Momence Meadows Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Momence, Illinois.
- Location
- 500 South Walnut, Momence, Illinois 60954
- CMS Provider Number
- 145713
- Inspections on file
- 37
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Momence Meadows Nursing & Rehab during CMS and state inspections, most recent first.
A resident with a history of suspected abuse, care planned to be kept in a safe environment, sustained a head injury and facial laceration requiring sutures after being struck in the head with a cane by another resident. Staff documentation noted bleeding below the resident’s right eye and subsequent hospital evaluation confirmed the need for sutures. The facility’s incident report described inappropriate physical contact between the two residents, and the Administrator reported that one resident hit the other with his cane. The resident who struck the other had a care plan addressing inappropriate sexual behavior but lacked assessment or planning for potential physical aggression, despite the facility’s abuse prevention policy prohibiting physical abuse such as hitting.
A resident who was fully dependent on gastrostomy tube (G-tube) feedings for nutrition experienced significant weight loss and severe protein-calorie malnutrition after staff failed to consistently provide ordered enteral feedings on time. The resident appeared cachectic and repeatedly communicated hunger, while several CNAs reported that he often was not fed, especially during night and early-morning hours. Although the MAR showed most feedings as signed off, an audit revealed numerous late entries, feedings documented hours after scheduled times, some signed days later, and some apparently pre-dated. The PCP and RD both stated there was no medical reason for the weight loss other than inadequate feedings, and that the ordered Jevity regimen should have prevented weight loss if administered as ordered.
The facility failed to maintain adequate licensed nurse staffing, resulting in delayed or missed medications and inconsistent gastrostomy tube feedings for multiple residents. An LPN reported being the only nurse on one side of the building with numerous overdue medications on the eMAR, while an RN on an extended shift did not begin morning med pass until late morning, causing scheduled antihypertensives to be given hours late. A resident fully dependent on G‑tube feeding experienced significant weight loss, and the physician stated there was no medical cause other than not being fed. Facility records confirmed repeated shifts with fewer nurses than the staffing plan required, and several alert residents and CNAs reported nights with no nurse on the floor, residents not receiving pain or sleep medications, and residents begging or threatening to call 911 for their medications, while leadership acknowledged awareness of shifts staffed with only one nurse.
Multiple residents did not receive significant medications as ordered or within required time frames, including repeated late, missed, and incorrectly transcribed doses. A resident with severe chronic conditions reported frequently receiving muscle relaxants and neuropathic pain medications hours late, while the eMAR showed numerous overdue medications for residents on the hall. Several residents with diabetes received short-acting and long-acting insulin doses far outside scheduled times, with evening doses often given the following morning and pre-meal doses clustered late in the morning or afternoon. A resident with serious psychiatric diagnoses had clozapine, lithium, and benztropine routinely administered several hours after scheduled times. Another resident with brain cancer and epilepsy experienced highly irregular administration of twice-daily anticonvulsants, including overnight delays, clustered doses, and at least one missed evening dose. A resident with functional quadriplegia and recent pneumonia had a hospital order for levofloxacin 750 mg once daily for five days incorrectly transcribed and administered as intermittent twice-daily doses on two separate days, with doses given only hours apart. These practices met the facility’s own definition of medication administration errors related to timing and missed doses.
The facility failed to immediately report multiple abuse allegations to the state agency as required by its abuse policy. An alert and oriented resident reported that another resident threatened her with a knife, and staff later found weapons and other dangerous items belonging to that resident, but the Administrator did not report the allegation. Another alert and oriented resident alleged that staff ripped his shirt and placed a knee on his neck during a verbal altercation; although this was reported internally, the external report was delayed by several days and omitted the ripped-shirt allegation. In a separate event, a resident reported that while choking, one CNA assisted her but another CNA stated he would have let her choke, and this allegation, though reported to the Administrator, was not reported to the state agency.
The facility failed to promptly investigate and report multiple abuse allegations and to protect residents during the investigation period. An alert and oriented resident alleged that staff ripped his shirt and placed a knee on his neck during an altercation, which was reported by a CNA to the Administrator and DON, but the Administrator delayed the investigation and late-reported the incident to the state without all details. Another alert and oriented resident reported that another resident held a knife to her neck and threatened her; CNAs confirmed hearing the threat and later found a knife, taser, pocketknife, hammer, drill, and lighters belonging to that resident, yet the Administrator did not investigate or report the abuse allegation. The same resident also reported that a CNA stated he would have let her choke after another CNA assisted her while choking, and although this was reported to the Administrator, no investigation or state report was initiated, contrary to the facility’s abuse policy.
