Odin Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Odin, Illinois.
- Location
- 300 Green Street, Odin, Illinois 62870
- CMS Provider Number
- 145649
- Inspections on file
- 36
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Odin Health And Rehab Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and chronic wounds experienced a significant decline, including decreased urine output, refusal to eat, and worsening pressure ulcers. Despite clear signs of deterioration and facility policy requiring physician notification, staff failed to inform the physician or responsible party in a timely manner. The resident was only sent to the hospital after a wound care NP identified severe infection, and the resident died shortly after admission with sepsis and dehydration.
Two residents with pressure ulcers did not receive consistent wound care or timely physician notification when their wounds worsened. One resident with multiple comorbidities experienced a decline in condition, with missed wound treatments and lack of documentation, leading to hospital transfer for wound infection and sepsis. Another resident's wound care was not documented for several days. Staff interviews confirmed lapses in both performing and documenting wound care, and the facility's policy for pressure ulcer management was not followed.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident with a history of psychosocial risk was physically struck by another resident known for aggressive behavior, and staff separated them with no injuries noted. The incident was not documented in the nurse's notes, and no new interventions were added to care plans to prevent recurrence. Key facility leaders were unaware of the event details, and a family member was not informed of the outcome.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with severe cognitive impairment and multiple medical conditions was transferred to the hospital for a procedure and admitted as an inpatient, but the facility failed to notify the resident's designated representative or family member. Staff interviews revealed confusion about notification responsibilities, and documentation did not show evidence of timely family contact, resulting in a deficiency related to notification of changes.
The facility failed to provide narcotic pain medications per physician's orders and did not assess the effectiveness of non-narcotic pain medication for two residents, leading to unrelieved pain. One resident did not receive prescribed lidocaine patches and Norco, experiencing pain at a level of ten. Another resident did not receive hydrocodone, with pain levels ranging from 3 to 9, and Tylenol was given with mixed effectiveness. The facility's Director of Nurses indicated issues with medication reordering responsibilities.
The facility failed to provide adequate CNA staffing, affecting all 66 residents. Residents reported significant delays in call light responses, especially during the 7pm to 7am shift and on weekends. CNAs confirmed frequent understaffing, with shifts often operating below the required minimum. The facility's staffing policy was not effectively implemented, leading to ongoing concerns about unmet resident needs.
The facility failed to respond to call lights promptly, affecting five residents who required assistance with toileting and repositioning. Residents reported waiting for extended periods, sometimes up to six hours, leading to incidents of incontinence and discomfort. Staff cited short staffing as a reason for delays, and the Director of Nurses was unaware of the issue, despite existing policies requiring timely responses.
The facility failed to provide twice-weekly showers for three residents due to staffing issues. A resident with multiple sclerosis and diabetes type 2 did not receive showers during two weeks in March 2025. Another resident with hemiplegia did not receive any showers in March, except for two refusals. A third resident with COPD and diabetes type 2 only received one shower since admission. A CNA confirmed that staffing shortages led to missed showers.
A facility failed to provide medications per physician orders for three residents, resulting in deficiencies in pharmaceutical services. One resident with severe cognitive deficits did not receive benztropine due to unavailability. Another resident with minimal cognitive deficits and multiple diagnoses experienced severe pain when lidocaine patches and norco were unavailable. A third resident also faced unavailability of hydrocodone for pain management. The DON noted issues with agency nurses not reordering medications.
The facility failed to report a COVID-19 outbreak to the local health department and NHSN, starting with a staff member testing positive. Despite multiple staff and residents testing positive, the facility did not conduct contact tracing or testing, nor did they report the outbreak as required. Interviews revealed a lack of understanding and execution of reporting obligations by the DON and administrators.
The facility failed to respond to resident call lights promptly, affecting five residents who reported excessive wait times for assistance. Despite grievances and a policy requiring responses within 10 minutes, observations showed call lights were often ignored while staff socialized. This deficiency impacted residents' rights to a dignified existence and self-determination.
A resident with severe cognitive impairment was subjected to mental abuse when a CNA took a video of them and shared it with outsiders, violating privacy policies. The incident was reported by a community member, leading to an investigation and the CNA's termination.
The facility failed to store medications properly, with missing temperature logs for medication refrigerators and an LPN leaving a medication cart unlocked and unattended. This affected all 68 residents, with several confused wandering residents nearby.
The facility failed to implement enhanced barrier precautions for 10 residents, as staff were unaware of which residents required isolation and lacked understanding of the precautions. Residents with conditions like MRSA, indwelling catheters, and wounds were not managed with appropriate PPE, despite the facility's policy requiring it. This deficiency indicates a significant gap in staff training and protocol adherence.
A resident with bipolar disorder was inaccurately coded in the MDS as not having a serious mental illness, despite a PASRR determination requiring mental health follow-up. The error was attributed to an oversight by a corporate nurse, and the facility lacks a specific MDS policy, relying instead on the RAI manual.
The facility failed to provide meal preferences for two residents, one of whom did not consistently receive toast and eggs for breakfast despite requests, and another who was not given a hamburger as a substitute for pork chops or chicken breast as per family preference. The dietary manager cited issues with updating meal cards and being busy as reasons for these oversights.
A resident with severe cognitive impairment and malnutrition did not receive prescribed health shakes with meals due to a lack of awareness by the dietary manager and CNAs. The facility's policy for implementing diet orders was not followed, leading to the resident not receiving the therapeutic diet as ordered.
A resident with hemiplegia and hemiparesis was not provided with the prescribed adaptive utensils for self-feeding. Despite physician orders for foam built-up utensils, the resident was observed using regular utensils during meals. A staff member confirmed the need for adaptive utensils and retrieved them once, but the issue persisted in subsequent observations.
A resident with a UTI was prescribed Cipro without waiting for culture and sensitivity results, which later showed resistance to the antibiotic. The facility lacked a system to track pending lab results, leading to a delay in administering the correct medication.
The facility failed to protect residents from sexual abuse by a Physician/Co-Medical Director, who made inappropriate sexual comments to three residents over several months. The behavior caused significant anxiety and distress to the residents, who felt afraid to report the incidents.
A resident with a history of confusion and high elopement risk exited the facility undetected and walked 4.4 miles to a neighboring town. Staff were unaware of the resident's whereabouts, and the resident's wander guard was not functioning or removed. The facility failed to provide adequate supervision and monitoring, leading to the elopement incident.
The facility failed to ensure residents were free from significant medication errors, leading to severe consequences for three residents. One resident experienced critically low blood glucose levels due to insulin administration without prior testing, another was given insulin without a blood glucose check, and a third resident was hospitalized due to a medication error involving anxiety treatment.
