Mattoon Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mattoon, Illinois.
- Location
- 2121 South Ninth, Mattoon, Illinois 61938
- CMS Provider Number
- 145480
- Inspections on file
- 51
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Mattoon Rehab & Hcc during CMS and state inspections, most recent first.
A resident with multiple lymphedema-related leg wounds did not receive wound care as ordered by an outside wound clinic, with treatment orders not properly transcribed to the TAR, no documented wound assessments for several weeks, and multiple days where wound treatments were not signed as given. A PTA performed dressing changes without documenting wound characteristics, reported deterioration with green drainage and odor, and did not use a gown or perform hand hygiene with each glove change despite open wounds and facility policies requiring Enhanced Barrier Precautions and specific hand hygiene practices. The resident was later found to have worsening wounds with purulent drainage and drug-resistant infection requiring hospitalization. In a separate case, another resident with severe cognitive impairment who self-propelled in a wheelchair sustained repeated skin tears to the same leg area, and the facility did not develop or document any interventions to prevent further skin tears after these incidents.
The facility failed to follow its own controlled substance policies for multiple residents, including not ensuring that Diazepam administrations were supported by an active order and documented on the MAR, and leaving controlled medications in the cart after a resident’s discharge. An LPN reported giving Diazepam out of habit without checking the MAR, while the DON confirmed that a pharmacy order had not been entered into the electronic record. Additionally, controlled medications such as Lorazepam, Norco, Morphine Sulfate, Lorazepam concentrate, and Fentanyl patches were documented as destroyed by an LPN, but the required second signature from a witnessing licensed professional was missing from the destruction forms, despite statements that the destruction had been jointly performed.
The facility failed to follow CDC guidance and its own policies for infection prevention and control. Two residents with RSV and coronavirus were placed only on droplet precautions, with missing contact precautions, incomplete PPE supplies, and staff entering their rooms wearing only masks or masks and gloves while providing direct care, handling items, and not discarding masks upon exit. A resident who developed multiple pressure ulcers, including a debrided stage 4 ulcer, was not placed on Enhanced Barrier Precautions (EBP), and staff reported that no gowns were used during care. Another resident with a stage 4 pressure ulcer, PICC line, and indwelling catheter had an EBP order and signage, yet two LPNs performed wound care wearing only gloves, without gowns, and one LPN did not perform hand hygiene between dirty and clean steps, changing gloves but not using hand sanitizer or washing hands.
A resident with severe cognitive impairment, multiple comorbidities, high Braden risk, and dependence for mobility developed multiple facility-acquired pressure ulcers, including a stage 4 ankle ulcer and unstageable heel, sacral, trochanter, and shin injuries. The care plan documented impaired skin integrity and use of pressure-reducing boots and mattress but did not include turning/repositioning needs or frequency. Pressure-relieving boots were discontinued during a hospital transfer and not resumed on return, and the resident remained on a flip foam pressure-reducing mattress that manufacturer information indicated was suitable only up to stage 2 ulcers, rather than an alternating pressure air mattress for stage 3–4 wounds. Staff interviews confirmed that repositioning and heel-floating standards were not clearly care-planned and that appropriate pressure-relieving interventions, including resumption of boots and use of an air mattress, were not implemented in accordance with facility policy and the resident’s condition.
Two residents with severe cognitive impairment and identified fall risks experienced multiple falls related to environmental hazards and incomplete fall investigations. One resident fell in the bathroom while attempting to toilet, with worn nonskid grip strips noted and no documentation of the last toileting, and later fell again after a room change when previously care-planned “call don’t fall” signs and grip strips were not documented as being in place. Another resident fell beside the bed after an attempted self-transfer and later fell from a wheelchair in the hallway, with investigations not clearly documenting the presence or condition of nonskid mats, and also sustained a skin tear when a CNA’s foot caught on a floor mat during a transfer. The DON confirmed that these investigations lacked key details such as toileting times and whether required environmental interventions were in place.
A resident with severe cognitive impairment and communication deficits was verbally abused by a visitor, who was witnessed by staff loudly shouting insults and profanities at the resident. The facility's policy requires immediate removal of such individuals and timely notification of law enforcement, but the report does not indicate these actions were taken at the time of the incident. The abuse was confirmed by multiple staff and documented in the resident's medical record.
The facility did not update care plans for two residents to reflect their current needs. One resident's care plan included interventions for personal items and a mirror that were no longer present or used, as confirmed by staff and observation. Another resident's care plan included staff education for denture assistance, despite the resident having natural teeth and no dentures, as documented in assessments and confirmed by staff and the resident.
Two residents at high risk for falls did not receive care in accordance with their care plans. One resident was transferred by a CNA alone, despite a requirement for two staff during transfers, and another resident did not have a required fall prevention sign in their room. These failures were confirmed through staff interviews, observation, and record review.
Several residents were affected by significant medication errors, including one who was given another resident's medications—among them a high dose of morphine—by an agency LPN unfamiliar with the facility's identification protocols. Other errors included a resident receiving an excessive dose of Trazodone due to overlapping orders and another receiving both Novolog and Aspart insulin because of incorrect order documentation. These incidents were linked to failures in resident identification and medication order management.
A resident with infected wounds did not receive proper wound care due to cross-contamination. An LPN used contaminated scissors to cut new wound dressings without cleaning them between uses, despite the facility's policy requiring clean or sterile scissors. The resident had recently completed IV antibiotics for a wound infection.
A facility failed to complete physician-ordered pressure ulcer treatments for a resident with severe pressure ulcers and other medical conditions. The resident's dressings were not changed as required, with documentation missing for a specific date. The Wound LPN confirmed the oversight, and the DON acknowledged issues with agency nurses not completing treatments, leading to a deficiency in care.
The facility failed to ensure call button accessibility for four residents with significant medical conditions, such as dementia and chronic obstructive pulmonary disease. These residents were found without accessible call buttons, contrary to their care plans, which increased their risk for accidents. The ADON confirmed the importance of having call buttons within reach, especially for high-risk residents.
Several residents in the facility experienced a lack of dignity and respect. A resident's request to change CNAs was ignored, another's privacy was breached by a visitor, and two residents felt disrespected by CNAs' behavior. These incidents highlight the facility's failure to honor residents' dignity and self-determination.
A resident sustained a fractured finger while being dressed by a CNA, but the facility failed to conduct a thorough investigation as per its abuse policy. The CNA was not interviewed or suspended, and the Director of Nursing admitted to not investigating the incident properly.
A resident with left side hemiplegia and cognitive intactness suffered a finger fracture due to inadequate nail care, as their long, untrimmed nails snagged on clothing. Despite a care plan to keep nails trimmed, observations showed nails nearly an inch long with debris underneath. The resident expressed a desire for nail clipping, indicating the facility's failure to follow the care plan.
