Mason City Area Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Mason City, Illinois.
- Location
- 520 North Price Avenue, Mason City, Illinois 62664
- CMS Provider Number
- 145616
- Inspections on file
- 22
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Mason City Area Nursing Home during CMS and state inspections, most recent first.
A cognitively intact resident with multiple medical conditions and a history of wandering and observing others was documented as placing his hand on the breast of a severely cognitively impaired resident in a common TV lounge, in violation of facility policy prohibiting sexual abuse and unwanted intimate touching. The cognitively impaired resident, who had dementia and was on 15-minute checks for wandering, was later again the focus of inappropriate contact concerns, including staff observing the other resident touching the back of her head and pacing the hallways looking for her. After an earlier incident, the resident who initiated contact had been placed on 15-minute checks for a limited period, which were then discontinued when no further concerns were noted, preceding the subsequent inappropriate interactions.
A resident with significant physical disabilities suffered two second-degree burns after spilling hot coffee on her thigh on separate occasions, due to the facility's failure to implement individualized care interventions and to identify the hot beverage dispenser as a burn hazard. The hot liquids were served at unsafe temperatures, and staff were not adequately trained or aware of care plan requirements, placing all residents at risk.
Two cognitively impaired residents were improperly restrained in their wheelchairs using gait belts by an LPN, without physician orders or consent, due to insufficient staff to provide one-on-one attention. The residents, both with severe cognitive impairments, were restrained without medical justification, violating facility policies.
The facility did not have a Registered Nurse (RN) on duty for at least eight consecutive hours on five days in January, as required by their staffing policy. This deficiency was confirmed by the Director of Nursing and potentially affects all 56 residents in the facility.
The facility failed to immediately report the inappropriate use of physical restraints on two residents. An LPN used a gait belt to restrain residents in their wheelchairs, which was witnessed by another LPN and a CNA who did not report the incident. The issue was eventually reported by another CNA to the Administrator, who is the facility's Abuse Coordinator.
The facility did not have an RN on duty for eight consecutive hours on eight specific days in October and November, as required by policy. The administrator acknowledged the difficulty in hiring an RN for weekends, potentially affecting all 52 residents.
The facility failed to document diagnoses, identify behaviors, and monitor targeted behaviors for residents on psychotropic medications, leading to inappropriate use without attempts at gradual dose reduction (GDR). For example, a resident on Seroquel for dementia without behavioral disturbance had no documented behaviors justifying the medication, and GDR recommendations were denied due to family preferences. Staff confirmed that residents did not exhibit behaviors warranting antipsychotic use, and the facility did not adhere to its policy requiring documentation and GDR attempts.
A facility failed to follow Enhanced Barrier Precautions for a resident with a burn on her thigh. CNAs did not wear gowns and one wore only one glove while changing the resident's brief. An LPN also did not wear a gown during wound care. Both incidents were acknowledged by staff, and the Director of Nursing confirmed the requirement for PPE as per facility policy.
Failure to Prevent Resident-to-Resident Sexual Abuse of a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent abuse when a cognitively intact resident engaged in inappropriate sexual contact with a severely cognitively impaired resident. Facility policy dated 8/25/2025 states that all residents have the right to be free from verbal, sexual, physical, and mental abuse, and defines sexual abuse as non-consensual sexual contact, including unwanted intimate touching of the breasts. The Final Facility Incident Report for 01/02/2026 documents a resident-to-resident interaction in the TV lounge in which one resident was observed with his hand on another resident’s chest and admitted he had a moment of weakness and placed his hand on the other resident’s breast over clothing. The resident who initiated the contact had diagnoses including a displaced right acetabulum fracture, COPD, heart failure, atrial fibrillation, peripheral vascular disease, and hypertension, and was documented as cognitively intact with a BIMS score of 15/15 and able to understand and be understood. The resident who was touched had diagnoses including dementia, depression, hypertension, and hyperlipidemia and was documented as severely cognitively impaired. This resident also had an existing physician’s order for 15-minute observation checks due to wandering. A CNA later reported visualizing another resident making inappropriate contact with this severely cognitively impaired resident. The administrator reported that after an incident on 12/28/2025, the cognitively intact resident was placed on 15-minute checks for three days and, when no concerns were identified, those checks were discontinued. Subsequently, staff observed this same resident touching the back of the cognitively impaired resident’s head, and a CNA reported observing him pacing the hallways looking for her. These events, in the context of the facility’s stated abuse-prevention policy, demonstrate that the facility did not effectively prevent sexual abuse of a vulnerable resident by another resident.
