Nexus At Mascoutah
Inspection history, citations, penalties and survey trends for this long-term care facility in Mascoutah, Illinois.
- Location
- 901 North Tenth Street, Mascoutah, Illinois 62258
- CMS Provider Number
- 145785
- Inspections on file
- 33
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Nexus At Mascoutah during CMS and state inspections, most recent first.
Surveyors found that appropriate care was not provided for residents regarding bowel and bladder continence, catheter management, and UTI prevention, resulting in a deficiency.
Staff failed to follow the facility's Enhanced Barrier Precautions policy by not donning required gowns and gloves while providing care to two residents with indwelling urinary catheters. In both cases, staff interacted with catheter equipment and performed care activities without appropriate PPE, despite clear signage and available supplies, contrary to the residents' care plans and facility policy.
Multiple residents dependent on staff for toileting assistance experienced significant delays in call light responses, with one resident left on a bedpan for nearly half an hour, resulting in pain and skin redness. Other residents reported similar delays, leading to feelings of frustration and lack of dignity. Staff acknowledged the importance of prompt care, but cited staffing shortages as a factor. Facility policies emphasized timely care, but these were not followed as observed.
An LPN misappropriated hydrocodone-acetaminophen prescribed to two cognitively impaired residents by documenting administration on narcotic count sheets but not on MARs, taking the medication for personal use. The discrepancy was discovered when another nurse noticed unusual documentation and pill count reductions, leading to an internal investigation and the LPN's admission of theft.
A resident with significant cognitive and mobility impairments, identified as high risk for falls, did not consistently receive prescribed fall prevention interventions such as grippy socks and a non-slip mat. Staff were unaware of these interventions, and the resident experienced multiple falls, including one with injury, indicating a failure to implement and communicate care plan updates.
A facility failed to respect a resident's privacy and dignity when an LPN posted a social media comment describing a resident with identifiable characteristics. Although the post did not name the resident or facility, staff recognized it as referring to a specific resident, who expressed that such posts would hurt his feelings. The facility's policies prohibit disrespectful comments about residents, highlighting a breach of these standards.
A resident with a complex medical history experienced multiple falls without new preventive measures being implemented. The facility failed to update the care plan with progressive interventions after each fall, despite acknowledging the need for new strategies. Staff interviews confirmed the oversight, which did not align with the facility's fall prevention policy.
Two residents were involved in an incident where one, with a history of aggression, hit another in the mouth despite staff attempts to intervene. The facility's documentation confirmed the occurrence of physical abuse, indicating a failure to protect residents from harm.
The facility failed to maintain proper hand hygiene and food temperature protocols during meal preparation and service, affecting all 50 residents. A cook was observed plating food without gloves and not performing hand hygiene after leaving the serving line. Food temperatures were not checked before plating, with some items below safe levels, requiring reheating. The Dietary Manager and District Manager acknowledged these lapses, which contravened the facility's policies.
The facility failed to maintain a pest-free environment, with flies present in the rooms of several residents, causing discomfort and complaints. The issue was exacerbated for residents using bedside commodes due to infrequent cleaning. Despite a pest control policy, minimal action was taken, and the Maintenance Director was unaware of the problem's extent.
The facility failed to properly administer medications, including giving expired and incorrect doses, and leaving medications unsupervised with residents. An RN was observed administering expired Multi-Vitamins and incorrect Lisinopril doses, and placing Lorazepam on a dirty surface. Medications were left unsupervised with residents, contrary to policy requiring supervision to ensure medications are taken.
Expired medications, including vaccines and insulin, were found in a facility's medication storage areas. A nurse was observed attempting to administer an expired Multi-Vitamin to a resident. The facility's policies on medication storage and administration were not followed, leading to the presence of expired drugs.
The facility did not meet the required 80 square feet per resident bed for nine residents, providing only 77.5 square feet in certain rooms. Despite this, no complaints were voiced by residents, and the affected individuals were documented as receiving a room waiver.