A resident with a history of muscle weakness and previous shoulder dislocation was injured during a transfer when a CNA failed to follow the care plan requiring two staff members and the use of a gait belt. The resident's shoulder was dislocated, necessitating hospitalization and surgery.
A facility failed to protect residents from verbal and mental abuse, affecting three residents. A CNA threatened a cognitively intact resident with physical harm for using the call light. Additionally, two residents with depression engaged in a verbal altercation, exchanging curses and expletives, witnessed by the Social Services Director. The facility confirmed these behaviors as unacceptable.
The facility failed to employ a full-time DON, affecting all 90 residents. On a survey date, no DON was present to complete entrance paperwork. A Regional Nurse, not full-time, assisted in the absence of a DON. The previous DON's last working day was July 31, 2024.
A resident with a primary diagnosis of alcohol abuse returned to the facility intoxicated and belligerent on two occasions, yet the care plan was not updated to include interventions for alcohol abuse. Despite a care plan meeting and staff awareness of the issue, the care plan lacked necessary updates, leading to a deficiency.
A resident with a history of Bipolar Disorder, Depression, and Neuromuscular Dysfunction of the Bladder experienced a delay in receiving a physician-ordered urinalysis and culture for a suspected UTI. Despite reporting symptoms, the facility took three days to send the urine sample to the lab, resulting in a six-day delay in treatment. The resident's condition worsened, leading to hospitalization and treatment with intravenous antibiotics.
The facility failed to maintain proper food storage, dishwashing equipment, and cleanliness of food contact equipment, potentially affecting all 99 residents. Raw pork was improperly stored above raw hamburger, and the dishwasher was not sanitizing effectively due to low chlorine levels. The mixer was also found with dried food residues, indicating improper cleaning.
The facility did not hold the required quarterly QAPI meetings for the first quarter of 2024 and failed to ensure the presence of an Infection Preventionist at the fourth quarter 2023 meeting. The Director of Nursing confirmed the absence of documentation for the first quarter meeting and the missing Infection Preventionist in the previous meeting, contrary to the facility's policy requiring specific attendees.
The facility did not establish a water management program to prevent Legionella growth, lacking a risk evaluation, testing protocols, and intervention plans. The Clinical Director of Operations acknowledged the absence of these elements, citing the lack of a Maintenance Director. This deficiency potentially impacts all 99 residents.
The facility failed to ensure call lights were within reach for four residents, compromising their right to dignity and respect. Residents with various medical conditions, including dementia, fractures, and cognitive deficits, were found with call lights out of reach. An LPN confirmed that call lights should always be accessible, indicating a lapse in protocol adherence.
The facility failed to address resident concerns about laundry services, as noted in multiple Resident Council Meetings and the facility's Grievance Log. Residents reported delays and issues with the cleanliness of returned clothing. Observations showed a backlog of personal items in the laundry room, with staff indicating insufficient time to manage laundry duties effectively. The facility lacked a formal laundry policy.
A resident with Metabolic Encephalopathy and Unspecified Convulsions was discharged without a complete discharge summary. Only two out of five sections of the discharge summary were filled, contrary to the facility's policy requiring a full recapitulation of the resident's stay. The Director of Nurses confirmed the summary was incomplete, indicating a lapse in the discharge process.
A resident's pressure ulcer treatment was inaccurately administered by an LPN, who applied collagen to both the wound bed and peri-wound area, contrary to physician orders and manufacturer's instructions. The DON noted that the LPN should have measured the wound bed to apply collagen correctly.
A resident with a PICC line returned from the hospital with orders for intravenous antibiotics, but the facility failed to routinely monitor the PICC line. The resident, who is cognitively intact, reported that nursing staff only assessed the line during antibiotic administration. The DON confirmed that intravenous sites should be monitored and flushed every shift, with documentation of the site status.
A resident with Bilateral Primary Osteoarthritis of the Knee did not receive prescribed Oxycodone-Acetaminophen due to unavailability. The LPN discovered the shortage and contacted the doctor, but three doses were missed as the night shift failed to reorder or use the stat safe box. The DON noted that medication cards should prompt reordering before running out.
A resident with mobility issues developed a skin wound that was documented but not treated for four days. The LPN failed to notify the wound nurse and medical doctor promptly, contrary to the facility's policy on pressure ulcer prevention.
A resident sustained a burn injury from an electric space heater in their room, which was not removed by the facility. The resident, who requires assistance with daily activities, had purchased the heater and believed staff were aware of it. The heater was left on the floor, leading to the burn incident. The facility administrator admitted staff were unaware of the prohibition on electric heaters, highlighting a lapse in safety policy enforcement.
The facility failed to protect residents from physical abuse by another resident, R3, who exhibited aggressive behaviors. R3 physically assaulted other residents, including R7, R5, and R6, while being wheeled down the hallway by an LPN. Additionally, R4 was involved in a physical altercation with R3 in the dining room. The facility's staff failed to intervene appropriately, and the facility's abuse prevention policies were not adequately followed.
The facility failed to protect residents from physical abuse by another resident with known aggression and did not investigate abuse allegations by both residents and staff. An LPN wheeled an aggressive resident past others, resulting in physical altercations. Additionally, a resident reported feeling unsafe due to inappropriate behavior by a male CNA, but the facility did not investigate. These failures affected five residents out of a sample of twelve.
A CNA was observed going through a resident's drawers without permission, causing discomfort to the resident. The facility's Director of Nursing confirmed the grievance, and both the Assistant Director of Nursing and the Regional Clinical Director of Operations agreed that staff should always ask for permission before accessing a resident's personal belongings.
The facility failed to follow its abuse policy when a resident reported feeling unsafe due to a CNA. The Administrator did not investigate or report the allegation, and the CNA continued to work until later suspended. The Regional Clinical Nurse and Regional Director of Operations confirmed the policy was not followed.
The facility failed to report allegations of physical and potential sexual abuse involving a male CNA and a resident, as well as multiple resident-to-resident altercations. The incidents were not reported to the State Agency within the required timeframe, and there was a lack of documentation and investigation.