Two alert and oriented residents were involved in an incident where one resident reportedly held a knife to another resident’s neck and threatened her, after which staff discovered multiple potentially dangerous items, including knives, a taser, a drill, a hammer, lighters, scissors, and razor blades, in resident rooms and later stored in the med room and Administrator’s office. CNAs reported hearing the threats and finding these items, and the resident who made the threats admitted keeping a hammer, drill, and pocketknife for protection. The Administrator confirmed the items belonged to this resident and acknowledged they made the environment unsafe. Record review showed this resident had a care plan for maladaptive behaviors that may detrimentally affect others, but no care plan focus on aggressive behaviors or possession of weapon-like objects, while another resident had intact cognition and a care plan addressing mood and psychosocial well-being. The facility’s policy required that the environment and furnishings be safe, clean, and comfortable.
A resident dependent on staff for ADL and incontinence care, with a history of chronic ulcers and a stage 3 sacral pressure ulcer, was found with soiled bedding and a strong urine odor after waiting extended periods for assistance. Staff interviews and observations confirmed that incontinence care was not provided as required by the care plan and facility policy, resulting in inadequate hygiene and increased risk of skin complications.
Two residents with cognitive impairments and histories of behavioral issues were involved in separate incidents of inappropriate physical and sexual contact with other residents. In both cases, staff did not witness the incidents, and the affected residents either reported the abuse or were found with minor injuries. The facility's policy required identification and monitoring of residents at risk for abuse, but repeated incidents occurred involving residents with known behavioral risks.
A resident with a history of cognitive impairment and bipolar disorder was physically abused by a CNA who slapped the resident's hand during an altercation involving the CNA's personal laptop. The incident, witnessed by other staff, led to the resident's increased agitation and emotional distress. The facility's investigation confirmed the abuse, resulting in the CNA's termination.
A resident with severe cognitive impairments and vision loss was not protected from sexual abuse by another resident with dementia and a history of boundary issues. A cook witnessed the inappropriate touching in a hallway, but the facility's investigation did not substantiate the abuse allegation despite the resident's known vulnerabilities.
The facility failed to maintain its kitchen to prevent foodborne illness, affecting 74 residents. Observations revealed expired food items, improperly stored and open food packages, dented cans in use, and a sour odor from the milk cooler. The walk-in cooler contained improperly wrapped and expired food items, and an oscillating fan was covered with dust and grease. Additionally, there was no log for documenting sanitizer concentration, violating facility policies.
The facility failed to provide written discharge notices and notify the ombudsman for four residents transferred to the hospital. The DON admitted to not notifying the ombudsman and relying on phone notifications for residents and their representatives. Residents were transferred due to various medical conditions, including aggressive behavior, suicidal ideations, and altered mental status, without receiving the required written notices.
The facility failed to provide written notification of the bed hold policy to residents and their families or POAs during hospital discharges. This deficiency affected four residents who were transferred to the hospital for various medical reasons, including aggressive behavior, respiratory issues, and suicidal ideations. The facility's administrator acknowledged that the bed hold policy should be provided during each hospital discharge, but this was not done.
The facility failed to obtain physician orders and conduct self-administration assessments for three residents who had medications at their bedside. One resident's nasal spray was found on her roommate's dresser without proper orders or assessments, and another resident had pills on his bedside table without documentation. The facility's policy requires assessments and orders for self-administration, which were not completed.
A resident with a PICC line had a gauze dressing that was not changed by staff, leading to a deficiency in infection control. The resident reported changing the dressing herself after 4 to 5 days, and the dressing was found to be soiled and exposing the insertion site. The facility's policy required more frequent changes, but there was no documentation of dressing changes in the resident's medical record.
The facility failed to refund resident funds after discharge, affecting three residents. The Business Office Manager acknowledged the oversight and stated that he would contact the new facilities of two residents to transfer the funds, while he would continue to try to locate the third resident or send the funds to social security if unsuccessful. The Corporate BOM confirmed that the facility has a policy requiring resident funds to be returned within 30 days of discharge.
The facility failed to follow the menu plan and provide residents with alternatives for refused food items. Menus were often not posted, and the food served did not match the planned menu. Residents reported dissatisfaction due to menu changes and unmet dietary needs. The dietary manager acknowledged issues with food orders, and the administrator confirmed that the facility should not run out of food.