A resident with cognitive impairment and mobility issues experienced a lack of timely assistance with toileting, resulting in unsanitary conditions in their room. Despite the care plan requiring regular checks and assistance, the resident's bedside commode was not cleaned for extended periods, leading to distress and a violation of the facility's policy for a clean environment. The DON acknowledged the oversight, indicating a failure to uphold resident dignity and cleanliness.
A facility failed to provide a SNF ABN of Non-coverage to a resident with multiple diagnoses, including Osteomyelitis and Morbid Obesity. The resident's records showed a service discharge date, but no SNF ABN form was found in the EHR. The resident could not recall receiving the notice, and the administrator confirmed the absence of the form and acknowledged the lack of a policy for issuing SNF ABN forms.
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital. One resident's family did not receive a bed hold notice or discharge reason in writing, while another resident's Power of Attorney was informed by phone but not in writing. The facility's policies require written notifications, but documentation was lacking.
A facility failed to provide a resident's representative with written notification of a voluntary discharge and bed hold notice. The resident, who was alert and oriented, was transferred to a hospital for pain management and a UTI. Upon review, it was found that the resident's husband did not receive the required written documentation. The facility administrator acknowledged this oversight.
A resident with multiple health issues, including a nonhealing wound, did not receive timely follow-up on nurse practitioner recommendations for a vascular surgeon referral and an MRI. Despite physician's orders, the facility's electronic medical record lacked documentation of these actions. The resident reported inadequate repositioning care, and the receptionist was delayed in scheduling the MRI. The facility lacked a policy for scheduling consults.
A resident with a history of falls and severe cognitive impairment was transferred by a CNA without using a gait belt and with the wheelchair unlocked, contrary to the facility's safety policies. The resident's care plan required supervision and assistance due to high fall risk, but these protocols were not followed, resulting in a deficiency in maintaining a safe environment.
A resident with severe cognitive impairment and multiple diagnoses did not receive complete incontinent care. A CNA failed to have necessary supplies ready, did not use a gait belt properly, and neglected hand hygiene after wiping the resident's anal area. The CNA also did not clean the resident's front side, despite the incontinence brief being wet. The facility's policy emphasizes the importance of proper incontinence care to prevent skin breakdown.
The Facility failed to protect two residents from abuse, resulting in one resident feeling fearful and having trouble sleeping due to another resident's inappropriate sexual behaviors. Despite staff awareness, insufficient actions were taken to prevent further incidents.
The Facility failed to report allegations of abuse involving two residents. One resident alleged rape by a kitchen worker and had bruising, while another resident reported feeling extremely uncomfortable and scared after inappropriate sexual advances from a roommate. The Facility's Administrator did not report these incidents as required by their abuse policy.
The Facility failed to investigate an allegation of sexual abuse involving two residents. Despite one resident expressing discomfort and fear due to another resident's inappropriate sexual behavior, the Facility did not conduct an investigation as required by their abuse policy.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Follow Enhanced Barrier Precautions for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) policy regarding the use of personal protective equipment (PPE) when providing care to two residents with indwelling urinary catheters. In the first instance, a resident with multiple diagnoses including rheumatoid arthritis, malnutrition, heart failure, and neurogenic bladder was observed with her catheter bag uncovered and lying on the floor. A Care Plan Coordinator/LPN entered the room, picked up the catheter bag, placed it in a cover, and attached it to the bed without donning gloves or a gown, despite clear signage indicating enhanced barrier precautions and readily available PPE at the door. The resident's care plan specifically required staff to wear gown and gloves during activities of daily living due to the risk of infection associated with the indwelling catheter. In the second instance, two CNAs provided catheter care to another resident with multiple diagnoses, including multiple myeloma and obstructive uropathy, who also required enhanced barrier precautions due to an indwelling catheter. During the observed care, neither CNA donned gowns, even though enhanced precautions signage and PPE were available at the room entrance. The resident's care plan and physician orders both specified the need for gown and glove use during high-contact care activities. The facility's EBP policy, dated 10/6/22, mandates the use of gown and gloves for high-contact care activities for residents with indwelling medical devices, but this protocol was not followed in these observed cases.