Failure to Provide Ordered Wound Care, Infection Control, and Skin Tear Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and skin management according to physician orders, facility policies, and resident needs for two residents. For one resident with multiple lower extremity lymphedema wounds, the facility did not ensure that wound care orders from an outside wound clinic were accurately transcribed and clarified, and the resident’s leg wound treatment orders were not placed on the Treatment Administration Records for November and December. The wound clinic ordered daily wound care, while the physician orders in the facility reflected wound care three times weekly tied to lymphedema treatments, with no documentation that this discrepancy was clarified. After a wound/skin assessment documented multiple leg wounds and their measurements in mid-December, there were no further documented wound assessments in the medical record until the resident was seen again at the wound clinic in early January, except for one refusal with no documented follow-up attempts. During this period, a Physical Therapy Assistant (PTA) performed lymphedema treatments and wound dressing changes three times weekly, but the PTA’s notes did not document wound characteristics or specific treatments. The PTA reported that the resident’s wounds deteriorated, with increased drainage and odor, and lymphedema therapy was stopped when the wounds began draining copious green fluid. Nursing notes documented a significant decline in the leg wounds with purulent green drainage and foul odor, and a wound culture was ordered along with oral antibiotics; however, the culture could not initially be obtained due to lack of culture kits. Later, a wound culture showed drug-resistant organisms. An infectious disease consultation documented that the resident’s wound dressings had not been changed for an extended period, with purulent drainage weeping through the dressings and foul odor, and that the resident required hospitalization for worsening chronic leg wounds and concern for infection. Hospital discharge instructions listed cellulitis of both legs, complicated wound infection, polymicrobial bacterial infection, and MDR Acinetobacter baumannii infection. The January Treatment Administration Record also showed multiple days when leg wound treatments were not signed as administered, and the resident reported that leg dressings were supposed to be changed daily but were sometimes forgotten. The facility also failed to implement appropriate infection control practices during wound care for this resident. The PTA reported that the resident was not on Transmission-Based Precautions or Enhanced Barrier Precautions and that a gown was not worn during wound treatments, despite the resident having open wounds. The PTA described performing hand hygiene before and after treatment but not routinely during glove changes, stating that hand hygiene during the procedure was only done if hands were visibly soiled, which did not align with the facility’s hand hygiene policy requiring hand hygiene with each glove change. The DON later confirmed that Enhanced Barrier Precautions should be implemented for open wounds and that a gown should be worn during wound care, and that hand hygiene should be performed with each glove change. For a second resident with severe cognitive impairment, the facility failed to develop and implement interventions to prevent recurrent skin tears. Incident reports documented that this resident, who self-propelled in a wheelchair, sustained a skin tear to the left lower leg and shin after hitting the leg on the bed, and then a subsequent skin tear to the left knee after bumping the knee while in the wheelchair. Despite these repeated skin tears, there was no documentation in the medical record of any interventions being developed or implemented to protect the resident’s skin from additional tears. The DON confirmed that there were no documented skin interventions following these incidents.
Failure to Properly Document and Destroy Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for, document, and destroy controlled medications in accordance with its own policies for multiple residents. The facility’s Controlled Substance Destruction Policy requires that controlled substances be destroyed by a licensed nurse and a licensed professional, with the destruction, quantity destroyed, and date documented on the controlled medication count sheet and signed by both individuals. The Controlled Substance Policy also requires nurses to sign out controlled medications on the Controlled Substance Proof of Use Form immediately and document administration on the MAR immediately after giving the dose. For one resident (R9), the Controlled Substance Record for Diazepam 2 mg showed single doses dispensed on four late-night occasions, all signed by an LPN, but these administrations were not recorded on the resident’s January and February MARs because there was no active order entered after 1/22/26. The resident’s census showed discharge on 2/14/26, and a subsequent check of the medication cart revealed remaining Diazepam tablets still present after discharge. The DON later confirmed that an active Diazepam order existed from the pharmacy but had not been entered into the electronic medical record and MAR, and the LPN acknowledged administering the medication “out of habit” without verifying it on the MAR. For another resident (R7), the Controlled Substance Record documented destruction of remaining Lorazepam and Norco tablets by an LPN on 2/9/26. The Narcotics Destruction Form for that date also listed destruction of multiple controlled medications for R7 and a third resident (R15), including Norco tablets, Morphine Sulfate solution, Lorazepam concentrate, and Fentanyl patches. However, these destruction forms contained only the LPN’s signature and lacked the required second signature of a witnessing licensed professional, contrary to the facility’s policy that controlled medications are destroyed with a floor nurse and either the DON or ADON, with two signatures documented. The DON and ADON both stated that they participated in the destruction but acknowledged that the ADON forgot to sign the destruction forms, leaving the documentation incomplete and not in compliance with the facility’s controlled substance procedures.
Failure to Implement Appropriate Precautions and Hand Hygiene for Residents With RSV and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate transmission-based precautions for residents with Respiratory Syncytial Virus (RSV) and coronavirus, and to follow CDC guidance and its own policies. Physician orders for two residents with RSV specified droplet precautions but did not include contact precautions, despite the facility’s RSV policy describing transmission via droplets and contaminated surfaces. Droplet isolation signs were posted on their doors, but one PPE container lacked gowns and there were no contact isolation signs. Staff, including CNAs and an OT, entered these rooms wearing only masks or masks and gloves, without gowns or eye protection, while providing direct care and assisting with mobility. One CNA delivered a meal tray, touched the overbed table, handled a used disposable cup, and exited the room without wearing gown, gloves, or eye protection and without discarding the mask upon exit. Staff interviews showed inconsistent understanding of required PPE, and the DON later stated that both droplet and contact precautions with full PPE should have been followed for RSV. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident who developed multiple pressure ulcers. This resident had a facility-acquired unstageable pressure ulcer on the left ankle that progressed and was later reclassified as a stage four pressure ulcer requiring debridement, and also developed an unstageable pressure ulcer on the left heel. Despite the presence and progression of these open wounds, there was no documentation in the medical record that EBP had been initiated, and the DON confirmed there was no EBP order. A CNA who cared for the resident on the day of transfer to the hospital stated the resident was not on any precautions and gowns were not worn during care, contrary to CDC guidance and the DON’s statement that EBP is implemented for open wounds. In addition, the facility did not ensure adherence to its hand hygiene policy and EBP requirements during wound care for another resident with a stage four pressure ulcer, a PICC line, and an indwelling urinary catheter. This resident had an EBP order and signage on the door instructing staff to wear gown and gloves for high-contact care activities, including wound care. Two LPNs entered the room wearing only gloves, without gowns, and one LPN performed wound cleansing and dressing changes without a gown and without performing hand hygiene between dirty and clean steps of the procedure, changing gloves but not using hand sanitizer or washing hands. The LPN later confirmed not wearing a gown and not performing hand hygiene, believing it was only necessary when hands were visibly soiled, despite the facility’s policy requiring hand hygiene even when gloves are used and the DON’s expectation for hand hygiene with each glove change during wound care.
