Nexus At Columbia
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbia, Illinois.
- Location
- 253 Bradington Drive, Columbia, Illinois 62236
- CMS Provider Number
- 145717
- Inspections on file
- 41
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Nexus At Columbia during CMS and state inspections, most recent first.
Two cognitively intact residents with histories of behavioral issues engaged in a physical altercation after one repeatedly demanded money and became verbally abusive. During a group activity, one resident pushed and pulled the other's chair, leading to the other swatting and making contact with her breast, after which both exchanged physical blows. Staff were unable to intervene in time, and the incident left one resident feeling unsafe.
Two residents experienced undignified treatment when CNAs failed to provide timely toileting assistance and made dismissive or harsh remarks, including in public areas. One resident, dependent on a mechanical lift, was made to wait for bathroom help and spoken to in a demeaning manner, leading to emotional distress and incontinence. Another resident felt depressed after being told her personal belongings took up too much space. These actions did not align with facility policy on resident dignity and a home-like environment.
The facility failed to provide scheduled showers for four residents, as documented in records and confirmed through interviews. A resident reported issues with the shower room lacking heat and hot water, while others missed scheduled showers due to documentation inconsistencies and lack of oversight. Staff interviews revealed discrepancies in documentation practices, and the facility's policy requires showers to be provided as per schedule or request, with completed or refused showers documented in the medical record.
The facility failed to serve food at a palatable temperature, as observed during a survey. Cognitively intact residents reported receiving consistently cold meals, an issue highlighted in a resident council meeting. Observations showed that trays were prepared with lids but no bases, and food was placed on wire carts, leading to temperatures below the required 135 degrees Fahrenheit. The Dietary Regional Manager acknowledged the problem, noting that the lack of coverage on wire carts caused the temperature drop.
A facility failed to notify a resident's POA of new psychotropic medication orders, including Buspirone and Seroquel, for a resident with Huntington's Disease. The POA was not informed of the risks and benefits, nor was consent obtained as required by the facility's policy. The Director of Nursing expected nurses to notify the POA, but this did not occur, leading to a deficiency in communication and consent procedures.
A resident received multiple psychotropic medications without the facility obtaining informed consent from the Power of Attorney (POA). The POA was not informed of the risks and benefits of the medications until after administration, and was unaware of some medications being given. The facility's guidelines require informed consent before administering new psychotropic medications, but this was not followed, leading to the deficiency.
A resident with severe cognitive impairment was verbally and physically abused by her brother, despite a care plan restricting his visits. The facility failed to enforce these restrictions, allowing unsupervised access that led to multiple abuse incidents. Staff reported the brother's behavior, but the facility did not take adequate action to protect the resident.
The facility failed to alternate physician and NP visits every 60 days for four residents, as required by policy. Residents with various medical conditions were predominantly seen by NPs, with minimal physician visits documented. Interviews revealed a lack of clarity regarding visit frequency, and the facility lacked documentation for required physician visits.
The facility failed to report and investigate suspected abuse and injuries of unknown origin for two residents. One resident, with severe cognitive impairments, was found with a bruise of unknown origin, and verbal abuse by a family member was witnessed but not reported. Another resident accused an LPN of inappropriate conduct, but the allegation was not immediately reported or investigated. These incidents highlight deficiencies in the facility's handling of suspected abuse and injuries.
A facility failed to investigate allegations of verbal abuse and injury of unknown origin for a resident with severe cognitive impairment. The resident was found with a bruise, but the DON did not conduct a thorough investigation. Multiple reports of verbal abuse by a family member were not reported to the state by the Administrator. The facility's abuse policy was not followed, resulting in a deficiency in addressing the resident's safety.
The facility failed to provide the required protein portions to residents, as observed when turkey servings were not weighed accurately, resulting in insufficient portions. Residents complained about food portions and running out of food. The Dietary Manager was unsure of the cause, while the Consulting Dietician noted insufficient food ordering. Facility policy requires 6 ounces of protein daily per resident.
A Dietary Aide in an LTC facility failed to maintain hygienic practices while handling food, including rubbing her nose and brow without washing her hands, despite being instructed to do so. This occurred while she was preparing and distributing food to residents, contrary to the facility's policy requiring adherence to FDA food code standards.
The facility failed to uphold residents' rights to privacy and dignity, as multiple residents reported CNAs frequently using cell phones during care, leading to ignored requests and compromised privacy. The DON acknowledged the issue, particularly with agency CNAs, and stated efforts to address it.
The facility failed to provide personal hygiene care to two residents who were dependent on staff for ADLs. One resident was found with a dirty mouth, dry skin, messy hair, and untrimmed nails, while another had similar hygiene issues. Both residents had diagnoses requiring assistance with personal care, as documented in their MDS and care plans. The DON confirmed that staff are responsible for providing morning care to these residents.
