Parker Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Streator, Illinois.
- Location
- 516 West Frech Street, Streator, Illinois 61364
- CMS Provider Number
- 145989
- Inspections on file
- 39
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Parker Nursing & Rehab Center during CMS and state inspections, most recent first.
Two residents, both with behavioral and medical diagnoses, engaged in a physical altercation in the dining room, with one resident striking the other multiple times and staff unable to immediately stop the incident. Video surveillance and staff interviews confirmed the abuse, which occurred despite facility policies prohibiting such actions.
Two residents with histories of trauma and mental health conditions reported sexually explicit remarks and unwanted advances from another resident, but staff failed to promptly report or investigate the allegations as required by policy. The affected residents were left unprotected, resulting in their withdrawal from social activities and ongoing distress, while the alleged perpetrator continued to have access to them. Multiple staff members did not escalate the complaints, and management did not initiate an investigation or protective measures until days later, leading to an Immediate Jeopardy finding.
The facility did not follow its discharge planning and unplanned discharge procedures for several residents, including failing to notify APS or emergency contacts when residents left unexpectedly, and not providing active discharge planning for residents who expressed a desire to leave. Staff confirmed that discharge planning was not initiated unless specifically requested, and documentation showed no evidence of required actions being taken.
A resident with multiple comorbidities and a history of falls was found on the floor with a laceration after staff failed to keep the bed in the low position and did not place a floor mat as required by the care plan. The resident, dependent for care and requiring a mechanical lift, attempted to reach for a drink and fell, sustaining an injury that required sutures.
A resident experienced an episode of incontinence and reported being subjected to derogatory remarks and laughter from CNAs during cleanup, leading to emotional distress. The incident was communicated to an LPN and the DON, but was not immediately reported to the facility abuse coordinator as required by policy, resulting in a failure to follow abuse reporting procedures.
A resident reported being subjected to derogatory remarks and laughter from three CNAs during an episode of incontinence. The incident was relayed to an LPN by the resident's daughter and subsequently reported to the DON, but the Administrator was not informed and no investigation was conducted, contrary to facility policy.
A resident with multiple health issues fell from a wheelchair while being lifted into a van, but the LTC facility failed to notify the resident's POA as required. The resident continued to dialysis treatment without the dialysis center being informed of the fall. The dialysis nurse later contacted the facility, which then attempted to reach the POA. The resident was discharged without proper documentation or notification, later admitted to the hospital, and passed away after transitioning to hospice care.
A resident with multiple medical conditions fell from a wheelchair during transport, and the facility failed to conduct timely neurological checks or notify dialysis staff. The resident was later diagnosed with a subdural hematoma and T8 fracture. The facility lacked a system to ensure wheelchair safety during public transport.
A resident with multiple medical conditions experienced a fall, and the facility failed to document the incident accurately and timely. The incident note and progress note were completed days after the fall, and medications were inaccurately documented as administered when the resident was not present. The Director of Nursing and Administrator acknowledged the documentation deficiencies.
A resident with pressure ulcers and MRSA was not provided proper infection control measures during wound care. Staff failed to wear appropriate PPE, and wounds were not cleansed according to facility policy, increasing the risk of cross-contamination.
The facility failed to provide scheduled showers to three residents, leading to a deficiency in maintaining their ability to perform activities of daily living. One resident, moderately impaired for cognition, reported not receiving showers for about two weeks, while another, cognitively intact, had only two showers since admission. A third resident, requiring total assistance, also missed scheduled showers. Staff interviews revealed inconsistencies in shower documentation and adherence to the schedule.
The facility failed to ensure that two residents who required thickened liquids had access to fluids at night. Nursing staff ran out of thickener, and since the kitchen was locked, they could not replenish their supply, leaving the residents without necessary fluids.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents in the dining room. One resident, with a history of hemiplegia, hemiparesis, anxiety, and delusional disorder, approached another resident, who had diagnoses including traumatic subdural hemorrhage, drug-induced Parkinson's, and anxiety disorder. Both residents were alert and able to verbalize their needs. During the incident, one resident began yelling, prompting the other to approach and physically strike him multiple times. The second resident retaliated, and the altercation continued until staff intervened. Video surveillance confirmed that the physical altercation involved multiple strikes and that staff were unable to immediately stop the incident. Staff interviews revealed that the nurse on duty was attending to another resident when the altercation began and responded by yelling and attempting to intervene. Additional staff, including human resources and kitchen staff, arrived after hearing the commotion and assisted in separating the residents. Both residents and staff acknowledged that the physical contact constituted abuse. The facility's policy prohibits resident abuse, including physical abuse such as hitting, slapping, and other forms of corporal punishment. Despite these policies, the incident occurred, and staff were not able to prevent or immediately stop the abuse between the residents.
