incontinence care during which CNAs failed to disinfect the bedside table before placing clean washcloths, repeatedly used contaminated gloved hands in a shared basin of wash water, and used a soiled brief to catch additional urine without providing further perineal care. The same contaminated gloves were then used to remove the saturated brief and apply a clean one without hand hygiene or glove change, and no barrier cream was applied, resulting in a failure to prevent cross contamination during incontinence care.
The facility failed to consistently provide hot, palatable meals at safe temperatures to residents receiving room or hall trays. A test tray showed an entrée temperature below the facility’s policy standard and felt cold to the touch, and the grievance log documented complaints about cold food. Several cognitively intact residents who ate in their rooms reported that their meals were frequently or always cold, including specific examples such as cold fries and generally unappetizing food. Multiple CNAs confirmed that residents often complained about cold food, citing lack of heating pucks under plates and delays in meal delivery, while the Dietary Manager acknowledged ongoing issues with maintaining food temperature, particularly with certain items like shoestring fries and with inconsistent use of hot pucks.
Multiple residents with cognitive impairments were involved in physical altercations, including slapping, pushing, and kicking, after unwelcome physical contact from another resident. Staff and other residents reported ongoing issues with inappropriate touching and physical responses, indicating a failure to prevent resident-to-resident abuse.
A resident with severe cognitive impairment and a diagnosis of dementia exhibited ongoing behaviors such as touching other residents, leading to altercations and complaints. The care plan did not address these behaviors, and staff did not recognize them as problematic. Multiple staff members reported not receiving dementia training, and the facility lacked a dementia unit or coordinator.
The facility did not notify law enforcement after multiple incidents where a resident was struck by two different residents and another resident was allegedly sexually assaulted by a visitor. Although internal reports were completed and the state agency was notified, the administrator stated they were unaware of the requirement to contact police, despite facility policy mandating such reporting.
A resident with severe cognitive impairment was physically abused on separate occasions by two other residents with no cognitive impairment. In one case, a resident struck the victim in the face after becoming angry, an act witnessed by staff. In another, a resident forcefully pushed the victim's wheelchair and struck her on the arm in the dining room while staff were not present. Both incidents demonstrate a lack of adequate supervision and failure to prevent peer-to-peer abuse.
After a resident with no cognitive impairment physically assaulted another resident, staff did not remove him from direct access to his severely cognitively impaired, non-verbal, and fully dependent roommate. Despite staff concerns and the facility's policy requiring immediate protective actions after abuse is identified, the administrator instructed staff not to move either resident, leaving the vulnerable roommate at risk.
Two residents' medical records were found incomplete after incidents of physical abuse, with missing documentation of injuries, lack of family and physician notifications, and absence of required 72-hour follow-up assessments. Nursing staff and administration confirmed that documentation did not meet facility policy, resulting in gaps in recordkeeping after the events.
A facility staff member failed to immediately report an allegation of staff-to-resident abuse to the administrator, affecting a resident. The incident was observed by a cook and reported to their manager, who delayed informing the administrator until the next day, contrary to the facility's abuse prevention policy and federal regulations requiring immediate reporting.
A facility failed to identify the root cause of pain for a resident with multiple diagnoses, including a fractured neck of the right femur. Despite severe pain and cognitive impairment, the facility did not conduct a comprehensive pain assessment or attempt other interventions to identify the cause of the pain. The resident continued to experience severe pain, requiring narcotic pain medications, and was later found to have a broken femur head requiring a total hip replacement.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, with the Dietary Manager admitting to not meeting state standards. Additionally, the dietary staff failed to prevent cross-contamination of food and maintain sanitary storage areas, affecting all 53 residents.
The facility failed to prevent direct cross-contamination of stored food and maintain sanitary food storage areas. Mold was observed on shelving in the kitchen walk-in cooler, and condensation from the walk-in freezer's evaporator/condenser supply lines leaked onto food items. The Dietary Manager confirmed the contamination. The facility housed 53 residents at the time.
The facility failed to ensure residents' rights to dignified activities of daily living, affecting six residents. Residents experienced long wait times for meals and toileting assistance, leading to distress and incontinence. Additionally, a resident with severe cognitive impairment was repeatedly observed in soiled clothing, compromising their dignity and hygiene.
The facility failed to supervise a resident at risk for self-harm and did not document another resident's fall, initiate neurological checks, conduct a fall investigation, determine a root cause, or implement a specific fall intervention. These deficiencies affected two residents reviewed for accidents and supervision.
