Monmouth Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Monmouth, Illinois.
- Location
- 117 South I Street, Monmouth, Illinois 61462
- CMS Provider Number
- 146057
- Inspections on file
- 31
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Monmouth Rehab And Nursing during CMS and state inspections, most recent first.
A resident with Alzheimer’s/dementia, poor safety awareness, and a documented history of elopement and exit-seeking behaviors was not consistently protected by appropriate elopement interventions. Despite prior elopement incidents and assessments identifying elopement risk, the resident did not have a wander guard in place, and a reported refusal to wear one was not documented. On one occasion, staff last observed the resident ambulating in the hallway with a walker, later realized the resident was missing, and found the resident offsite at a nearby coffee shop after EMS had been called by a concerned citizen. The event was not documented in the resident’s EMR, and required incident documentation per facility policy was not completed, demonstrating a failure to provide adequate supervision and to follow elopement assessment and documentation procedures.
The facility failed to maintain complete and accurate clinical records for two residents when incident-related documentation was not entered into their medical charts. For one resident who eloped, there was no nurse progress note or assessment describing the elopement, staff response, or the resident’s condition upon return, despite subsequent care plan and MD order updates for a wander guard. For another resident with Alzheimer’s disease and dementia, a healing bruise under the eye was noted, but there was no documentation of how the bruise occurred or any follow-up assessment or investigation. The DON reported that incident and accident information was documented only in an internal risk management system that does not populate the residents’ EMR.
A resident with neuromuscular conditions fell from a wheelchair during an outing, resulting in immediate hand pain and swelling. Despite ongoing complaints and visible worsening of the injury, staff did not promptly notify the physician as required by facility policy. The delay led to a late diagnosis of multiple hand fractures, with staff interviews confirming missed opportunities for earlier intervention.
A resident who was cognitively intact experienced repeated intrusions by another resident, including being struck with a shoe, having water thrown at her, and finding her room soiled with urine and feces. Despite reporting these incidents and expressing fear to facility leadership, the only action taken was installing a bathroom door lock, which did not prevent further unauthorized entries through the main door. The resident continued to feel unsafe and her right to a dignified, safe environment was not maintained.
Two residents were subjected to physical abuse by another resident, including being struck with a shoe and having hair pulled, while staff failed to conduct required abuse investigations or notify the State Agency. Despite staff witnessing and reporting these incidents to facility leadership, no formal investigations were initiated, leaving residents feeling unsafe.
The facility did not follow its abuse policy by failing to immediately report and investigate two separate incidents of resident-to-resident physical abuse. In both cases, staff and administration did not promptly notify the State Agency or initiate required investigations after one resident struck another with a shoe and, in a separate event, when a resident grabbed another's hair and walker.
Two separate incidents of alleged abuse occurred in which one resident struck another with a shoe and, in a separate event, a resident grabbed another's hair and attempted to take her walker. In both cases, the Administrator and other relevant parties were notified, but no immediate abuse investigation was initiated and the State Agency was not informed as required.
The facility did not investigate two separate abuse allegations involving three residents. In one case, a staff member saw a resident strike another with a shoe, and in another, a resident grabbed another's hair and clothing. The administrator acknowledged both incidents as potential abuse but did not initiate required investigations as outlined in facility policy.
A resident with a history of multiple falls and high fall risk, as documented in the care plan, was repeatedly observed without required gripper socks while seated in common areas. Staff confirmed the resident should have been wearing gripper socks at all times, but this intervention was not implemented as directed.
Two residents requiring continuous oxygen therapy did not receive care in accordance with physician orders and facility policy. Staff failed to date and label oxygen tubing and humidifier bottles, and one resident received oxygen at a higher flow rate than prescribed, while another was observed without oxygen despite a continuous order.
Two residents with cognitive impairment or recent decline experienced multiple falls without appropriate safety interventions or therapy evaluations, as required by facility policy. One resident suffered a foot fracture and repeated falls, while another sustained rib and arm fractures and was later placed on hospice. Staff interviews and documentation revealed inadequate care plan updates, lack of therapy involvement, and issues with supervision and equipment such as nonfunctional call lights.
A resident with cognitive impairment and poor safety awareness was provided with half bed rails as a fall intervention without a completed entrapment assessment prior to their application. Staff interviews confirmed that the required assessment was not initiated until after the rails were in use and was never completed, contrary to facility policy that mandates evaluation before bed rail installation.
Two residents with cognitive impairments exited the facility unsupervised, with one found outside in the grass and another in the parking lot. Additionally, a resident at risk for falls was transferred by a single CNA instead of the required two, resulting in skin tears. These incidents highlight failures in supervision and adherence to care plans.