The facility failed to provide alternate food to meet residents' needs, affecting three residents who reported not receiving requested or necessary food items. The Dietary Manager and Facility Administrator provided conflicting information on the policy for ordering meal substitutes, contributing to the deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Head Injury
Penalty
Summary
The facility failed to protect a resident from abuse when one resident struck another in the head with a cane, causing a head injury and laceration that required sutures. On 12/26/25, staff progress notes documented that the injured resident was observed bleeding from below the right eye and that another resident had hit him. A subsequent hospital report confirmed a head injury and a laceration requiring three sutures, and later observation on 12/31/25 showed a bruise to the upper right cheek below the eye and three sutures on the right eyelid. The facility’s incident report to the state agency described that the two residents engaged in inappropriate physical contact, and the Administrator stated it had been reported that one resident hit the other in the head with his cane. The injured resident had a care plan dated 12/24/25 noting a history of suspected abuse with an intervention to assure he was in a safe environment, while the other resident’s care plan, focused on inappropriate sexual behavior, did not include an assessment for potential physical abuse against others, despite the facility’s Abuse Prevention Program policy prohibiting and seeking to prevent resident abuse and neglect, including physical abuse such as hitting.
Failure to Provide Ordered G-Tube Feedings Resulting in Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident receiving all nutrition via gastrostomy tube was provided adequate and timely tube feedings to maintain his weight. The resident, an adult male with brain damage from a lightning strike, functional quadriplegia, dysphagia, cognitive communication deficit, and gastrostomy status, was entirely dependent on enteral nutrition and took no food orally per physician orders. During observation, he appeared very thin and frail, and communicated via a communication board that he frequently did not receive his feedings or medications, and that when he did, they were often late. Multiple CNAs reported that the resident had told them he was hungry, that he had lost a lot of weight, and that they rarely or never saw him receive his scheduled early-morning or night-time feedings. The resident’s weight records showed a decline from 114.2 pounds to 98.8 pounds over 38 days, a 13.49% weight loss. A recent hospital discharge summary documented severe protein-calorie malnutrition, a 30% weight loss in less than one year, severe muscle mass loss in specific muscle areas, and described his appearance as cachectic. The December medication administration record (MAR) showed an order for Jevity 1.2, 300 ml every 6 hours via gastrostomy tube at four scheduled times daily. The MAR boxes were largely checked as if feedings were given, with only a few blanks, and the DON stated that if there is nothing documented in the EMAR, the medications or feedings were not given. However, the MAR audit report revealed that many feedings were documented as administered significantly later than scheduled, sometimes hours late, and in some cases signed off days later or even pre-dated as if given before the actual date. Numerous entries showed feedings signed more than three or four hours after the scheduled times, and some early-morning and night-time feedings were not observed by staff on those shifts. The resident’s primary care physician stated he had not been informed of the weight loss or missed feedings and that there was no medical reason for the weight loss other than not being fed. The registered dietician stated that if the resident had received the ordered feedings, he would not have lost weight because the prescribed regimen exceeded his nutritional needs, and concluded that the only reason for the weight loss was that he was not getting enough feedings. The administrator acknowledged awareness that the resident was not being fed as ordered and that he was malnourished.
Insufficient Licensed Nurse Staffing Leading to Delayed Medications and Tube Feedings
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff to administer medications and gastrostomy tube feedings as ordered. On one survey day late in the morning, a cognitively intact resident remained in bed, restless, reporting that he had not received his morning medications and that on many nights his 9:00 PM medications were not given until around midnight, with morning medications often delayed until late morning. At the same time, an LPN passing medications showed an eMAR screen with 14 residents on the hall having overdue medications, confirming that the pink color indicated overdue doses. This LPN stated there was only one nurse on that side of the building when there were supposed to be two, and that he had worked the overnight 12‑hour shift as well. Another RN reported she did not begin passing morning medications until around late morning because she had been working on the other side of the building with another new nurse, and she had been on duty since the previous night. Medication administration records showed that a resident’s 9:00 AM antihypertensive medications with blood pressure parameters were actually administered around midday. A resident dependent on gastrostomy tube feeding, with diagnoses including functional quadriplegia, dysphagia, and gastrostomy status, experienced significant weight loss from 114.2 pounds in November to 98.8 pounds in late December. The resident’s physician stated there was no medical reason for the weight loss and that if the resident was losing weight, it would only be from not being fed. The ADON confirmed that the facility’s staffing plan required a minimum of three nurses on day shift and two on night shift, yet review of daily assignment sheets, staffing sheets, and time sheets showed multiple dates in November and December when only one nurse, or fewer than the planned minimum, were on duty for substantial portions of shifts. The ADON stated that not meeting minimum staffing affects care such as timely medication passes and tube feedings. Multiple alert and oriented residents reported that there were not enough nurses, that some nights there was no nurse on duty, and that they did not receive medications, including pain and sleep medications, sometimes having to yell or threaten to call 911. CNAs also reported there were not enough nurses, that some residents did not receive medications or G‑tube feedings and had to wait, and that they had notified leadership when only one nurse was on the floor and residents were waiting for medications and exhibiting behaviors, without receiving a response. The Administrator and DON acknowledged that the minimum number of nurses was not always met and that having only one nurse for the whole facility was unsafe, and that they were aware of at least one night when only one nurse was working.