Failure to Implement Appropriate Pressure-Relieving Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement appropriate pressure-relieving interventions and care planning for a resident at high risk for pressure ulcers who had multiple facility-acquired wounds. The facility’s policy required initiation of preventive and treatment interventions, updating the care plan with each intervention, use of pressure-reducing surfaces based on a mattress selection algorithm, and frequent repositioning for bed- or chair-bound residents. The resident’s care plan, revised in late January, documented impaired skin integrity related to recent surgery, impaired mobility, incontinence, diabetes, and multiple pressure ulcers, including a stage 4 left ankle ulcer and an unstageable left heel ulcer. However, the care plan did not include turning/repositioning needs or frequency, despite the resident’s high Braden risk score and dependence on staff for transfers and rolling in bed. Clinical documentation showed progressive worsening and development of multiple pressure ulcers over time. Initial skin/wound notes identified a facility-acquired unstageable left ankle pressure ulcer on 12/24, which later enlarged and was reclassified as a stage 4 pressure ulcer, and a new unstageable left heel ulcer identified in January. Additional facility-acquired unstageable/deep tissue injuries to the sacrum, left trochanter, and right shin were documented on 1/20. The wound NP’s note indicated differential diagnoses for the left ankle wound, including pressure injury, and directed continuation of pressure-relieving interventions such as a pressure-reducing mattress, routine repositioning, and offloading boots as tolerated. The resident also had significant comorbidities, including dementia, adult T-cell lymphoma/leukemia not in remission, chemotherapy-induced pancytopenia, and type 2 diabetes, and had experienced substantial recent weight loss with poor intake. Staff interviews and record review revealed failures to implement and maintain ordered pressure-relieving devices and to use an appropriate support surface consistent with facility policy and manufacturer guidance. Pressure-relieving boots were initiated when the left ankle ulcer was first identified but were discontinued when the resident was transferred to the emergency room and were not resumed upon return, as confirmed by the DON and TAR review. The LPN and wound nurse acknowledged that the resident did not have an air/alternating pressure mattress and was on a standard pressure-relieving (flip foam) mattress, which manufacturer information indicated was appropriate only up to stage 2 pressure wounds. The wound nurse stated that air mattresses are used for stage 3 or 4 ulcers but that this was not discussed with a provider because boots were in place, and later acknowledged not realizing the limitation of the standard mattress. Staff also reported that the resident required two-person assistance for repositioning, that the standard of care was to float heels and reposition at least every two hours, and that the care plan lacked repositioning instructions and pressure-relieving interventions for the feet prior to late December.
Failure to Maintain Safe Environment and Adequate Fall Prevention for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and fall interventions for cognitively impaired residents at risk for falls. The facility’s Skilled Fall Policy requires completion of an occurrence report after each fall to determine root cause and implement interventions. For one resident with severe cognitive impairment and a care plan identifying fall risk related to muscle weakness, dementia, impaired hearing and vision, impaired balance, and a history of falls, the care plan included interventions such as “call don’t fall” signage and nonskid grip strips in the bathroom, in front of the bathroom door, in front of the recliner, and on the bathroom floor. During a fall on 1/10/26, the resident was found on the floor in front of the toilet with pants down and incontinent of bowel movement after attempting to go to the bathroom, and the MDS Coordinator noted the grip strips in front of the toilet were worn down and replaced them. The fall investigation did not document when the resident was last toileted prior to the fall. A subsequent fall for the same resident on 1/19/26 occurred after a room change. The resident, who normally used the call light, was described as more confused that night and attempted to get up unassisted from a recliner and fell in front of the bathroom. Staff interviews and interdisciplinary notes indicated that the resident was more confused due to the recent room change and attempted to self-transfer. There was no documentation that the new room had the previously care-planned “call don’t fall” signs and nonskid grip strips in place at the time of the fall. The DON confirmed that grip strips and “call don’t fall” signs were current interventions that should have been moved with the resident during the room change and that the fall investigation did not document whether these interventions were in place when the resident fell. Another resident with severe cognitive impairment and requiring partial/moderate assistance for transfers experienced multiple falls where investigations lacked key information and environmental hazards were not fully addressed. A fall on 12/19/25 occurred when the resident was found sitting on the floor beside the bed, later documented as an attempted self-transfer from wheelchair to bed with incontinence at the time of the fall; the investigation did not identify the last time the resident was toileted, and a new intervention of nonskid grip strips next to the bed was added. A later fall on 2/3/26 involved the resident falling from a wheelchair in the hallway with the wheelchair tipped and a foot pedal under the resident; the investigation did not identify whether a nonskid mat was in the wheelchair, though the care plan was updated to replace the nonskid mat. Another incident on 2/19/26 occurred during a staff-assisted transfer when a CNA’s foot became caught on a floor mat, causing loss of balance and the resident being lowered to the floor, resulting in a skin tear; the DON later confirmed that the post-fall intervention was to pick up the floor mat when the resident was out of bed.
Failure to Protect Resident from Verbal Abuse by Visitor
Penalty
Summary
A resident with severe cognitive impairment, dementia, and impaired mobility was subjected to verbal abuse by a visitor. The facility's policy requires that residents be protected from abuse by anyone, including visitors, and specifies immediate removal of the alleged perpetrator from contact with residents pending investigation. On the day of the incident, a visitor was observed by staff and another resident's family member verbally abusing the resident, including yelling derogatory statements such as calling the resident a child, idiot, and using profane language. Multiple staff members, including an LPN and a CNA, witnessed the visitor in close proximity to the resident, loudly shouting insults and profanities. The resident, who has documented communication problems and requires staff assistance for activities of daily living, appeared confused and unsure of the situation during the incident. The facility's records confirm that the verbal altercation occurred and that the resident was the victim of verbal abuse by the visitor. The incident was reported to the state agency, and the facility's Director of Nursing and Regional Nurse Consultant both confirmed the occurrence of the abuse. The report does not detail any immediate removal of the visitor at the time of the incident, nor does it mention timely notification of law enforcement as outlined in the facility's policy.
Failure to Update Care Plans to Reflect Residents' Current Status
Penalty
Summary
The facility failed to revise and update care plans to accurately reflect the current status of two residents reviewed for falls. For one resident, the care plan included interventions to ensure personal items, including a mirror, were within reach, but repeated observations showed that no personal items or mirror were present in the resident's room. Staff interviews confirmed that the resident no longer had or used these items, and had not done so for a significant period. For another resident, the care plan included an intervention to educate staff to assist with dentures, but both the resident and staff confirmed that the resident had natural teeth and did not have dentures. Nursing and nutritional assessments also documented that the resident had natural teeth and no dentures, indicating the care plan was not updated to reflect this change.