Failure to Provide Timely Toileting Care Compromising Resident Dignity
Penalty
Summary
The facility failed to provide timely care to residents dependent on staff for toileting hygiene, resulting in compromised dignity and comfort for multiple residents. One resident, who was cognitively intact and a bilateral lower extremity amputee with morbid obesity, reported waiting between 30 minutes to over an hour for call lights to be answered, leading to episodes of soiling herself and significant frustration. During direct observation, this resident was left on a bedpan for 29 minutes after requesting assistance, resulting in a pain level of 9 out of 10 and visible skin redness. The resident expressed concern for others who might not be able to advocate for themselves. Staff interviews confirmed that residents should be removed from bedpans within 5-10 minutes to avoid discomfort, but staffing shortages due to call-offs were noted as a contributing factor to delays. Other residents also reported excessive wait times for call light responses, ranging from 15 to 30 minutes, which made them feel uncared for and diminished their sense of dignity. Resident council meeting minutes from several months documented ongoing concerns about untimely call light responses. Facility policies on pain management and resident rights emphasized the importance of timely care to promote comfort and dignity, but these standards were not met as evidenced by the experiences and observations described.
Misappropriation of Narcotic Medication by LPN
Penalty
Summary
An LPN at the facility misappropriated narcotic pain medication prescribed to two residents who were both cognitively impaired and unable to advocate for themselves. The LPN was regularly assigned to these residents and documented the administration of hydrocodone-acetaminophen on the narcotic count sheets, but did not record these administrations on the residents' Medication Administration Records (MARs). The discrepancies were discovered when another nurse noticed unusual documentation and a rapid decrease in the pill count for one resident, despite the resident rarely requesting or receiving narcotic pain medication. Upon review, it was found that the LPN had signed out significantly more doses on the narcotic count sheets than were documented as administered on the MARs for both residents. The LPN admitted to taking the medication for personal use, stating she was in pain and did not have health insurance. She described a method of removing the medication from the cart, signing it out, and then pretending to administer it in the resident's room, where she would instead pocket the pills. The facility's audit confirmed that the LPN had taken a substantial number of pills over a period of several weeks. The residents involved had diagnoses including chronic pain, GERD, osteoarthritis, and cholecystitis, and were prescribed hydrocodone-acetaminophen on an as-needed basis. Both residents were described as not interviewable and did not have a history of frequent narcotic use. The misappropriation was only detected due to the vigilance of another nurse who noticed inconsistencies in the documentation and pill counts, leading to an internal investigation and subsequent admission by the LPN.
Failure to Implement and Communicate Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that progressive fall interventions were implemented and that staff were aware of these interventions for a resident identified as high risk for falls. The resident, who had diagnoses including diabetes mellitus, cerebral infarction, hypotension, dementia, and gait abnormalities, was severely cognitively impaired, used a wheelchair, and required partial assistance with walking. Despite being care planned as a fall risk and having a history of falls, interventions such as ensuring the resident wore grippy socks and the addition of a non-slip mat to the wheelchair were not consistently in place. On observation, the resident was found wearing regular socks without grips, and staff members interviewed were unaware of the requirement for grippy socks or the use of a non-slip mat. The resident experienced multiple falls, including one that resulted in a laceration, hematoma, and skin tears, requiring emergency room evaluation. Documentation showed that after each fall, interventions were updated in the care plan, but these were not effectively communicated or implemented by staff. Interviews with CNAs revealed a lack of awareness regarding the specific fall prevention measures, indicating a breakdown in communication and execution of the care plan interventions designed to prevent further accidents.
Breach of Resident Privacy and Dignity via Social Media Post
Penalty
Summary
The facility failed to respect a resident's rights regarding privacy and dignity, as evidenced by a social media post made by an LPN. The post, dated 9/10/2024, described a resident with identifiable characteristics, such as having five teeth and a receding hairline, without naming the resident or the facility. The post was intended as a joke among employees, but it was recognized by other staff members as referring to a specific resident, R2, who was alert and aware of the situation. R2 expressed that such a post would hurt his feelings and emphasized that no employee should post personal details about him on social media. The facility's administrator received an anonymous call about the post and forwarded the screenshots to human resources, who initially saw no issue since no names were mentioned. However, interviews with staff confirmed that the post was about R2, and comments from other employees on the post further identified the resident. The facility's Resident Rights Policy and Social Media Handbook prohibit disrespectful or discourteous comments about residents, highlighting a failure to uphold these standards. The incident underscores a breach of the resident's right to dignity and privacy, as outlined in the facility's policies.