The facility failed to provide residents with food at an appetizing temperature, with meals often served up to one and a half hours late, resulting in hot food being served cold. The issue persisted despite discussions between the Dietary Manager and nursing staff, and was documented in Resident Council meeting notes for three consecutive months.
The facility failed to provide bedtime snacks for four residents, including two with Diabetes Mellitus, due to the snack cart being placed in the linen room instead of the nurses' station. This made snacks inaccessible to residents, and the issue was not known to the Dietary Manager, ADON, or DON.
The facility failed to follow up on abnormal lab results for a resident with severe cognitive impairment, delaying necessary medication adjustments. Additionally, a CNA improperly administered Zinc Oxide paste, a task reserved for licensed nurses, indicating a lapse in staff training and protocol adherence.
The facility failed to provide timely incontinence care for a resident with moderate cognitive impairment and limited mobility, leading to prolonged periods of sitting in wet briefs and resulting in skin irritation and discomfort. Staff and the resident's roommate confirmed delays in responding to call lights, compromising the resident's dignity and comfort.
The facility failed to follow physician-ordered pressure ulcer treatments and repositioning interventions for a resident with multiple Stage 4 pressure ulcers. The resident was left in a reclined wheelchair for extended periods, causing discomfort, and an LPN did not properly cleanse and dress the wounds as per physician orders.
A facility failed to check the placement of a PEG tube before administering medication and enteral feeding to a resident with severe cognitive impairment and multiple medical diagnoses. The RN did not follow the facility's policy, and the DON confirmed the importance of these checks.
The facility failed to maintain respiratory equipment according to physician orders and facility policy, affecting three residents. Issues included undated oxygen tubing and nasal cannulas, lack of humidifier bottles, and outdated equipment. Staff confirmed these deficiencies during observations.
The facility failed to provide mail service to residents on Saturdays, affecting all 53 residents. Staff confirmed that while mail is delivered by the post office on Saturdays, it remains locked up and inaccessible until Monday, resulting in residents not receiving their mail until the following Monday.
The facility failed to provide a clean, homelike environment for two residents. One resident's bathroom was found with feces on the walls and floor, while another's bathroom had a broken toilet and a strong musty odor. Despite complaints and acknowledgment from the Director of Nurses, the issues were not promptly addressed, highlighting deficiencies in housekeeping and maintenance practices.
A resident with severe cognitive impairment was found with unexplained bruises on their back. The facility's staff did not report the injuries to the State Agency, despite the facility's policy requiring such reports. The Director of Nurses and Administrator acknowledged the failure to report, citing a misunderstanding of the reporting requirements.
Failure to Provide Palatable Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that meals were palatable, attractive, and served at a safe and appetizing temperature, with the potential to affect all 58 residents in the building. A grievance dated 12/1/25 documented that the food was cold. On 2/24/26 at 1:00 PM and again on 2/25/26 at 12:55 PM, surveyors observed numerous resident meal trays sitting in the main dining room with more than half of the food left on each of twelve and fifteen trays, respectively. On 2/25/26 at 1:15 PM, a test tray was obtained and the CDM measured the beef stew at 132°F; the beef stew and mixed vegetables did not taste warm. One resident stated his meal was cold, described the food as looking like “slop,” reported that the food is always cold and does not taste good, and said it is frequently overcooked, burned, or dried out. Another resident stated the food is usually served cold, reported being served cold, inedible pancakes, and noted that although the facility obtained heating “pucks” to place under plates after complaints, the pucks were sometimes not warm or were not used by staff. The Administrator acknowledged awareness of multiple complaints about food being served cold or not tasting good.
Cross Contamination Risk from Contaminated Meal Tickets and Kitchen Condensate
Penalty
Summary
Surveyors identified a deficiency in food service practices related to cross contamination during meal service. The facility census documented 58 residents residing in the facility. During observation of the kitchen, the air conditioning unit mounted inside the kitchen was found to be dripping water onto the dishwashing area and onto the floor, with splashing extending approximately three to four feet into the food service area. This condition was present during active meal service. Later the same day, during meal service, the Certified Dietary Manager (CDM) accidentally knocked resident paper meal tickets off the counter, causing them to scatter over a three to four foot area on the kitchen floor. The CDM, wearing gloves, picked up the paper tickets from the floor and placed them back on the corner of the warmer counter. Another staff member assisted in picking up the tickets and then placed the pile of contaminated meal tickets on resident meal trays to be served. The CDM acknowledged that the air conditioner had broken earlier that morning and was dripping condensate throughout the kitchen, and further acknowledged that the meal tickets became contaminated when they touched the floor and that there was a good chance all of the trays would have been contaminated because the tickets stay with the trays.