The facility failed to ensure residents met infection standards and lacked policies for those with symptoms not meeting infection criteria, leading to inappropriate antibiotic prescriptions for two residents. The facility's undated policy on antibiotic stewardship lacked standardization, and there was no education provided to healthcare providers on this matter, potentially affecting all 40 residents.
The facility failed to adhere to guidelines for psychotropic medication use, including appropriate indications, gradual dose reductions, and limiting as-needed use to 14 days. A resident was prescribed Seroquel without documented behaviors or dose reduction attempts. Another resident received Abilify for depression enhancement without behavior documentation. A third resident was on Olanzapine and Bupropion without dose reduction attempts. Lastly, a resident was prescribed Lorazepam without a stop date, contrary to policy.
A resident expressed her desire to change her doctor, as she did not like the current one. Despite her communication to the facility staff, the doctor continued to see her. The Social Service Director confirmed that residents have the right to choose their own doctor, but was not informed of the resident's request.
The facility failed to ensure that the electronic medical records and care plans of three residents matched their POLST regarding CPR code status. One resident's physician's order indicated a full code, but the POLST indicated comfort-focused treatment/DNR. Another resident's physician's order documented a DNR, but the POLST indicated selective treatment. A third resident's physician's order and care plan documented a DNR, but the POLST indicated selective treatment. The administrator acknowledged the need for care plans to match the POLST forms.
A resident with a bruise on the knee provided inconsistent accounts of its origin, and the facility failed to report this injury of unknown origin to the state agency as required by their policy. Despite the resident being cognitively intact and staff being unaware of any incident, the facility did not adhere to its reporting obligations.
A facility failed to accurately document a resident's hospice services in the MDS. The resident, with multiple diagnoses including Traumatic Brain Injury and Dementia, was admitted to hospice services as per a physician's order. However, the MDS entries incorrectly indicated the resident was not on hospice services, an error confirmed by the LPN/MDS Coordinator.
The facility failed to coordinate and document hospice care plans for two residents, resulting in incomplete care plans lacking specific hospice interventions. Staff relied on facility care plans without access to hospice records, and hospice binders were found empty. The absence of a hospice policy and reliance on hospice agreements for outlining responsibilities contributed to the deficiency.
A facility failed to follow policy when a resident's G-tube became clogged, leading to its replacement with an indwelling urinary catheter without a physician's order. The catheter was used for enteral feeding, causing the resident to experience emesis and loose stools, resulting in hospitalization. The facility did not notify the physician or verify the catheter's placement, contributing to the deficiency.
A resident experienced emesis and diarrhea for two days, leading to hospitalization, after the facility failed to notify the physician of abnormal radiology results and a change in condition. The resident's G-tube was replaced with an indwelling urinary catheter without physician consultation, and the physician was not informed of the resident's vomiting and diarrhea.
A resident with a G-tube experienced emesis and diarrhea after an LPN, lacking proper training, replaced the G-tube with an indwelling urinary catheter and administered feedings without verifying placement. The facility failed to ensure nursing staff were competent in G-tube care, leading to the resident's hospitalization.
The facility failed to ensure that four CNAs completed the required 12 hours of annual education, including dementia management training. This deficiency, confirmed by the Clinical Director, affects the care of 41 residents.
The facility failed to report an allegation of neglect to the State Agency as required by its policy. A resident was found in a neglected state during a medical appointment, and despite an internal investigation, the State Agency was not notified.
Failure to Supervise and Implement Elopement Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement interventions for a resident with a known history of elopement and exit-seeking behaviors, resulting in an elopement event. The facility’s Wandering & Elopement Assessment and Prevention policy requires all residents to be assessed for elopement/unsafe wandering and defines elopement as a resident unable to protect themself who departs the facility or enters a non-resident area unsupervised or undetected. The resident was admitted in February 2023 and had documented elopement risk on assessments dated 9/7/23 and 4/3/25, including a history of leaving the facility and exhibiting exit-seeking behaviors. The care plan documented Alzheimer’s/dementia, poor safety awareness, fall risk, and the need for staff supervision when ambulating with a walker. Despite this known history, the resident did not have a wander guard in place prior to the elopement event, and the administrator later stated that the resident had refused a wander guard, but this refusal was not documented. The administrator confirmed the resident had previously eloped in September 2023 and was found walking on a street, and the resident’s friend reported another prior elopement shortly after admission when the resident left to go to a parade and was found walking on a busy street. On the date of the cited elopement, multiple CNAs reported seeing the resident ambulating in the hallway with a walker shortly before staff realized the resident was missing. Staff then searched the facility and perimeter, and the administrator drove offsite and found the resident at a local coffee shop two blocks away, where EMS had responded after a concerned citizen called 911 upon seeing the resident walking with a walker. The facility also failed to document the elopement event in the resident’s electronic medical record, despite the policy requirement that an incident report be completed noting investigative procedures, witness statements, and pertinent information. The DON stated she was made aware that staff were looking for the resident and joined the search, and later acknowledged there was no documentation in the chart regarding the elopement and that such documentation should have been present. A nurse progress note dated two days after the event documented that the resident remained on 15-minute checks for safety and observation after a recent exit-seeking episode, but there was no progress note or assessment specifically addressing the elopement that occurred. These actions and omissions led surveyors to determine that the facility failed to ensure adequate supervision and implementation of interventions to prevent elopement for a resident at known risk.
