Mt Zion Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Zion, Illinois.
- Location
- 1225 Woodland Drive, Mount Zion, Illinois 62549
- CMS Provider Number
- 145546
- Inspections on file
- 36
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Mt Zion Health & Rehab Center during CMS and state inspections, most recent first.
A resident with no cognitive impairment suffered emotional distress after a CNA stole and used her credit card for over $1,000 in unauthorized purchases. The CNA was arrested following a police investigation, but staff reported no internal investigation was conducted at the time, and the facility lacked an Administrator during the incident.
A resident with Alzheimer's disease and high fall risk experienced two falls from a wheelchair during transport when staff proceeded despite the resident leaning forward and attempting to stand. The facility also failed to complete required fall investigations for two of the resident's falls, as confirmed by the DON.
A resident with multiple cardiac conditions and recent orthopedic surgery did not receive physician-ordered Coumadin for 14 days due to a failure by an LPN to transcribe the medication order into the electronic record. The medication was available at the facility, but the omission was not identified by other nursing staff, resulting in missed anticoagulation therapy until the medical director discovered the error during rounds.
A resident who was cognitively intact and typically continent requested toileting assistance before breakfast but was refused by a CNA delivering meal trays, who told the resident to urinate in her brief instead. The resident was left in urine for an extended period, causing emotional distress and humiliation. Staff interviews confirmed the incident and that facility policy requiring prompt response to resident needs was not followed.
A resident with severe cognitive impairment reported a missing amethyst ring, which was a birthday gift from family. Multiple staff, including CNAs and the Social Service Director, were informed and searched for the ring, but no timely report or investigation was made to IDPH as required by facility policy. The incident was not documented in reportable or grievance logs, and the family received no follow-up until weeks later when a new Administrator became involved.
Two residents' allegations of misappropriation were not investigated by facility staff as required by policy. One resident's credit card was stolen and used by a CNA, but key witnesses were not interviewed and no internal investigation was conducted. In a separate incident, a cognitively impaired resident's missing ring was reported by family and staff, but no investigation or state report was initiated until prompted by surveyors. The facility failed to follow its abuse policy, resulting in delayed identification and investigation of both incidents.
A resident admitted to hospice care had physician orders for staff to use incontinence pads instead of incontinence briefs to protect skin integrity. Multiple staff members, including an LPN and CNAs, were unaware of this order and continued using incontinence briefs until the resident's death. The DON confirmed the order may not have been communicated to staff and acknowledged it should have been followed.
A resident with a history of stroke, left-sided weakness, and other medical conditions was transported in a wheelchair without foot pedals, resulting in her weak leg becoming caught in the wheel and causing a fall that led to a nasal bone fracture. Staff confirmed the absence of footrests during transport, and the facility lacked a policy on their use.
A resident with multiple diagnoses and a high fall risk experienced a significant fall resulting in facial injuries. There were conflicting accounts from the resident, a dietary aide, a physical therapy assistant, and an LPN regarding whether wheelchair footrests were in place at the time of the fall. Documentation in the medical record and the incident report submitted to the state agency were inconsistent, and the LPN who documented the event was not listed as a witness. The administrator acknowledged awareness of these discrepancies, indicating a failure to maintain an accurate and consistent medical record.
A resident with a history of trauma and mental health conditions was physically assaulted by another resident with severe cognitive impairment, who struck her in the arm and attempted to pull her from her chair in the dining room. Staff intervened after the incident, but the assaulted resident reported feeling unsafe for several days. The facility's abuse policy requires protection from such incidents, but this event demonstrated a failure to prevent physical abuse.
A resident with a history of falls and multiple health conditions was transferred to a wheelchair by CNAs using a bed sheet sling after an unwitnessed fall, without a nurse's assessment. The resident, who was cognitively intact, later complained of severe hip pain and was diagnosed with a fractured hip. This action was against the facility's policy, which requires a nurse's assessment before moving a fall victim.
A resident with significant medical conditions and on hospice care fell and sustained injuries due to a single CNA attempting a transfer that required two-person assistance. The CNA did not lock the wheelchair, and the resident fell forward, resulting in a nosebleed, a bruise, and a skin tear. The incident was witnessed by the resident's roommate, who reported inappropriate behavior by the staff after the fall. The facility's DON confirmed that the resident required two-person assistance, which was not provided.