Failure to Prevent Cross Contamination and Provide Timely Incontinence Care During Wound Management
Penalty
Summary
Surveyors identified a deficiency in providing appropriate treatment and care according to orders and in preventing cross contamination during wound care for one resident with coccyx wounds. The resident’s MDS documented moderate cognitive intactness and a need for assistance with toileting and personal hygiene, and the POS included an order to apply a hydrocolloid dressing to the coccyx every other day starting 2/23/26. On 2/25/26, the resident remained seated in a wheelchair from 9:00 AM to 1:00 PM without being provided incontinence care, despite being incontinent and requiring assistance. During wound care at 2:35 PM, an LPN gathered wound care supplies (gauze, dressing, scissors, wound cleanser) by holding them against her zip-up hoodie jacket and then placed the supplies on the resident’s bedside table before ensuring the table was disinfected. The previous dressing on the coccyx was a simple foam dated 2/23/26. At the time of the observation, the resident’s coccyx had an open, red wound approximately the size of a quarter with a non-blanchable peri-wound area, and a separate open, red, line-shaped wound approximately an inch long. The LPN acknowledged that she contaminated the resident’s wound care supplies by holding them against her contaminated jacket and stated that the coccyx wound had been the size of a pencil eraser a few days earlier and that the resident previously had no open areas on the right buttock. The wound nurse later stated that staff do not lay the resident down after breakfast as they should and attributed the open areas on the resident’s bottom to this, and also stated she was not aware that the coccyx wound had worsened or that there was a new area on the right buttock. The DON stated that staff are expected to provide incontinence care every two hours and as needed, and to provide preventative care such as repositioning and toileting to prevent wounds, and confirmed that the resident is incontinent and requires assistance with incontinence care.
Failure to Prevent Cross Contamination During Incontinence Care
Penalty
Summary
The deficiency involves failure to prevent cross contamination during incontinence care for one resident who was cognitively intact and required assistance with toileting and personal hygiene, as documented on the resident’s MDS. During observed incontinence care, the CNAs did not disinfect the bedside table before placing clean, dry washcloths on it. One CNA then used both gloved hands to provide front perineal care and repeatedly used the same contaminated gloved hands to obtain and wring out a washcloth from a basin of warm water, thereby contaminating the wash water each time. After completing the initial front incontinence care, the resident was assisted to the left side and verbalized that urination was occurring again. As the resident urinated, the CNA used the already contaminated incontinence brief to catch the urine and did not provide additional front perineal care afterward. The CNA then used the same contaminated gloves to remove the urine-saturated brief and place a new brief without removing gloves, performing hand hygiene, or donning clean gloves. Barrier cream was not applied at the end of incontinence care. The CNA later acknowledged that incontinence care should have been repeated after the resident urinated again and that gloves and wash water had been contaminated during the process.
Failure to Provide Hot, Palatable Meals to Residents Receiving Room Trays
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide hot, palatable meals at safe and appetizing temperatures to residents receiving room trays, despite having a Food Temperatures Policy requiring hot foods to be held at 135°F or above and reheated to 165°F for at least 15 seconds. A test tray served on 12/30/25 at 12:50 PM contained a fish fillet, vegetables, pasta, bread, and peach cobbler; the internal temperature of the fish fillet was measured at 130°F and felt cold to the touch. The facility’s grievance log from 9/25/25 to 12/1/25 documented two grievances related to cold food during that period. The Dietary Manager acknowledged awareness of resident concerns about cold food from a resident council meeting about a month prior and stated that hot pucks were used for breakfast and lunch but not for supper, and that shoestring fries cooled rapidly after cooking and temperature checks. Multiple cognitively intact residents reported that food delivered to their rooms was frequently or consistently cold. One resident who eats in her room stated that the food is cold every time and that the heaters under the trays do not work. Another resident described the food as gross and often cold, citing a recent meal where the hamburger was served with fries that were ice cold. Additional residents reported that the food was so-so and often cold, that their only complaint was that room-delivered meals were always cold, and that the food was often cold and very institutionalized. Several CNAs corroborated these concerns, stating that residents receiving room or hall trays often complained that their food was cold, attributing this in part to dietary staff not placing heating pucks under plates and to delays in delivering meals to residents who do not eat in the dining room.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse, as evidenced by multiple incidents involving four residents. One resident with severe cognitive impairment and diagnoses including Major Depressive Disorder, Anxiety Disorder, Alzheimer's Disease, and Dementia with Psychotic Disturbance, struck another severely cognitively impaired resident with an open hand on the cheek during an altercation in a hallway. Staff observed the incident and intervened, but the altercation resulted in distress for both residents involved. Documentation shows that both residents had significant cognitive impairments, and the incident was reported to the state agency. In another series of incidents, a cognitively intact resident with Parkinson's Disease, Atherosclerosis, Prostate Cancer, and Aphasia pushed and kicked a severely cognitively impaired resident with Dementia, Psychosis, and Depression after being touched by her in the dining room. Multiple residents and staff reported that the cognitively impaired resident frequently touched others, which was unwelcome and led to physical responses from other residents, including being punched and kicked. Staff and residents acknowledged ongoing issues with this behavior, and staff interviews confirmed awareness of the situation, but the touching and resulting altercations continued to occur.