A medication error occurred when a resident in hospice care was mistakenly given another resident's medications due to an incorrect room assignment in the electronic health care record. The error involved a narcotic, Methadone, among other medications. The mistake was discovered when the second resident requested his medications. The resident who received the wrong medications was monitored and experienced no adverse effects.
A resident with a history of aggressive behavior assaulted another resident, causing physical harm and distress. Despite previous incidents, the facility failed to implement effective interventions to prevent further occurrences, resulting in a significant deficiency.
The facility failed to maintain a clean environment, as observed in the 300/400 hall shower room, which had a persistent foul odor and dirty clothing on the floor. Residents reported having to clean the shower room themselves before use, and the Housekeeping Manager admitted that cleaning protocols were not consistently followed.
The facility failed to cohort COVID-19 positive residents and ensure consistent PPE use among staff, affecting all 112 residents. An occupational therapist and other staff members did not adhere to full PPE protocols, and a COVID-19 positive resident was housed with a negative resident due to room shortages.
The facility failed to notify family representatives of two residents about positive COVID-19 test results and the presence of COVID-19 in the building. One resident, moderately cognitively impaired, was not documented as having their responsible party informed of their positive status. Another resident, severely cognitively impaired, was not documented as having their POA informed about exposure to a COVID-positive resident or the outbreak. This was contrary to the facility's policy requiring notification of changes in condition.
The facility failed to administer medications timely to four residents, with observations showing delays in the scheduled 8:00 AM medication pass. Residents reported receiving medications late, sometimes as late as noon, due to the division of nursing assignments and workload. The Director of Nursing confirmed the expectation for timely administration but denied concerns, despite the facility's policy emphasizing proper timing.
The facility failed to maintain, clean, and return resident clothes in a timely manner, leading to missing, stained, or incorrect clothing for six residents. Despite multiple complaints and grievance forms, the issues persisted, causing significant distress and inconvenience for the residents.
The Facility failed to provide appetizing and warm food for seven residents, with multiple reports of cold meals in both the dining room and on hall trays. Observations confirmed unattended food carts and inadequate food temperatures, contrary to the Facility's policy.
The facility failed to have an RN on duty for 8 hours daily, as required. Time cards showed that an RN did not stay until 8:00 AM on certain Sundays, resulting in non-compliance with the 8-hour RN coverage requirement. The Administrator confirmed the staffing schedule, and the facility's policy states that staffing is based on IDPH requirements. The facility has a census of 107 residents.
A facility failed to identify and assess an AV shunt for a severely cognitively impaired resident, leading to a lapse in required daily checks and precautions. The oversight was only discovered after the resident was sent to the hospital for evaluation due to arm pain.
The facility failed to protect residents from abuse, including physical and verbal abuse by a family member and staff, and physical assault by another resident. Despite clear evidence and witness statements, the facility did not substantiate the abuse.
The facility failed to report multiple allegations of abuse involving a resident, who was observed being verbally and physically abused by a male individual. Despite staff and EMS personnel witnessing the abuse and reporting it to the administration, the facility did not take appropriate action to address and report these incidents as required by their abuse policy.
The Facility failed to investigate allegations of abuse involving a resident by a male individual. Multiple staff members and EMS personnel reported witnessing the individual verbally and physically abusing the resident. Despite these reports, the Facility only provided one investigation report dated several months prior, indicating a lack of thorough investigation into the ongoing abuse allegations.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two cognitively intact residents with documented histories of behavioral issues, including verbal aggression and inappropriate interactions with peers and staff. One resident, who had diagnoses including metabolic encephalopathy and generalized anxiety disorder, was noted to have escalating behaviors such as demanding money, verbal abuse, and combative actions toward both staff and other residents. The other resident, with major depressive disorder and bipolar disorder, also had a history of verbal aggression and was identified as being at risk for abuse and neglect. On the day of the incident, the first resident was observed asking for money from peers and staff, becoming verbally abusive when refused. During a music activity in the dining room, the second resident confronted the first resident about their behavior. Video footage and multiple staff interviews confirmed that the second resident aggressively pushed and pulled the first resident's chair, after which the first resident swatted at the second resident, making contact with her breast. The second resident then retaliated by hitting and kicking the first resident. Staff present at the time reported difficulty in de-escalating the situation, and one aide had to leave the room to seek additional help, during which time the altercation occurred. The facility's investigation confirmed that an altercation took place, with both residents engaging in physical contact. The incident resulted in the second resident feeling unsafe in the facility. The facility's abuse prevention policy prohibits physical abuse, including hitting and controlling behavior, but the measures in place were insufficient to prevent this resident-to-resident altercation.