Failure to Follow Care Plans for Safe Transfers and Fall Prevention
Penalty
Summary
The facility failed to ensure safe transfers and implement fall prevention interventions as outlined in the care plans for two residents. One resident, identified as high risk for falls, had a care plan requiring two staff members for all transfers. Despite this, a Certified Nursing Assistant reported transferring the resident alone, having the resident wrap their arms around her neck and performing the transfer without assistance. This was confirmed through staff interview and review of the resident's care plan and progress notes, which documented a recent fall and the resident's unsteady condition during transfers. Another resident, also assessed as high risk for falls with a documented history of multiple falls, had a care plan intervention requiring a "call don't fall" sign to be placed in their room. Observation revealed that the sign was not present, and this was confirmed by a Licensed Practical Nurse. The absence of the required signage and failure to follow the care plan intervention were directly observed and verified through staff interview and record review.
Multiple Medication Administration Errors Due to Misidentification and Order Documentation Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving the administration of incorrect medications or dosages to several residents. One resident was administered another resident's scheduled medications, which included a large dose of extended-release morphine, after an agency LPN misidentified the resident. The error was discovered when the resident refused a medication not prescribed to him, but by that time, he had already ingested the other pills. The resident subsequently experienced prolonged side effects, including nausea, vomiting, lethargy, and refusal of meals, and required administration of Narcan to reverse the opioid effects. Another resident received an excessive dose of Trazodone due to a failure to discontinue a previous order when the dosage was increased, resulting in the resident receiving both the old and new dosages. The resident was informed of the error and reported no ill effects other than increased drowsiness. Additionally, a third resident was administered both Novolog and Aspart insulin due to an incorrectly documented order, rather than receiving only the prescribed Novolog with meals. The resident did not experience adverse effects, as her blood sugars had been running high. Interviews with staff revealed that proper resident identification protocols were not consistently followed, with reliance on visual identification and verbal confirmation that proved insufficient. The agency LPN involved in the morphine error was unfamiliar with the facility's bed numbering system, contributing to the misidentification. The DON and clinical director acknowledged the errors and the need for further staff education on using two resident identifiers and verifying medication orders to prevent such incidents.
Failure to Prevent Cross-Contamination During Wound Care
Penalty
Summary
The facility failed to prevent cross-contamination during wound treatments for a resident with infected wounds. The resident, who had no cognitive impairment, was at risk for pressure ulcers and had two venous and arterial ulcers. The resident's treatment orders included specific wound care instructions and antibiotic medication for a multi-organism wound infection. During an observation, it was noted that the resident's compression stockings were soiled, and the wound dressing on the right lower leg had wet drainage. The LPN involved in the wound care did not adhere to proper infection control practices. After removing the soiled gauze wrap from the resident's right lower leg, the LPN used the same contaminated scissors to cut a new calcium alginate pad for the wound bed. The scissors were placed on the bedside table next to clean dressing supplies without being cleaned. This process was repeated for the resident's left lower leg wound, again using the contaminated scissors without cleaning them between uses. The Director of Nursing confirmed that the facility's policy required clean or sterile scissors to prevent cross-contamination during wound treatments. The LPN acknowledged the oversight, stating that the scissors should have been cleaned with an alcohol or bleach wipe after each use. The Wound Nurse also observed the failure to clean the scissors, noting that the resident had recently completed intravenous antibiotics for an infection in the right ankle wound.
Failure to Complete Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to complete physician-ordered pressure ulcer treatments for a resident with significant medical conditions, including the absence of both legs, peripheral vascular disease, and severe pressure ulcers. The resident's medical records indicated the presence of a Stage III pressure ulcer on the right trochanter and a Stage IV pressure ulcer on the coccyx, with specific treatment orders to be followed daily. However, the Treatment Administration Record showed no documentation of treatment completion on a specific date, indicating a lapse in care. During an observation, it was noted that the resident's pressure ulcer dressings were not changed as required, with the dressing dated two days prior and visibly saturated with drainage. The Wound LPN acknowledged the oversight, stating that the dressings should be changed daily and that the resident was on antibiotics for osteomyelitis related to the wounds. The resident confirmed that no nurse attended to the dressings the previous day, highlighting a failure in the facility's wound care protocol. The Director of Nursing provided the facility's policy on pressure injury assessment and treatment, which mandates that wound dressings be dated and initialed by the nurse completing the treatment. The DON acknowledged issues with agency nurses not completing treatments, which contributed to the deficiency. This lapse in care was observed and documented by surveyors, indicating a failure to adhere to established treatment guidelines and physician orders.
Failure to Ensure Call Button Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call buttons were accessible to residents, which is a critical aspect of resident safety and care. Four residents, all with significant medical conditions such as dementia, chronic obstructive pulmonary disease, and difficulty walking, were found without accessible call buttons. For instance, one resident with chronic obstructive pulmonary disease and dementia was found in bed with her call button out of reach, despite her care plan indicating the need for it to be within reach due to her fall risk and communication problems. Another resident, who was at risk for falls and had swallowing difficulties, was found in a family room without access to a call button and without supervision while eating, which is contrary to his care plan requirements. Additionally, a resident with congestive heart failure and vascular dementia was found in a recliner with no accessible call button, and she expressed difficulty in finding it. Another resident, diagnosed with dementia and a history of falls, was found asleep in bed with the call button on the floor, far from reach. The Assistant Director of Nurses confirmed that all residents should have call buttons within reach, especially those at higher risk for accidents. This deficiency highlights a systemic issue in ensuring resident safety and adherence to care plans regarding call button accessibility.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to honor the dignity and self-determination of several residents, as evidenced by multiple incidents. One resident, who was cognitively intact and dependent on staff for activities of daily living, expressed dissatisfaction with the care provided by a specific CNA. Despite the resident's complaint and the facility's documentation stating that the CNA would no longer provide care to this resident, the CNA continued to do so, disregarding the resident's wishes. Another resident experienced a breach of privacy and dignity when a roommate's boyfriend entered her room while she was undressed and did not leave immediately, causing her distress and embarrassment. Additional incidents involved residents feeling disrespected by staff. One resident reported that a CNA was unkind and dismissive of her requests, yet continued to provide care despite the resident's complaints. Another resident, who was dependent on staff for mobility and toileting, felt disrespected when two CNAs laughed while assisting her, making her feel uncomfortable and disrespected. These incidents highlight the facility's failure to ensure the dignity and respect of its residents, as well as a lack of adherence to residents' expressed preferences and needs.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident who sustained a fractured finger. The facility's abuse policy mandates a comprehensive investigation involving interviews with witnesses, staff, and residents, as well as the suspension of the alleged perpetrator pending the investigation's outcome. However, the investigation into the resident's injury was incomplete, as no interviews were conducted with the Certified Nursing Assistant (CNA) involved, nor with other staff or residents who might have had relevant information. Additionally, the CNA was not suspended during the investigation process. The incident involved a resident who was found with a bruised left hand, and an X-ray confirmed a fracture in the third finger. The injury reportedly occurred while the CNA was dressing the resident. Despite the facility's policy, the Director of Nursing admitted to not investigating the cause of the injury thoroughly, citing being off-site and preoccupied with other tasks. The lack of a comprehensive investigation and failure to suspend the CNA during the investigation process contributed to the deficiency identified by the surveyors.