Failure to Investigate and Protect Residents Following Alleged Sexual Abuse
Penalty
Summary
The facility failed to identify and investigate an allegation of sexual abuse involving two residents who reported that another resident made sexually explicit remarks and unwanted advances toward them. Despite the residents expressing fear and distress, and reporting the incidents to multiple staff members, including an activities aide and several certified nurse aides, the allegations were not promptly reported to management or nursing leadership as required by the facility's abuse prevention policy. The staff members who received the initial complaints either deferred responsibility, failed to escalate the concerns, or dismissed the urgency of the situation, resulting in a lack of immediate protective measures for the affected residents. The residents involved had documented histories of trauma and mental health conditions, including anxiety, schizophrenia, major depressive disorder, and post-traumatic stress disorder. Both were assessed as cognitively intact and had no recent behavioral symptoms according to their medical records. The alleged perpetrator also had a history of sexually inappropriate behavior documented in his care plan, yet no immediate action was taken to separate him from the complainants or to initiate an investigation when the allegations were first reported. Instead, the residents were advised to avoid the alleged perpetrator and to report the matter to management at a later time, leaving them unprotected and causing them to withdraw from social activities and remain isolated in their rooms. Multiple staff statements confirmed that the allegations were not investigated in a timely manner, and that management was not notified promptly. Written statements from the certified nurse aides were not followed up with interviews or further inquiry by facility leadership. The administrator and social services director did not initiate an investigation or increase monitoring of the alleged perpetrator until days after the initial report. This failure to respond appropriately to the allegations resulted in the residents continuing to experience fear and distress, and led to a finding of Immediate Jeopardy by surveyors.
Failure to Follow Discharge Planning and Unplanned Discharge Procedures
Penalty
Summary
The facility failed to follow its own policies and procedures for discharge planning and unplanned discharges for multiple residents. For three residents who left the facility unexpectedly, there was no documentation that Adult Protective Services (APS) were notified or that any attempts were made to locate the residents after they left. In one case, a resident left the facility with all her belongings and was later found at a local fast-food restaurant in a disheveled state, but there was no evidence that the facility contacted emergency contacts, APS, or the police, nor did staff attempt to locate her. Similarly, two other residents left the facility, one after refusing to sign an Against Medical Advice (AMA) form, and no further action was taken by the facility to ensure their safety or notify appropriate authorities. Additionally, the facility did not provide adequate discharge planning for three residents who expressed a desire to return to the community or move to a less structured environment. Care plans and progress notes indicated that these residents were cognitively intact and had self-sufficiency skills, yet there was no evidence of active discharge planning or social service involvement to assist them in transitioning out of the facility. In interviews, these residents reported that although they had communicated their wishes to leave, they were not receiving help from the facility to facilitate their discharge. The Social Service Director and other staff confirmed that discharge planning was not initiated unless specifically requested by the resident, and that no active discharge plans were in place for the residents who had expressed a desire to leave. The facility's own policies require the involvement of social work staff in assessing discharge potential and coordinating community services, but documentation and staff interviews revealed that these procedures were not followed. The lack of action and documentation regarding both planned and unplanned discharges resulted in a failure to ensure safe and appropriate transitions for the affected residents.
Failure to Maintain Bed in Low Position and Use Floor Mat Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was in the low position and that a floor mat was in place as required by the resident's care plan. The resident, who was dependent for care and required a mechanical lift for transfers, was found on the floor next to the bed with a laceration above the right eyebrow after attempting to reach for a drink. The bed was observed to be in a high position and the floor mat was missing at the time of the incident. Staff interviews confirmed that the resident was left in bed with the mechanical lift sling under him, and the required safety interventions were not in place. The resident's medical history included significant risk factors such as a history of CVA with right hemiplegia, COPD, atrial fibrillation, CHF, epilepsy, and other chronic conditions. The care plan specifically directed staff to keep the bed in the lowest position and to apply floor mats to the side of the bed. Despite these interventions being documented, they were not implemented, resulting in the resident sustaining an injury that required sutures and evaluation at the emergency room.