Failure to Provide Dignified Care and Respect Resident Rights
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner by not providing timely toileting assistance and by not respecting residents' rights to a home-like environment. One resident, who was morbidly obese, had reduced mobility, and was dependent on staff for toileting hygiene, was repeatedly made to wait for bathroom assistance. Certified Nursing Assistants (CNAs) assigned to her hall, particularly one CNA, were reported to have spoken harshly to her, told her to wait until after meal service or until the next shift, and made dismissive comments about her age and emotional responses. Multiple staff and the resident's sister confirmed that the resident was left waiting, sometimes resulting in incontinence, and that the CNA in question was resistant to using the mechanical lift required for the resident's safe transfer. The resident expressed feeling mistreated and was moved to another hall as a result of these interactions. Another resident, diagnosed with depression and anxiety and cognitively intact, reported feeling nervous and a little depressed due to a CNA's comments about her personal belongings taking up too much space in her room. The resident was reluctant to discuss the issue but indicated that the CNA's tone and remarks negatively affected her emotional well-being. Staff interviews corroborated that the CNA had a pattern of speaking harshly to residents and that such interactions occurred in public areas, further impacting residents' dignity. The facility's own policy emphasizes the importance of accommodating resident needs and preferences to maintain dignity and a home-like environment, including the right to retain personal possessions and receive timely assistance. However, observations, interviews, and record reviews demonstrated that these standards were not upheld for at least two residents, resulting in emotional distress and a lack of respect for their rights.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for four residents, as documented in the facility's records and confirmed through interviews. The residents, identified as R1, R11, R12, and R15, did not receive showers according to their scheduled days, with multiple instances marked as 'not applicable' in the shower documentation. R1, who is cognitively intact, reported that the shower room on the 500 hall lacked heat and hot water, and due to his size, he could not use the equipment in the 400 hall. R11, who is moderately cognitively impaired, and R12, who requires partial/moderate assistance, also missed several scheduled showers. R15, who requires similar assistance, refused a shower on one occasion but also missed several scheduled showers. Interviews with staff revealed inconsistencies in documentation practices, with some CNAs stating they document completed showers in the computer, while others use a shower sheet due to lack of charting ability. The Regional Nurse confirmed that the bath and skin report sheet is a QA tool and not mandatory. The facility's policy requires showers to be provided as per schedule or request, and staff are expected to document completed or refused showers in the medical record. However, the facility failed to provide January's shower documentation, and the Director of Nursing was unaware of the broken shower room on the 500 hall, indicating a lack of communication and oversight in ensuring residents' hygiene needs were met.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to serve food at a palatable temperature for four residents, as observed during a survey. The residents, who are cognitively intact, reported that their meals were consistently cold upon delivery. The issue was highlighted in a resident council meeting, where it was noted that the wire racks used for room trays did not keep the food warm, resulting in cold meals. During an observation, it was found that trays were prepared with lids but no bases, and the food was placed directly on wire carts. The temperature of the food was measured, with the pasta and ground beef mix at 126 degrees Fahrenheit and the green beans at 120 degrees Fahrenheit, both below the required hot holding temperature of 135 degrees Fahrenheit. The Dietary Regional Manager acknowledged the problem, stating that while food is held at the correct temperature on the steam table, the lack of coverage on the wire carts leads to a drop in temperature by the time the food is served. The facility's policy requires hot foods to be held at temperatures greater than 135 degrees Fahrenheit, but this was not adhered to, resulting in the deficiency. The residents expressed dissatisfaction with the cold food, and the issue was noted as ongoing, with no resolution at the time of the survey.
Failure to Notify POA of Medication Changes
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) of medication changes for a resident diagnosed with Huntington's Disease, anxiety, and metabolic encephalopathy. The resident's care plan indicated the use of psychotropic medications, including Risperidone, Clonazepam, Ativan, Fluoxetine, and Mirtazapine, to manage mood, behavior, anxiety, and depression. However, the POA was not informed of the addition of Buspirone and Seroquel to the resident's medication regimen until after the medications had been administered. The facility's policy requires that the resident or their representative be informed of the risks and benefits of new psychotropic medications and that informed consent be obtained. Interviews revealed that the POA was not aware of the resident's new medication orders until a week after they were implemented, and the psychiatric nurse confirmed that the family had not given consent for the psychotropic medications. The Director of Nursing stated that while the Nurse Practitioner enters orders into the system, it is expected that nurses notify the POA of new orders. The facility's psychotropic program guidelines emphasize the necessity of obtaining informed consent, either verbally or in writing, for new psychotropic medications, which was not adhered to in this case.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication for one resident, identified as R5, who was part of a sample of 15 residents reviewed for unnecessary medication. R5's care plan indicated the use of multiple psychotropic medications, including Risperidone, Clonazepam, Ativan, Fluoxetine, and Mirtazapine, to manage mood, anxiety, and depression related to Huntington's Disease and other diagnoses. Despite the administration of these medications, the facility did not obtain informed consent from R5's Power of Attorney (POA) until after the medications had been administered. The POA was not informed of the risks and benefits of the medications until a later date, and was unaware of certain medications, such as Buspirone, being administered. Interviews with the POA and facility staff, including the Director of Nursing (DON) and a psychiatric nurse, revealed that the facility had issues with obtaining and documenting consents for psychotropic medications. The DON acknowledged the problem and stated that the facility was working on addressing it. The facility's psychotropic program guidelines require that informed consent be obtained and documented before administering new psychotropic medications, but this protocol was not followed in R5's case, leading to the deficiency.