The facility failed to track and address medication errors, resulting in hospital admissions and emergency room evaluations for some residents. The QA minutes and documents did not reflect concerns regarding medication availability or errors, and the Medical Director was unaware of these issues. The facility's policies on Medication Error and QAPI were not followed, leading to significant deficiencies in resident care.
The facility failed to ensure medications were available and administered as ordered for three residents. One resident did not receive multiple medications on various dates, another resident's Potassium Chloride was unavailable, and a third resident experienced a hypoglycemic event where dextrose was administered intravenously without a documented physician's order.
A resident with schizoaffective disorder and a history of suicidal ideations exited the facility without staff knowledge and was found approximately two-tenths of a mile away. The resident's elopement risk was inconsistently assessed, and staff failed to respond promptly to the disappearance. The door alarm codes had not been changed, and no alarms sounded when the resident left.
A facility failed to ensure staff were trained and had the necessary equipment for a resident with a tracheostomy, leading to the resident experiencing shortness of breath and being transferred to a hospital. Staff were unfamiliar with the equipment and lacked training, resulting in inadequate care.
The facility failed to ensure sufficient staff to meet the needs of 93 residents, leading to delays in care and unsanitary conditions. Multiple CNAs and LPNs reported understaffing during night shifts, resulting in residents waiting for assistance and being left in soiled conditions. Specific instances included residents not receiving timely showers and being found in urine and feces due to insufficient staff.
The facility failed to respond promptly to residents' needs for incontinence care, leading to four residents experiencing prolonged periods in soiled conditions. One resident was observed in urine-soaked pants for over two hours, another reported waiting up to 30 minutes for assistance, a third waited up to an hour, and a fourth was found in a bed saturated with urine and feces. Staff shortages and lack of attentiveness contributed to these deficiencies.
The facility failed to provide adequate ADLs for seven residents, including bathing and incontinence care, due to equipment shortages and staff workload. Residents were left in soiled clothing or bedding for extended periods, and necessary showers were missed, indicating significant lapses in care.
The facility failed to implement their Abuse policy when an RN did not report a missing card of Norco to the Administrator immediately. Instead, the RN sent a message via WhatsApp to the MDS Coordinator, who was not on call. The Administrator was unaware of the incident until informed by a surveyor, leading to a delayed formal report to authorities.
A facility failed to report a narcotics diversion allegation to the Administrator in a timely manner. An RN reported missing Norco via a personal message to the MDS Coordinator, who did not receive it. The Administrator was unaware until informed by a surveyor, leading to a delayed investigation and notification of authorities.
A resident with chronic pain and moderate cognitive impairment reported not receiving pain medication on two occasions. The facility's documentation was inconsistent, with discrepancies between the narcotics sign-out log and the electronic health record. The facility's pain management policy was not followed, leading to inadequate pain management for the resident.
The facility failed to provide proper pharmacy services and documentation for two residents, leading to unaccounted doses of pain medication. Discrepancies between the MAR and narcotic sign-out logs, along with the DON's inconsistent handling of records, contributed to the issue.
Failure to Notify Physician of Change in Condition Leads to Resident Death
Penalty
Summary
A deficiency occurred when facility staff failed to notify a physician of a resident's significant change in condition, which included decreased urine output, refusal to eat, lethargy, and a worsening pressure ulcer. The resident, who had multiple comorbidities such as diabetes, peripheral vascular disease, and severe cognitive impairment, was totally dependent on staff for care and had a history of chronic wounds, including a stage 4 sacral pressure ulcer and a right heel arterial ulcer. Despite care plans and physician orders requiring prompt notification of changes in condition, staff did not communicate the resident's decline to the physician or responsible party in a timely manner. Documentation and interviews revealed that over several days, the resident exhibited clear signs of deterioration, including poor oral intake, minimal urine output, and a decline in wound status. Staff failed to consistently document meal and fluid intake, urine output, and wound care treatments, with some treatments not performed or recorded as required. Multiple staff members, including CNAs and nurses, observed or were informed of the resident's declining condition but did not escalate these findings to the physician, often citing uncertainty, lack of recall, or the expectation that the wound care provider would address the issue during scheduled rounds. The resident was ultimately sent to the emergency room only after a wound care nurse practitioner assessed the resident and found significant deterioration, including a necrotic, malodorous wound and signs of systemic infection. The resident was hospitalized with diagnoses of sepsis, dehydration, and failure to thrive, and died less than 24 hours after admission. Interviews with the resident's power of attorney and the medical director confirmed that neither had been notified of the resident's decline prior to the hospital transfer, despite facility policy requiring such notification for changes in condition.
Removal Plan
- A full house review of all residents with wounds was conducted to verify current wound status and ensure any noted decline was promptly communicated to the physician.
- A 72-hour audit of all residents for change in condition was conducted, including a review of Nurses Notes, Progress Notes, and Alert Charting.
- A full-house review of all residents was completed to verify current wound status and ensure any noted decline was promptly communicated to the physician. Any discrepancies identified were immediately corrected through direct physician notification and documentation updates.
- All licensed nursing staff received education on the requirements at F580, emphasizing timely physician and responsible party notifications for any change in condition, abnormal labs/vitals, new or worsening wounds, decreased urine output/fluid intake, and functional decline, and appropriate documentation of same.
- Certified Nursing Assistants (CNAs) were re-educated to immediately report any observed changes in condition to the charge nurse.
- The facility's Physician Notification and Change in Condition Policies were reviewed.
- Ongoing monitoring activities will be conducted: a. Conduct daily reviews of the Nursing 24 Hour Report to verify timely and accurate physician/responsible party notifications. b. Review a minimum of three random resident charts weekly to confirm compliance with F580 documentation standards. c. Immediately correct and reeducate any staff involved in identified discrepancies. d. Present audit findings and corrective actions during weekly Quality Assurance /Interdisciplinary Team Meetings. e. Provide ad hoc education and reinforcement as indicated.
- The Administrator will conduct the following ongoing monitoring activities: a. Validate and monitor audit outcomes weekly to ensure continued compliance. b. Conduct monthly Inservice education for all nursing staff on F580 notification standards and documentation requirements.