Failure to Administer Significant Medications as Ordered and Within Required Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to ensure that significant medications were administered as ordered, including repeated late, missed, and incorrectly transcribed doses for multiple residents. One cognitively intact resident with malignant lung neoplasm, bilateral above-knee amputations, and chronic painful skin disease reported frequently not receiving his 9:00 PM medications until around midnight and his morning medications until around 11:00 AM or 12:00 PM, stating that he needed them and that not getting them on time was making him sicker. On one observed day, his baclofen and gabapentin, ordered three times daily and scheduled for 9:00 AM, 5:00 PM, and 9:00 PM, were actually administered at 11:24 AM, 4:35 PM, and 8:10 PM, respectively. At the time of observation, the eMAR system showed his medications as overdue, and the nurse confirmed that 14 residents on the hall had overdue medications. Another resident with diabetes and hyperglycemia had short-acting insulin ordered three times daily before meals and long-acting insulin once daily in the evening. On the observed day, the 7:00 AM and 11:00 AM short-acting insulin doses were both signed as administered at 11:35 AM. For the long-acting insulin scheduled at 8:00 PM, the audit report showed that several consecutive evening doses were actually given the following mornings between approximately 6:00 AM and 7:00 AM, with one dose documented as refused at 8:00 PM but administered the next morning at 6:48 AM, and another dose given about 14 hours after its scheduled time. A resident with schizoaffective disorder, bipolar type, and recurrent major depressive disorder had benztropine, clozapine, and lithium ordered at specific times (twice daily or three times daily). On one day, all three 9:00 AM doses were signed as administered at 12:58 PM, and the 1:00 PM lithium dose at 12:59 PM; on the previous day, the 9:00 AM doses were signed at 2:58 PM and the 1:00 PM lithium dose at 2:20 PM. A resident with diabetes with hyperglycemia and foot ulcer, combined heart failure, and hypertension had daily amlodipine and lisinopril ordered at 9:00 AM with parameters to hold for low systolic blood pressure, and insulin orders including long-acting insulin at bedtime and short-acting insulin before meals. On the observed day, the RN stated she began passing medications around 11:00 AM, and the resident’s blood pressure had last been taken the previous afternoon; the 9:00 AM hypertension medications were administered around noon. The prior day’s 9:00 AM hypertension medications were administered at 3:00 PM. For this resident’s insulin, an 11:00 AM short-acting insulin dose on one date was administered at 6:20 PM, and another 11:00 AM dose on a different date at 2:23 PM. The bedtime long-acting insulin scheduled for 9:00 PM was repeatedly administered the following mornings between about 6:00 AM and 7:00 AM on several consecutive days, with one dose given approximately 14 hours after its scheduled time. A resident with malignant brain neoplasm and epileptic seizures had levetiracetam and lacosamide ordered twice daily, twelve hours apart at 9:00 AM and 9:00 PM. The audit report showed a pattern of significant deviations from the ordered schedule: on multiple consecutive days, 9:00 PM doses were administered the following mornings between about 6:00 AM and 7:00 AM, 9:00 AM doses were delayed by several hours into the afternoon or evening, and on one day three doses were given within approximately 15 hours. On another day, the 9:00 PM doses were not signed off as administered at all, and the next day’s 9:00 AM doses were given about 22 hours after the prior morning dose. Another resident with functional quadriplegia, dysphagia, and a history of acute respiratory failure and pneumonia was discharged from the hospital with instructions to start levofloxacin 750 mg daily for five days. In the facility, the order was transcribed incorrectly as levofloxacin 750 mg twice a day via gastrostomy tube every five days, and the MAR showed 9:00 AM and 5:00 PM doses signed as administered on two non-consecutive days instead of once daily for five straight days. The audit report further showed that on one of those days, the 9:00 AM dose was administered at 5:19 PM and the 5:00 PM dose at 7:13 PM, less than two hours apart. The facility’s medication error policy defined medication not administered within an allowed time frame greater than one hour from its scheduled time or missed medications as administration-based errors, which were present in these cases.