Failure to Prevent Resident Abuse by Family Member
Penalty
Summary
The facility failed to prevent verbal and physical abuse of a resident by her brother, who had a known history of abusive behavior towards her. Despite previous incidents and a care plan that restricted the brother's visits to supervised window and phone interactions, he was allowed unsupervised access to the resident. This led to multiple instances of verbal and physical abuse, including an incident where he threatened to break her neck and physically shoved her head. The resident, who is severely cognitively impaired and dependent on staff for all activities of daily living, was left vulnerable due to the facility's failure to enforce the care plan and monitor the brother's interactions. Staff members, including CNAs and LPNs, reported hearing the brother's abusive language and witnessing his aggressive behavior, yet these reports were not adequately addressed by the facility's administration. The facility's inaction and lack of proper documentation and communication among staff and management contributed to the continuation of the abuse. Despite being aware of the brother's behavior, the facility did not implement effective interventions to protect the resident, resulting in a situation of Immediate Jeopardy.
Removal Plan
- The administrator initiated the abuse investigation.
- To ensure the safety and well-being of R2, the DON completed an assessment. The result of the assessment was documented in the resident's EHR, and the attending physician will be notified.
- The following actions were taken to prevent alleged aggressor from perpetrating additional abusive behaviors: Visitor was banned from visitation pending investigation, Police were notified of incident, Interdisciplinary team (IDT) will review and revise R2's care plan and implement interventions to ensure R2's safety, The care plan review and revision were completed by the DON/MDS Nurse.
- All residents have the potential to be affected by the alleged deficiency.
- Administrator and DON education. RNC/designee will provide training to administrator and DON. The training will include abuse prevention, allegation of abuse checklist, reporting abuse within required timeframe, completing investigation per policy and protocols, reporting and investigation injuries of unknown origin, immediate action to ensure all potential abuse allegations are identified, reported, and investigated as abuse to safeguard the residents' safety, protection of residents from further abuse from alleged perpetrators.
- Staff Education - the administrator will provide training to all staff. The training will include abuse prevention including identification of the Abuse Coordinator, reporting abuse allegations to the administrator, abuse investigation procedures and documentation process, reporting and investigation of injuries of unknown origin, immediate action to ensure all potential abuse allegations are identified, reported to the administrator to safeguard the residents' safety, protection of residents from further abuse from alleged perpetrator.
- The training will be started.
- All staff who are not available and/or currently on vacation will also receive the same education upon their return to work. The administrator will provide the same training.
- The facility will provide similar training to the agency staff.
- Residents were interviewed to identify if they felt safe and/or if they have experienced verbal or physical abuse while living in this facility. No concerns were identified.
- Care plan meetings. The IDT will review care plans at least quarterly and as needed.
- As part of monitoring, the Administrator will monitor through facility audit tools five staff members daily for one week and then weekly to ensure any allegations of abuse are reported to the abuse coordinator and investigated and reported to organizations.
Failure to Alternate Physician and NP Visits Every 60 Days
Penalty
Summary
The facility failed to ensure that physician visits were alternated with Nurse Practitioner (NP) visits every 60 days after the first 90 days of admission for four residents. The facility's policy requires that each resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 days thereafter, with the option to alternate visits with an NP. However, the records for residents R1, R2, R6, and R7 showed that they were predominantly seen by NPs, with minimal physician visits documented. Resident R1, who has multiple diagnoses including hemiplegia and congestive heart failure, was seen by an NP 26 times in the past year but only once by a physician. Similarly, resident R2, with severe cognitive impairment and multiple health issues, was seen by an NP 32 times and by a physician only once. Resident R6, also severely cognitively impaired, was seen by an NP 25 times and by a physician twice. Resident R7, who is cognitively intact but has several health conditions, was seen by an NP 16 times and by a physician only once since admission. Interviews with staff revealed a lack of clarity regarding the frequency of physician visits, with the Assistant Administrator acknowledging the absence of documentation for the required physician visits. The Regional Director of Operations expected the policy to be followed, indicating a discrepancy between policy and practice. The facility's failure to adhere to its policy on physician visits resulted in a deficiency in ensuring adequate medical oversight for the residents.