Removal Plan
- In-service all staff members on the elopement policy and procedure.
- In-service all remaining staff members via telephone prior to their next shift on the elopement policy and procedure.
- Conduct an audit of medical charts to ensure interventions are in place and documentation of the event with all actions taken is recorded.
- In-service all nurses on incident charting and completion.
- Complete updated wandering/elopement assessments for all residents.
- Review care plans for accuracy.
Incomplete Clinical Documentation for Incidents and Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with its own Charting & Documentation Policy for two residents. For one resident with an elopement event, the electronic medical record contained no nurse progress note or assessment regarding the elopement, no description of the event itself, no documentation of staff response, and no record of the resident’s condition after being returned to the facility. Although the resident’s care plan and physician orders were updated the following day to include a wander guard, there was no contemporaneous documentation of the incident in the resident’s chart. The DON later confirmed that this documentation was missing and the Administrator stated she was not aware the incident had not been documented. For another resident with documented Alzheimer’s disease and dementia, whose care plan identified risks for falls and elopement/wandering and included a wander guard, a nurse progress note recorded a healing bruise under the left eye. However, there was no documentation in the resident’s chart explaining how the bruise occurred, nor any follow-up assessment or investigation related to this injury. The DON stated that all incident/accident documentation had been recorded in the facility’s internal risk management system, which does not interface with or carry over into the resident’s electronic medical record, and that assessments related to incidents would therefore not be found in the residents’ charts.
Failure to Timely Notify Physician After Resident Fall and Change in Condition
Penalty
Summary
The facility failed to ensure timely and complete physician notification following a resident's accident and subsequent change in condition. A resident with Myasthenia Gravis and Cerebellar Ataxia, both affecting muscle strength and mobility, fell from her wheelchair during a supervised outing when traversing a grassy area without foot pedals. The resident landed on her knees and hands, and immediately reported pain in her right hand to staff at the scene. Upon return to the facility, the resident was assessed, and initial documentation indicated minimal pain and mild swelling, with ice applied to the hand. Over the next several hours, the resident's right hand became increasingly swollen, bruised, and painful, with the resident unable to grip with the hand. Multiple staff, including CNAs and an LPN, observed and documented the worsening condition and the resident's complaints of pain. Despite these observations and the facility's policy requiring immediate physician notification for significant changes in condition, the physician was not promptly notified of the resident's increased pain and swelling. The DON directed staff to monitor the resident rather than seek further evaluation, and staff reported being discouraged from escalating concerns. It was not until the following day that the medical director was contacted and an X-ray was ordered, which revealed prominent displaced fractures in the resident's right hand. Interviews with staff and the medical director confirmed that the physician expected to be notified of such changes and would have ordered emergency evaluation if made aware of the resident's pain and swelling sooner. The delay in physician notification resulted in the resident experiencing excruciating pain and a delay in diagnosis and treatment of her injury.
Failure to Protect Resident Rights and Dignity Due to Repeated Room Intrusions
Penalty
Summary
The facility failed to maintain a resident's right to a dignified existence and safety by not preventing repeated intrusions and inappropriate behaviors from another resident. One cognitively intact resident reported multiple incidents where another resident entered her room without permission, struck her with a shoe, threw water at her, and defecated and urinated on her floor and bed. Despite the resident expressing fear and reporting these incidents to the Administrator and Director of Nursing multiple times, the only intervention implemented was placing a lock on the shared bathroom door, which did not prevent further unauthorized entries through the main room door. Nursing progress notes and interviews confirm that the resident continued to experience distressing and undignified situations, including being awakened to find the other resident standing over her, taking her clothing, and soiling her living space. Staff and social services were aware of the ongoing issues, and the resident continued to express fear and discomfort due to the lack of effective measures to prevent these intrusions and maintain her right to a safe and homelike environment.