Failure to Recognize, Assess, and Document Pressure Ulcer Deterioration and Provide Ordered Wound Care
Penalty
Summary
The facility failed to recognize, assess, and appropriately document the worsening symptoms of pressure wounds and to provide wound treatments as ordered for two residents. For one resident with multiple comorbidities, including diabetes, peripheral vascular disease, and severe cognitive impairment, the facility did not perform or document required wound care treatments on at least one occasion. Staff failed to notify the physician of significant changes, such as decreased intake, decreased urine output, and signs of wound infection, including malodorous and purulent drainage from a sacral ulcer. The resident's condition deteriorated over several days, culminating in a hospital transfer where the wound was found to be infected with both gram-positive cocci and gram-negative bacilli, and the resident was diagnosed with sepsis, dehydration, and failure to thrive. Interviews and record reviews revealed that staff did not consistently perform or document wound care as ordered, and there was a lack of communication regarding the resident's decline. Nursing staff, including RNs, LPNs, and CNAs, reported not recalling or not being aware of the need to notify the physician or document wound care treatments. The wound care nurse practitioner noted that the sacral wound had a strong necrotic odor and heavy purulent drainage upon assessment, and that the facility had not notified the physician about the resident's decline or signs of infection prior to the hospital transfer. Additionally, the treatment administration record showed missed documentation of wound care, and staff interviews confirmed that if documentation was missing, the treatment likely was not performed. A second resident with a deep tissue injury to the left heel also did not have wound care treatments documented as completed for multiple consecutive days, including weekends. The responsible nurse stated that treatments were generally performed but not always documented, and was unsure if treatments were completed on weekends. The facility's pressure ulcer policy required regular assessment, documentation, and physician notification for wound deterioration, but these procedures were not consistently followed for either resident.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a resident-to-resident altercation occurred in a common area. One resident, who was cognitively intact and had a history of psychosocial risk, was struck in the neck by another resident with a history of physical aggression related to dementia. Staff immediately separated the residents and assessed for injuries, with none noted. However, there was no documentation in the nurse's notes regarding the incident, and the care plan interventions for both residents did not reflect any new measures to prevent further altercations following the event. Interviews revealed that the current administrator and director of nursing were not aware of the details of the incident, and the director of nursing had not been informed of any new interventions implemented after the altercation. Additionally, a family member of the affected resident reported not being informed of the outcome and expressed concern about the lack of increased monitoring. The facility's abuse policy requires procedures to prevent abuse, but the lack of documentation and follow-up interventions indicated a failure to fully address the incident.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Notify Resident's Representative of Hospital Admission
Penalty
Summary
The facility failed to notify a resident's representative of a hospital admission, resulting in a deficiency related to notification of changes. The resident in question had a history of severe cognitive impairment, as evidenced by a BIMS score of 6, and multiple complex medical diagnoses including post-surgical amputation care, type 2 diabetes with neuropathy, severe malnutrition, osteomyelitis, and local skin infection. Despite these conditions and the resident's inability to make informed decisions, the facility did not inform the designated representative or family member when the resident was transferred to the hospital for a procedure and subsequently admitted as an inpatient. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for notifying the family. The DON acknowledged that residents with severe cognitive impairment should have their family or POA notified of significant changes, such as hospital admission. The Social Service Director confirmed that POA paperwork had been completed by the resident's wife, but it had not been filed due to pending additional signatures. The transportation staff, who were involved in taking the resident to the hospital, stated that notifying family was not within their job responsibilities and expected nursing staff to handle such communication. The family member only learned of the hospitalization through a call from the hospital social worker, not from the facility. Documentation review showed that the facility had a policy requiring appropriate documentation and notification during transfers or discharges, but there was no evidence that the resident's representative was contacted regarding the hospital admission. The resident's admission record listed the wife as the emergency contact, and the POA document was present but not reflected in the admission record. The lack of timely notification and documentation of the hospital transfer constituted the deficiency identified by surveyors.
Failure in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide narcotic pain medications per physician's orders and did not assess the effectiveness of non-narcotic pain medication for two residents, leading to unrelieved pain. Resident 1, who has diagnoses including Bipolar Disorder and Chronic Obstructive Pulmonary Disease, did not receive prescribed lidocaine patches and Norco due to unavailability. The resident's pain levels ranged from 0 to 6, and Tylenol was administered without documentation of its effectiveness. The resident reported experiencing pain at a level of ten on a ten-point scale during this period. Resident 3, with diagnoses including Hemiplegia and Diabetes Type 2, also did not receive prescribed hydrocodone due to unavailability. The resident's pain levels ranged from 3 to 9, and Tylenol was given, with mixed effectiveness. The resident reported that the Tylenol did not adequately manage the pain. The facility's Director of Nurses indicated that the responsibility for reordering medications lies with the nurse passing medications, and issues may arise from agency nurses not fulfilling their duties. The facility's Management of Pain Policy emphasizes the importance of effective pain management to promote resident comfort and dignity. However, the facility failed to adhere to this policy, resulting in residents experiencing significant pain. The Director of Nurses mentioned that narcotic pain medications are generally available in the facility's emergency medication kit, but there was no documentation of accessing these for the residents in question.
Inadequate CNA Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate direct care CNA staffing, affecting all 66 residents. Multiple residents reported significant delays in response to call lights, particularly during the 7pm to 7am shift and on weekends. One resident mentioned waiting up to an hour for assistance, while another reported being left in a wet adult brief for an hour. Another resident stated that call lights sometimes went unanswered for up to six hours overnight. These delays were attributed to frequent CNA call-ins and insufficient staffing levels. Interviews with CNAs revealed that the facility often operated with fewer staff than required, particularly on the 10pm to 6am shift, which should have a minimum of four CNAs but sometimes had only two. CNAs reported that management did not provide adequate coverage for call-ins, and the facility's pay and benefits were not competitive, contributing to staffing issues. The facility's staffing policy indicated that the Director of Nursing Services could revise work schedules to meet residents' needs, but this was not effectively implemented. The Resident Council Meeting Minutes documented ongoing concerns about showers not being done and call lights not being answered. The March 2025 schedule showed multiple instances of inadequate staffing, with no CNA coverage assigned to A Hall on several dates. The facility's staffing policy outlined the need for 24-hour nursing service, but the implementation was insufficient to meet residents' needs, leading to the reported deficiencies.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to uphold resident dignity by not responding to call lights in a timely manner, affecting five residents. Residents reported waiting for extended periods, sometimes up to six hours, for assistance with toileting and repositioning. This delay in response led to incidents where residents experienced bowel and bladder accidents, causing them humiliation and discomfort. The residents involved had various medical conditions, including Bipolar Disorder, Chronic Obstructive Pulmonary Disease, Morbid Obesity, Left Lower Leg Fracture, Epilepsy, Multiple Sclerosis, Diabetes Type 2, Hemiplegia, and Hemiparesis. These conditions necessitated substantial or maximal assistance for toileting, making timely staff response critical. Interviews with residents revealed that the delays were particularly pronounced during evenings and weekends, with staff often citing short staffing as the reason for the delays. The Director of Nurses was unaware of the extent of the delays, despite the facility's policy stating that call lights should be answered within a reasonable time. The Resident Council Meeting Minutes also documented concerns about call light response times, indicating an ongoing issue. The facility's failure to respond promptly to call lights violated the residents' rights to a dignified existence and self-determination, as outlined in their Resident Rights Policy.