Failure to Report and Investigate Suspected Abuse and Injuries
Penalty
Summary
The facility failed to report and investigate incidents of suspected abuse and injuries of unknown origin for two residents, R2 and R8. R2, who has severe cognitive impairments and multiple medical conditions, was found with a bruise of unknown origin on her left upper arm. Despite the facility's care plan indicating R2's risk for abuse and neglect, the Director of Nursing did not report the bruise to the Illinois Department of Public Health (IDPH) or conduct an investigation. Additionally, staff members witnessed R2's brother, V6, verbally abusing R2, but these incidents were not reported or investigated by the facility's administration. For R8, who is moderately cognitively impaired, an allegation of inappropriate conduct was made against an LPN, V25. R8 accused V25 of inappropriate behavior, but V25 did not immediately report the allegation to management, as required by the facility's abuse policy. Instead, V25 reported the incident the following morning, after his shift had ended. The Director of Nursing was informed of the allegation but did not take immediate action to investigate or report the incident to the appropriate authorities. The facility's failure to adhere to its abuse policy and report these incidents to the IDPH highlights a significant deficiency in handling suspected abuse and injuries of unknown origin. The lack of timely reporting and investigation of these incidents demonstrates a failure to protect residents from potential harm and ensure their safety within the facility.
Failure to Investigate Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate allegations of verbal abuse and injury of unknown origin for a resident with severe cognitive impairment and multiple diagnoses, including dementia and intellectual disabilities. The resident was found with a bruise of unknown origin on her left upper arm, which was reported by a CNA to an LPN. The LPN evaluated the bruise, notified the family and the facility's Nurse Practitioner, and an interdisciplinary team meeting was held. However, the Director of Nursing did not conduct a thorough investigation, assuming the bruise was from a transfer without interviewing staff or documenting the investigation in the resident's electronic medical record. Additionally, there were multiple reports of verbal abuse by the resident's family member, V6, who was witnessed by maintenance staff and CNAs yelling and using vulgar language towards the resident. Despite these reports, the facility's Administrator did not report the incidents to the state or take appropriate action. The maintenance staff expressed concerns about the lack of proper steps being taken and the discomfort caused by V6's behavior towards both the resident and staff. The facility's abuse policy requires immediate reporting and investigation of any allegations or suspicions of abuse, but this was not followed. The policy also mandates that suspicious bruises be reported and documented, which was not done in this case. The Regional Director of Operations acknowledged the expectation for the Administrator to report abuse but was unsure if the allegations were ever investigated. The facility's failure to adhere to its abuse prevention program and reporting procedures resulted in a deficiency in addressing the resident's safety and well-being.
Failure to Provide Adequate Protein Portions
Penalty
Summary
The facility failed to provide the required amount of protein to its residents, as observed during a survey. The facility's recipe for Oven Herb Roasted Turkey Breast specified that each portion should weigh 2.5 ounces to provide a 2-ounce protein serving. However, the facility was initially not using a scale to weigh the turkey portions, and the District Manager, V21, indicated that they were serving about one slice per person. Upon weighing, the turkey portions were found to be only 2 ounces, and the kitchen ran out of turkey, necessitating a substitute. Residents expressed dissatisfaction with the food portions and the facility running out of food during a Resident Council Meeting. The Dietary Manager, V12, was unsure why they ran out of turkey, suggesting it might have been due to double portions or requests for more. The Consulting Dietician, V22, stated that if the facility ran out of food, it was because they did not order enough. The facility's policy on meal planning requires that each resident be served food to meet their needs and physician's orders, including a total of 6 ounces of good quality protein daily. The facility has 102 residents, as documented in the CMS 671 form.
Failure to Maintain Hygienic Food Handling Practices
Penalty
Summary
The facility failed to maintain hygienic practices in food handling, which has the potential to affect all residents. On 10/22/24, a Dietary Aide was observed placing diet cards and lids on residents' trays while repeatedly rubbing her nose and wiping sweat from her brow. Despite being asked by direct care staff and an Area Manager to wash her hands, the Dietary Aide appeared confused and did not comply. After washing her hands, she immediately rubbed her nose again and continued to scoop ice cream from a large bucket into bowls, which were then distributed to residents. The facility's policy, dated 2/2023, requires all food to be prepared in accordance with the FDA food code, including proper handwashing and glove use.
Violation of Resident Privacy and Dignity Due to CNA Cell Phone Use
Penalty
Summary
The facility failed to respect residents' rights to privacy and dignity during care, as evidenced by multiple reports from residents during a council meeting. Four residents reported that Certified Nursing Assistants (CNAs) were frequently on their cell phones while providing care, which compromised their privacy and dignity. One resident specifically mentioned a CNA using speaker mode on her phone while assisting him in the bathroom, leading to a lack of privacy. Other residents expressed that their requests for care were ignored because CNAs were preoccupied with their phones. The Director of Nurses (DON) acknowledged the issue, particularly with agency CNAs, and stated efforts were being made to address it. The facility's Resident Rights policy emphasizes creating a home-like environment that respects residents' dignity and preferences, which was not upheld in these instances. The DON mentioned that disciplinary actions are taken against CNAs who continue to use their phones during work, and agency CNAs may be placed on a do-not-return list if the behavior persists.