Failure to Protect Residents from Physical Abuse and Inadequate Abuse Investigation
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, despite having a policy in place to prevent such incidents. In one instance, a resident entered another resident's room and struck her on the shoulder with a shoe, an event witnessed by a CNA. The affected resident reported feeling afraid and stated that the perpetrator had previously thrown a pitcher of water at her and repeatedly entered her room, even after a lock was placed on the bathroom door. The administrator did not conduct an abuse investigation or notify the State Agency, despite being informed of the incident and the resident's fear. Documentation and interviews confirmed that the incident was witnessed and reported to facility leadership, but no formal investigation was initiated. In a separate incident, the same resident was observed grabbing another resident's hair and attempting to take her walker. This event was witnessed by an LPN, who documented the incident and reported it to the administrator and DON, identifying it as potential abuse. However, the administrator did not immediately begin an investigation or report the incident to the State Agency. Both incidents demonstrate a failure to follow facility policy and regulatory requirements for investigating and reporting allegations of abuse, leaving residents unprotected from further harm.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not immediately reporting and investigating two separate incidents of resident-to-resident physical abuse. In the first incident, a staff member witnessed one resident striking another on the shoulder with a shoe. Although the incident was documented and the local police were notified, the State Agency was not notified until several months later, and no abuse investigation was conducted at the time of the event. The facility administrator confirmed awareness of the incident but acknowledged that the required investigation and timely reporting to the State Agency did not occur. In the second incident, a resident was observed grabbing another resident's hair and attempting to take her walker. The involved parties were separated, and notifications were made to the health care power of attorney, physician, administrator, and director of nursing. However, the administrator stated she only became aware of the situation the following day and had not immediately initiated an abuse investigation or reported the incident to the State Agency as required by facility policy. These failures were identified for three residents reviewed for abuse in a sample of five.
Failure to Immediately Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to immediately report two separate allegations of abuse involving three residents to the State Agency, as required. In the first incident, one resident was observed entering another resident's room and striking her on the shoulder with a shoe. Although no injuries were noted and the resident stated she was not hurt, she expressed fear of the other resident. The incident was documented in the nursing progress notes, and the Power of Attorney, Administrator, and Medical Doctor were notified, but the Administrator confirmed that no abuse investigation was initiated and the State Agency was not notified. In the second incident, a resident was seen grabbing another resident's hair and attempting to take her walker. Both parties were separated, and the Health Care Power of Attorney, Physician, Administrator, and Director of Nurses were notified. However, the Administrator stated she only became aware of the situation the following day and did not immediately begin an abuse investigation or report the incident to the State Agency.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to investigate two separate allegations of abuse involving three residents. In the first incident, a staff member reported witnessing one resident strike another on the shoulder with a shoe. The administrator confirmed awareness of this event and acknowledged it as a potential abuse incident but did not initiate an abuse investigation. In the second incident, a resident was observed grabbing another resident's hair and clothing while self-propelling in a wheelchair near the nurses' station. The administrator became aware of this situation the following day and confirmed that an immediate investigation into the allegation of abuse was not started. These failures occurred despite facility policy requiring thorough investigation of all alleged violations of abuse.
Failure to Implement Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall precautions for a resident identified as high risk for falls. According to the facility's Fall Reduction policy, residents with a high fall risk should have individualized interventions documented and implemented in their care plan. The resident in question had multiple diagnoses, including unsteadiness on feet, dementia, and a history of repeated falls. The care plan specifically required the use of gripper socks as an intervention to reduce fall risk. Despite these documented interventions, observations on two separate occasions showed the resident seated in common areas without gripper socks or any foot coverings, with bare feet on the floor. Staff present at the time confirmed that the resident was supposed to wear gripper socks at all times due to the high risk of falls and previous incidents. The lack of adherence to the care plan's fall prevention measures constituted a failure to provide adequate supervision and implement necessary precautions.
Failure to Properly Administer and Document Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required continuous oxygen therapy. For one resident with diagnoses including Paroxysmal Atrial Fibrillation and Chronic Respiratory Failure, staff did not ensure that oxygen tubing and humidifier bottles were dated as required by facility policy. The resident was observed sitting in a hallway without oxygen, despite a physician's order for continuous oxygen at 3 liters per minute with humidification. The oxygen tubing was found undated and lying in a wheelchair, and the humidifier bottle was also undated. Additionally, the oxygen concentrator in the resident's room was left running while the resident was not present, and undated oxygen tubing was observed on the floor. Staff confirmed the lack of dating and labeling on the equipment and acknowledged the resident's order for continuous oxygen. For another resident with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Cor Pulmonale, Chronic Congestive Heart Failure, and Pan lobular Emphysema, the facility did not date the oxygen tubing or humidifier bottle as required. The resident was observed receiving oxygen at a flow rate of 3 liters per minute, which was higher than the physician-ordered rate of 2 liters per minute. Staff confirmed both the incorrect flow rate and the absence of required dating on the oxygen equipment. These deficiencies were identified through observation, interview, and record review.