Failure to Provide Twice-Weekly Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide twice-weekly showers for three residents, resulting in a deficiency in the care and assistance for activities of daily living. Resident 12, who has multiple sclerosis and diabetes type 2, is totally dependent on staff for bathing. The March 2025 shower documentation indicated that Resident 12 did not receive any showers during the weeks of March 2 and March 16, 2025. Resident 12 confirmed that she was not receiving her showers due to understaffing. Similarly, Resident 3, who has hemiplegia and hemiparesis following a cerebral infarction, did not receive any showers in March 2025, except for two instances where she refused. Resident 3 stated that showers were only given if residents complained. Resident 14, who has chronic obstructive pulmonary disease and diabetes type 2, requires substantial assistance for bathing. He refused a shower on March 20, 2025, and only received one shower on March 24, 2025, since his admission. A Certified Nursing Assistant (CNA) stated that residents are supposed to receive at least two showers a week, but she is often pulled from shower duties to work the floor due to staffing shortages. The CNA Supervisor confirmed the issue, acknowledging that showers were not being completed as required.
Medication Unavailability Leads to Deficiencies in Pharmaceutical Services
Penalty
Summary
The facility failed to provide medications according to physician orders for three residents, leading to deficiencies in pharmaceutical services. For one resident with severe cognitive deficits and diagnoses including Diabetes Type 2 and Unspecified Psychosis, the prescribed medication benztropine was not available during a medication pass, and the nurse was unsure why it was missing. The medication was not administered as it was not available, and the nurse indicated it would not arrive until the following day. Another resident with minimal cognitive deficits and diagnoses including Bipolar Disorder and Chronic Obstructive Pulmonary Disease did not receive prescribed lidocaine patches and norco for pain management due to unavailability. The resident reported severe pain during this period, and the facility's records showed delays in obtaining the necessary prescriptions from the physician. A third resident, dependent on staff for toileting and with no cognitive deficits, also experienced unavailability of hydrocodone for pain management. The Director of Nurses acknowledged that the responsibility for reordering medications lay with the nurses, and issues with agency nurses not fulfilling their duties were noted.
Failure to Report and Manage COVID-19 Outbreak
Penalty
Summary
The facility failed to implement a surveillance plan for tracking, monitoring, and reporting communicable diseases and outbreaks, specifically related to COVID-19. The deficiency was identified when the local health department was not properly informed about a COVID-19 outbreak that occurred in the facility. The outbreak began with a staff member testing positive on July 8, 2024, and continued with multiple staff and residents testing positive until August 14, 2024. Despite the outbreak, the facility did not report the required information to the local health department or the National Healthcare Safety Network (NHSN). Interviews with various staff members, including the Director of Nursing (DON), revealed a lack of understanding and execution of the reporting requirements. The DON admitted to receiving inquiries from the health department but failed to provide the necessary outbreak information. Additionally, the facility's administrator and interim administrator were unaware of the reporting obligations, leading to a failure in communication and documentation of the outbreak status. This lack of action resulted in the health department not being informed of the outbreak until much later. Furthermore, the facility did not conduct contact tracing or testing following a positive COVID-19 test result from a Certified Nurse Assistant (CNA) on September 7, 2024. The CNA had informed her supervisors of her positive test, but no subsequent actions were taken to trace or test other staff and residents who may have been exposed. This inaction was contrary to the facility's policy and the guidelines set by the Illinois Department of Public Health, which require immediate testing and contact tracing in such situations.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, affecting five out of eight residents reviewed. Residents reported excessive wait times for assistance, with one resident waiting up to two hours. The facility's grievance log documented multiple complaints about call light response times, with grievances filed by residents on several occasions. Despite these grievances, the facility's responses indicated that staff were verbally educated, but the issue persisted. Observations during the survey confirmed that call lights were not answered promptly, with one resident's call light remaining unanswered for 22 minutes and another for 36 minutes. Residents expressed frustration with the lack of timely response, and the issue was also raised during a Resident Council Meeting. The facility's policy stated that call lights should be answered within a reasonable time, and staff were expected to respond within 10 minutes. However, multiple staff members were observed socializing while call lights were activated, indicating a failure to adhere to the facility's policy and expectations. The deficiency highlights a significant lapse in the facility's ability to provide timely assistance to residents, impacting their right to a dignified existence and self-determination.
Resident Privacy Breach and Mental Abuse by Staff
Penalty
Summary
The facility failed to protect a resident, identified as R2, from mental abuse by a staff member, V5. R2, who has severe cognitive impairment due to Alzheimer's and other conditions, was admitted to the facility with a care plan that highlighted the potential for abuse and neglect. Despite this, an incident occurred where V5, a Certified Nurse Assistant, allegedly took a video of R2 and shared it with individuals outside the facility. The video reportedly showed R2 repeating a phrase that indicated distress, which was shared in a social setting by V5, leading to a breach of privacy and potential mental abuse. The incident came to light when a community member, V6, reported to the Director of Nursing, V2, that V5 had shown a video of R2 during a social gathering. V6 did not see the video but heard it and recognized the voice and statement of R2, which was confirmed by V2 as a common phrase R2 would say. This led to an investigation by the facility, during which V5 was suspended. The investigation confirmed that V5 had shared information about R2 with individuals not affiliated with the facility, violating the facility's policies on privacy and abuse. The facility's policies clearly prohibit the use of personal devices to capture or share images or recordings of residents without explicit consent, which V5 violated. The investigation concluded that V5 purposefully shared information about R2, leading to her termination. The facility's failure to prevent this incident highlights a deficiency in ensuring the protection of residents from abuse, as outlined in their policies.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly stored at appropriate temperatures and in locked compartments, potentially affecting all 68 residents. On multiple occasions, temperature logs for the medication and insulin refrigerators were missing, and staff members, including the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator, were unable to locate them. The Administrator acknowledged the absence of a specific policy for logging refrigerator temperatures, although it was expected that temperatures would be monitored. A new log was initiated only after the issue was identified by the surveyors. Additionally, a Licensed Practical Nurse (LPN) was observed leaving a medication cart unlocked and unattended while passing medications, which is against the facility's policy. The cart was left in the hallway with the keys on top, and no staff members were present to monitor it. This occurred in an area where several residents with confused wandering behaviors resided, increasing the risk of unauthorized access to medications. The facility's policy clearly states that medication carts should be locked when not in use and not left unattended, which was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its policy and procedure for enhanced barrier precautions, affecting 10 out of 13 residents reviewed for infection control. During an initial tour, no resident rooms were observed with signage indicating isolation or enhanced barrier precautions. Additionally, the facility's Matrix for Providers did not mark any residents for transmission-based precautions. Staff members, including a CNA and an LPN, expressed uncertainty about which residents were on isolation and the use of enhanced barrier precautions, indicating a lack of awareness and training. Several residents with conditions requiring enhanced barrier precautions were not properly managed. For instance, one resident with a diagnosis of MRSA and chronic osteomyelitis had specific wound care orders, yet there was no indication of enhanced barrier precautions being implemented. Another resident with an indwelling catheter and a history of sepsis also lacked appropriate precautions. These residents, among others, had various medical conditions such as dementia, diabetes, and chronic obstructive pulmonary disease, which necessitated careful infection control measures. The facility's policy on enhanced barrier precautions, revised in April 2024, outlines the use of PPE during high-contact care activities to prevent the spread of multidrug-resistant organisms. However, interviews with staff, including the Director of Nursing, revealed a lack of understanding and implementation of these precautions. This deficiency in infection control practices highlights a significant gap in staff training and adherence to established protocols, potentially compromising resident safety.