Failure to Prevent Misappropriation of Resident's Credit Card by CNA
Penalty
Summary
A facility failed to protect a resident from the misappropriation of her credit card by a Certified Nursing Assistant (CNA). The resident, who was cognitively intact with a BIMS score of 15, experienced emotional distress and tearfulness after her credit card was stolen and used for unauthorized purchases totaling $1,350.01. The CNA was arrested by local police, and the investigation was supported by evidence including camera footage and messages from the CNA apologizing for the theft. The incident was confirmed by both the police department and facility staff interviews. At the time of the incident, the facility did not have an Administrator in place, and there was no evidence that an internal investigation was conducted by the previous Administrator. Staff, including an LPN, reported being unaware of any investigation or being interviewed about the theft. The facility's abuse policy assigns responsibility for abuse prevention and reporting to the Administrator or designee, but this protocol was not followed in this case, resulting in the resident experiencing psychosocial harm.
Failure to Safely Transport Resident and Complete Fall Investigations
Penalty
Summary
The facility failed to ensure safe transport and adequate supervision for a resident with Alzheimer's disease, adult failure to thrive, rhabdomyolysis, and gait abnormalities, who was identified as a high fall risk. The resident experienced three falls in one month, two of which occurred during transport in a wheelchair when staff members pushed the resident forward despite her leaning forward and attempting to stand. Both CNAs involved confirmed that the resident frequently leaned forward and tried to stand while seated, and that they proceeded with transport under these conditions, resulting in the resident falling forward out of the wheelchair. One of these falls resulted in a hematoma to the resident's forehead. Additionally, the facility did not complete required fall investigations for two of the resident's falls, as mandated by their Accidents and Incidents Policy. The Director of Nursing confirmed that staff should not have transported the resident while she was leaning forward or attempting to stand, and acknowledged that fall investigations were not conducted for two incidents. These failures affected one resident reviewed for falls out of a sample of 31.
Failure to Transcribe and Administer Physician-Ordered Anticoagulant
Penalty
Summary
A significant medication error occurred when a physician-ordered anticoagulant, Coumadin, was not transcribed into the facility's electronic medical record for a resident who had recently undergone left femur fracture surgery (ORIF) and had multiple high-risk cardiac diagnoses, including atrial fibrillation and cardiomyopathy. The hospital discharge instructions specified that Coumadin therapy should be continued, with a detailed dosing schedule, and the medication was delivered to the facility and available for administration. However, the Coumadin order was not entered into the Physician Order Sheet upon admission, resulting in the medication not appearing on the Medication Administration Record (MAR) and not being administered by nursing staff. The error was traced to an LPN who admitted the resident and failed to transcribe the Coumadin order, citing confusion regarding the dosing schedule. This omission was not identified by subsequent nursing staff, as there was no verification or follow-up on the admission orders or discharge instructions. As a result, the resident missed 14 consecutive days of prescribed anticoagulation therapy. The error was only discovered when the medical director, during rounds, noticed the absence of anticoagulation therapy and intervened. Documentation from the facility's pharmacy confirmed that the Coumadin prescription matched the hospital discharge orders and was available for use. The medical director and pharmacist both acknowledged that the missed doses posed a significant risk to the resident, given their recent surgery and underlying cardiac conditions. The incident was recorded in the facility's Quality Assurance report, which also noted an additional transcription error regarding the Coumadin dosing schedule.
Failure to Provide Timely Toileting Assistance and Maintain Resident Dignity
Penalty
Summary
A deficiency occurred when a staff member failed to provide timely toileting assistance to a resident who was cognitively intact and typically continent of bowel and bladder, but required substantial assistance for transfers. The resident requested to be taken to the bathroom before breakfast, but the Certified Nursing Assistant (CNA) delivering the meal tray refused, stating she was not assigned to the resident and was too busy, and told the resident to urinate in her incontinence brief. As a result, the resident was left sitting in urine for an extended period, which caused her significant emotional distress and humiliation. The incident was corroborated by the resident's roommate and another CNA, both of whom confirmed the resident's upset state and the inappropriate response from the staff member. Further interviews with staff revealed that the CNA responsible for delivering trays did not assist the resident or ensure that another staff member promptly addressed the toileting request. The resident's incontinence brief was found to be dry when she was later assisted to the bathroom, confirming her usual continence when toileted in a timely manner. The facility's policy requires all staff to treat residents with dignity and to respond to their needs regardless of assignment, but this was not followed in this instance, resulting in a failure to maintain the resident's dignity and respect.