Failure to Provide Effective Dementia Care and Staff Training
Penalty
Summary
The facility failed to provide effective dementia treatment and services for a resident diagnosed with dementia, psychosis, and depression. The resident was noted to be severely cognitively impaired and exhibited behaviors such as touching other residents, which led to altercations. Multiple staff members, including registered nurses and certified nursing assistants, observed and reported the resident's behavior of touching others, and other residents expressed discomfort and frustration with these actions. Despite these ongoing behaviors, the resident's care plan did not document the behaviors or include interventions to address them, and behavior tracking records did not reflect any incidents. Interviews with staff revealed that they did not recognize the resident's touching as a behavioral issue, and several staff members, including CNAs, a dietary aide, and an LPN, reported not having received dementia training at the facility. The facility did not have a dementia unit or a dementia coordinator, and the administrator acknowledged the need for more dementia training, including early intervention and behavior management. These findings indicate a lack of appropriate assessment, care planning, and staff training related to dementia care for the resident in question.
Failure to Report Suspected Abuse and Sexual Assault to Law Enforcement
Penalty
Summary
The facility failed to recognize and report reasonable suspicion of a crime to law enforcement in three separate incidents involving allegations of physical and sexual abuse. In the first incident, a licensed practical nurse witnessed one resident striking another in the face, leaving a visible red mark. In a second incident, a resident was observed by another resident to have been struck on the upper arm by a different resident, with an audible 'pop' heard at the time. In both cases, the facility completed internal incident reports and notified the Illinois Department of Public Health (IDPH), but did not notify local law enforcement as required. A third incident involved an allegation of sexual assault against a resident by a visitor. The facility documented the allegation and reported it to IDPH, but again failed to notify law enforcement. The administrator/abuse prevention coordinator stated that they were unaware of the requirement to report such allegations to the police, believing that reporting to IDPH and completing an internal investigation was sufficient. Facility policies reviewed during the investigation clearly outlined the requirement to report reasonable suspicion of a crime to both the state survey agency and local law enforcement, including incidents of physical and sexual abuse.
Failure to Protect Cognitively Impaired Resident from Peer Abuse
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident from physical abuse by two other residents. One incident involved a resident with no cognitive impairment who, after becoming frustrated and angry due to unsuccessful attempts to contact family, physically struck the cognitively impaired resident in the face. This act was witnessed by staff, who observed the aggressor approach the victim, raise a fist, and hit her on the cheek, resulting in visible redness and distress. The victim was assessed for injuries and was found to be upset and nervous following the incident. A second incident occurred in the dining room, where the same cognitively impaired resident was struck on the arm by another resident with no cognitive impairment. This event was reported by another resident, who witnessed the aggressor push the victim's wheelchair forcefully and then strike her on the arm after she attempted to greet him. The aggressor admitted to 'batting at' the victim and acknowledged having to swat at her to get her to leave him alone. Staff were not present in the dining room at the time of this altercation, and the incident was only reported after a resident sought out staff following the event. Both incidents highlight a lack of adequate supervision and monitoring, particularly during times when staff were occupied with other duties, such as meal service. The facility's own policy requires staff to monitor for behaviors that may provoke reactions and to review resident-to-resident altercations as potential abuse situations. Despite this, the cognitively impaired resident was subjected to repeated physical aggression by peers, with staff either not present or unable to intervene in time to prevent harm.