Inaccurate MDS Coding for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident, identified as R57, who was part of a sample of 46 residents. R57 is a female resident with a history of unspecified dementia, bipolar disorder, hypotension, edema, anxiety, and venous insufficiency. The deficiency was identified when R57's MDS annual assessment inaccurately documented that the resident was not considered by the state Level II PASRR process to have a serious mental illness, despite having a PASRR determination indicating bipolar disorder requiring routine follow-up with a mental health professional and a medication regimen. The error was discovered during an interview with a Registered Nurse/Minimum Data Set Nurse (V4), who stated that the MDS was completed by a corporate nurse and acknowledged the incorrect coding in Section A1500. The corporate nurse later explained that the incorrect coding was an oversight. The facility does not have a specific policy on the Minimum Data Set but relies on the Resident Assessment Instrument (RAI) manual for guidance.
Failure to Accommodate Meal Preferences for Residents
Penalty
Summary
The facility failed to accommodate meal preferences for two residents, R14 and R69, as observed during a survey. R14, who is cognitively intact, expressed a preference for toast and fried eggs for breakfast, which was not consistently provided. Despite the facility acquiring a toaster, R14 did not receive toast and eggs as requested on multiple occasions. The dietary manager acknowledged the oversight, citing issues with updating meal cards and being busy in the kitchen. R14's meal card was eventually updated to include toast, but eggs were not consistently provided as per his preference. Similarly, R69, who has a history of adult failure to thrive and other medical conditions, was not provided with a hamburger as a substitute for pork chops or chicken breast, as requested by the family. The dietary manager admitted to serving pork chops to see if R69 would eat them before offering a hamburger, but due to being busy, did not check on R69's tray. The family confirmed the preference for hamburgers over pork chops or chicken breast, which was documented in R69's care plan. The facility's policy requires tray cards to be updated with residents' diet preferences, which was not adhered to in these cases.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide therapeutic diets as ordered for a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and protein-calorie malnutrition. The resident was admitted to the facility with a care plan that included a focus on altered nutrition and hydration, with specific interventions such as diet and supplements as ordered. However, the dietary manager was unaware of the resident's order for health shakes with meals, and this was not reflected on the resident's meal card. Observations revealed that the resident was not receiving the prescribed health shakes during meals. During two separate meal observations, the resident was served a pureed meal without the health shake, and the CNAs feeding the resident were unaware of the order for health shakes. The facility's policy on Food and Nutrition Services outlines the process for accepting and implementing diet orders, but this process was not followed, resulting in the resident not receiving the therapeutic diet as prescribed.
Failure to Provide Adaptive Utensils for Resident
Penalty
Summary
The facility failed to provide adaptive utensils for a resident who required them for self-feeding. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, as well as unspecified protein-calorie malnutrition, had physician orders for a regular diet with puree consistency and pudding thick liquids. The orders also specified the use of a divided plate and foam built-up utensils to facilitate self-feeding. However, during multiple meal observations, the resident was seen using regular utensils instead of the prescribed foam built-up utensils. On one occasion, a staff member confirmed the resident's need for adaptive utensils and retrieved them from the kitchen, but subsequent observations showed the resident continuing to use regular utensils.
Failure to Monitor Antibiotic Use and Sensitivity Results
Penalty
Summary
The facility failed to monitor culture and sensitivity results and prescribe an appropriate antibiotic for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of Peripheral Vascular Disease and Alzheimer's Disease, was admitted to the facility and later exhibited increased behaviors, prompting the medical doctor to order laboratory tests. A urinalysis was conducted, and the results were faxed to the medical doctor, but the culture and sensitivity (C&S) results were still pending. Despite this, the medical doctor prescribed Cipro, an antibiotic, without waiting for the C&S results. The Director of Nurses (DON) admitted to not having a system in place to track pending lab results. When the C&S results were finally obtained, they indicated that the organism, Proteus Mirabilis (ESBL), was resistant to Ciprofloxacin, the prescribed antibiotic. This oversight led to a delay in administering the correct antibiotic, which was later adjusted to gentamicin based on the sensitivity results. The facility's Antibiotic Stewardship Policy outlines the need for systems to identify and alert staff about multidrug-resistant organisms, but this was not effectively implemented in this case.
Failure to Protect Residents from Sexual Abuse by Physician
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse, as evidenced by the inappropriate behavior of V4, a Physician/Co-Medical Director, towards three residents (R2, R9, R11). The deficiency was identified when a surveyor overheard V4 making inappropriate sexual comments to R9 while she was sitting in the lobby. R9 reported that V4's behavior had been ongoing for several months, causing her significant anxiety and distress. She felt afraid to report the incidents, fearing that no one would believe her. V4's inappropriate comments included asking to see and touch her genitalia and breasts, which R9 found highly distressing and inappropriate for a physician. Further investigation revealed that R9 had previously experienced similar inappropriate comments from V4, which she initially thought were jokes but later realized were serious. R9's anxiety increased before V4's scheduled visits, and she began to blame herself for his behavior. Despite V4's claims that R9 had been flirtatious and had propositioned him, other residents and staff did not corroborate these allegations. R9's medical records indicated she was cognitively intact, and there were no documented instances of sexually inappropriate behavior on her part. Additionally, R11 reported feeling uncomfortable with V4's comments, which she interpreted as flirtatious and inappropriate. R11 mentioned that V4 had told her she was pretty and hinted at a romantic interest. Another resident, R2, had also experienced inappropriate comments from V4, who suggested that she needed more sex to address a medical issue. The facility's failure to protect these residents from sexual abuse by V4 constitutes a significant deficiency in ensuring a safe and respectful environment for all residents.