Failure to Immediately Report Alleged Resident Abuse to Abuse Coordinator
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was immediately reported to the facility abuse coordinator as required by policy. The incident involved a resident who experienced a significant episode of loose stools, resulting in soiling of her clothes, the toilet, floors, and walls. During the cleanup, the resident reported that one CNA made a derogatory comment about the situation and told her to clean it up herself, while two other CNAs laughed at her. The resident felt embarrassed and upset by the staff's behavior and subsequently called her daughter to report the incident. The daughter then contacted the LPN on duty, who stated she reported the concern to the DON. However, the DON could not recall if the LPN had called her and mentioned that the resident's daughter may have texted her about the incident. The Social Services Director documented the daughter's concern but did not report the potential abuse to the facility abuse coordinator. As a result, the required immediate reporting of the abuse allegation to the administrator did not occur, contrary to facility policy.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident who experienced an episode of incontinence resulting in a significant mess. The resident reported feeling embarrassed and stated that a CNA made a derogatory comment about cleaning up the mess and told the resident to clean it up herself, while two other CNAs laughed at her. The resident did not initially report the incident to nursing staff but called her daughter, who then contacted the LPN on duty. The LPN reported the allegation to the DON, but the Administrator was not made aware of the incident and no investigation was initiated, as required by facility policy. The lack of investigation into the reported abuse constituted a failure to respond appropriately to an alleged violation.
Failure to Notify POA After Resident Fall
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) following a fall incident, which was a requirement according to their guidelines. The resident, who had multiple diagnoses including Hemiplegia, Morbid Obesity, and End Stage Renal Disease, fell out of his wheelchair while being lifted into a public transportation van. Although the resident reported hitting his head, he refused to go to the Emergency Department and proceeded to his dialysis treatment. The dialysis center's nurse noted the fall and contacted the nursing home for more information, discovering that the facility had not informed the POA about the incident. The facility's guidelines required immediate notification of the resident's physician and POA in the event of an accident or significant change in condition. Despite this, the facility did not notify the POA until after the dialysis center's nurse had already done so. Additionally, the facility failed to inform the dialysis center about the fall before the resident's treatment. The resident was later discharged from the facility without documentation of the discharge details or notification to the POA or physician. The resident was admitted to the hospital with septic shock and passed away after being transitioned to hospice care.
Failure to Assess and Intervene After Resident Fall
Penalty
Summary
The facility failed to ensure proper assessment and intervention following a fall incident involving a resident. The resident, who had multiple medical conditions including hemiplegia, morbid obesity, and end-stage renal disease, fell out of a wheelchair while being lifted into a public transportation van. Despite the resident stating they hit their head, no immediate neurological checks or vital sign monitoring were conducted, and the resident was transported to an off-site dialysis unit without notifying the dialysis staff of the fall. The facility's policy required neurological checks for unwitnessed falls, but these were not performed until several hours after the incident, just before the resident was transferred to the hospital for severe pain. The hospital diagnosed the resident with a subdural hematoma and a T8 fracture, indicating significant injuries from the fall. The facility's failure to conduct timely assessments and notify relevant parties contributed to the delay in addressing the resident's injuries. Additionally, the facility did not have a system in place to ensure the safety of residents using public transportation, as evidenced by the lack of intervention to secure wheelchair brakes during transport. The Director of Nursing acknowledged that no intervention was in place to ensure wheelchair brakes were applied for residents using public transportation, and the facility did not communicate with the dialysis staff regarding the resident's fall or the need for safety checks during transport.