Failure to Remove Aggressive Resident from Room with Vulnerable Roommate After Abuse Incident
Penalty
Summary
The facility failed to remove a resident, identified as the perpetrator of physical abuse, from direct access to his vulnerable, dependent, and non-verbal roommate after an incident of physical aggression. The resident who committed the abuse was assessed as having no cognitive impairment, while his roommate was documented as having severe cognitive impairment, being totally dependent on staff for all activities of daily living, and unable to ambulate. After the aggressive resident physically struck another resident, leaving a visible injury, staff expressed concern for the safety of his non-verbal roommate, who could not defend himself or communicate effectively. Despite these concerns, the administrator and abuse prevention coordinator directed staff not to move the aggressive resident or his vulnerable roommate to different rooms. Staff, including an LPN and a CNA, reported their worries about the roommate's safety and monitored the situation closely, but the two residents remained in the same room overnight following the incident. The facility's own policy requires immediate steps to protect residents from further abuse once abuse has been identified, but this was not followed in this case.
Failure to Maintain Complete and Accurate Medical Records Following Abuse Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents involved in incidents of physical abuse. In one case, a resident became physically aggressive with another resident, resulting in a red mark on the victim's right upper cheek. The nursing progress notes did not include documentation of the physical abuse, measurements of the injury, or notifications to family or physician. Additionally, there was no ongoing assessment or monitoring of the resident's response to the incident, and required 72-hour follow-up documentation was not initiated. In a separate incident, another resident was reported to have struck the same victim on the arm in the dining room. The medical records for both the alleged perpetrator and the victim did not contain documentation of the physical abuse, notifications to family or physician, or any ongoing assessment or monitoring following the event. The facility's own policy requires documentation of assessment, notifications, interventions, and evaluation, including 72-hour alert charting after incidents or changes in condition, which was not followed in these cases. Interviews with nursing staff and administration confirmed that documentation was incomplete and did not meet facility policy expectations. The staff acknowledged the lack of injury measurement, absence of abuse documentation in the medical records, and failure to document required notifications and follow-up assessments. The deficiency was identified through review of progress notes, incident reports, and staff interviews, which revealed gaps in recordkeeping and failure to adhere to established documentation protocols.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Facility staff failed to immediately report an allegation of staff-to-resident physical and verbal abuse to the facility administrator, affecting one resident. The facility's abuse prevention policy mandates reporting all allegations of abuse within required timeframes according to Federal and State statutes. The Code of Federal Regulations requires that all alleged violations involving abuse be reported immediately, or not later than 2 hours if serious bodily injury is involved, or within 24 hours if not. However, the incident report and subsequent investigation revealed that a cook (V4) observed another cook (V3) allegedly abusing a resident (R1) on the evening of 8/7/2024. V4 reported the incident to their manager (V6) during suppertime, but V6 did not inform the facility administrator (V1) until the following morning. Interviews conducted on 8/20/2024 and 8/21/2024 confirmed the delay in reporting. V4 reported the abuse allegation to V6 between 6-6:30 PM on 8/7/2024, requesting V6 to inform V1. V6 acknowledged receiving the report but did not take immediate action, stating they were leaving work for the day. Another cook (V5) corroborated V4's account, observing the report to V6 and hearing V6's assurance to contact V1 as soon as possible. V6 admitted to not informing V1 until the next day and did not make any observations or inquiries regarding the alleged perpetrator or victim after receiving the report. This inaction resulted in a failure to comply with the required reporting timeframes for abuse allegations.
Failure to Identify Root Cause of Pain
Penalty
Summary
The facility failed to identify the root cause of pain for a resident who had multiple diagnoses, including a fractured neck of the right femur with open reduction and internal fixation, right hip pain, dementia, and osteoarthritis. The resident was admitted to the facility from a local hospital and was noted to be in severe pain. Initial pain management with Tylenol was ineffective, and the resident continued to experience severe pain, which was later managed with narcotic pain medication. Despite this, the facility did not assess the root cause of the increasing pain following the resident's fall or attempt other interventions to identify the cause of the pain. The resident's care plan and progress notes documented severe pain and cognitive impairment, with indicators of pain such as nonverbal sounds, vocal complaints, facial expressions, and protective body movements. The resident fell while trying to get out of bed, and although no immediate injuries were noted, the resident continued to experience severe pain. The facility's pain management policy required a comprehensive pain assessment upon admission, transfer, or onset of new pain, but there was no documentation that such an assessment was conducted to identify the root cause of the resident's pain. The resident's family member reported that the resident was in a lot of pain during the entire stay at the facility and had a large bump on the right hip upon discharge. The orthopedic surgeon confirmed that the resident had broken the entire head off the femur bone and required a total hip replacement. The facility's failure to investigate the cause of the resident's pain and provide appropriate interventions resulted in the resident experiencing continued severe pain and requiring narcotic pain medications.