Failure to Supervise High-Risk Resident Leads to Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident assessed as being at high risk for elopement. The resident, who had a history of confusion and was previously homeless, exited the facility without staff knowledge and walked 4.4 miles to a neighboring town along a busy highway. The resident was found by facility staff at 7:00 AM, but the exact time of departure from the facility was unknown. Despite being assessed as a high risk for elopement, the resident's elopement risk was not adequately addressed, and the resident was able to leave the facility undetected. The resident's medical history included disorders of the circulatory system, diabetes with hyperglycemia, hypertension, hypercholesterolemia, atrial fibrillation, and tobacco use. The resident had a BIMS score indicating cognitive intactness but had a documented history of confusion and wandering. On a previous occasion, the resident was found outside the facility holding a fence, confused, and was redirected back inside. Despite these incidents, the resident's elopement risk was not consistently recognized or managed, leading to the elopement event. Staff interviews revealed that there were lapses in monitoring and communication. Several staff members, including CNAs and LPNs, were unaware of the resident's whereabouts during the night and early morning hours. The resident's wander guard was not functioning or was removed, and door alarms were not effective in preventing the elopement. The facility's failure to maintain adequate supervision and monitoring of the resident, despite known risks, directly contributed to the elopement incident.
Removal Plan
- Resident located and returned to facility.
- Head to toe assessment, no injuries noted, nursing assessment complete.
- MD notification completed.
- Wanderguard on and functioning.
- Investigation initiated.
- Staff educated on wandering/elopement policy and responding to door alarm immediately-door alarms, supervision, wanderguard verifications- ongoing.
- Trauma, pain, skin, elopement risk, abuse risk assessments completed, resident put on visuals.
- All residents Elopement assessment- Residents at risk- care plan reviewed with appropriate interventions in place or initiated.
- Elopement books updated with current assessments.
- Elopement assessments will be completed upon admission with additions to care plan and elopement books as indicated, i.e., high/moderate risk.
- 100% Staff in-servicing on Elopement Policy, door alarms, supervision of residents, wanderguard verifications.
- 100% Residents completed Elopement Assessment with Care Plan Reviews and Interventions Implemented as indicated.
- Nursing staff will visualize resident.
- Nursing staff or designees will audit door alarms for functionality and sound until reviewed by QA Committee.
- Administrator or DON will audit rounding daily for compliance until review by QA Committee.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, resulting in severe consequences for three residents. One resident, who had a history of Type 2 Diabetes Mellitus, was administered insulin without a prior blood glucose check due to a shortage of glucose monitoring strips. This led to a critically low blood glucose level of 37, causing altered mental status and necessitating emergency medical intervention. The nurse on duty did not notify the physician about the inability to check the blood sugar levels and proceeded with insulin administration based on incorrect assumptions and incomplete communication among staff members. Another resident, also with diabetes, did not have their blood glucose level checked before insulin administration due to the same shortage of glucose strips. Despite the lack of a blood glucose reading, the resident was given multiple doses of insulin, which could have led to severe health complications. The facility's policies on insulin administration and blood glucose monitoring were not followed, and there was a lack of proper documentation and communication regarding the shortage of supplies and the necessary medical procedures. A third resident experienced increased anxiety and behavioral symptoms due to a medication error. The resident was prescribed hydralazine instead of hydroxyzine for anxiety, leading to inappropriate treatment and subsequent psychiatric hospitalization. The error was not identified or corrected in a timely manner, and the resident missed doses of their prescribed medication, further exacerbating their condition. The facility's failure to ensure accurate medication administration and proper communication with the prescribing physician contributed to the resident's deteriorating mental health and need for hospitalization.
Removal Plan
- Immediate actions taken for residents identified: R23 was sent to the ER and received care for hypoglycemia.
- How the facility identified other residents who could potentially be affected: All residents that are diabetic, have physician's orders for accuchecks, and receive insulin have the potential to be affected by the alleged deficient practice.
- Measures put into place/ System changes: Facility staff were educated by phone or in person prior to start of scheduled next shift. Facility nurse staff will not be allowed to work until the following categories have been in-serviced: Licensed nursing staff were educated on the Accucheck policy by: RN Regional Nurse Consultant with emphasis on obtaining and documenting as ordered. Licensed nursing staff were educated on Insulin Administration by: RN Regional Nurse Consultant with an emphasis on insulin being administered as ordered and in accordance with current standards of practice. Education was provided for licensed nursing staff of what to do when they don't have appropriate or adequate diabetic supplies by: RN, Regional Nurse Consultant. Facility did an inventory for accucheck test strips with an estimated supply of 30 days. Illinois Department of Professional Regulation was contacted by: Chief Executive Officer via email involving incident. Facility has completed a full facility review of all residents that have diabetes with orders for accuchecks and insulin, with reviews and updates to their plan of care as needed. Facility company management reviewed and/or revised any policies and procedures to ensure necessary care and services are provided to residents with Diabetes Mellitus. Those polices consisted of: Medication Administration. Insulin Administration. Following Physician's orders. Accucheck policy. Change of Condition Policy. Medication Error Policy. Those that reviewed those policies were: RN, Chief Nursing Officer RN Regional Clinical Consultant Regional Operations/Clinical Consultant Chief Executive Officer.
- How the corrective actions will be monitored: The Director of Nursing or designee will complete random audits of 5 residents per week for a period of 8 weeks of the following categories: 1.) Accucheck was completed per physician's orders and documented. 2.) Insulin was administered as per physician's orders and documented. 3.) Appropriate and adequate supplies to complete per physician's orders. Any issues with accucheck completion of insulin administration will be addressed per policy and ad hoc education will be provided at that time. Results of the above reviews will be discussed at a weekly quality assurance meeting for a period of 4 weeks and will provide additional education as needed and implement interventions for improvement until resolution.
