Mclean County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Normal, Illinois.
- Location
- 901 North Main, Normal, Illinois 61761
- CMS Provider Number
- 145494
- Inspections on file
- 30
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Mclean County Nursing Home during CMS and state inspections, most recent first.
The facility failed to follow its infection prevention and control program for residents with internal urinary drainage devices. Two residents with urinary catheters had drainage bags that were allowed to rest on the floor while they were in wheelchairs, despite care plans directing staff to keep tubing and drainage systems off the floor and to use Enhanced Barrier Precautions (EBP). Another resident with a long-term indwelling catheter, also on EBP, had a drainage bag hanging from a garbage can without a dignity bag, and a CNA emptied the bag without wearing PPE. The DON later acknowledged that drainage bags should not be on the floor and that PPE should always be used for residents on EBP.
A resident with moderate cognitive impairment and limited ability to perform ADLs, including grooming, had a care plan and facility policy requiring staff to assist with bathing and nail care. Despite documented showers and partial baths, the resident was repeatedly observed with jagged, untrimmed fingernails and brown material under the nails. CNAs and a shower aide confirmed that shower staff are responsible for cleaning and trimming nails with each shower and as needed, and acknowledged that this nail care should have been done but was not.
The facility failed to keep toilet safety frames and commode assistive bars in safe working condition for two residents with normal cognition but significant fall histories and mobility impairments. Both residents reported that the toilet handrails or commode bars were wobbly and made them feel unsafe, and surveyors directly observed that these devices were loose and moved easily when grabbed. Manufacturer manuals required regular and, in one case, weekly inspection and tightening of all components to ensure stability. Therapy records documented that each resident required toilet stabilizer bars or grab bars for safe toileting and transfers, and therapy staff stated that loose or unsecure bars could contribute to falls. Facility leadership and maintenance staff reported that quarterly preventive bathroom checks were done but used no formal documentation process, and they were unable to produce records showing that the affected toilet safety frames and commode had been routinely inspected.
A resident reported to a CNA that a staff member forcibly took a gown from her, causing a scratch and a red spot on her forearm. The CNA relayed this allegation to the administrator, who did not notify the state agency as required by facility policy. Medical records confirmed there was no documentation of state agency notification regarding the abuse allegation.
A resident with a history of psychotic disorder and moderate cognitive impairment struck one resident and threw coffee on another, causing physical harm. Despite increased supervision measures, the facility failed to prevent these incidents, highlighting a lapse in adherence to abuse prevention policies.
The facility did not maintain the juice dispenser in a sanitary condition, with dried juice and green fuzzy material observed on it. Additionally, opened containers of almond milk, juices, thickening agents, and ice cream toppings were not dated when opened. The Dietary Manager confirmed the juice machine should be cleaned daily, and containers should be labeled with the opening date.
A facility failed to maintain a clean and sanitary mechanical wheelchair for a hospice resident with severe protein malnutrition. The resident expressed discomfort with the dirty chair, which was observed to have a chunky brown and white substance on the seat. The DON confirmed that night shift staff were responsible for cleaning wheelchairs, but the facility lacked a specific policy for equipment cleaning.
The facility failed to secure and position catheter tubing properly for two residents, leading to impeded urine flow and tension at the insertion site. One resident's catheter tubing was compressed under the leg, while another experienced pulling due to lack of anchoring, causing redness and swelling. Staff confirmed the absence of securement devices, contrary to care plans and physician orders.
The facility failed to implement dietician recommendations for two residents who experienced significant weight loss. Both residents were at nutritional risk, and the dietician recommended adding a house shake with lunch to maintain their weight. However, these recommendations were not included in the physician's orders, and the residents did not receive the shakes. The Director of Nursing confirmed that the dietary recommendations were missed and not documented in the care plans.
A facility failed to justify the use of an antipsychotic medication for a resident by not identifying or tracking specific behaviors. The resident's record showed orders for psychotropic medications, but only documented self-isolating and refusal of care, with no nonpharmacological interventions attempted. The RN Unit Manager confirmed these behaviors do not justify antipsychotic use, violating the facility's policy on unnecessary medications.
Two residents experienced medication administration errors at the facility. An LPN administered expired insulin to a resident with diabetes, while another resident received only half of the prescribed Vitamin C dosage. These errors resulted in a medication error rate of 6.67%, surpassing the acceptable 5% threshold.