Failure to Prevent Burns from Hot Liquids Due to Lack of Individualized Interventions and Hazard Identification
Penalty
Summary
The facility failed to implement individualized care planned interventions to prevent a resident with significant physical disabilities from sustaining multiple burns. The resident, who had diagnoses including Spastic Cerebral Palsy, Scoliosis, Dysphagia, and Muscle Spasms, required supervision or assistance with eating and was dependent on staff for all other activities of daily living. Despite these needs, the resident was allowed to handle hot coffee independently, resulting in two separate incidents where hot coffee was spilled on her left posterior thigh, causing second-degree burns on both occasions. The care plan did not include a hot liquid risk assessment, and interventions to prevent such injuries were either not in place or not followed by staff. The facility also failed to identify the hot water/coffee dispenser in the main dining room as a potential burn hazard. The dispenser was accessible to all residents, and the coffee and hot water were routinely served at temperatures ranging from 170 to 177 degrees Fahrenheit, well above the threshold known to cause burns. There were no protocols or adequate monitoring in place to ensure that hot liquids were served at safe temperatures. Staff interviews revealed a lack of awareness regarding residents' care plans and the need for assistance with hot liquids, and some staff did not know how to access or update care plans. Additionally, the dining room doors were sometimes left open or unlocked, allowing residents unsupervised access to the hot beverage dispenser. The facility did not have a Hot Liquids Policy in place prior to the incidents, and staff were not in-serviced on the risks associated with hot liquids or the need for individualized interventions. The lack of a systematic approach to assessing residents' risk for hot liquid injuries, combined with inadequate staff training and supervision, directly contributed to the resident's repeated injuries. The failures affected not only the resident who was burned but also placed all 59 residents who accessed the hot beverage dispenser at risk.
Removal Plan
- All residents were interviewed by V8/Wound Nurse, V22/Restorative Nurse, V23/Business Office Manager, and V24/Social Service Director for hot liquid spills with injury.
- R1 was removed from the dining room, laid down, clothes were removed, and a head-to-toe skin assessment was completed. V7/R1's Physician and V25/R1's Family member was notified. A wound dressing was ordered, R1's care plan was updated to ensure staff assisted R1 with a waterproof clothing protector and lap blanket to be worn during all meals and as needed for food and fluid intake and to continue Occupation therapy three times a week for twelve weeks.
- A Hot Liquid Policy was developed and implemented.
- A Hot Liquid Risk Assessment was developed and implemented.
- V1/Administrator in-serviced Department Managers (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the facility's Hot Liquid Policy. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- All residents, including R1, were assessed with the facility hot liquids assessment to determine if they are at risk of being injured.
- R1's care plan was updated to include interventions for hot liquid spills with injury and for Speech Therapy to Evaluation and Treat.
- The facility implemented utilizing colored napkins to alert each member of the team that the resident is at high risk for burn injury.
- All at risk residents for being injured due to hot liquids were identified on meal tray cards.
- V4/MDS Coordinator updated all resident care plan with interventions that were identified as at risk for spilling hot liquids causing injuries.
- The coffee machine in the main dining room was disconnected.
- The coffee machine was removed from the main dining room. Coffee and other hot liquids are being served from the kitchen and temped prior to being served.
- A new coffee machine was ordered and will be dispensed at 150 degrees Fahrenheit.
- Waterproof adult clothing protectors and waterproof blankets were ordered for the residents identified at risk for injury from hot liquid.
- A Food Temperature Log for Meal Services was implemented with coffee/hot water to be served at 150 degrees Fahrenheit or less.
- V1 in-serviced each department manager (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool will be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, and that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- A system was put in place for an audit to be done by V2/Director of nursing, for five residents daily, five days a week, for six weeks to ensure compliance with interventions being put in place. V2/Director of Nursing is utilizing the audit tool to ensure care plan interventions are being followed. These are monitored/audited for compliance by V1/Administrator one time per week.
- V4/MDS Coordinator reviewed and updated R1 and the residents identified to be at risk for injury from hot liquids care plans.