Failure to Provide Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care to two residents who were dependent on staff assistance for activities of daily living (ADLs). On October 22, 2024, one resident was observed in bed with a dirty mouth, dry and flaky facial skin, messy hair, and dirty, untrimmed nails. This resident had diagnoses of hemiplegia, weakness, need for assistance with personal care, and dementia, and was documented as dependent on hygiene in their Minimum Data Set (MDS) and care plan. Similarly, another resident was observed with a dirty mouth, messy hair, a dirty gown, and dirty, untrimmed nails. This resident had diagnoses of hemiplegia, hemiparesis following cerebral infarction, and encephalopathy, and was also documented as dependent on hygiene in their MDS and care plan. The Director of Nursing acknowledged that staff are responsible for providing morning care to these residents, who require assistance with their daily care needs.
Medication Error Due to Incorrect Room Assignment
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, resulting in a medication error involving two residents. One resident, who was admitted to the facility in hospice care, was mistakenly given the medications intended for another resident. This error occurred because the electronic health care record did not reflect a room change, leading to both residents being listed for the same bed. The error was discovered when the second resident asked for his medications, prompting the realization of the mistake. The medications given in error included a narcotic, Methadone, among others. The Licensed Practical Nurse involved in the incident was an agency nurse who administered the wrong medications. The Director of Nursing was notified immediately, and the resident who received the incorrect medications was monitored for any adverse effects. The pharmacist and nurse practitioner confirmed that the ingestion of Methadone did not pose increased clinical significance due to the resident's current medication regimen, and no negative side effects were observed.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in a significant deficiency. Two residents, both with severe cognitive impairments, were involved in multiple altercations. One resident, with a history of aggressive behavior, physically assaulted another resident, causing physical harm and psychosocial distress. The incidents were documented in facility reports and nursing notes, highlighting a pattern of resident-to-resident altercations that were not adequately addressed by the facility. The resident identified as R5, who has a diagnosis of dementia and severe cognitive impairment, was involved in several altercations with other residents. Despite previous incidents of aggression, the facility did not implement effective interventions to prevent further occurrences. On multiple occasions, R5 physically assaulted other residents, including an incident where R5 slapped another resident in the dining room and another where R5 kicked and pushed a resident in a wheelchair. These incidents were documented, but the facility's response was insufficient, as no new interventions were added to R5's care plan after some of these altercations. The most severe incident occurred when R5 assaulted R2, another resident with severe cognitive impairment, in their shared room. R5 was observed on video repeatedly hitting R2 and attempting to choke her with a blanket. This incident resulted in physical injuries to R2, including facial bruising, and caused significant distress. Despite the severity of the incident, the facility's previous interventions had not effectively prevented such occurrences, indicating a failure to protect residents from abuse and neglect.
Failure to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for three of the six residents reviewed. Observations on two consecutive days revealed that the 300/400 hall shower room had a persistent foul odor of feces, dirty clothing, and a bag of dirty linen on the floor. The toilet in the shower room contained toilet paper, although no feces were noted. Residents reported having to clean the shower room themselves before use due to its unclean state, with one resident mentioning that the room always had dirty clothes and towels on the floor, some with feces. Another resident reported a pile of feces on the floor next to the toilet that remained for almost a full day before being cleaned. Interviews with residents indicated that housekeeping did not regularly clean the shower rooms, and residents had to request cleaning services. The Housekeeping Manager acknowledged that while they aim to clean resident rooms and shower rooms daily, they sometimes get sidetracked, resulting in incomplete cleaning. The housekeeping protocols outlined a morning and PM walk-through to address trash, restock supplies, sweep/mop, and manage odors, but these were not consistently followed, leading to the unsanitary conditions observed.
Inadequate Cohorting and PPE Use for COVID-19
Penalty
Summary
The facility failed to properly cohort residents with COVID-19 and adhere to infection control protocols, potentially affecting all 112 residents. On July 16, 2024, it was observed that an occupational therapist was in a room with two COVID-19 positive residents, wearing only an N95 mask without additional PPE, under the mistaken belief that the residents were no longer in isolation. Despite contact/droplet precaution signage, there was inconsistency in PPE usage among staff, with some unaware of the requirement to wear full PPE, including face shields. A housekeeper was unaware of the need for face shields, and a computer technician was not informed about the COVID-19 status of residents, leading to non-compliance with mask-wearing protocols. Additionally, the facility's failure to cohort residents appropriately was highlighted when a COVID-19 positive resident was housed with a negative resident due to a lack of available rooms. The facility's policy required full PPE for staff and cohorting of residents with the same respiratory pathogen, but these measures were not fully implemented. The administrator acknowledged the lack of available rooms and the decision to house residents together despite the risk, citing centralized admitting processes and room availability issues.