Unqualified Dietary Manager and Sanitation Issues
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 53 residents in the facility. On 4/9/2024, the Dietary Manager (V8) was observed supervising dietary operations and reported being the full-time manager of the facility food service. However, V8 admitted to not being a clinically qualified Certified Dietary Manager or having equivalent training, and did not meet the State of Illinois standards to be a food service manager or dietary manager. V8 also confirmed that the facility dietician does not work full-time in the facility. Additionally, on 4/9/2024, the facility dietary staff failed to prevent direct cross-contamination of food and did not maintain sanitary food storage areas. V8 reported that the food prepared in the facility kitchen is available for all residents to eat. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated 3/9/2024, documents that 53 residents reside in the facility.
Failure to Maintain Sanitary Food Storage Areas
Penalty
Summary
The facility failed to prevent direct cross-contamination of stored food and maintain sanitary food storage areas. On 4/9/2024 at 11:05 AM, three wire shelving sections in the kitchen walk-in cooler were observed to be partially covered with a gray-colored, fuzzy biological growth resembling mold. Boxes of food items, pans of prepared food, and jugs of milk were stored directly on these contaminated shelving racks. Additionally, on 4/9/2024 at 11:21 AM, the walk-in freezer's evaporator/condenser supply lines were leaking accumulated condensation onto boxes of food stored below on shelving. The leak had dripped directly into a fully open box of frozen green beans, partially covering the product. The Dietary Manager confirmed the presence of condensation on the green beans. The facility's Long-Term Care Facility Application for Medicare and Medicaid documented that 53 residents resided in the facility at the time of the survey.
Failure to Ensure Dignified Activities of Daily Living
Penalty
Summary
The facility failed to ensure residents' rights to dignified activities of daily living, affecting six residents. On multiple occasions, residents in the dining room were observed waiting for meals for extended periods, with some waiting up to fifty minutes after others had been served. This issue was corroborated by resident council meeting minutes and resident interviews, indicating that meals were consistently served late, causing distress and dissatisfaction among the residents. Another deficiency involved a resident who required extensive assistance for toileting due to limited mobility and cognitive impairment. The resident and her roommate reported long wait times for assistance, sometimes up to an hour and a half, leading to incontinence episodes. Staff interviews confirmed the resident's history of moisture-associated skin damage and urinary tract infections, and acknowledged the delays in responding to call lights, which compromised the resident's dignity and comfort. Additionally, a resident with severe cognitive impairment and multiple medical diagnoses was repeatedly observed in soiled clothing over several days. Despite the availability of clothing protectors and staff's responsibility to assist with hygiene, the resident remained in dirty clothes, which was confirmed by the resident's power of attorney and the Director of Nurses. This failure to maintain the resident's dignity and hygiene was evident through multiple observations and staff interviews.
Inadequate Supervision and Documentation of Falls
Penalty
Summary
The facility failed to adequately supervise a resident (R40) at risk for self-harm and did not document a resident (R159) fall into the facility's risk management system, initiate neurological checks, conduct a fall investigation, determine a root cause, and implement a specific fall intervention to aid in future fall prevention. R40, who has severe cognitive impairment and uses a wheelchair for mobility, exhibited behaviors such as eating non-food items, taking items that are not his, and becoming verbally and physically aggressive. Despite multiple incidents where R40 ingested or attempted to ingest hazardous substances like hand sanitizer and medicated cream, the facility did not provide constant supervision, especially on weekends when ancillary staff were not present. Staff and physicians acknowledged the need for diligent supervision, but lapses continued to occur, leading to repeated incidents of self-harm risk for R40. R159, diagnosed with repeated falls, psychotic disorder, mild cognitive impairment, dementia, motor and sensory neuropathy, and muscle weakness, experienced an unwitnessed fall while attempting to self-transfer to his wheelchair. The fall was not documented in the risk management system, and no neurological checks were initiated. Additionally, a fall investigation was not conducted, a root cause was not determined, and no new fall interventions were implemented. This lack of documentation and follow-up led to another fall for R159 within a week. The facility's failure to supervise R40 adequately and to document and investigate R159's fall demonstrates significant lapses in ensuring resident safety and preventing accidents. These deficiencies affected two of the five residents reviewed for accidents and supervision, highlighting the need for improved monitoring and documentation practices to prevent future incidents.