Failure to Timely Report Multiple Abuse Allegations to State Agency
Penalty
Summary
The facility failed to timely report multiple allegations of abuse to the Illinois Department of Public Health as required by its Abuse Prevention Program policy. An alert and oriented resident (R5) reported that another resident (R1) held a knife to her neck and threatened her on 12/7/25. A CNA (V4) stated she heard R1 threatening R5 with a knife and observed R1 standing over R5, and staff found knives, a drill, a hammer, and lighters in R5's room that night. The next day, another CNA (V3) searched R1's room at the direction of the DON (V2) and found a taser and a pocketknife under R1's bed. Various potentially dangerous items, including a drill, hammer, scissors, razor blades, and lighters, were later observed in the medication room and then removed to the Administrator's office. The Administrator (V1) verified the objects belonged to R1 and acknowledged that R5's allegation of being threatened with a knife on 12/7/25 was not reported to the Illinois Department of Public Health. A second incident involved an alert and oriented resident (R9) who alleged that during a verbal altercation with staff on 12/14/25, staff ripped his shirt and had a knee on his neck. R9 reported the ripped shirt and physical aggression to a CNA (V5) and a nurse, and V5 confirmed that R9 showed her the ripped shirt and that she reported the allegation to the Administrator and DON. The facility did not submit its initial report to the Illinois Department of Public Health until nine days after the incident and the report omitted the allegation that staff ripped R9's shirt. In a third incident, R5 reported that while she was choking and a CNA assisted her, another CNA (V17) stated he would have let her choke; R5 reported this to the Administrator, who acknowledged receiving the report but did not report it to the Illinois Department of Public Health because R5 said it occurred before the Administrator started working at the facility. These actions and inactions demonstrate failures to immediately report allegations of staff-to-resident and resident-to-resident abuse as required by facility policy.
Failure to Investigate and Report Multiple Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to follow its Abuse Prevention Program policy by not promptly investigating and reporting multiple allegations of abuse and by not ensuring resident protection during the investigation period. An alert and oriented resident (R9) reported that during a verbal altercation on 12/14/25, staff ripped his shirt and placed a knee on his neck. A CNA confirmed that R9 showed her the ripped shirt that night and that she reported the incident to the Administrator and DON. The Administrator acknowledged that R9 had reported staff being physically aggressive and that the incident occurred on 12/14/25, but did not begin investigating until 12/23/25, after R9 reported the allegation to the state agency. The initial report to the Illinois Department of Public Health was made nine days after the incident and did not include the allegation that staff ripped R9’s shirt. The facility also failed to investigate and report other abuse allegations involving alert and oriented residents. One resident (R5) reported that another resident (R1) held a knife to her neck and threatened her; a CNA stated she heard R1 threatening R5 with a knife and later found a knife, drill, hammer, and lighters in the room. Another CNA reported that, the next day, she was instructed by the DON to search R1’s room and found a taser and pocketknife under the bed, and another CNA confirmed that R5 reported being threatened with a knife and being scared. The Administrator verified that the confiscated items belonged to R1 but stated she did not investigate or report R5’s abuse allegation. In a separate incident, R5 reported that a CNA told her he would have let her choke after another CNA assisted her while she was choking; the Administrator acknowledged receiving this report but did not investigate or report it, stating it occurred before her start date. These actions and inactions were inconsistent with the facility’s policy requiring immediate investigation, separation of the alleged perpetrator, assurance of resident safety, and completion of an incident report for any alleged abuse.