Failure to Timely Report and Investigate Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to report the suspected misappropriation of a resident's amethyst stone ring to the Illinois Department of Public Health (IDPH) in a timely manner. The incident involved a resident with severe cognitive impairment, whose family had gifted her the ring for her birthday. The ring was last seen before Thanksgiving, and its disappearance was reported by the resident's family member to staff. Multiple staff members, including CNAs and the Social Service Director, were made aware of the missing ring, and some staff conducted a search of the resident's room. However, there was no documentation of an investigation or timely reporting to IDPH at the time the ring was discovered missing. Interviews revealed that staff were aware of the missing ring and discussed it in morning meetings, but there was confusion regarding who was responsible for reporting and investigating the incident. The Director of Nursing assumed the Social Service Director had reported and investigated the matter, while the Social Service Director did not consider the missing ring as abuse and did not log or report it. The CNA who initially received the report wrote a statement and submitted it as instructed, but was not contacted for further details. The family member of the resident did not receive any follow-up from the facility until weeks later, after the new Administrator became involved. The facility's own abuse policy requires all allegations of abuse, including misappropriation of property, to be reported immediately to the Administrator and in a timely manner to appropriate authorities such as IDPH. Despite this policy, the missing ring was not reported or investigated as required, and the incident was not documented in the facility's reportable or grievance logs. The lack of timely reporting and investigation resulted in a deficiency related to the facility's failure to follow its abuse prevention and reporting procedures.
Failure to Investigate Allegations of Misappropriation
Penalty
Summary
The facility failed to investigate allegations of misappropriation involving two residents. One resident, who was cognitively intact, reported the theft of her credit card, which was later confirmed by a police investigation to have been used fraudulently by a CNA. Despite the resident and her roommate both having knowledge of the incident, the facility's Regional Nurse Consultant did not conduct an internal investigation or interview key witnesses, citing workload as the reason for inaction. The roommate, who was present during the suspected theft, was never interviewed by facility staff, and her knowledge of another misappropriation event involving a different resident was also not solicited. Another resident, who had severe cognitive impairment, was reported by her family to have lost a ring of significant sentimental value. The DON recalled hearing about the missing ring in a morning meeting but did not initiate an investigation or notify authorities, assuming another staff member would handle it. The Social Service Director, although aware of the missing ring, did not investigate because she was not directed to do so by the interim administrator. Multiple staff members and the resident's family reported the missing ring, but no formal investigation or report to the state health department was made until prompted by the survey process. The facility's own abuse policy requires immediate and thorough investigation of all allegations of misappropriation, including interviews with all relevant parties. However, in both cases, the facility failed to follow its policy, resulting in delayed identification and investigation of the incidents. Documentation of investigations was lacking, and key witnesses were not interviewed, leading to a failure to respond appropriately to the alleged violations.
Failure to Communicate and Implement Hospice Care Orders
Penalty
Summary
The facility failed to implement a physician's order for a resident who was admitted to hospice care, specifically regarding the use of incontinence pads instead of incontinence briefs to protect the resident's skin. Multiple staff members, including LPNs and CNAs, reported they were not aware of the order and continued to use incontinence briefs for the resident until the resident's death. The Director of Nursing confirmed uncertainty about whether the order had been communicated to nursing or CNA staff and acknowledged that this information should have been shared and followed.
Resident Injury Due to Improper Wheelchair Transport
Penalty
Summary
A resident with multiple diagnoses, including osteoporosis, left hemiparesis, Parkinson's disease, and a history of stroke, was identified as high risk for falls. The resident was being transported in a wheelchair without foot pedals in place. During this transport, the resident's weak leg became caught in the front wheel of the wheelchair, causing the resident to fall forward onto her face and sustain a bilateral nasal bone fracture and soft tissue hematoma. The resident reported significant pain, anxiety, and visible injuries following the incident. Staff interviews confirmed that the footrests were not attached to the wheelchair at the time of the fall, and that the resident's foot became entangled in the wheel, leading to the accident. The acting DON stated that it was her expectation that foot pedals should be in place when transporting residents in wheelchairs. The facility did not provide a policy regarding the use of foot pedals during transport. This failure to ensure proper use of wheelchair footrests resulted in the resident's injury.