Failure to Serve Meals at Appetizing Temperature
Penalty
Summary
The facility failed to provide residents with food at an appetizing temperature, affecting four residents who were cognitively intact. During a resident group meeting, the residents reported that their meals were often served up to one and a half hours late, resulting in hot food being served cold. The Dietary Manager (DM) confirmed that the food comes out of the kitchen at safe hot temperatures but sits on the hall for 30 to 45 minutes before being delivered by the Certified Nursing Assistants (CNAs). The DM also observed food sitting in the dining room for 30 minutes before being served, leading to complaints from residents about the temperature of their meals. The issue was documented in the facility's Resident Council meeting notes for three consecutive months, indicating ongoing concerns about meal temperatures. The DM stated that the kitchen is willing to reheat the food if notified, but the CNAs need to communicate this. The problem persisted despite the DM discussing it with the nursing staff, highlighting a breakdown in the process of delivering meals promptly to residents. The residents confirmed that no cold food had been served since the state surveyors arrived, suggesting temporary improvements during the survey period.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to provide bedtime snacks for four residents (R11, R12, R18, and R31) who were reviewed for bedtime snacks. These residents, who have no cognitive impairment, reported during a resident group meeting that snacks are not stocked daily or offered at bedtime. Additionally, the snack cart is sometimes placed in the linen room instead of the nurses' station, making it inaccessible to residents. Two of the residents, who have Diabetes Mellitus, expressed the need for snacks to manage their blood sugar levels. The Dietary Manager was unaware of any issues with snack availability, while the Assistant Director of Nursing and Director of Nursing were not aware that snacks were not being provided at bedtime. The ADON mentioned that the snack cart is placed in the linen room to prevent a wandering diabetic resident from consuming inappropriate snacks.
Failure to Follow Up on Lab Results and Improper Medication Administration
Penalty
Summary
The facility failed to follow up with the physician regarding laboratory results for a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and anxiety. The resident's lab results, which were abnormal, were faxed to the physician, but the necessary follow-up did not occur until 19 days later, after the surveyor inquired about the labs. This delay prevented the timely adjustment of the resident's medication, specifically the increase of Ferrous Sulfate to address low iron levels. Additionally, the facility allowed unlicensed personnel to administer medication. A Certified Nurse Aide (CNA) applied Zinc Oxide paste to a resident's perineal area after completing urinary catheter care, which is against the facility's standard of care. The Director of Nursing confirmed that only licensed nurses are permitted to apply medicated creams, and the CNA was unaware of this protocol. This incident highlights a lapse in staff training and adherence to medication administration policies.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R15), who has moderate cognitive impairment and requires extensive assistance for toileting due to limited range of motion and other health issues. Despite having a care plan that mandates peri-care anytime R15 is toileted and as needed, staff often delayed responding to R15's call light, sometimes taking up to an hour or more. This delay led to R15 experiencing incontinence episodes and sitting in wet incontinence briefs, causing discomfort and skin irritation. R15's roommate and other staff confirmed these delays, noting that R15 often had to wait long periods for assistance, which compromised her dignity and comfort. R15's medical history includes taking Furosemide, which increases urine production, and a history of urinary tract infections (UTIs) and Moisture Associated Skin Damage (MASD). Staff interviews revealed that R15 frequently experienced redness and soreness in her peri-area due to prolonged exposure to wet briefs. Although staff applied barrier creams to manage skin irritation, the delays in providing timely incontinence care persisted. The Assistant Director of Nursing acknowledged the issue, stating that call lights should be answered within five minutes and bathroom call lights within a minute, but this standard was not consistently met for R15.
Failure to Follow Pressure Ulcer Treatment and Repositioning Interventions
Penalty
Summary
The facility failed to follow a physician-ordered pressure ulcer treatment and implement pressure ulcer interventions for a resident with multiple Stage 4 pressure ulcers. The resident, who has medical diagnoses including paraplegia and muscle weakness, was observed multiple times laying on his back in a reclined wheelchair, despite care plan interventions requiring repositioning every two hours and only being on his back while eating. The resident expressed discomfort and pain from being in the wheelchair for extended periods, indicating that the repositioning interventions were not being followed by the staff. Additionally, during a dressing change, an LPN did not cleanse the resident's Left Ischium pressure ulcer before applying a new dressing and used the wrong type of dressing on the Right Ischium pressure ulcer. The LPN admitted to not reviewing the physician orders prior to the dressing change and acknowledged the mistake. The Director of Nurses confirmed that the physician orders were not followed and that the facility did not have a specific policy for clean dressing changes, relying instead on standard nursing education and practice.