The facility failed to label medications with the date opened for two residents. A resident's Refresh tears and another's Maxitrol eye ointment were found on the medication cart without the required date of opening. An LPN confirmed the omission, noting that the facility's policy did not address this requirement.
A resident with severe cognitive impairment experienced a delay in reporting a change in condition to their physician and power of attorney. The resident complained of knee pain, which was later diagnosed as a fracture. The facility's policy to notify the physician of significant changes was not followed, resulting in a delay of several days before the physician was informed.
Failure to Implement Enhanced Barrier Precautions and Proper Urinary Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP) and urinary catheter care practices, for residents with internal urinary drainage devices. For one resident with obstructive uropathy requiring an internal urine drainage device, surveyors observed the urinary drainage bag dragging on the floor while the resident propelled in a wheelchair down the hall and later resting on the ground beneath the wheelchair during an activity in the dining room. This occurred despite the resident’s care plan directing staff to avoid allowing tubing or any part of the drainage system to touch the floor and documenting the need for EBP, including teaching the resident and staff about the chain of infection, methods of transmission, and principles of infection control. Another resident with a flaccid neuropathic bladder and an internal urine drainage device was observed in the dining room with the urinary drainage bag hanging beneath the wheelchair and resting on the ground, contrary to the care plan instructions that no part of the drainage system should touch the floor and that EBP would be used to reduce transmission of multidrug-resistant organisms. A third resident, alert and oriented with a long-term indwelling urinary catheter and on EBP, was found in bed with the catheter bag hanging from a garbage can and not in a dignity bag. A CNA emptied this resident’s catheter drainage bag without wearing any personal protective equipment (PPE), even though the resident’s status on EBP required PPE use. The DON later confirmed that urine drainage bags should never rest on the ground and that PPE should always be worn when a resident is on EBP, corroborating that these observed practices were inconsistent with facility policy and the residents’ care plans.
Failure to Provide Required Fingernail Care and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s personal hygiene by not providing routine fingernail care as required by facility policy and the resident’s care plan. The facility’s ADL policy states that residents unable to carry out activities of daily living will receive necessary services to maintain grooming and personal hygiene, including nail care. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 10 and documented limited ability with ADLs, requiring assistance due to impaired cognition, general weakness, and pain related to Alzheimer’s disease, ulcerative colitis, and low back pain. The resident’s care plan required staff assistance with showering twice weekly, partial bathing twice daily, and assistance with hair, lotion, and nail care. On multiple observations, the resident was seen sitting in a wheelchair near the nurses’ station with fingernails that were jagged, untrimmed, and with brown material beneath them, despite documentation that the resident had recently received showers and bathing assistance. Staff interviews confirmed that shower aides are responsible for providing nail care, including cleaning under the nails with every shower and as needed, and that this care should have been provided during the resident’s most recent shower. One CNA acknowledged that the resident’s nails should have been cleaned and trimmed but “it doesn’t look like it was done.” Another CNA stated they documented the shower but did not provide it, and confirmed that nail care should have been done. The shower aide also confirmed the expectation that nail care be provided with each shower, indicating that the resident’s nail care was not completed as required.
Failure to Maintain Safe and Secure Toilet Safety Frames and Commode Bars
Penalty
Summary
The facility failed to maintain toilet safety frames and a bariatric commode in safe operating condition for two residents who required assistive devices for toileting and transfers. For one resident (R70), who had normal cognition, a diagnosis of repeated falls, urinary incontinence, and a care plan requiring staff assistance with toileting, the toilet safety frame in her bathroom was observed to be wobbly and easily moved when grabbed. The manufacturer’s manual for the toilet safety frame required regular checks to ensure it was securely locked onto the toilet before use. R70 reported that the bathroom handrails around her toilet were wobbly and that she had recently fallen off the toilet, which scared her, though she was not injured. Therapy documentation showed that R70 needed grab bars and toilet stabilizer bars for safe toileting with assistance, and both the PT and COTA stated that she definitely needed secure safety handrails and that an unsecure or loose stabilizer bar could contribute to a fall. For another resident (R4), who also had normal cognition, a history of repeated falls, weakness, CVA with left-sided weakness, and impaired mobility, the handrails attached to his bariatric commode were likewise observed to be unsecure and moved easily when grabbed. The bariatric commode manual required periodic visual inspection and weekly checks of all nuts, bolts, and knobs to ensure stability and safe use. R4 reported feeling unsafe on the toilet because the bars moved around too much. His care plan documented difficulty with transfers, risk for falls, and the need for toileting assistance and reminders not to transfer without help, and OT documentation indicated he required adaptive equipment and assistive devices, including a raised toilet seat/3-in-1 commode, for safe toileting. The COTA confirmed that, due to his CVA and left-sided weakness, he most definitely needed toilet stabilizer bars and that a loose stabilizer bar had the potential to contribute to a fall. The Administrator and Maintenance Director stated that quarterly preventive maintenance was done on resident bathrooms and that a checklist existed but was not used for documentation; the Maintenance Director and Mechanic could not provide documentation that the toilet safety frames for these residents had been routinely checked, and only undated “chicken scratch” notes from a prior period were available.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by its own Abuse Prevention Policy. On 4/30/25, a certified nurse's assistant (V7) reported to the administrator (V1) that a resident (R1) alleged a staff member (V3) had snatched a gown from her, resulting in a scratch to her hand and a red spot observed on her forearm. Despite receiving this report, the administrator confirmed that the state agency was not notified of the allegation. Review of the resident's medical record also showed no documentation that the state agency had been informed of the incident.