Failure to Notify Family Representatives of COVID-19 Cases
Penalty
Summary
The facility failed to notify the family representatives or Power of Attorney (POA) of two residents, R3 and R4, about positive COVID-19 test results and the presence of COVID-19 in the building. R3, who is moderately cognitively impaired, was placed under strict contact/droplet isolation due to COVID-19. However, the facility did not document notifying R3's responsible party about the positive COVID-19 status on the date of the test. Although R3's daughter stated she was informed of the positive test result, she was not notified when the facility first identified COVID-19 in the building. R4, who is severely cognitively impaired, tested negative for COVID-19 but was in proximity to a COVID-positive resident, R3. The facility's records did not document any notification to R4's POA about the exposure to a COVID-positive resident or the outbreak in the facility. The facility's policy requires notifying the resident, their physician, and responsible party of any change in condition, which was not adhered to in these cases.
Medication Administration Delays
Penalty
Summary
The facility failed to administer medications timely to four residents, as observed and documented in the report. Resident 1, who has multiple diagnoses including hypertension and diabetes, was observed receiving her 8:00 AM medications at 9:20 AM. This delay in medication administration was not in accordance with the prescribed schedule documented in her Medication Administration Record (MAR). Resident 2, who is cognitively intact and has a history of reporting late medication administration, stated that he often receives his 8:00 AM medications as late as noon. On the day of observation, his medications were administered at 9:45 AM. The resident had previously reported these delays to the facility's Administrator and Director of Nursing, but no explanation was provided to him. The delay was attributed to the nursing staff's workload and the division of hallways, which resulted in the 400 hall being attended to last. Residents 3 and 4 also experienced delays in receiving their 8:00 AM medications, with administration occurring at 9:25 AM and 9:38 AM, respectively. The nursing staff cited various reasons for these delays, including the time it takes to complete the medication pass and interruptions during the process. The Director of Nursing confirmed the expectation that medications should be administered within one hour before or after the scheduled time, yet denied any concerns regarding late administration. The facility's Medication Administration Policy emphasizes the importance of timely medication administration, but the observed practices did not align with this policy.
Laundry Management Deficiency
Penalty
Summary
The facility failed to ensure that resident clothes were being maintained, cleaned, and returned in a timely manner for six out of thirteen residents reviewed for laundry. Residents reported that their clothes were often missing, returned with bleach stains, or replaced with someone else's clothes. Specific instances included residents finding their clothes with white spots, missing clothes for months, and being forced to wear clothes that did not belong to them. One resident even noted that their clothes were labeled, yet still went missing, and another resident mentioned that their clothes were not labeled correctly, leading to further confusion and distress. The issue was brought up multiple times during resident council meetings and through grievance forms, but the problems persisted. The facility's administrator acknowledged the complaints and mentioned that activities staff were helping to ensure residents received their clothes. However, the residents continued to experience issues with their laundry, indicating that the measures taken were insufficient. The facility outsourced its laundry services, and the EVS Area Manager for Laundry stated that they were aware of the complaints and were in the process of addressing them, but the problems had not been fully resolved. The facility's policies on resident rights and personal clothing emphasize the importance of maintaining a homelike environment and ensuring the dignity and well-being of residents. Despite these policies, the facility failed to uphold these standards, leading to significant distress and inconvenience for the residents. The ongoing issues with laundry management highlight a critical deficiency in the facility's ability to provide a safe, clean, and comfortable environment for its residents.
Failure to Provide Palatable and Warm Food
Penalty
Summary
The Facility failed to provide food that is appetizing and at palatable temperatures for seven residents. Multiple residents reported that the food served in the dining room and on hall trays was often cold. Specific instances included a resident stating that breakfast was cold and staff were unwilling to warm it, another resident mentioning that food is never hot whether eaten in the dining room or in their room, and another resident noting that food takes a long time to be served, resulting in it being cold. Additionally, the Ombudsman confirmed that residents had been complaining about cold food in both March and May Resident Council Meetings, with no resolutions being implemented by the Facility. On the day of observation, a cart with hall trays was left unattended beside the nurse's station, and a family member had to take a tray to a resident's room to ensure the food was warm. Test tray temperatures were taken, revealing that the fried egg and waffle were cool to the touch, measuring 84°F, and the oatmeal measured 126°F. The Facility's policy states that food should be prepared and served at safe and appetizing temperatures, but this was not adhered to, as evidenced by the observations and resident interviews.