Failure to Implement Safety Interventions and Therapy Evaluations After Multiple Resident Falls
Penalty
Summary
The facility failed to implement appropriate safety interventions and complete therapy evaluations for cognitively impaired residents who experienced multiple falls. According to the facility's Fall Reduction policy, residents at risk for falls should receive a therapy screen, and care plans should be reviewed and updated after each fall. However, two residents with a history of falls did not receive therapy evaluations after repeated incidents, and their care plans were not adequately updated with effective interventions. One resident with dementia and poor safety awareness experienced three falls within a 24-day period, resulting in a left foot fracture. The resident was found on the floor multiple times, often attempting to go to the bathroom independently, and was observed without gripper socks or with the bed not in the lowest position. Staff interviews revealed that the resident was confused, especially at night, and unable to remember to use the call light. Despite these risks, the resident's care plan continued to document independence with transfers and mobility, and no therapy evaluation was completed after the falls. Another resident, admitted for rehabilitation after a fall at home, experienced a decline in condition after multiple falls in the facility. This resident sustained a displaced rib fracture and right radial neck fracture following an unwitnessed fall and was subsequently placed on hospice care. Documentation and interviews indicated that the resident was initially alert and oriented but became increasingly unsteady and confused after repeated falls. The call light system in the resident's room was reported as nonfunctional, and there was no evidence of a therapy evaluation or effective intervention following the falls.
Failure to Complete Entrapment Assessment Prior to Bed Rail Use
Penalty
Summary
The facility failed to complete an entrapment assessment prior to the application of bed rails for a resident who was at risk for falls and had poor safety awareness. According to the facility's policy, bed rails are considered restraints and require an evaluation for appropriateness, including a side rail assessment, before installation. In this case, after an unwitnessed fall, half side rails were added to the resident's care plan as a fall intervention, but the required entrapment assessment was not initiated until several days later and remained incomplete as of the survey date. The resident was observed in bed with metal half rails in place, and documentation showed cognitive impairment and no prior record of bed rail use on the Minimum Data Set. Interviews with facility staff revealed a lack of awareness regarding the requirement to complete the assessment before applying bed rails. The staff member responsible for medical entrapment assessments confirmed that the process was not started until after the rails were already in use and was never completed. Additionally, the Maintenance Director stated that he only performed quarterly entrapment prevention checklists for residents with existing bed rails and did not conduct new assessments when bed rails were first applied.
Inadequate Supervision and Transfer Protocols Lead to Resident Incidents
Penalty
Summary
The facility failed to provide adequate supervision to prevent two cognitively impaired residents from exiting the facility without staff supervision. One resident, identified as R4, who was severely cognitively impaired and at risk for elopement, managed to exit the facility and was found lying in the grass outside. The incident occurred when a CNA was attending to another resident and heard the door alarms going off. Despite the alarms, R4 was able to leave the building and was later found with no injuries except for a slight redness on the leg. Another resident, R7, also severely cognitively impaired, was found outside the facility in the parking lot without a coat and holding her purse. R7 had removed her oxygen tubing and was confused, but was safely returned inside by staff without any injuries. The facility also failed to implement the required two-staff assistance for transfers as indicated in a resident's care plan, leading to a fall. Resident R2, who was cognitively impaired and at risk for falls, was being transferred by a single agency CNA instead of the required two staff members. During the transfer, R2's feet slid, causing the CNA to lower R2 to the floor, resulting in multiple skin tears on R2's legs. The care plan for R2 clearly stated the need for two staff members to assist with transfers, but this protocol was not followed, leading to the incident. These deficiencies highlight the facility's failure to adhere to its own policies regarding supervision and transfer protocols, resulting in unsafe conditions for the residents. The incidents involving R4 and R7 demonstrate a lack of adequate supervision to prevent elopement, while the incident with R2 shows a failure to follow established care plans to prevent falls. These lapses in protocol and supervision contributed to the residents' exposure to potential harm.
Deficiency in Infection Standards and Antibiotic Stewardship
Penalty
Summary
The facility failed to ensure that residents met the standards for infections and did not have standards in place for residents experiencing infection symptoms that did not meet the criteria for infections. This deficiency was identified for two residents, R4 and R23, who were prescribed antibiotics for urinary tract infections (UTIs) without meeting the McGeer Criteria for infections. The facility's Director of Nursing (V2) confirmed that the infections for these residents in October and November did not meet the McGeer Criteria. The facility's policy on The Core Elements of Antibiotic Stewardship for Nursing Homes was undated and lacked standardization in practices for residents suspected of infections or started on antibiotics. The policy emphasized the importance of improving the evaluation and communication of clinical signs and symptoms, optimizing diagnostic testing, and implementing an antibiotic review process. However, the facility did not have written or verbal standards or policies for residents who did not meet the definition of an infection, leading to inappropriate antibiotic prescriptions. Additionally, the facility failed to educate healthcare providers about antibiotic stewardship, which is crucial for optimizing infection treatment and reducing adverse events associated with antibiotic use. The Director of Nursing admitted that there was no documentation of education provided to healthcare providers regarding antibiotic stewardship. This lack of education and standardized practices has the potential to affect all 40 residents residing in the facility.