Failure to Protect Residents from Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from abuse by another resident, resulting in multiple incidents involving three residents. On the morning of December 8, 2024, in the Main Dining Room, a resident struck another resident on the face after becoming agitated by the latter's singing. This incident was witnessed by dietary staff who responded to the raised voices. Later that day, the same resident threw coffee on another resident, causing redness on the arm and abdomen. This incident was confirmed by a registered nurse and a visitor who witnessed the event. The resident responsible for the abuse has a history of psychotic disorder with delusions and anxiety disorder, and is noted to have moderate cognitive impairment. The resident's care plan documented potential for verbal and physical behaviors directed at staff and others, including hitting and kicking. Despite these documented behaviors, the facility's response to the initial incident was to increase supervision and encourage the resident to stay in her room, but this did not prevent the subsequent incident later that day. The facility's policy affirms the right of residents to be free from abuse, yet the incidents indicate a failure to adequately supervise and protect residents from harm. The Director of Nursing confirmed that increased supervision should have involved staff being close enough to observe the resident as she moved around the facility. However, during the coffee-throwing incident, no staff were present in the dining room, highlighting a lapse in supervision and adherence to the facility's abuse prevention policy.
Unsanitary Juice Dispenser and Undated Perishable Foods
Penalty
Summary
The facility failed to maintain the juice dispenser in a clean and sanitary manner and did not date perishable refrigerated foods when opened. During a walkthrough of the main kitchen, the juice dispenser was observed with dried juice on the nozzles and surrounding flat surfaces, some of which were covered by green fuzzy material. This dispenser is used to pour drinks for all residents in the facility. Additionally, opened containers of almond milk, juices, thickening agents, and ice cream toppings in the refrigerator were not labeled with the date they were opened. The Dietary Manager confirmed that the juice machine should be cleaned daily, and the containers should be labeled with the opening date.
Failure to Maintain Clean Wheelchair for Hospice Resident
Penalty
Summary
The facility failed to maintain a mechanical wheelchair in a clean and sanitary manner for one resident, identified as R16, who was under hospice care due to severe protein malnutrition. R16's care plan indicated a decline in cognitive and physical abilities, with care focused on maintaining comfort through end-of-life. On August 12, 2024, R16 was observed seated in a mechanical wheelchair in her room, which she stated was provided by hospice and was comfortable but dirty. The wheelchair was noted to be caked with a chunky brown and white substance around the padded seat, which R16 expressed dissatisfaction with. On August 13, 2024, the Director of Nursing, identified as V2, confirmed that the night shift staff were responsible for cleaning wheelchairs and that all staff should remove visible debris as soon as it is noticed. However, the facility did not have a specific policy for cleaning wheelchairs or other equipment, contributing to the deficiency in maintaining a clean environment for R16.
Deficiencies in Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to deficiencies in securing and positioning catheter tubing. For one resident, the care plan indicated the need for an indwelling urinary catheter due to urinary retention, with instructions to avoid obstructions in the drainage. However, during an observation, the catheter tubing was found to be compressed under the resident's leg, impeding urine flow and leaving a red imprint on the thigh. It was confirmed by the CNAs and the LPN that the resident did not have a securement device for the catheter tubing, which should not have been placed under the leg. Another resident with a physician's order for an indwelling urinary catheter experienced tension at the insertion site during catheter care, causing redness and slight swelling of the urinary meatus. The CNAs noted that the catheter should have been anchored to prevent pulling, especially since the resident had difficulty turning due to a previous leg injury. The DON confirmed that an anchoring device was necessary to prevent the catheter tubing from pulling.