- V1/Administrator provided all staff in-servicing regarding the use of red napkins at meals for the residents identified at risk for injury from hot liquids.
- V1/Administrator in-serviced all Agency Staff regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool will be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit, and the use of red napkins at meals for the residents identified at risk for injury from hot liquids.
- A copy of the facility's Hot Liquid Policy was added to the new orientation manual and the agency orientation manual.
- A system was put in place for an audit to be done by V3/Dietary Manager, for five residents daily, five days a week, for six weeks to ensure compliance with temperatures of hot liquids prior to being served to ensure they are below the appropriate temperatures. V3/Dietary Manager is utilizing this audit form to ensure hot liquids are being served at appropriate temperatures. These are monitored/audited for compliance by V1/Administrator once time per week.
Improper Use of Physical Restraints on Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary physical restraints, as evidenced by the improper restraint of two residents, R1 and R2, using gait belts fastened behind their wheelchairs. This action was taken by an LPN who admitted to restraining the residents to prevent them from standing up due to a lack of available staff to provide one-on-one attention. The restraint was applied without physician orders, medical justification, or consent from the residents or their responsible parties, which is a violation of the facility's policies and procedures. Both residents, R1 and R2, were severely cognitively impaired, with BIMS scores indicating significant cognitive deficits. R1 had diagnoses including unspecified dementia with agitation and Alzheimer's dementia, while R2 had dementia with behavioral disturbance and was identified as a fall risk. Despite their conditions, there was no documentation in their medical records justifying the use of restraints, nor were there any physician orders or medical symptoms warranting such measures. The incident was not reported immediately by the staff who witnessed it, and the facility's policies on restraint usage and abuse prevention were not followed. The LPN involved acknowledged the inappropriate use of restraints, citing a busy and hectic time with insufficient staff as the reason for her actions. The facility's Director of Nursing and Administrator were notified of the Immediate Jeopardy situation, which was identified to have started when the restraints were applied, causing psychosocial harm to the residents.
Removal Plan
- Department Managers were in-serviced by V1 Administrator on the facility's restraint policy, care of residents with restlessness and agitation, improper restraint usage, the need for alternative interventions, appropriate diagnosis, physician's orders, care planning, the facility's abuse policy and reporting procedure. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies.
- All residents have been assessed to ensure that none are restrained improperly or unnecessarily.
- Care Plans were reviewed by the Care Plan Coordinator and updated as needed for residents with restlessness or agitation.
- A full physical assessments of R1 and R2 were conducted for any signs of injury from restraint usage with no findings of injury.
- All facility staff, contracted Therapy staff and Agency staff utilized by the facility were in-serviced on the following: care of the resident with restlessness and/or agitation; the facility's restraint policy, improper restraint usage, the need for alternative interventions, care of the resident with restlessness and/or agitation, appropriate diagnosis, physician's orders, care planning, the facility's abuse policy and reporting procedure.
- V15 verified R2 was care planned with interventions addressing potential for abuse and proper restraints related to her diagnoses. Restraint consents were present in R2's medical record for R2's cushioned lap restraint, mattress, and bed pressure alarm. V15 verified R1 was care planned for falls and restlessness, agitation with interventions. No restraints were in use for R1.
- A system was put in place for an audit to be done by the V1 Administrator or designee three times weekly to ensure compliance with the interventions put in place. V2 DON conducted daily reviews of the 24-hour Report for any new or additional restraint usage. These are monitored/audited for compliance by V1 three times per week. The results of the audits will be discussed at the next Quality Assurance meeting.
- All residents were interviewed regarding history or existence of unnecessary restraint usage and abuse incidents. No incidents were reported by the residents. These interviews were conducted and documented by the V2 DON, V1 Administrator, V15 MDS/Care Plan Coordinator, V13 ADON/Assistant Director of Nursing and Department Managers.
- V15 Care Plan Coordinator reviewed and updated Care Plans for those residents with restraints, agitation, restlessness or exhibition of behaviors. R2 was the only resident identified with restraint utilization.
- Agency staff were inserviced and Resident Rights, improper restraint usage and the Abuse/Neglect policy to the Agency Orientation Binder.
- The Interdisciplinary Team met and reviewed, discussed and approved the facility's Immediate Jeopardy Removal Plan.