Failure to Adhere to Psychotropic Medication Guidelines
Penalty
Summary
The facility failed to provide appropriate indications for the use of antipsychotic medications, attempt gradual dose reductions, and limit the use of as-needed psychotropic medications to 14 days for several residents. Resident 5 was admitted with a diagnosis of dementia without behavioral disturbance and was prescribed Seroquel, an antipsychotic medication, without any documented behaviors or attempts at gradual dose reduction. The Director of Nursing (DON) acknowledged that the resident was not referred to behavioral health as per the facility's typical practice. Resident 16 was admitted with a diagnosis of depression and was prescribed Abilify, an antipsychotic medication, to enhance the effectiveness of an antidepressant. The resident had no documented behaviors since admission, and the DON could not confirm the appropriateness of the antipsychotic medication's indication. Additionally, Resident 19 was prescribed Olanzapine for schizophrenia and Bupropion for major depressive disorder, with no documented behaviors or attempts at gradual dose reduction, despite a pharmacy recommendation for dose reduction. Resident 26 was prescribed Lorazepam as needed for anxiety without a stop date, contrary to the facility's policy of limiting as-needed psychotropic medications to 14 days. The DON admitted to not knowing how this oversight occurred. These deficiencies highlight the facility's failure to adhere to federal regulations and its own policies regarding the use of psychotropic medications.
Resident's Right to Choose Doctor Not Honored
Penalty
Summary
The facility failed to honor a resident's right to choose her own doctor, as required by the Illinois Long-Term Care Ombudsman Residents' Rights for People in Long Term Care Facilities. The deficiency involved one resident, R11, who expressed her desire not to be seen by her current doctor, V10, as documented in the nurse's notes on 7/21/24. Despite R11's clear communication to the facility staff that she did not want V10 as her doctor, V10 continued to see her. On 12/19/24, R11 reiterated her preference to not have V10 as her doctor, stating that she did not like him. The Social Service Director, V4, confirmed that residents have the right to choose their own doctor, but was not informed of R11's request to switch doctors.
Discrepancies in Advanced Directives and POLST Forms
Penalty
Summary
The facility failed to ensure that the electronic medical records and care plans of three residents matched their Physician's Order for Life-Sustaining Treatment (POLST) regarding their cardio-pulmonary resuscitation (CPR) code status. For one resident, the physician's order indicated a full code status, but the POLST signed by the resident's Power of Attorney (POA) indicated a preference for comfort-focused treatment only, which is a do-not-resuscitate (DNR) status. Another resident's physician's order documented a DNR status, but the POLST signed by the resident indicated a preference for selective treatment. Additionally, a third resident's physician's order and care plan documented a DNR status, but the POLST signed by the resident's POA indicated a preference for selective treatment. The facility's Advanced Directives policy requires that the plan of care for each resident be consistent with the resident's treatment preferences and/or advanced directives. However, the discrepancies between the physician's orders, care plans, and POLST forms indicate a failure to adhere to this policy. The administrator acknowledged that care plans should identify the resident's advanced directive and that physician orders should match the POLST form, highlighting a gap in the facility's compliance with its own policy and the residents' documented wishes.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R192, to the state reporting agency as required by their policy. The facility's Abuse, Prevention, and Prohibition policy mandates that any allegations of abuse, neglect, or injuries of unknown origin must be reported to the state agency within specific timeframes. In this case, R192 was found to have a faint bruise on the left knee, and when questioned, provided three different accounts of how the injury might have occurred. Despite the inconsistency in the resident's accounts and the policy requirement, the facility did not report the injury to the state agency. R192, who is cognitively intact with a BIMS score of 15/15, complained of knee pain and had a bruise noted on the knee cap. The resident mentioned a possible incident during a mechanical lift transfer but could not recall a specific injury. Staff members, including CNAs and nurses, reported no knowledge of the knee being bumped during transfers, and it was noted that the resident often voiced pain during movement. The facility administrator later confirmed that the bruise should have been considered an injury of unknown origin and reported to the state agency, which was not done, leading to the deficiency.
Inaccurate MDS Documentation for Hospice Services
Penalty
Summary
The facility failed to accurately document the assessment for a resident receiving hospice services in the Minimum Data Set (MDS), which is a federally mandated assessment. The resident in question was admitted with diagnoses including Traumatic Brain Injury, Mood Disorder, Anxiety Disorder, Dementia, and Major Mood Disorder. A physician's order dated March 27, 2023, indicated the resident was to be admitted to hospice services, and the resident's record confirmed this admission to hospice services effective the same date. However, the quarterly MDS assessments dated June 28, 2024, and September 27, 2024, incorrectly documented that the resident was not on hospice services. This error was acknowledged by the LPN and Care Plan/MDS Coordinator, who confirmed that the resident had elected hospice services on March 27, 2023, and remained on hospice services at the time of the survey.