Failure to Implement Progressive Fall Interventions
Penalty
Summary
The facility failed to implement progressive interventions for a resident identified as high risk for falls, leading to multiple incidents without adequate preventive measures. The resident, who has a complex medical history including encephalopathy, COPD, hemiplegia, and dementia, experienced several falls over a short period. Despite these incidents, the facility did not document or implement new interventions to prevent future falls, as required by their fall prevention policy. The resident's care plan and incident reports repeatedly noted the same interventions following each fall, without any new strategies being introduced. This lack of progressive intervention was acknowledged by the facility's staff, including the Assistant Director of Nursing, Care Plan Coordinator, and Director of Nursing, who admitted that the same interventions were used multiple times without modification. The facility's policy mandates that each fall should be followed by a new intervention, which was not adhered to in this case. Interviews with facility staff revealed that the interdisciplinary team was supposed to meet to discuss and implement new interventions after each fall, but this process was not effectively carried out. The Care Plan Coordinator admitted to an error in not updating the care plan with new interventions, and the Director of Nursing, who was new to the position, confirmed that the care plan should reflect each fall with appropriate interventions. This oversight resulted in a failure to provide adequate supervision and preventive measures for the resident, as required by the facility's fall policy.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving two residents. Resident 1, who was moderately cognitively impaired and required assistance with mobility, had a history of verbal aggression and physical altercations with other residents. On the day of the incident, Resident 1 was observed by the Environmental Services Director swatting at Resident 2, who was severely cognitively impaired but independent with ambulation. Despite attempts to intervene, Resident 1 hit Resident 2 in the mouth. The facility's documentation, including the initial and final reports to the Illinois Department of Public Health, confirmed the occurrence of physical abuse. The facility's abuse policy, which prohibits abuse and mistreatment of residents, was not effectively implemented in this case. The incident was substantiated as physical abuse, highlighting a failure to protect residents from harm and ensure their safety within the facility.
Failure in Hand Hygiene and Food Temperature Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene and food temperature protocols during meal preparation and service, potentially affecting all 50 residents. On the observed date, a cook was seen plating food without wearing gloves and without performing hand hygiene after leaving and returning to the serving line multiple times. The cook also handled gluten-free bread with bare hands before being instructed to use tongs. Additionally, the cook did not check food temperatures before plating, which is against the facility's policy. The temperatures of various food items, including mechanically altered and pureed foods, were found to be below the required safe levels, necessitating reheating. The facility's policies require that food temperatures be checked at multiple stages, including before plating, and that proper hand hygiene and utensil use be maintained to prevent contamination. However, the kitchen staff did not follow these protocols, as evidenced by the lack of documented temperature checks at the time of service and the observed lapses in hand hygiene. The Dietary Manager and District Manager acknowledged these failures, noting that the cook should have checked temperatures before plating and performed hand hygiene as necessary.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of flies in the rooms of six residents. Observations and interviews revealed that residents were experiencing significant discomfort due to the flies, with some residents having fly swatters in their rooms as a makeshift solution. Residents reported that the issue had persisted for several months, and complaints had been made without any effective action taken by the facility. The presence of flies was particularly problematic for residents using bedside commodes, as the lack of frequent cleaning exacerbated the situation. The Director of Nursing and the Maintenance Director were both made aware of the issue, with the Maintenance Director initially unaware of the extent of the problem. The facility's pest control policy, dated 2017, mandates an ongoing pest control program, yet the last recorded pest control service was on 7/17/2024. Despite this, the Maintenance Director claimed that there were not many flies and that minimal action had been taken, such as placing sticky fly traps in hallways but not in residents' rooms.