- V15 Care Plan Coordinator completed Care Plan audits for all residents and a system was put in place to audit five residents' Care Plans per week.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours daily, as required by their staffing policy dated January 16, 2018. This policy mandates that a skilled nursing facility must have at least one RN on duty for eight consecutive hours, seven days a week. However, a review of the facility's nurse schedules for January 2025 revealed that there were no RNs on duty for the required duration on five specific days: January 1, January 4, January 5, January 18, and January 19. The Director of Nursing confirmed the accuracy of these schedules, acknowledging the absence of an RN for the mandated hours on the specified dates. This deficiency potentially affects all 56 residents residing in the facility, as documented in the facility's Resident Roster dated February 11, 2025.
Failure to Report Inappropriate Use of Physical Restraints
Penalty
Summary
The facility failed to immediately report the inappropriate use of physical restraints on two residents to the facility's Abuse Coordinator. The incident involved a Licensed Practical Nurse (LPN) who fastened a gait belt around two residents while they were seated in their wheelchairs, securing the belt behind the chairs, which constituted an inappropriate physical restraint. This action was witnessed by another LPN and a Certified Nursing Assistant (CNA), both of whom recognized the action as wrong but did not report it to a supervisor or the Abuse Coordinator immediately. The incident was eventually reported by another CNA who was informed by an unidentified colleague about the restraint of one of the residents. This CNA reported the incident to a supervising nurse and the Administrator, who is also the facility's Abuse Coordinator. The Director of Nursing (DON) confirmed that the physical restraint should have been reported immediately but was not brought to her attention until several days later.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours in a 24-hour period on eight specific days across October and November, as per the facility's nursing schedules. This deficiency was identified on four weekend days in October and four weekend days in November. The facility's policy, dated 1/16/18, mandates that there must be at least one RN on duty for eight consecutive hours every day in a skilled nursing facility. The absence of an RN for the required hours was acknowledged by the facility's administrator, who stated that efforts to hire an RN for the weekend schedule have been challenging. This deficiency has the potential to affect all 52 residents residing in the facility.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to document a diagnosis, identify behaviors, and monitor for identified targeted behaviors to warrant the use of psychotropic medications and attempt a gradual dose reduction (GDR) of an antipsychotic medication for five residents. For instance, one resident, who was on Seroquel for dementia without behavioral disturbance, had no documented behaviors that justified the use of the medication. Despite recommendations for a GDR, the resident's physician denied these due to family preferences, even though the resident did not exhibit psychotic behaviors or pose a risk to themselves or others. Another resident was prescribed Seroquel for unspecified dementia without behavioral disturbance. The resident's behavior monitoring report documented only one incident of public sexual acts, which was resolved with redirection. Staff confirmed that the resident did not exhibit behaviors warranting the use of antipsychotic medication. Similarly, another resident was on Seroquel for visual hallucinations, but there was no documentation of behavior monitoring for the identified target behaviors. The facility's policy on psychotropic medication use requires that these medications be given to treat a specific condition or medical symptom that is diagnosed and documented in the clinical record. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and monitoring for the residents' behaviors. Additionally, the policy mandates attempts at GDR within the first year and annually thereafter, unless clinically contraindicated, which was not consistently followed for the residents in question.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions during the care of a resident with a burn on her thigh, leading to a deficiency in infection prevention and control. On two separate occasions, staff members did not wear the required personal protective equipment (PPE) while providing care to the resident. During the first incident, two CNAs were observed changing the resident's adult incontinent brief without wearing gowns, and one CNA only wore a glove on her right hand. After completing the care, they did not apply gowns or gloves before transferring the resident into her wheelchair. Both CNAs acknowledged that they should have been wearing gowns and gloves throughout the care process. In a subsequent incident, an LPN performed a dressing change and wound care on the resident's left thigh without wearing a gown, despite the resident being on Enhanced Barrier Precautions. The LPN confirmed the oversight and acknowledged the requirement to wear a gown during such procedures. The Director of Nursing also stated that staff should be wearing the required PPE when providing care to residents under Enhanced Barrier Precautions, as outlined in the facility's protocol policy. The policy specifies the use of gowns and gloves during high-contact resident care activities to prevent the transfer of Multi-Drug-Resistant Organisms (MDROs).
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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