Failure to Implement Performance Improvement Activities for Medication Errors
Penalty
Summary
The facility failed to ensure performance improvement activities were implemented to track medical errors and adverse events, analyze causes, and implement preventative actions for Quality Assurance (QA) and resident care. This deficiency has the potential to affect all 89 residents residing in the facility. The facility's Medication Error reports documented that only two residents were noted to have medication errors during a specified period. However, additional medication errors involving other residents were not identified or documented, resulting in hospital admissions and emergency room evaluations for some residents. Specifically, insulin was administered without completing blood glucose testing as ordered, and incorrect medication was administered to another resident over several days. The Chief Clinical Officer confirmed that the facility's QA minutes and documents did not reflect concerns regarding medication availability or errors specific to certain residents. The Medical Director was also unaware of the medication errors and the lack of blood glucose testing supplies. The facility's policies on Medication Error and QAPI emphasize the need for systematic tracking, investigation, and monitoring of adverse events, but these were not followed. The facility's failure to adhere to these policies and properly document and address medication errors led to significant deficiencies in resident care.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure medications were available and administered as ordered for three residents (R23, R24, and R28). For R28, multiple medications including Baclofen, Mirtazapine, Omeprazole, Venlafaxine, and Tramadol were documented as either not available or not given on various dates in March and April 2024. The Director of Nursing (DON) confirmed that medications should be documented as administered, and blank squares on the Medication Administration Record (MAR) indicate that the medication was not given. The facility's policy requires that all administered medications be charted on the electronic MAR. For R24, the Licensed Practical Nurse (LPN) was observed preparing medications and noted that Potassium Chloride tablets were not available in the medication cart. The LPN ordered the medication online from the facility's pharmacy and checked the medication room for a stock supply, which was also unavailable. The Potassium Chloride was not delivered by the time of the follow-up observation, and the MAR documented that the medication was not available on that day. For R23, the resident experienced a hypoglycemic event with a blood sugar level of 37. The Certified Nurse Assistant (CNA) found the resident unresponsive and called for the LPN, who attempted to administer oral glucose gel without success. The DON started an intravenous (IV) line and administered dextrose without a documented physician's order. The ambulance report confirmed that the facility staff administered approximately 50 mL of D5 intravenously before the resident was transported to the hospital. The facility's protocol requires physician notification and documentation of any medication administered, which was not followed in this case.
Failure to Supervise Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with psychiatric diagnoses, who was at risk of elopement, was accurately assessed and appropriately supervised. This failure resulted in the resident, who has a diagnosis of schizoaffective disorder and a history of suicidal ideations, exiting the facility without staff knowledge. The resident was found approximately two-tenths of a mile from the facility, sitting outside an abandoned building in the rain, after crossing a busy highway. The incident occurred between 4:45 AM and 5:30 AM, and the resident was located around 6:30 AM. The resident's elopement report documented that the resident was not located in her room and had been exhibiting odd behaviors. The resident was last seen in the dining room at 4:54 AM and was reported missing around 5:00 AM. Staff attempted to locate the resident and notified management and local authorities. The resident was found and stated she had left the facility to take a walk due to feeling depressed. The report noted that the resident was sent to the emergency room for evaluation due to increased depression, but no injuries were observed at the time of the incident. Interviews with staff revealed inconsistencies in the timeline of events and a lack of immediate response to the resident's disappearance. Staff members reported that the door alarm codes had not been changed since a specific date, and no alarms sounded when the resident left the facility. The resident's care plan included interventions for self-harm ideations and elopement risk, but the elopement risk assessments showed varying scores, indicating inconsistent evaluations. The facility's policy on wandering and elopement risk was not effectively implemented, leading to the resident's unsupervised exit and subsequent Immediate Jeopardy citation.
Removal Plan
- ADHOC QAPI completed
- Wander guard placed
- Door alarms checked
- Door code changed
- Elopement assessment completed
- Elopement policy education
- 15-minute check policy education
- Door alarm education
Failure to Provide Adequate Tracheostomy Care
Penalty
Summary
The facility failed to ensure staff were trained and had the necessary equipment to meet the needs of a resident with a tracheostomy. This deficiency resulted in the resident becoming short of breath shortly after admission, with the facility unable to locate the necessary equipment to provide oxygen via the tracheostomy. The resident became anxious and scared and was subsequently transferred to the local hospital for oxygenation. The resident was admitted with multiple diagnoses, including a tracheostomy, and had physician orders for specific tracheostomy care and oxygen administration. However, upon admission, the facility staff were unable to locate the necessary equipment to provide oxygen to the resident. The staff, including an LPN, were unfamiliar with the tracheostomy equipment and lacked the necessary training to provide appropriate care. The resident's oxygen saturation levels fell, and despite attempts to use available equipment, the resident remained anxious and requested to be sent to the hospital. Interviews with staff and family members revealed that the facility did not have the required tracheostomy supplies readily available and that the staff were not adequately trained in tracheostomy care. The facility's Director of Nursing and other managers confirmed that the necessary equipment was present but not properly utilized. The lack of training and preparedness led to the resident's transfer to the hospital, where it was noted that the facility staff were uncomfortable and unfamiliar with tracheostomy care.
Insufficient Staffing Leading to Delayed Care and Unsanitary Conditions
Penalty
Summary
The facility failed to ensure sufficient staff was in place to meet the needs of the residents, affecting all 93 residents currently residing at the facility. Multiple CNAs and LPNs reported that the night shift was often understaffed, leading to delays in answering call lights and providing necessary care. For instance, on several occasions, there were only three or four CNAs working during the night shift, which was insufficient to meet the needs of residents, especially those with behaviors or requiring two-person assistance for transfers and toileting. This resulted in residents experiencing delays in receiving care, such as being left in soiled incontinence briefs for extended periods and not receiving timely assistance with activities of daily living (ADLs) like bathing and toileting. One resident, admitted with multiple diagnoses including sepsis and chronic kidney disease, did not receive a shower for seven days due to the lack of a specific mechanical lift sling and insufficient staff to assist. Another resident, with diagnoses including local infection and heart failure, did not receive a shower for several days, and it was noted that new admits were supposed to get showers within 24 hours but often did not due to CNA refusals. Additionally, residents reported waiting up to 30 minutes for assistance after incontinence episodes, and staff confirmed that care was often delayed due to insufficient staffing. Several residents were found in unsanitary conditions, such as being covered in urine and feces, indicating that they had not been checked or changed for extended periods. For example, one resident was found with brown, urine-stained bed pads, and another resident reported not being checked on since the morning, resulting in being left in soiled conditions. Staff members, including the DON and Administrator, acknowledged the staffing issues and the challenges in meeting the residents' needs with the current staffing levels, despite using a staffing calculator to determine the required number of staff per shift.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to respond in a timely manner to residents' requests and needs for assistance, leading to a lack of dignity for four residents. One resident with severe cognitive impairment was observed sitting in urine-soaked pants for over two hours without receiving incontinence care, despite being in visible discomfort. The CNA responsible for the resident claimed not to have noticed the wet pants, indicating a lack of attentiveness and care. Another resident, who is cognitively intact, reported having to wait up to 30 minutes for assistance after an incontinence episode. This resident had communicated the issue to a nurse, but no follow-up action was taken to address the delay in care. Similarly, a third resident with moderate cognitive impairment and multiple health issues reported waiting 30 minutes to an hour for incontinence care and had been found without a call light or blanket, further compromising their dignity and comfort. The fourth resident, who requires substantial assistance for toileting, was found in a bed saturated with urine and feces, indicating that they had not been checked or changed for an extended period. Multiple staff members confirmed that the resident had been left in this condition due to staffing shortages and miscommunication. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was clearly not upheld in these instances.