Lack of Coordination and Documentation for Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination and accessibility of hospice care plans for two residents receiving hospice services. For one resident, admitted with conditions including intracranial injury and dementia, the facility's records only included the hospice admission agreement and letter, lacking detailed documentation about hospice services, frequency, or specific interventions. Similarly, another resident with diagnoses such as infective endocarditis and prostate cancer had only a notification of hospice admission documented, with no further details on hospice services or interventions in the care plan. Interviews with facility staff revealed that hospice binders at the nurse's station were empty, and staff relied solely on the facility's care plan, which did not include specific hospice interventions. The Care Plan Coordinator confirmed the absence of a hospice policy and stated that hospice agreements were used to outline responsibilities. The Administrator acknowledged the need for the facility to obtain and incorporate the hospice's plan of care into their records for staff review, which was not done, leading to the deficiency.
Improper Use of Indwelling Urinary Catheter for Enteral Feeding
Penalty
Summary
The facility failed to follow its policy and obtain a physician order for care after a resident's Gastronomy tube (G-tube) became clogged. This led to the replacement of the G-tube with an indwelling urinary catheter, which was used to administer enteral tube feedings for two days. As a result, the resident experienced emesis, loose stools, and was hospitalized. This incident affected one resident reviewed for Gastrostomy Tubes in a sample of three, resulting in an Immediate Jeopardy situation. The facility's policy on the care and treatment of feeding tubes requires that only tubes designed for enteral feeding be used, except under extenuating circumstances and for the shortest time possible. The policy also mandates notifying and involving the medical provider in case of complications. However, the Assistant Director of Nursing instructed a Licensed Practical Nurse to replace the clogged G-tube with an indwelling urinary catheter without obtaining a physician's order or verifying the placement. The nurse, who had not received training or competency in replacing G-tubes, administered bolus feedings through the urinary catheter, leading to the resident's adverse symptoms. The facility's failure to notify the resident's physician, verify the placement of the indwelling urinary catheter, and document the change in the resident's condition contributed to the deficiency. The resident's physician was not informed of the G-tube being clogged or removed, and the facility did not send the resident to the emergency department for evaluation and tube replacement. The lack of proper training and oversight by the nursing staff further exacerbated the situation, resulting in the resident's hospitalization.
Removal Plan
- V15/Regional Director of Operations educated V1 and V2/RN and DON/Director of Nurses on their responsibilities to provide nursing staff with education and resources to provide appropriate oversight. Educational Tools included in the teaching also consisted of Audit tools, Weekly Committee Meeting policy, Rounding forms, Nurse's Skills Checklist Schedule, Monthly Education Calendar, and CNA's (Certified Nurses Aide) Competency schedule. V15 ensured V2/RN/ DON/Director of Nurses was competent to perform the education and in-servicing with the staff.
- Facility nurses were in-serviced, and competencies were completed on Enteral Feeding via Gravity Bag, via Continuous pump via Syringe, Enteral Feedings-Safety Precautions, Confirming Placement of Feeding Tubes, Changing a Gastrostomy Feeding Tube, Significant Condition Change & Notification and Charting and Documentation. Two nurses (one prn staff and one on medical leave) are scheduled to receive training/competency.
- The Employee Orientation Nursing Policies/Agency Orientation included a review of the following policies: Enteral Feeding via Gravity Bag, via Continuous pump via Syringe, Enteral Feedings-Safety Precautions, Confirming Placement of Feeding Tubes, Changing a Gastrostomy Feeding Tube, Significant Condition Change & Notification and Charting and Documentation. Two nurses (1 prn/as needed staff and 1 on medical leave) are scheduled to receive training/competency. The Administrator or Director of Clinical Operations ensures when an Agency staff member books an open position, the DON or Nurse Manager receives the required documentation.
- V8's (Licensed Practical Nurse) Employee Corrective Action Plan Form documented a 3-day suspension for failure to follow department policies and procedures: no MD notification, no documentation of G-tube difficulty or the G-tube was changed. V3's (Assistant Director of Nursing/Registered Nurse) Employee Corrective Action Form documented a 3-day suspension for failure to follow/enforce department policies and procedures, practiced outside of scope, failed to provide nurse manager oversight. The Time Detail Reports documented V3 nor V8 worked.
- The Change of Condition Audit was revised and accurately completed.
- Dietary Order Audit completed by V2/RN and DON/Director of Nurses.
- The Order Recap Report was reviewed for new orders and proper notifications.