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to properly administer medications to residents, as evidenced by several incidents involving incorrect medication administration and handling. A registered nurse (RN) was observed administering expired Multi-Vitamin tablets to a resident and incorrectly dosing Lisinopril, contrary to the physician's order. The nurse acknowledged the error and intended to verify and correct the order. Additionally, the nurse was seen placing a Lorazepam tablet on a dirty surface before administering it to another resident, which is against proper medication handling protocols. In another instance, a resident was left with a cup of medications on their bedside table while being attended to by staff. The medication administration record indicated that some medications were not signed off as administered, and the nurse admitted to not completing the administration of all prescribed medications. Similarly, another resident was found with a bottle of Cinacalcet tablets in their wash basin and a cup of medications on their bedside table. The nurse admitted to leaving the medications for the resident to take on their own, which is against the facility's policy of ensuring residents take their medications under supervision. The facility's medication administration policy requires that medications be administered safely and appropriately, with nurses remaining with residents to ensure they swallow their medications. The policy also mandates that expired medications be removed from stock and disposed of properly. The incidents observed indicate a failure to adhere to these policies, resulting in improper medication administration and handling, which could potentially compromise resident safety.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to properly manage and store medications, leading to the presence of expired drugs in the medication room refrigerator, medication shelf, and medication cart. During an inspection, several expired medications were found, including a COVID-19 vaccine, insulin pens, and various vials of insulin and Daptomycin. Additionally, expired Aspirin bottles were discovered in the medication storage room. A Licensed Practical Nurse confirmed the expiration of these medications, and the facility's Administrator stated that the Director of Nursing and Assistant Director of Nursing are responsible for monthly checks of the medication storage areas. Furthermore, a Registered Nurse was observed administering an expired Multi-Vitamin to a resident, which was only discovered upon examination of the bottle. The nurse then attempted to find a non-expired bottle on another medication cart, but it was also expired. The facility's policies on medication storage and administration emphasize the importance of checking expiration dates and ensuring medications are stored and administered correctly. However, these policies were not adhered to, resulting in the use of expired medications.
Deficiency in Room Size Compliance
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident bed for nine residents in a sample of 41. During the survey, it was observed that rooms on the 100 hall, which were Medicare and Medicaid certified, provided only 77.5 square feet per resident bed. The administrator confirmed that there had been no changes in the measurements and accuracy of the facility's waivered resident room numbers and certifications. Despite the deficiency, no residents vocalized concerns or complaints about the room size during observations and a resident group meeting. The facility documented that the affected residents were all receiving a room waiver.
Failure to Maintain Resident Dignity and Cleanliness
Penalty
Summary
The facility failed to maintain a dignified and respectful environment for a resident, identified as R11, by not providing timely removal of urine and feces from the resident's bedside commode. R11, who was admitted with diagnoses including anxiety, major depressive disorders, and a fracture of the spine, was documented as moderately cognitively impaired and required partial assistance for toileting. Despite these needs, the facility did not adhere to the care plan that required rounding every two hours to assist with toileting and ensure the resident was clean and dry. During the investigation, it was observed that R11's commode was not cleaned for extended periods, leading to unsanitary conditions with stool and urine present, attracting flies. R11 reported waiting four hours for the commode to be emptied and expressed distress over the situation. Observations confirmed that the commode remained uncleaned over multiple days, and the floor was smeared with stool. The Director of Nursing acknowledged the issue and stated that the commode should have been cleaned after each use, highlighting a failure to comply with the facility's Resident Rights Policy to provide a clean and homelike environment.