Deficiency in Providing Activities of Daily Living
Penalty
Summary
The facility failed to ensure activities of daily living (ADLs) were provided per current standards of practice for seven residents. For instance, one resident (R1) did not receive assistance with bathing for seven days due to the unavailability of a specific mechanical lift sling required for his comfort. Despite the resident's complaints and the staff's awareness of the issue, the necessary equipment was not consistently available, leading to missed showers and inadequate hygiene care. Additionally, the facility's shower aids were overwhelmed with the number of showers they had to complete, further contributing to the deficiency in care. Another resident (R3) did not receive a shower or bath for several days following admission, despite the care plan indicating the need for such assistance. The staff's failure to provide the necessary care was attributed to the refusal of CNAs to give showers and the overwhelming workload of the shower aids. This lack of care was evident in the resident's electronic health record, which showed no documentation of showers or baths being offered or done for several days. Other residents, such as R8, R11, R12, R4, and R5, experienced similar issues with incontinence care and assistance with ADLs. Observations revealed that residents were left in soiled clothing or bedding for extended periods, indicating a significant lapse in the provision of timely and appropriate care. Staff interviews confirmed that the facility was often short-staffed, and CNAs were unable to keep up with the demands of providing adequate incontinence care and assistance with ADLs, leading to residents being neglected and not receiving the necessary care to maintain their hygiene and dignity.
Failure to Report Narcotics Diversion Timely
Penalty
Summary
The facility failed to implement their Abuse policy when they did not ensure an allegation of narcotics diversion was reported timely to the Administrator. A resident, who was cognitively intact and had multiple diagnoses including chronic pain, had two cards of Norco delivered. An RN reported that one of the cards was missing but did not report this to the Administrator immediately. Instead, the RN sent a message via WhatsApp to the MDS Coordinator, who was not on call and did not receive the message until much later. The Administrator was unaware of the incident until informed by a surveyor during a complaint survey. The facility's Abuse Policy requires all allegations of abuse, including narcotics diversion, to be reported immediately to the Administrator and timely to the proper authorities. However, this procedure was not followed. The MDS Coordinator and other administrative staff conducted a search and suspended two nurses, but the Administrator was not involved in the initial investigation. The incident was only formally reported to the local police, physician, and ombudsman after the surveyor's notification, indicating a significant delay in addressing the allegation.
Delayed Reporting of Narcotics Diversion
Penalty
Summary
The facility failed to ensure an allegation of narcotics diversion was reported to the Administrator in a timely manner. A resident with multiple diagnoses, including chronic pain and stage 4 pressure ulcers, had two cards of Norco delivered. An RN reported that one of the cards went missing, but the report was sent via a personal message to the MDS Coordinator, who was not on call and did not receive the message. The Administrator was unaware of the incident until informed by a surveyor months later. The facility's abuse policy mandates immediate reporting of such allegations to the Administrator and proper authorities. However, the incident was not reported until the surveyor's intervention, leading to a delayed investigation. The local police, physician, and ombudsman were only notified after the surveyor brought the issue to the Administrator's attention. The facility's failure to follow its own abuse policy resulted in a significant delay in addressing the narcotics diversion allegation.
Failure to Ensure Proper Pain Management and Documentation
Penalty
Summary
The facility failed to ensure proper pain management and documentation for a resident with chronic pain. The resident, who has a moderate cognitive impairment and multiple diagnoses including sepsis, chronic kidney disease, and osteoarthritis, reported not receiving pain medication on two occasions despite being in significant pain. The resident's care plan included specific interventions for pain management, but these were not consistently followed, as evidenced by the lack of documentation in the Medication Administration Record (MAR) and the narcotics sign-out log. Interviews with staff revealed inconsistencies in the administration and documentation of pain medication. One nurse stated that the narcotics were signed out in the narcotics log but not always in the electronic health record. The Director of Nursing (DON) confirmed that the narcotics sign-out logs did not include a place to document pain assessments or the effectiveness of the medication, which should have been recorded in the electronic health record. This discrepancy indicates that the facility did not have reproducible evidence that the resident's pain was assessed and managed appropriately. The facility's policy on pain management emphasizes the importance of promptly assessing and documenting pain, as well as monitoring the effectiveness of pain treatments. However, the review of the resident's progress notes and MAR showed that pain assessments and the effectiveness of pain medication were not consistently documented. This failure to adhere to the facility's pain management policy resulted in inadequate pain management for the resident, as evidenced by the resident's complaints and the lack of proper documentation in the medical records.
Failure to Ensure Proper Pharmacy Services and Documentation
Penalty
Summary
The facility failed to ensure pharmacy services were provided per current standards of practice for two residents. Resident 1 (R1) was admitted with multiple diagnoses including sepsis, chronic kidney disease, and chronic pain. Despite having a care plan that included administering pain medication as ordered and monitoring for side effects, R1 reported not receiving pain medication on two occasions in February. The Medication Administration Record (MAR) and narcotic sign-out log showed discrepancies, with the MAR indicating fewer doses administered than the narcotic log. The Director of Nursing (DON) and other staff were unable to provide consistent explanations or documentation to resolve the discrepancies. Resident 7 (R7) was admitted with diagnoses including pain due to orthopedic prosthetic devices and stage 4 pressure ulcers. R7's care plan also included administering pain medication and monitoring for side effects. The MAR and narcotic sign-out log for R7 showed significant discrepancies, with the MAR documenting 15 doses of oxycodone administered while the narcotic log documented 54 doses. The Quality Assurance Pharmacist confirmed that 122 doses were dispensed, but the facility could not account for 53 doses. The DON admitted to destroying some narcotic sign-out logs, further complicating the reconciliation process. The facility's Controlled Substances Policy requires proper documentation and reconciliation of controlled medications. However, the facility failed to comply with these requirements, leading to unaccounted doses of pain medication for both residents. The DON's inconsistent handling and destruction of narcotic logs contributed to the inability to verify the administration of the medications, highlighting significant lapses in the facility's pharmacy services and documentation practices.
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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