Failure to Prevent Resident Possession and Use of Potential Weapons
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision when a resident was able to possess and use multiple objects that could be used as weapons. One alert and oriented resident reported that another alert and oriented resident held a knife to her neck and threatened her, causing her to feel scared. A CNA stated she heard the threatening incident and observed the resident with the knife standing over the other resident. Staff reported that on the same night, a knife, drill, hammer, and lighters were found in the threatened resident’s room, and that the resident who made the threats also threatened to burn down the facility before being transferred to the hospital. The following day, a CNA, under direction from the DON, searched the threatening resident’s room and found a taser and pocketknife under the bed, and reported that a hammer and drill had also been found there the previous night. The threatening resident, who was alert and oriented, later stated she kept a hammer, drill, and pocketknife in her room for protection. Surveyors observed a pink and black electric drill, a pink and black hammer, scissors, razor blades, and lighters in the medication room, and a metal folding utility-type knife in the Administrator’s desk, which the Administrator confirmed belonged to the resident who had made the threats and had been confiscated after the incident. The Administrator acknowledged that residents having such items in the facility made it unsafe. Review of the resident’s records showed a prior care plan for maladaptive behaviors that may detrimentally affect others, but there was no care plan focus on aggressive behaviors or on the resident’s possession of objects that could be used as weapons. Another resident’s records showed intact cognition and a care plan for risk of alteration in mood and psychosocial well-being with an intervention to provide a calm and positive environment. The facility’s policy on a homelike environment stated that the environment and furnishings should be safe, clean, and comfortable.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
A resident with multiple diagnoses, including an above-knee amputation, chronic ulcers, and a stage 3 sacral pressure ulcer, was dependent on staff for activities of daily living (ADL) and incontinence care. The resident's care plan required staff to check and change incontinence briefs every two hours and as needed. Observations and interviews revealed that the resident often had to wait up to 30 minutes for assistance after a bowel movement and was found in bed with soiled linens, a strong urine odor, and heavily stained bedding. Staff assigned to the resident's care stated they were occupied with other duties and had not yet attended to the resident, despite being expected to complete incontinence care within the first two hours of their shift. The facility's policies required timely and thorough incontinence care and morning rounds to ensure residents' needs were met. Documentation from the nurse practitioner indicated the resident had incontinence-associated dermatitis, attributed to prolonged moisture exposure from incontinence episodes. The failure to provide timely incontinence care and maintain cleanliness of the resident's environment was directly observed and confirmed through staff interviews, highlighting a lapse in adherence to the resident's care plan and facility policies.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents out of a sample of ten. In one incident, a resident with moderate cognitive impairment and a history of behavioral disturbances made inappropriate physical contact with another cognitively intact resident while waiting in a hallway. The incident was not witnessed by staff, and the affected resident reported that the inappropriate contact continued until staff arrived to open the door. The resident who committed the act had previous allegations of similar behavior involving other residents, some of which were witnessed by staff. In a separate incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room and attempted to take items from his table. This led to a physical altercation, during which the resident with severe dementia sustained a small scratch above her eyebrow. The altercation was witnessed by a roommate, who sought help from staff. The resident who initiated the physical contact was also severely cognitively impaired. The wandering resident had a documented history of similar incidents involving entering other residents' rooms and making physical contact. The facility's abuse prevention policy requires staff to identify residents at risk for abuse or with behaviors that may lead to conflict, and to address these risks through care planning and regular monitoring. Despite this policy, the facility did not prevent repeated incidents of resident-to-resident abuse, including both inappropriate sexual contact and physical altercations, involving residents with known behavioral risks and histories of similar incidents.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident, identified as R3, from physical abuse by a staff member, resulting in emotional distress and increased agitation for the resident. R3, who has a medical history including cerebral infarction, bipolar disorder, and moderate cognitive impairment, was involved in an incident where a Certified Nursing Assistant (CNA), V3, slapped R3's hand. This occurred when R3 attempted to grab V3's personal laptop, which should not have been present in the work environment. Witnesses, including other staff members, confirmed the physical contact initiated by V3, which led to R3 responding by hitting V3. The incident was observed by multiple staff members, including V5 and V6, who reported that V3's actions were inappropriate and contrary to the facility's policy on handling residents. R3 was known to become agitated when approached in a loud or rushed manner, and staff familiar with R3 were aware of the need for a calm approach. Despite this knowledge, V3 did not call for assistance or attempt to redirect R3 appropriately, leading to the escalation of the situation. The facility's investigation substantiated the abuse allegation against V3, who was subsequently terminated. The facility's policy on abuse prevention emphasizes the prohibition of physical abuse and the importance of a resident-sensitive environment. However, in this case, the failure to adhere to these policies resulted in a deficiency in protecting the resident from abuse, as evidenced by the physical altercation and the emotional impact on R3.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. A cook at the facility witnessed one resident, who has moderate dementia and a history of inappropriate behavior, inappropriately touching another resident who is nonverbal, blind, and has severe cognitive impairments. The incident occurred in a hallway, where the cook observed the resident patting the other resident above her right breast and then slipping his hand down her shirt to her left breast. The cook reported that the resident stopped the inappropriate behavior upon realizing her presence. The resident who was subjected to the abuse has a history of profound intellectual disabilities, vision impairment, and requires 24-hour care due to her vulnerable status. Despite the cook's eyewitness account and the resident's known vulnerabilities, the facility's investigation concluded that the allegation of abuse could not be substantiated. The facility's policy defines abuse as a willful infliction, requiring deliberate action, yet the incident was not substantiated in their final report to the Illinois Department of Public Health.