Failure to Provide SNF ABN of Non-Coverage
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) of Non-coverage to a resident, identified as R6, who was reviewed for Beneficiary Notice. R6 was admitted to the facility with diagnoses including Osteomyelitis of Vertebra, Morbid Obesity, Weakness, and Difficulty Walking. The facility's records indicated a service discharge date for R6, but there was no SNF ABN form associated with this date in R6's Electronic Health Record (EHR). During an interview, R6 could not recall receiving a SNF ABN regarding the discharge. The facility administrator confirmed the absence of the SNF ABN form in both R6's EHR and the facility's Notice of Medicare Non-Coverage (NOMNC) folder, acknowledging the error and the lack of a current policy for issuing SNF ABN forms.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding an involuntary discharge and the opportunity for appeal. In the case of one resident, identified as R51, there was no documentation that the resident's husband received written notification of the discharge to the hospital or a bed hold notice. The resident was initially admitted to the facility and later requested to be sent back to the hospital due to pain, where they were admitted for a urinary tract infection and pain management. The facility administrator acknowledged that the family should have been provided with the necessary written notifications. Additionally, another resident, identified as R9, was transferred to the hospital following a fall. The resident's Power of Attorney was notified by phone but did not receive any written documentation regarding the transfer. The facility's bed hold policy, last reviewed in September 2023, requires that written information be provided to the resident or their representative upon transfer. However, there was no documentation that this was done for R9. The facility's discharge policy also lacked documentation on the need to provide written notification to residents' representatives upon transfers.
Failure to Provide Written Discharge and Bed Hold Notice
Penalty
Summary
The facility failed to notify a resident's representative in writing regarding the voluntary discharge and bed hold notice. The resident, who was alert and oriented, was admitted to the facility and later requested to be sent back to the hospital due to severe pain. The resident was transferred to the hospital via EMS, where they were admitted for a urinary tract infection and pain management. Upon review, it was found that there was no documentation indicating that the resident's husband received written notification of the discharge reason or a bed hold notice. The facility administrator acknowledged that the family should have been provided with this information in writing.
Failure to Follow NP Recommendations for Resident Care
Penalty
Summary
The facility failed to follow the nurse practitioner's recommendations in a timely manner for a resident with multiple diagnoses, including an unspecified open wound on the left lower leg, Type II Diabetes Mellitus, paraplegia, and polyneuropathy. The resident's care plan indicated a risk for skin complications due to immobility. Physician's orders were documented for a referral to a vascular surgeon and an MRI of the left knee to address a nonhealing wound. However, the electronic medical record showed no documentation of a referral to a vascular surgeon or a scheduled MRI appointment. The resident reported that staff did not regularly turn or reposition him every two hours, and he had not refused such care. He confirmed that he had not undergone an MRI or consulted with a vascular surgeon, despite the nurse practitioner's recommendations. The receptionist responsible for scheduling appointments stated that she had contacted the hospital to arrange an MRI but was waiting for a callback. The facility administrator expected nurses to enter orders, obtain consent, and notify the scheduler for consults, but there was no policy for scheduling consults, only for medication orders.
Failure to Ensure Resident Safety During Transfers
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as R5, during transfers, which is a deficiency in maintaining a safe environment free from accident hazards. R5, who has a history of multiple falls and is considered a high fall risk, was observed being transferred by a Certified Nursing Assistant (CNA) without the use of a gait belt and with the wheelchair left unlocked. This action is contrary to the facility's Gait Belt Policy, which requires the use of a gait belt for weight-bearing residents needing hands-on assistance during transfers. R5's medical history includes severe cognitive impairment, dementia, traumatic brain injury, and a history of falls, among other conditions. The resident's care plan highlights the need for supervision and assistance with activities of daily living, including transfers. Despite these documented needs and the resident's high fall risk status, the CNA did not follow the prescribed safety procedures during the transfer, which included securing the wheelchair and using a gait belt. The facility's policies on fall prevention and gait belt usage emphasize the importance of maintaining resident safety through proper transfer techniques and the use of assistive devices. The Director of Nursing confirmed the expectation that staff should use gait belts and lock wheelchairs during transfers to ensure resident safety. However, these protocols were not adhered to in the case of R5, leading to a deficiency in the facility's safety procedures.
Incomplete Incontinent Care for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide complete incontinent care for a resident with severe cognitive impairment and multiple diagnoses, including dementia, traumatic brain injury, and osteoarthritis. The resident, who is always incontinent of both bowel and bladder, was observed being assisted by a CNA to use the restroom. The CNA did not have the necessary supplies ready and had to leave the resident unattended to gather them. During the care process, the CNA did not use a gait belt properly and failed to perform hand hygiene after wiping the resident's anal area before applying Peri-Guard cream with the same soiled gloves. Additionally, the CNA did not clean or wipe the resident's front side, despite acknowledging that the incontinence brief was wet. The Director of Nursing later stated that staff are expected to provide complete incontinent care, including having necessary supplies available and performing hand hygiene. The facility's Incontinence Care Policy emphasizes the importance of keeping residents dry, comfortable, and odor-free to prevent skin breakdown, and specifies that cleansing should be done from front to back.