Failure to Provide Adequate Nail Care Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for activities of daily living due to left side hemiplegia. The resident, who was cognitively intact, suffered a fracture on the left middle finger after a cracked fingernail snagged on clothing during dressing. This incident was documented in a facility report dated 11/26/24, following the discovery of a bruise and subsequent X-ray on 11/25/24. The resident's care plan, updated on 11/26/24, specified the need to keep nails trimmed to prevent snagging. However, observations on 12/12/24 and 12/16/24 revealed that the resident's nails were nearly an inch long with food and brown matter underneath, indicating a lack of proper nail care. The resident expressed a desire to have the nails clipped, highlighting the facility's failure to adhere to the care plan and prevent the injury.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a right shoulder dislocation that required hospitalization and surgical intervention. The incident occurred when a Certified Nurses Assistant (CNA) transferred the resident into bed without assistance from another staff member and without using a gait belt, despite the resident's care plan indicating the need for two staff members for transfers. The resident, who has a history of muscle weakness, unsteadiness, repeated falls, reduced mobility, and a previous shoulder dislocation, reported that the CNA pulled on her arm or moved it incorrectly during the transfer, leading to the injury. The CNA admitted to transferring the resident alone and without a gait belt, and was unsure if the resident was supposed to be wearing a sling, which was required at all times according to the physical therapist. The resident experienced extreme pain following the transfer, which was not addressed until the following morning when a nurse assessed the situation and sent the resident to the emergency room. The facility's failure to adhere to the resident's care plan and ensure proper transfer procedures directly contributed to the resident's injury.
Verbal and Mental Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse, affecting three out of four residents reviewed for abuse. One incident involved a Certified Nurses Assistant (CNA) making inappropriate and threatening statements to a resident, who was cognitively intact and had medical diagnoses including cerebral infarction and muscle weakness. The resident reported that the CNA threatened to beat him if he continued to use his call light, which was confirmed by the facility's administrator as unacceptable behavior. Another incident involved a verbal altercation between two residents, both diagnosed with depression, where one resident blocked the dining room entrance and refused to move, leading to an exchange of curses and expletives. The altercation was witnessed by the Social Services Director, who confirmed that the behavior was inappropriate and not condoned by the facility. The resident involved in the altercation had a history of verbal altercations with other residents, as documented in their care plan.
Absence of Full-Time Director of Nursing
Penalty
Summary
The facility failed to employ the services of a full-time Director of Nursing (DON), which has the potential to affect all 90 residents residing in the facility. On August 14, 2024, at 9:05 AM, there was no DON present in the building to complete entrance paperwork. At 9:10 AM, a Registered Nurse/Minimum Data Set/Care Plan Coordinator confirmed that the facility does not have a full-time DON. At 9:25 AM, a Regional Nurse, who is not full-time at the facility and works there on average two days a week, completed the entrance paperwork. This Regional Nurse was helping the facility in the absence of a full-time DON. On August 15, 2024, at 11:45 AM, the previous DON stated that her last day working in the facility was July 31, 2024. The facility's 802 Matrix dated August 14, 2024, documented that 90 residents are currently residing in the facility.
Failure to Update Care Plan for Alcohol Abuse
Penalty
Summary
The facility failed to revise a resident's care plan to reflect the actual health status after a change in the resident's condition. The resident, who had a primary diagnosis of uncomplicated alcohol abuse, returned from being out in the community with the smell of alcohol and exhibited belligerent behavior. Despite this change in condition, the resident's care plan did not include interventions related to alcohol abuse or strategies to prevent future exacerbations. This oversight was noted during a review of the resident's care plan, which was last updated without addressing the primary diagnosis or the recent incidents of alcohol intoxication. The resident experienced two significant events related to alcohol intoxication, both of which were documented in the facility's records. The first incident involved the resident returning to the facility intoxicated, leading to a hospital evaluation. A care plan meeting was held afterward, but the care plan was not updated to include interventions for alcohol abuse. The second incident occurred two weeks later, with the resident again exhibiting signs of intoxication and belligerence, resulting in a 72-hour psychiatric hold. Despite these events, the care plan remained unchanged, lacking any mention of alcohol-related interventions. Interviews with facility staff revealed a lack of communication and coordination in updating the resident's care plan. The Social Service Director and the Care Plan Coordinator were unaware of the need to update the care plan to address the resident's alcohol issues. The Regional Nurse confirmed that alcohol abuse should have been included in the care plan. The facility's policy on care planning emphasizes the importance of addressing all relevant care issues, yet this was not adhered to in the resident's case, leading to the deficiency.
Delayed Diagnostic Testing for UTI
Penalty
Summary
The facility failed to obtain a physician-ordered diagnostic test in a timely manner for a resident diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of the Bladder, who was cognitively intact. The resident began experiencing symptoms of a urinary tract infection (UTI), including painful and burning urination, abdominal pressure, and overall discomfort. Despite notifying the medical director and receiving an order for a urinalysis and culture and sensitivity test, the facility delayed sending the urine sample to the lab for three days. Consequently, the resident's symptoms persisted without treatment for six days. The medical director confirmed that the urinalysis should have been sent to the lab on the day it was ordered. Due to the delay, the resident's condition worsened, leading to a request to go to the emergency room, where the resident was diagnosed with a UTI and treated with intravenous antibiotics. The resident expressed frustration over the delay in treatment, stating that she knew her body and needed to be treated sooner. The medical director acknowledged that if the urine had been sent to the lab sooner, treatment could have been initiated earlier.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage, dishwashing equipment, and cleanliness of food contact equipment, potentially affecting all 99 residents. During an inspection, it was observed that raw pork sausage was improperly stored on top of raw hamburger in the walk-in refrigerator, contrary to the FDA Code and facility policy, which require separation to prevent cross-contamination. The Dietary Manager in Training acknowledged the error, and the Dietary District Manager confirmed adherence to the FDA Code for food storage hierarchy. Additionally, the facility's dishwasher was not sanitizing dishware effectively due to insufficient chlorine levels. A test conducted by the Dietary Manager in Training showed less than 10 ppm of chlorine, below the recommended 50-100 ppm. The dishwasher log was found to be illegible and altered, with discrepancies in recorded chlorine levels. Furthermore, the mixer in the kitchen was found with dried food residues, indicating it was not cleaned properly. These deficiencies highlight lapses in maintaining sanitary conditions in food preparation and storage areas.