Deficiencies in Kitchen Maintenance and Food Storage
Penalty
Summary
The facility failed to maintain its kitchen in a manner that prevents foodborne illness, affecting 74 residents receiving dietary services. During an inspection, it was observed that the dry storage area contained several large bins of food items such as breadcrumbs, oatmeal, rice, flour, and thickener, all of which were past their use-by dates. Additionally, several bags of pasta were found open to air, and dented cans of various food items were in rotation for use, contrary to the facility's policy that requires dented cans to be stored separately and marked for return or disposal. The milk cooler emitted a sour/spoiled odor, indicating improper maintenance. Further inspection of the walk-in cooler revealed multiple food items, including corn, pancakes, breakfast sausage patties, cheese slices, bologna, shredded cheese, turkey meat, boiled eggs, hot dogs, and raw liquid eggs, that were either open to air, improperly wrapped, or past their use-by dates. The facility's policy mandates that all foods be wrapped in moisture-proof wrapping or placed in suitable containers to prevent contamination and that meats be stored below ready-to-eat foods. Additionally, an oscillating fan in the dish area was covered with dust and grease, and there was no separate log for documenting the sanitizer concentration for sanitizing buckets, which is required by the facility's policy.
Failure to Provide Written Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reasons for their transfer to the hospital, as well as failing to notify the ombudsman of these transfers. This deficiency was identified in four residents who were reviewed for discharge. The Director of Nursing (DON) admitted that the facility does not notify the ombudsman about hospital transfers and does not provide written notices to residents or their representatives, relying instead on phone notifications. Resident R74 was transferred to the hospital for a CT scan and psychiatric evaluation after being found verbally aggressive and positioned on the floor. The facility notified the resident's Power of Attorney (POA) by phone but did not provide a written notice or notify the ombudsman. Similarly, Resident R7 was transferred to the hospital multiple times due to various medical conditions, including low hemoglobin and deep vein thrombosis, without receiving written discharge notices or ombudsman notification. Resident R26, who was cognitively intact, was transferred to the hospital after expressing suicidal ideations and contacting a suicide hotline. The facility did not provide a written discharge notice or notify the ombudsman. Resident R38, also cognitively intact, was transferred to the hospital due to altered mental status and other medical conditions, with no written notice or ombudsman notification provided. The facility's administrator acknowledged the lack of awareness regarding the requirement for written discharge notices and ombudsman notifications.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to residents and their families or Power of Attorney (POA) regarding the bed hold policy at the time of discharge to the hospital. This deficiency was identified for four residents who were reviewed for discharge in a sample of eighteen. The Director of Nursing (DON) acknowledged that the facility holds the bed for ten days but does not typically keep a copy of the bed hold notice. The facility was unable to show proof that the bed-hold policy was provided to the residents or their POAs. Resident R74 was transferred to the hospital for a CT scan and psychiatric evaluation following an incident of aggressive behavior. Despite the transfer, there was no documentation in the electronic medical record regarding the provision of the bed hold policy to the resident or their POA. Similarly, Resident R7, who had multiple hospital admissions due to various medical conditions, also lacked documentation of the bed hold policy being provided. The facility was unable to provide information regarding the bed hold policy given to R7 or their POA. Resident R26, who was cognitively intact and had multiple hospital admissions due to suicidal ideations, also did not have documentation of the bed hold policy being provided. Additionally, Resident R38, who had several hospital admissions due to altered mental status and other medical conditions, lacked documentation of the bed hold policy. The facility's administrator confirmed that residents and their family representatives should receive a bed hold policy each time a resident is discharged from the facility or admitted to the hospital, but this was not done for the admissions to the hospital.
Failure to Obtain Physician Orders and Conduct Self-Administration Assessments
Penalty
Summary
The facility failed to obtain physician orders for residents to have medications at the bedside and did not complete self-administration of medication assessments for three residents. One resident, who was cognitively intact, had her Fluticasone Propionate nasal spray found on her roommate's dresser without a physician's order for bedside storage or a self-administration assessment. The resident confirmed she had not been taught how to use it, although she claimed to know how to administer it herself. Her roommate, who was nonverbal and had multiple diagnoses including dementia and severe mood disorders, had no orders for the nasal spray and no self-administration care plan. Another resident was found with two white pills on his bedside table without a physician's order for bedside medication storage or a self-administration assessment. This resident, who was also cognitively intact, had multiple diagnoses including cerebral infarction and cocaine abuse. The facility's policy requires an interdisciplinary team assessment for self-administration, including cognitive and physical ability evaluations, and a physician's order for bedside medication storage, none of which were documented for these residents.