Failure to Check PEG Tube Placement Before Medication and Feeding Administration
Penalty
Summary
The facility failed to check the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube prior to the administration of medication and enteral feeding for one resident. The resident, who has severe cognitive impairment and multiple medical diagnoses including Hemiplegia, Hemiparesis, and Cerebrovascular Disease, had a physician's order to check the PEG tube placement and residual volume before administering medications and feedings. However, during an observation, a Registered Nurse (RN) administered medications and resumed enteral feeding without performing the required checks for tube placement and residual volume. The RN admitted to not following the facility's policy, which mandates checking the PEG tube placement and residual volume before each medication administration and feeding. The Director of Nurses (DON) confirmed that the nursing staff should always check the placement of the PEG tube to ensure that medications, water, and feeding are administered correctly. The facility's policy on tube feeding outlines specific steps for verifying tube placement and checking residual gastric contents, which were not followed in this instance.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide, change, date, and maintain respiratory equipment according to physician orders and facility policy, affecting three residents. For Resident 8, the oxygen tubing and nasal cannula were not dated, and there was no humidifier bottle attached to the oxygen concentrator, despite physician orders and facility policy requiring these actions. The family member and an LPN confirmed the lack of proper equipment maintenance. Resident 8 was on hospice care, and the hospice was supposed to provide the necessary supplies, which were not present at the time of observation. For Resident 22, the oxygen concentrator was dispensing oxygen at 2 liters per minute, but the nasal cannula tubing and humidifier water bottle were not dated to indicate when they were last changed. An LPN confirmed that the equipment should have been changed. Resident 31's oxygen tubing and humidifier bottle were outdated and not changed according to the schedule. The humidifier bottle was empty, and the resident was unaware of the maintenance schedule. An LPN confirmed the outdated equipment and the empty humidifier bottle. The facility policy requires weekly changes and proper dating of respiratory equipment, which was not followed in these cases.
Failure to Provide Mail Service on Saturdays
Penalty
Summary
The facility failed to provide mail service to residents on Saturdays, affecting all 53 residents. During a resident group meeting, multiple residents confirmed that no mail is delivered to them on Saturdays. The Activity Director stated that while mail is delivered by the post office on Saturdays, it remains locked up and inaccessible to staff until Monday. The Human Resource Director/Front Desk Receptionist corroborated this, explaining that mail is sorted and given to Activity staff during the week, but not on Saturdays due to the absence of staff to sort it. Consequently, residents do not receive their mail until the following Monday.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, homelike environment for two residents, R5 and R7. R5's room and bathroom were observed to be in poor condition, with a recliner chair obstructing the bathroom door, scuffed walls, and feces splattered on the walls and floor. Despite the resident's complaints and the Director of Nurses' acknowledgment of the issue, the bathroom remained unclean the following day. R5 expressed frustration over the unsanitary conditions and the lack of timely cleaning by the facility staff. R7's bathroom was also found to be in an unacceptable state, with damp bath blankets piled in the corner, a strong musty odor, and a broken toilet. The resident had to use a toilet in a different location due to the malfunctioning toilet in her room. Despite the bathroom being out of commission, R7 continued to use it for handwashing, which the Director of Nurses was unaware of. The resident and a Certified Nurse Aide both expressed concerns about the cleanliness and odor of the bathroom. The Resident Council Minutes documented ongoing complaints about soiled incontinence briefs being left in trash cans, which were not adequately addressed despite multiple reports to the Director of Nurses. The facility's failure to maintain a clean and homelike environment for these residents highlights significant deficiencies in housekeeping and maintenance practices, impacting the residents' quality of life and comfort.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency for one resident out of three reviewed for skin alterations. The resident, who has severe cognitive impairment and multiple medical diagnoses including Alzheimer's Disease and a history of traumatic brain injury, was found with bruises on the right mid-back and right lower back. These bruises were discovered by a registered nurse in the shower room and were described as dark purple and square-shaped. The resident could not explain how the bruises occurred, and no staff witnessed the incident. The facility's Director of Nurses and Administrator discussed the bruises but did not report them to the State Agency, despite acknowledging that the bruises were in an unusual location and could not rule out abuse. The facility's policy requires that injuries of unknown origin be reported as potential crimes under State and Federal Law. However, the Director of Nurses and the Administrator did not report the bruises, believing that reporting was only necessary if the injuries required treatment outside the facility. The facility's failure to report the bruises was a violation of their own policy and regulatory requirements. The Director of Nurses admitted that the facility could not determine the exact cause of the bruises and should have reported them to the State Agency.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