Failure to Implement Dietician Recommendations for Weight Loss
Penalty
Summary
The facility failed to implement dietician recommendations for two residents, R39 and R40, who experienced significant weight loss. R39's care plan indicated she was at nutritional risk, and her weight decreased from 117.2 pounds to 106 pounds over three months, a 9.56% loss. The dietician recommended adding a house shake with lunch to maintain her weight, but this recommendation was not included in the physician's orders, and R39 did not receive the shake. The Director of Nursing confirmed that the dietary recommendation was missed and that the significant weight loss was not documented in R39's care plan. Similarly, R40 experienced an 11.4% weight loss over six months, dropping from 164.6 pounds to 149.2 pounds. The dietician also recommended a house shake with lunch for R40, but this was not reflected in the physician's orders, and R40 did not receive the shake. The Director of Nursing acknowledged that the dietary recommendation was overlooked and that the weight loss should have been added to R40's care plan. Both cases highlight a failure to follow through on dietician recommendations and update care plans accordingly.
Failure to Justify Antipsychotic Use and Implement Nonpharmacological Interventions
Penalty
Summary
The facility failed to identify and track specific behaviors to justify the use of an antipsychotic medication for a resident, leading to a deficiency in medication management. The resident's medical record showed current physician's orders for psychotropic medications, including Fluoxetine, Lorazepam, and Quetiapine. However, the Treatment Administration Record for August 2024 only documented episodes of self-isolating and refusal of care, with no documentation of nonpharmacological interventions attempted. The Registered Nurse Unit Manager confirmed that self-isolation and refusing care are not justifications for antipsychotic use. The facility's Psychotropic Medication Policy outlines that an unnecessary medication is one used without adequate indications of its use, among other criteria.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications in accordance with physician's orders and manufacturer's recommendations for two residents. For one resident, identified as R4, the Licensed Practical Nurse (LPN) administered insulin aspart from a vial that was past its expiration date. The insulin vial had an open date written on it, indicating it should have been discarded after 28 days. However, the LPN misread the date and proceeded to administer 12 units of the expired insulin to the resident, whose blood glucose level was recorded at 406, necessitating the insulin administration. In another instance, a resident identified as R25 was prescribed two 500 mg tablets of Vitamin C for a vitamin deficiency. The LPN responsible for administering the medication only provided one tablet instead of the prescribed two. This error was later confirmed by the Director of Nursing, who acknowledged that the resident should have received the full dosage as per the physician's order. These incidents contributed to a medication error rate of 6.67%, exceeding the acceptable threshold of 5%.
Failure to Label Medications with Date Opened
Penalty
Summary
The facility failed to properly label medications with the date they were opened for two residents, R150 and R151, out of a sample of 35 residents. R150's Medication Administration Record (MAR) included a physician's order for Refresh tears, which were observed on the medication cart without a date of opening. Similarly, R151's MAR included an order for Maxitrol eye ointment, which should be discarded 30 days after opening, but was also found without a date of opening. A Licensed Practical Nurse (LPN) acknowledged that multidose medication containers are supposed to be labeled with the time and date they are opened, but noted that the medications in question were not dated. The facility's medication administration policy did not address the requirement to label medications with the date opened.
Failure to Timely Report Change in Resident's Condition
Penalty
Summary
The facility failed to timely report a change in condition for a resident who was severely cognitively impaired and unable to communicate effectively. On May 31, 2024, a nurse noted that the resident was complaining of pain during care, specifically in the right knee, which was swollen and painful. Despite this observation, the physician and the resident's power of attorney were not notified of the change in condition and new onset pain until June 3, 2024, which was a delay of several days. During this period, the resident's condition was monitored, and Tylenol was administered for pain relief. The resident's care plan indicated a high risk for falls due to impaired mobility and cognition, among other factors. An x-ray ordered on June 3, 2024, revealed a right knee arthroplasty with an acute periprosthetic fracture of the distal femur. The facility's policy required that any significant change in a resident's condition be reported to the attending physician or power of attorney, which was not adhered to in this case. The Director of Nursing confirmed the lapse in communication, acknowledging that the necessary notifications were not made in a timely manner.
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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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