Failure to Protect Residents from Abuse
Penalty
Summary
The Facility failed to ensure an environment free from abuse for two residents, R1 and R2. R1, who has diagnoses including type 2 diabetes, COPD, congestive heart failure, anxiety, depression, osteoarthritis, and muscle weakness, was admitted to the facility and was documented as being at risk for abuse and neglect. R2, who has diagnoses including encephalopathy, multiple sclerosis, bipolar disorder, schizoaffective disorder, and major depressive disorder, was admitted to the facility and was documented as being moderately cognitively impaired. Despite R2's cognitive impairments and inappropriate sexual behaviors, R2's care plan did not address the risk for abuse or identified sexual behaviors. R1 and R2 were placed in the same room, which led to multiple incidents where R2 made sexual advances towards R1, including crawling into R1's bed, making sexual comments, and asking R1 to help with masturbation. These incidents caused R1 to feel fearful and have trouble sleeping. Staff members, including an LPN and a CNA, were aware of R2's inappropriate behaviors but did not take sufficient action to prevent further incidents. The LPN documented R2's behaviors and attempted to redirect R2, but the inappropriate actions continued. The CNA also witnessed R2's inappropriate behavior and separated the residents but did not ensure that R2 was moved to a different room. The facility's abuse policy affirms the right of residents to be free from abuse and requires the facility to protect residents from mistreatment by anyone, including other residents. However, the facility failed to follow this policy, resulting in R1 feeling scared and uncomfortable due to R2's actions.
Failure to Report Allegations of Abuse
Penalty
Summary
The Facility failed to report allegations of abuse involving two residents. Resident R2, who has multiple diagnoses including encephalopathy and schizoaffective disorder, was found to have made hypersexual statements and had bruising on her body. A Sexual Assault Nurse Examiner (SANE) from a local hospital reported that R2 tested positive for pregnancy and had bruising, and R2 alleged that a kitchen worker had raped her. Despite this, the Facility's Administrator did not report the alleged rape because Public Health was already present in the building, and she was unsure if it was necessary to report it. Additionally, Resident R1, who has diagnoses including type 2 diabetes and chronic obstructive pulmonary disease, reported feeling extremely uncomfortable and scared after R2 crawled into her bed, made sexual comments, and asked for help with masturbation. Staff members, including a CNA and an LPN, were aware of the incident and reported it to the Administrator. However, the Administrator did not report the incident because R1 stated she did not feel violated or harassed. The Facility's abuse policy mandates the immediate reporting of any allegations of abuse to the Illinois Department of Public Health, but this protocol was not followed in the cases of R1 and R2. The Facility's failure to report these incidents constitutes a deficiency in adhering to their own abuse prevention and reporting policies.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The Facility failed to investigate an allegation of sexual abuse involving two residents. Resident 1 (R1) was admitted with multiple diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and anxiety, and was documented as being at risk for abuse and neglect. Resident 2 (R2) was admitted with diagnoses including encephalopathy, multiple sclerosis, and schizoaffective disorder, and was moderately cognitively impaired. On the night of the incident, R2 was found in R1's bed making sexual comments and asking for help with masturbation. Despite R1 expressing discomfort and fear, the Facility did not conduct an investigation into the incident as required by their abuse policy. Staff interviews and progress notes revealed that R2 had a history of making inappropriate sexual comments and actions towards R1. R1 reported feeling scared and uncomfortable due to R2's behavior. The Facility's Administrator stated that no investigation was conducted because R1 did not feel violated or harassed. However, the Facility's abuse policy mandates that all incidents or allegations of abuse must be investigated, regardless of the resident's immediate feelings. This failure to investigate the incident constitutes a deficiency in the Facility's adherence to its abuse prevention and response protocols.
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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