Failure to Maintain Accurate Medical Record Following Resident Fall
Penalty
Summary
The facility failed to maintain an accurate and consistent medical record for a resident with multiple diagnoses, including osteoporosis, anxiety disorder, left hemiparesis, major depression, delusional disorder, history of right shoulder replacement, Parkinson's disease, type II diabetes, and a history of cerebral infarction. The resident was identified as high risk for falls and was cognitively intact. The resident experienced a significant fall resulting in bilateral nasal bone fracture and a soft tissue hematoma, as confirmed by a CAT scan. Multiple staff interviews and documentation revealed discrepancies regarding the presence of footrests on the wheelchair at the time of the fall. The resident and a dietary aide both stated that neither footrest was in place, and the resident's weak leg became caught in the front wheel, causing her to fall face-first. A physical therapy assistant also indicated that the footrests were not in use at the time of the incident. However, the progress note by an LPN documented that the resident's foot fell off the footrest, causing the fall, while the facility's final incident report to the state agency stated that the foot pedals were in place. The LPN who wrote the progress note was not listed as a witness on the incident report. When questioned about these discrepancies, the administrator acknowledged awareness of the inconsistent documentation and related issues. These conflicting accounts and documentation errors demonstrate the facility's failure to maintain an accurate and reliable medical record for the resident.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a history of depression, general anxiety disorder, PTSD, and prior experiences of abuse was physically assaulted by another resident diagnosed with dementia and severe cognitive impairment. The incident occurred when the resident with dementia approached the other resident in the dining room, demanded her seat, and, upon refusal, struck her in the left arm with a closed fist and attempted to pull her out of her chair. The assaulted resident called for staff, who intervened and separated the two individuals. The assaulted resident was visibly upset and reported feeling unsafe for several days following the incident. The care plan for the assaulted resident documented her vulnerability to abuse due to her medical and trauma history, including frailty and prior abuse. Staff interviews confirmed the sequence of events, and a witness corroborated that the physical assault took place. The facility's abuse policy requires staff to ensure residents remain free from abuse, but the incident demonstrated a failure to protect the resident from physical harm by another resident.
Failure to Assess Resident Before Transfer After Fall
Penalty
Summary
The facility failed to properly assess a resident before transferring them to a wheelchair following a fall. This incident involved a resident who was cognitively intact and had a history of conditions such as Metabolic Encephalopathy, Hypertension, Coronary Artery Disease, and Multiple Sclerosis, which increased their risk for falls and injuries. After the resident was found crawling on the floor by a CNA, they were transferred to a wheelchair using a bed sheet as a sling without being assessed by a nurse. The resident complained of severe hip pain and was later diagnosed with a fractured right hip at the hospital. The facility's policy on accidents and incidents clearly states that a victim should not be moved until they have been examined for possible injuries. However, in this case, the CNAs moved the resident without notifying a nurse first, which was against the policy. The nurse was only informed after the resident had already been transferred to the wheelchair. The facility's administration acknowledged that the resident should not have been moved without a nurse's assessment, indicating a breach in protocol.
Failure to Provide Safe Transfer for Dependent Resident
Penalty
Summary
The facility failed to provide a dependent resident, who required a two-person assist, with a safe transfer, resulting in a fall. The resident, who had significant medical conditions including Chronic Myelocytic Leukemia, COPD, diabetes, and hypertension, was on hospice care and had been experiencing a rapid decline in health. The resident's care plan clearly indicated the need for two-person assistance for transfers and toileting, which was not followed during the incident on 4/14/24. The resident fell forward out of a wheelchair while being assisted by a single CNA, resulting in injuries including a nosebleed, a bruise on the forehead, and a skin tear on the left forearm. The CNA did not lock the wheelchair, and the resident, who was already weak and dizzy, fell face forward onto the floor. The incident was witnessed by the resident's roommate, who confirmed that only one CNA was assisting the resident and that the wheelchair was not locked. The roommate also reported that the CNA and another staff member were laughing and talking inappropriately after the fall. The facility's Director of Nursing confirmed that the resident should have been on complete bedrest and required two-person assistance for any necessary transfers, which was not adhered to at the time of the incident.
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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