Failure to Conduct Quarterly QAPI Meetings with Required Members
Penalty
Summary
The facility failed to ensure that the required Quality Assurance Performance Improvement (QAPI) meetings were held quarterly and that all necessary members attended these meetings. Specifically, there was no documentation available to confirm that a QAPI meeting took place during the first quarter of 2024. Additionally, the sign-in sheet for the fourth quarter 2023 QAPI meeting, dated February 23, 2024, did not include the presence of an Infection Preventionist, which is a required attendee. The Director of Nursing confirmed the absence of the Infection Preventionist at this meeting and the lack of documentation for the first quarter 2024 meeting. The facility's policy mandates that QAPI meetings occur quarterly with specific attendees, including the Administrator, Director of Nursing, Infection Preventionist, and other key staff members.
Deficiency in Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to establish a comprehensive water management program to prevent the growth of Legionella and other waterborne pathogens in its water systems. The facility's documentation was lacking a risk evaluation to identify areas at risk for Legionella growth, protocols for routine testing, and interventions for when control limits are not met. The Clinical Director of Operations confirmed the absence of a risk assessment, routine testing, and planned interventions, attributing the oversight to the lack of a Maintenance Director on staff. This deficiency potentially affects all 99 residents residing in the facility.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to ensure that call light devices were within reach for four residents, leading to a deficiency in honoring residents' rights to be treated with respect and dignity. Resident 14, who has diagnoses including repeated falls, muscle weakness, and dementia, was found with their call light on the floor, out of reach. Resident 27, with a history of fractures and osteoarthritis, had their call light hanging on the bed rail, three to four feet away from their reach. Resident 77, diagnosed with malignant neoplasms and epilepsy, was asleep with their call light at the end of the bed, out of reach. Resident 95, with cognitive deficits and morbid obesity, reported being unable to reach their call light, which was also at the end of the bed. The observations were made on the same day, and a Licensed Practical Nurse (LPN) confirmed that call lights should be within residents' reach at all times. The LPN stated that staff should ensure call lights are accessible when starting their shifts and when returning residents to their rooms. The deficiency highlights a failure in the facility's protocol to ensure residents can easily access their call lights, which is crucial for their safety and ability to request assistance.
Facility Fails to Address Resident Laundry Concerns
Penalty
Summary
The facility failed to adequately address multiple concerns raised by the resident council and facility grievances regarding laundry services. During a Resident Council Meeting, five residents expressed dissatisfaction with the timeliness and cleanliness of their returned personal items and clothing. The meeting minutes from several months documented ongoing complaints about delayed returns, poorly organized closets, missing items, and clothes being returned dirty. Additionally, the facility's Grievance Log from February to June 2024 recorded numerous concerns about clothing not being returned promptly or at all. Observations revealed a large bin of personal items in the laundry room awaiting return to residents. The laundry attendant indicated that her dual role in housekeeping and laundry limited her ability to return items promptly, especially when CNAs brought full bins all at once. The Housekeeper/Laundry Supervisor noted that many clothes were unlabeled and undelivered, and the facility relied on contract services for laundry and housekeeping. Furthermore, the facility lacked a formal laundry policy, as confirmed by the administrator.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident, identified as R101, who was reviewed for discharge. R101 was admitted to the facility with diagnoses of Metabolic Encephalopathy and Unspecified Convulsions. Upon discharge, the discharge summary was found to be incomplete, with only two out of five sections filled out. The sections titled Discharge Summary Recapitulation of Stay, Social Service Summary of Resident Stay, Clinical Summary of Resident Stay, Dietary Summary of Resident Stay, and Activity Summary of Resident Stay were not fully completed, leaving critical information unrecorded. The facility's policy, dated November 2022, mandates that staff complete the Discharge Plan, Instructions, and Summary, which includes a recapitulation of the resident's stay. However, this was not adhered to in the case of R101. The Director of Nurses confirmed that if the discharge summary is not found under the resident assessment tab, it indicates it was not completed. This oversight in documentation was identified during an interview and record review, highlighting a lapse in the facility's discharge process.
Inaccurate Pressure Ulcer Treatment
Penalty
Summary
The facility failed to accurately provide treatment for a pressure ulcer for a resident reviewed for pressure ulcer treatments. The resident had physician orders to apply collagen to the wound bed of a right heel wound and a right medial ankle wound. During an observation, an LPN was seen applying approximately an inch in circumference of collagen on both the right heel wound and the right medial wound, covering not only the wound bed but also the peri-wound area. The Director of Nursing later stated that the LPN should have measured the wound bed to ensure the collagen was applied directly onto the wound bed without covering the peri-wound area, as per the physician's orders and the manufacturer's instructions for the collagen wound dressing.
Failure to Monitor PICC Line in Resident
Penalty
Summary
The facility failed to properly assess and monitor a Peripherally Inserted Central Catheter (PICC) for a resident diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of the Bladder. The resident, who is cognitively intact, returned from the hospital with a PICC line and new orders to start intravenous antibiotics after being admitted for a Urinary Tract Infection. However, the Physician Order Sheet did not include any orders regarding the PICC line, and the Medication or Treatment Administration Records indicated that the PICC line had not been routinely monitored by nursing staff since the resident's readmission. The resident reported that the nursing staff had not assessed the PICC line except during antibiotic administration. The Director of Nurses confirmed that intravenous sites should be monitored and flushed every shift, and staff should document the status of the intravenous site.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to manage a resident's pain effectively by not obtaining and administering prescribed pain medication. The resident, diagnosed with Bilateral Primary Osteoarthritis of the Knee, had a physician's order for Oxycodone-Acetaminophen to be administered every four hours for pain management. However, on a specific day, three doses were missed because the medication was unavailable. The LPN on duty discovered the shortage in the morning and contacted the doctor to place an order with the pharmacy. It was noted that the night shift nurses did not take action to call the doctor or pharmacy to replenish the medication. The Director of Nursing acknowledged that the medication cards should have prompted staff to reorder before running out and that the night shift should have used the stat safe box to provide an alternative pain medication until the original prescription was available.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment for a newly developed skin wound for a resident diagnosed with moderate protein-calorie malnutrition, muscle weakness, reduced mobility, and myasthenia gravis. The resident required substantial assistance with movements such as rolling, sitting, and standing. On June 14, 2024, a Nurse Skin Inspection Report documented the presence of redness, bloody drainage, and an open ulcer in the coccyx/sacrum/buttocks area. However, there was no documentation of any treatment or notification of the medical doctor on that date. Treatment for the wound did not commence until June 18, 2024, four days after the issue was identified. The Assistant Director of Nursing (ADON) stated that the Licensed Practical Nurse (LPN) should have informed the wound nurse and the medical doctor about the skin issue immediately. The LPN admitted to being busy and not reviewing the shower sheet, which led to the delay in addressing the skin issue. The facility's policy on pressure ulcer prevention requires immediate treatment to prevent further development of ulcers. The Administrator confirmed that any skin issue noted should prompt an immediate and thorough skin assessment by the nurse.