Failure to Change PICC Line Dressing
Penalty
Summary
The facility failed to appropriately manage the PICC line dressing for a resident, leading to a deficiency in infection control practices. The resident, who was admitted with conditions including cellulitis, diabetes mellitus, and a cutaneous abscess, had a PICC line with a border gauze dressing that was not changed by the staff. The resident reported that the dressing had been in place for 4 to 5 days and had changed it herself, indicating a lack of staff intervention in maintaining the dressing. Upon further investigation, it was found that the dressing was soiled and rolled on the sides, exposing the PICC insertion site. The facility's Assistant Director of Nursing was unsure about the frequency of dressing changes for gauze dressings, while the Director of Nursing stated that gauze dressings should be changed daily due to an increased risk of infection. There was no documentation of the dressing changes in the resident's electronic medical record, and the facility's policy required gauze dressings to be changed every 48 hours or if compromised.
Failure to Refund Resident Funds After Discharge
Penalty
Summary
The facility failed to refund resident funds after residents were discharged from the facility. This deficiency was identified for three residents who had been discharged over three months earlier. The facility's records showed that Resident 1 had a balance of $2,097.70, Resident 2 had a balance of $120.08, and Resident 3 had a balance of $30.09 in their respective accounts. The Business Office Manager (BOM) acknowledged the oversight and stated that he would contact the new facilities of Residents 1 and 2 to transfer the funds, while he would continue to try to locate Resident 3 or send the funds to social security if unsuccessful. The Corporate BOM confirmed that the facility has a policy requiring resident funds to be returned within 30 days of discharge. The facility's policy on resident trust funds, dated February 2020, mandates that a reconciliation between the resident trust fund and the bank statement be completed monthly and that funds be refunded to the proper person upon discharge. The BOM admitted that the failure to transfer the funds was an oversight, as the residents were out of sight and out of mind after being discharged.
Failure to Follow Menu Plan and Provide Alternatives
Penalty
Summary
The facility failed to follow the menu plan and provide residents with alternatives for food items refused. On multiple occasions, the menu was not posted for residents, and the food served did not match the planned menu. For instance, on 5/15/24, the lunch menu listed Cuban style pork chop, red beans and rice, chocolate mousse, and cornbread, but residents were served banana cream pie instead of chocolate mousse, and cornbread was unavailable. Additionally, some residents did not receive red beans and rice or the correct dessert. On 5/21/24, the breakfast and lunch menus were not posted until 10:00 AM, and the menu in the kitchen did not match the one posted in the hallway. Residents reported that the menu often changes, and they cannot order substitutes in advance, leading to dissatisfaction and unmet dietary needs. The dietary manager acknowledged issues with food orders and a mix-up with the new system, while the administrator confirmed that the facility should not run out of food. Resident council minutes and grievance forms from February to May 2024 indicated ongoing issues with the kitchen running out of food items, such as hot dog and hamburger buns, and not following alternative selections. Residents also complained about smaller food portions. The facility's undated and unsigned policy and procedure for meal service stated that each resident should be served a diet appropriate for their needs, and menus should be posted and documented properly. However, these guidelines were not followed, leading to the deficiencies observed by the surveyors.
Failure to Provide Alternate Food to Meet Residents' Needs
Penalty
Summary
The facility failed to provide alternate food to meet residents' needs, affecting three residents who were reviewed for alternate food and nutritional adequacy. Resident 1, who is cognitively intact, reported not receiving a vegetable salad she requested during lunch because she had not ordered it the previous day. Additionally, she mentioned that residents do not receive a breakfast menu and are served whatever the kitchen decides. Resident 6, also cognitively intact, stated that dietary staff refused to provide a peanut butter and jelly sandwich as a substitute. Resident 15, who is cognitively intact, reported not receiving lactose-free milk because the facility could not obtain it. The Dietary Manager confirmed that meal substitutes need to be ordered the day before, while the Facility Administrator contradicted this, stating that substitutes do not need to be pre-ordered. The resident grievances and concerns document complaints about the kitchen running out of food items such as hotdog and hamburger buns and not serving alternative food items. The facility's policy on substitutions indicates that substitutions should be selected from the same food group as the item being replaced. However, this policy was not followed, leading to residents not receiving their requested or necessary food items. The inconsistency between staff members' statements and the facility's policy contributed to the deficiency in providing adequate and appropriate food alternatives to residents.
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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