Inaccurate and Delayed Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure accurate and timely documentation for a resident who experienced a fall. The resident, who had multiple medical conditions including hemiplegia, morbid obesity, and end-stage renal disease, fell and hit their head. Despite the facility's policy requiring immediate and thorough documentation of such incidents, the incident note was completed more than two days after the fall and the resident's discharge to the hospital. Additionally, the progress note indicating the resident's refusal to be transferred to the hospital was completed three days after the fall. The resident's medical record inaccurately documented the administration of medications and treatments on a day when the resident was not present in the facility, as they had been discharged to the hospital. Furthermore, the facility's report indicated that the resident was monitored post-return from dialysis, but the medical record lacked documentation of the time the resident returned or any ongoing monitoring. The resident was later sent to the emergency department with a thoracic spine fracture and subdural hematoma, yet the medical record did not include details of the resident's condition or assessments related to the transfer. The Director of Nursing acknowledged the lack of documentation for post-fall assessments, the resident's return from the emergency department, and the reason for the emergency department visit. The Licensed Practical Nurse admitted to accidentally charting on the resident's medication administration record, and the Administrator confirmed that the documentation was inaccurate and incomplete, emphasizing the expectation for staff to complete documentation by the end of their shift.
Inadequate Infection Control and Wound Care Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during the care of a resident with pressure ulcers and MRSA in the sputum. The resident, who had diagnoses including metabolic encephalopathy, Down syndrome, and early onset Alzheimer's disease, was observed in a room with a sign indicating droplet precautions. However, the staff did not adhere to the required PPE protocols. The Wound Care Nurse did not wear a mask or eye protection, and the LPN wore a surgical mask but no eye protection while performing a dressing change on the resident's wounds. Additionally, the wounds were not cleansed properly, as the same gauze pad was used on multiple wounds, and the cleansing technique did not follow the recommended inward to outward method. The Director of Nurses confirmed that the resident was still on droplet precautions due to MRSA and required full PPE, including gowns, gloves, N95 masks, and face shields, which was not followed. The sign outside the resident's room was incorrect and did not reflect the necessary precautions. The facility's policies on wound cleansing and infection control were not adhered to, as the wounds were not cleansed individually with fresh pads, and the risk of cross-contamination was not mitigated. The failure to follow these protocols posed a high risk for cross-contamination between residents.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide showers to three residents, R1, R2, and R3, as per their scheduled shower days, which is a deficiency in maintaining the residents' ability to perform activities of daily living. R1, who is moderately impaired for cognition, reported not receiving showers as scheduled, with no documentation of showers from 9/1 to 9/6, 9/8 to 9/13, and 9/15 to 9/21. R1 expressed the need for assistance with showers and stated she had not received a shower for about two weeks. R2, who is cognitively intact, also had no showers documented from 8/27 to 9/18 and 9/21 to 9/24, and reported only having two showers since admission in August. R2 requires setup support for bathing and expressed a need for a shower before an upcoming doctor appointment. R3, who is cognitively intact and requires total assistance for bathing, had no showers documented from 9/8 to 9/14. R3 had previously filed a grievance in June regarding not receiving showers, which was unresolved. Observations and interviews with staff revealed inconsistencies in shower documentation and a lack of adherence to the shower schedule. CNAs and the LPN confirmed that residents are supposed to receive showers twice a week, but documentation was lacking, and there was no evidence of residents refusing showers. The facility's administrator acknowledged the issue with documentation and noted that R1, R2, and R3 were not receiving showers regularly.
Failure to Provide Thickened Liquids at Night
Penalty
Summary
The facility failed to ensure that residents who required thickened liquids had access to fluids at night. Specifically, two residents, R1 and R2, who had physician orders for honey thick and nectar thick liquids respectively, were unable to receive fluids during the night due to a lack of thickener. On the night of 5/1/24, the nursing staff ran out of thickener, and since the kitchen, where the thickener is stored, was locked, they could not replenish their supply. This resulted in R1 and R2 not having access to the necessary thickened liquids throughout the night. Observations and interviews confirmed that both residents were without drinks during the night. R1 was found awake in bed with an empty cup on the overbed table, and R2 was also lying in bed without any drinks available. The nursing staff, including an agency RN and another RN, confirmed they did not have access to thickener and had run out at the beginning of their shifts. The cook confirmed that the kitchen provides the thickener and that nursing staff do not have access to the kitchen at night. The Director of Nursing acknowledged that residents should be offered fresh drinks throughout the shift and that the facility needed to ensure nursing staff had access to thickener for those who require it.
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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