Failure to Maintain RN Coverage for 8 Hours Daily
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for 8 hours daily, as required. This deficiency was identified through the review of staff schedules and time cards for April 2024. Specifically, the time cards for an RN, identified as V13, did not document that he stayed until 8:00 AM on Sundays (4/7, 4/14, 4/21), resulting in the facility not meeting the 8-hour RN coverage requirement on those days. The Administrator confirmed that the Assistant Director of Nursing (ADON) works on the floor Monday through Friday, and another RN works from 11:00 PM to 8:00 AM on Fridays and Saturdays. The facility's policy on staffing, dated September 2023, states that staffing is based on the Illinois Department of Public Health (IDPH) requirements. The facility has a census of 107 residents.
Failure to Identify and Assess AV Shunt
Penalty
Summary
The facility failed to identify and assess an arteriovenous shunt for a resident who was severely cognitively impaired. The resident's medical records indicated the presence of an AV shunt placed in 2019 for dialysis, which required specific precautions and regular checks for bruit and thrill. However, the facility did not include these orders in the resident's care plan until after the resident was sent to the hospital for evaluation due to pain in the left arm. The hospital confirmed the presence of the AV shunt and noted it was functioning normally, but the facility had not been monitoring it as required by their own dialysis protocol. The Assistant Director of Nursing admitted that the order to check the AV shunt was forgotten, and the Administrator confirmed that the shunt was only discovered right before the resident was sent to the hospital. The facility's policy required daily checks of the dialysis site for signs of infection, bleeding, and proper function, but these checks were not performed until after the hospital visit. This oversight led to a failure in providing appropriate treatment and care according to the resident's needs and medical orders.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by multiple incidents involving four residents. One resident, who was severely cognitively impaired and required substantial assistance, was physically and verbally abused by her brother, who was also her POA. The abuse was witnessed by EMS personnel and reported to the police. Despite the brother's history of abusive behavior, the facility staff appeared to have normalized his actions, and there was no immediate intervention to protect the resident from further harm. Another incident involved a dietary staff member who verbally abused a resident. The staff member was heard cursing loudly and directed profanities at a resident who asked her to stop. The staff member was eventually escorted out of the building, but the incident caused significant distress to the resident and other witnesses. The facility's investigation concluded that the abuse was not substantiated because the employee's words were not directed specifically at the resident, despite multiple witness statements to the contrary. A third incident involved a resident who was physically assaulted by another resident in the dining room. The assaulted resident was moderately cognitively impaired and required assistance with mobility. The aggressor, who had a history of aggressive behavior, struck the resident on the head. Despite the clear evidence of physical abuse, the facility's administration did not substantiate the abuse, citing a lack of willful intent. This decision was made despite witness statements and the facility's own documentation of the incident.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving a resident, identified as R2, who was observed being verbally and physically abused by a male individual, V3. Multiple staff members and emergency medical services (EMS) personnel witnessed V3 yelling at R2, using vulgar language, and physically manipulating her head in a forceful manner. Despite these observations, the facility did not report these incidents to the appropriate authorities as required by their abuse policy and prevention program. On several occasions, EMS personnel, including V4, V5, V6, and V8, witnessed V3 verbally assaulting R2 and physically striking her forehead. V8, the EMS Chief, reported the incident to the local police department, and V3 was subsequently escorted off the premises. Staff members, including CNAs and LPNs, confirmed that V3's abusive behavior towards R2 was a common occurrence and had been reported to the facility's administration multiple times. However, the facility's administration failed to take appropriate action to address and report these allegations of abuse. The facility's abuse policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or compliance officer and documented. Despite this policy, the facility only had one documented instance of alleged verbal abuse involving R2 from May 2023. The Director of Nursing (DON) and other staff members acknowledged that no other instances of abuse had been reported, indicating a failure to adhere to the facility's abuse reporting procedures.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The Facility failed to investigate an allegation of abuse involving a resident (R2) by a male individual (V3). Multiple staff members and EMS personnel reported witnessing V3 verbally and physically abusing R2. V3 was observed yelling at R2, using vulgar language, and forcefully manipulating her head. Despite these reports, the Facility only provided one investigation report dated several months prior, indicating a lack of thorough investigation into the ongoing abuse allegations. On multiple occasions, EMS personnel and Facility staff witnessed V3's abusive behavior towards R2. EMS personnel reported hearing V3 yelling and using vulgar language towards R2, and observed him physically manipulating her head in a forceful manner. Staff members also reported that V3's abusive behavior was a common occurrence and had been reported to the administration multiple times. Despite these reports, the Facility failed to conduct a thorough investigation into the allegations. The Facility's failure to investigate the allegations of abuse is a violation of their own abuse policy, which requires immediate reporting and investigation of any incidents or allegations of abuse. The policy also mandates that the Facility take all necessary steps to protect residents from abuse, neglect, and mistreatment. The lack of a thorough investigation into the ongoing abuse allegations against V3 indicates a failure to adhere to this policy and protect the resident from harm.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