- The In-service Education Record documented education to all nurses regarding the Change in Condition Bulletin Board Documentation (Electronic Health Record).
- The New Order Audit tool was reviewed and appropriate for use.
- The In-service Education Report- Admission Policy was attended by V2 (Director of Nursing) and V6 (MDS Coordinator/Care Planning/LPN). Quality Assurance audit tool was reviewed and appropriate for use. Admission policy revised.
- Medical Doctor notified, and policies reviewed.
Failure to Notify Physician of Resident's Condition Change and Abnormal Imaging
Penalty
Summary
The facility failed to notify a physician of abnormal radiology results and a change in condition for a resident, leading to the resident experiencing emesis and diarrhea for two days followed by hospitalization. The resident had a history of dysphagia following cerebral infarction, gastrostomy status, hemiplegia, and aphasia. The resident's Physician Order Sheet documented orders for G-tube site cleaning and feedings. However, the facility did not inform the physician about the resident's condition changes, including vomiting and diarrhea, or the abnormal X-ray results recommending follow-up imaging. The report details that the resident had episodes of emesis and loose stool, and the G-tube was not tolerating bolus feeding. Despite these significant changes, there was no documentation of the physician being notified. The Assistant Director of Nursing and a Licensed Practical Nurse were involved in the decision to replace the resident's G-tube with an indwelling urinary catheter without consulting the physician. This action was taken after the G-tube clogged, and the resident began vomiting early the next day. Interviews with staff revealed that the physician was not informed about the resident's vomiting, diarrhea, or the use of an indwelling urinary catheter as a feeding tube. The Director of Nurses acknowledged that the physician should have been notified of the resident's condition changes and the G-tube issues. The physician confirmed that they were not informed about the staff's actions and would have ordered an evaluation and tube replacement if notified.
Failure in G-tube Care and Competency
Penalty
Summary
The facility failed to ensure that licensed nurses were trained and competent in caring for residents with a gastrostomy tube (G-tube), which affected one resident. The resident, who had a history of dysphagia following a cerebral infarction, was hospitalized after experiencing emesis and diarrhea for two days. The deficiency occurred when an indwelling urinary catheter was mistakenly used in place of the G-tube for feeding, without verifying its placement through an X-ray. The incident began when the resident's G-tube, placed on a previous visit to the emergency department, became non-patent. The Assistant Director of Nursing instructed a Licensed Practical Nurse (LPN) to remove the G-tube and insert an indwelling urinary catheter, which was not verified for correct placement. The LPN, who had not received training or demonstrated competency in replacing G-tubes, administered bolus feedings through the urinary catheter, leading to the resident's adverse symptoms. Despite the resident's ongoing symptoms and a radiology recommendation for follow-up imaging, the facility did not take appropriate action to verify the catheter's placement or send the resident to the emergency department promptly. The Director of Nursing later confirmed that the indwelling urinary catheter should not have been used for feedings and that placement should have been verified by X-ray, which was not done. The facility also had not provided specialized G-tube training to its nursing staff.
Deficiency in CNA Training Hours and Dementia Care Education
Penalty
Summary
The facility failed to ensure that four Certified Nurse Aides (CNAs) completed the required 12 hours of education per year, which is necessary to maintain their competence in providing care to residents. This deficiency was identified through interviews and record reviews, revealing that none of the CNAs reviewed had completed the mandatory training hours. Specifically, CNA V17 completed only 6.91 hours, CNA V18 completed 3.58 hours, CNA V19 completed 3.83 hours, and CNA V20 completed 8.25 hours of training annually. Additionally, none of these CNAs received training in dementia management or care for cognitively impaired residents, despite the facility's requirement for such training. The facility's assessment for 2024-2025 documented the need for in-service training to ensure the continuing competence of nurse aides, particularly in dementia management and abuse prevention. The Clinical Director, V16, confirmed that the CNAs did not meet the 12-hour education requirement. This failure has the potential to affect all 41 residents residing in the facility, as documented in the facility's Resident Listing Report.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency for a resident. The facility's Abuse, Prevention and Prohibition Policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately to the Administrator and subsequently to the State Agency within specified timeframes. However, the Administrator received a call from a nurse at the resident's surgeon's office, reporting multiple concerns of neglect, including incontinence without proper care, multiple falls, and the absence of a mechanical lift sling. Despite conducting an internal investigation, the facility did not notify the State Agency of the allegations as required. The investigation documented that the resident was found in a neglected state during a medical appointment, with issues such as incontinence and a wound on the coccyx that required attention. The nurse at the surgeon's office had to provide incontinence care and re-dress the wound. The Administrator confirmed that the State Agency was never notified of the neglect allegations, which is a clear violation of the facility's policy and regulatory requirements.
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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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