Resident Burned by Space Heater Due to Facility Oversight
Penalty
Summary
The facility failed to remove an electric space heater from a resident's room, resulting in the resident sustaining a burn injury. The resident, who is cognitively intact and requires assistance with transfers and activities of daily living, had purchased the heater after admission. The resident believed staff were aware of the heater's presence, as they would adjust it upon request. On the day of the incident, the heater was left on the floor, and the resident accidentally burned their leg while getting out of bed. The incident was reported to the Illinois Department of Public Health, and a medical doctor was notified. The resident received treatment for a fluid-filled blister and a scabbed burn area on the left lower leg. The facility administrator acknowledged that staff were unaware that electric heaters were prohibited, indicating a lack of communication and enforcement of safety policies within the facility.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving resident R3 who exhibited aggressive behaviors towards other residents. R3, who is cognitively intact and propels independently in a wheelchair, had documented incidents of hitting behaviors on multiple occasions. Despite these documented behaviors, R3's electronic medical record did not include an Abuse Risk Assessment. On several occasions, R3 physically assaulted other residents, including R7, R5, and R6, causing distress and potential harm. R7, who has multiple medical diagnoses and is cognitively intact, reported that R3 attempted to steal a personal item from her wheelchair and subsequently punched her when she resisted. R5, who is also cognitively intact and requires maximum staff assistance, was punched by R3 while waiting in the hallway. R6, who is severely cognitively impaired and dependent on staff for mobility, was also punched by R3 in a similar manner. These incidents occurred while R3 was being wheeled down the hallway by an LPN, who failed to remove other residents from R3's path, thereby exposing them to potential harm. Additionally, R4, who is severely cognitively impaired, was involved in a physical altercation with R3 in the dining room. R3 backed his wheelchair into R4's table, leading to a confrontation where R3 hit R4. The facility's staff failed to intervene appropriately to prevent these incidents, despite being aware of R3's aggressive behaviors. The facility's policies and procedures for abuse prevention were not adequately followed, resulting in multiple residents being subjected to physical abuse by R3.
Failure to Protect Residents from Abuse and Investigate Allegations
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident with known physical aggression and did not investigate allegations of abuse by both residents and staff. The facility's policy mandates that the Administrator or a designated person ensures a thorough investigation of alleged violations and takes steps to prevent further abuse. However, the facility did not adhere to this policy, resulting in multiple incidents of physical abuse and uninvestigated allegations. Specifically, a resident with known aggressive behavior (R3) was wheeled past other residents by an LPN, leading to physical altercations where R3 punched two other residents (R5 and R6). The Director of Nursing acknowledged that the LPN should have taken measures to prevent these incidents, such as removing other residents from the area or seeking additional staff assistance. Additionally, the facility did not conduct timely physical assessments or keep the aggressive resident away from others during the investigation process. Another incident involved a resident (R1) who reported feeling unsafe due to inappropriate behavior by a male CNA during a shower. The resident alleged that the CNA might have had an erection and went through her drawers, making her feel like he was going to steal from her. This allegation was reported to the facility's Director of Nursing and Administrator by an LPN at a local physician's office. Despite this, the Administrator did not consider the incident as abuse and did not initiate an investigation. The facility failed to provide documentation of any investigation into this allegation, and the Regional Clinical Nurse confirmed that the facility's policy required a complete investigation. The facility's failure to protect residents from abuse and to investigate allegations thoroughly affected five residents out of a sample of twelve. The incidents highlight significant lapses in following the facility's abuse prevention and prohibition policy, leading to unaddressed and uninvestigated abuse allegations. The lack of appropriate action and documentation underscores the facility's non-compliance with regulatory requirements for resident safety and abuse prevention.
Failure to Respect Resident's Personal Property
Penalty
Summary
The facility failed to ensure resident rights regarding personal property for one resident. The incident involved a CNA who was observed by another resident going through the first resident's drawers without permission, claiming to retrieve washcloths. The affected resident expressed discomfort with the CNA's actions. The Director of Nursing confirmed the grievance and acknowledged the CNA's actions. Both the Assistant Director of Nursing and the Regional Clinical Director of Operations agreed that staff should always ask for permission before accessing a resident's personal belongings.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy for one of twelve residents reviewed for abuse. The facility's abuse policy mandates that any allegations of abuse must be reported immediately to the Administrator, who is then responsible for ensuring a thorough investigation and taking steps to prevent further abuse. On May 6, 2024, a resident reported to an LPN at a local physician's office that a CNA at the facility made her feel unsafe. The LPN reported this to the facility immediately after the appointment. However, the Administrator decided that no abuse had occurred and did not investigate or report the allegation as required by the policy. Despite the resident's report, the CNA in question continued to work at the facility, as evidenced by the nursing schedule and the resident's statement. It was only later that the CNA was suspended pending investigation. The Regional Clinical Nurse and the Regional Director of Operations confirmed that the facility's policy was not followed in this case, as any allegation of abuse should have been investigated and reported immediately, and the accused individual should have been restricted from accessing the facility during the investigation.
Failure to Timely Report Allegations of Abuse and Resident Altercations
Penalty
Summary
The facility failed to report allegations of physical and potential sexual abuse timely to the State Agency for three residents. The facility's policy mandates that any allegations of abuse or neglect must be reported to the State Agency within two hours. However, an incident involving a male CNA who allegedly had an erection while giving a resident a shower and went through her drawers was not reported. The Administrator and Director of Nursing were informed of the incident, but the Administrator did not consider it abuse and failed to report it. There was no documentation of the incident, investigation, or report to the State Agency until the survey was conducted. Additionally, the facility did not report a resident-to-resident altercation involving three residents. An initial incident report documented an altercation between two residents, but the facility failed to report two other incidents where the same resident punched two other residents. The Administrator acknowledged the failure to report these incidents, which were witnessed by staff and documented in a written statement. The facility's policy requires immediate reporting and investigation of such incidents, which was not followed in these cases.
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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