Pinckneyville Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Pinckneyville, Illinois.
- Location
- 708 Virginia Court, Pinckneyville, Illinois 62274
- CMS Provider Number
- 146175
- Inspections on file
- 21
- Latest survey
- August 7, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pinckneyville Nursing & Rehab during CMS and state inspections, most recent first.
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.
The facility failed to provide RN coverage for 8 consecutive hours daily, 7 days a week, as required. Interviews and record reviews revealed inconsistent RN presence, especially on weekends, with several days lacking coverage. The facility's policy requires RN coverage, but it was not consistently met, potentially affecting all 42 residents.
The facility did not meet the required 80 square feet per resident in shared rooms, affecting several residents. Observations confirmed that rooms were only 75 square feet per resident. The DON acknowledged the requirement, and the Administrator confirmed that certain rooms do not meet this standard. Despite this, residents and a family member reported no issues with the space available.
The facility failed to implement effective surveillance and control measures for a potential scabies infestation, affecting seven residents. The Director of Nursing did not conduct a full skin audit or document the rashes on the Infection Control log. Permethrin treatment was ordered without confirming scabies through skin scrapings, and contact precautions were not implemented. Laundry procedures were not followed, contributing to the spread of rashes among residents and staff.
A resident with severe cognitive impairment and a risk for skin integrity issues did not receive appropriate care due to the facility's failure to follow physician's orders. Despite a care plan that included medication and a dermatology referral, the resident continued to suffer from severe itching and a rash. Miscommunication led to the resident not attending the dermatology appointment, and the Director of Nursing was unaware of the referral and biopsy orders, resulting in ongoing discomfort and potential harm.
A resident with cognitive deficits engaged in inappropriate sexual behavior with three other cognitively impaired residents. Despite being aware of the incidents, the facility failed to implement effective supervision or monitoring, allowing the behavior to continue. Staff reported inadequate staffing to manage the resident's behavior, and documentation of monitoring was inconsistent.
The facility failed to notify representatives of two residents about incidents of peer-to-peer sexual abuse. One resident was involved in an incident where another resident attempted to lift their shirt, which was not reported to the POA or the abuse coordinator. In another case, a resident was subjected to inappropriate behavior by a male resident, which was witnessed by a CNA but not documented or reported to the responsible party.
The facility failed to report peer-to-peer sexual abuse incidents involving three residents to the Administrator. An LPN witnessed a resident attempting to lift another's shirt but did not report it, and a CNA observed a resident masturbating with the door open, making sexual comments to another resident, but the incident was not reported. Both incidents involved residents with cognitive impairments.
A resident with Alzheimer's and cognitive deficits exhibited inappropriate sexual behaviors towards peers and staff. Despite medication adjustments and orders for increased supervision, the facility failed to consistently implement these interventions due to staffing challenges. This resulted in multiple incidents of inappropriate contact, highlighting a deficiency in ensuring resident safety.
The facility failed to provide adequate staffing, resulting in missed showers and delayed assistance for residents. Observations and interviews revealed that residents often experienced delays in receiving help, especially at night, and some had to attempt transfers without assistance, leading to falls. Staff reported operating with insufficient CNAs, struggling to meet the needs of residents requiring total assistance. The administration acknowledged the staffing issues, with wages not competitive enough to attract or retain staff.
The facility failed to provide timely ADL assistance to several residents due to staffing shortages. Residents missed scheduled showers, and there was inadequate documentation of care provided. Interviews revealed that the facility was often short-staffed, impacting the quality of care, with staff struggling to meet residents' needs and maintain proper documentation.
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 by regulations.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day, seven days a week, as required. This deficiency was identified through interviews and record reviews. Several staff members, including Licensed Practical Nurses (LPNs) and the Administrator, confirmed that RN coverage was inconsistent, particularly on weekends. The Director of Nursing (DON) and another RN attempted to cover the required hours, but there were days without RN coverage. The facility's nursing schedule from late February to early April documented multiple days without RN coverage. The facility's policy mandates RN coverage for 8 hours daily, 7 days a week, with LPNs covering in the absence of an RN, who would be on call. However, the policy was not adhered to, as evidenced by the lack of RN coverage on specific dates. The Administrator acknowledged the issue and mentioned efforts to hire more RNs to meet the requirement. This deficiency has the potential to affect all 42 residents living in the facility.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms for four residents. Observations revealed that two pairs of residents shared bedrooms that measured 150 square feet in total, equating to only 75 square feet per resident. These measurements were confirmed by the Maintenance Supervisor, who used a measuring tape to assess the room dimensions. The rooms did not include the closet or built-in dresser areas in the measurements, which did not affect the living area. The Director of Nursing acknowledged the requirement for two-resident bedrooms to have over 80 square feet per resident. The facility's Administrator confirmed that all rooms on A and B halls do not meet the 80 square feet per resident requirement, affecting rooms 1-10, 20-28, and other specified rooms. These rooms are dually certified for Medicare or Medicaid residents, and residents are notified of the room sizes upon admission. Despite the deficiency, residents and a family member expressed no issues with the room sizes, stating there was enough space for their needs, including the use of a mechanical lift for a resident in a wheelchair. The facility's floor plan indicates that these rooms are waivered for size.
Failure to Implement Effective Scabies Surveillance and Control
Penalty
Summary
The facility failed to implement effective surveillance measures to detect, treat, and prevent the spread of a potential scabies infestation among its residents. This deficiency was identified through interviews, observations, and record reviews, revealing that seven out of nine residents reviewed for infection control were affected. The failure to properly address the issue resulted in one resident experiencing intense itching for over a month, leading to distress, crying, facial grimacing, and a loss of appetite. The potential scabies infestation was not documented on the facility's Infection Control log, as the Director of Nursing, who also served as the Infection Preventionist, was unaware that such rashes needed to be included. The facility's Director of Nursing admitted that a 100% skin audit had not been conducted on all residents, and none had been seen by a dermatologist. The Medical Director had ordered Permethrin treatment for some residents, suspecting scabies, but no skin scrapings were performed to confirm the diagnosis. The facility's policy required that residents with scabies be placed on contact precautions, but this was not done. Additionally, the facility failed to follow proper procedures for handling potentially contaminated laundry, as residents' clothes and bed linens were not washed separately or in hot water as required. The report highlights that the facility's Infection Surveillance Monthly Report did not document the rashes as infections, and the facility's policies on scabies identification, treatment, and environmental cleaning were not followed. The Center for Disease Control (CDC) guidelines emphasize the importance of early detection, treatment, and appropriate isolation and infection control practices to prevent scabies outbreaks. However, the facility did not adhere to these guidelines, resulting in the spread of rashes among residents and staff, with some staff members having left the facility due to similar rashes.
Failure to Follow Physician's Orders for Resident's Skin Condition
Penalty
Summary
The facility failed to follow physician's orders for a resident with severe cognitive impairment, leading to a deficiency in care. The resident, who was admitted with diagnoses including Anxiety, Anorexia, Hyperlipidemia, Alzheimer's Disease, and Dementia, had a care plan addressing a risk for alteration in skin integrity. The care plan included medication for itching and a referral to a dermatology clinic. Despite these orders, the resident continued to experience severe itching and a rash, as documented in progress notes and observed by staff. The resident was seen scratching her arms, chest, and abdomen, with visible rashes, scabs, and bleeding under her fingernails. The deficiency arose from a miscommunication regarding the execution of the physician's orders. Although a referral to a dermatology clinic was documented, the resident never attended the appointment. The Director of Nursing was unaware of the referral and biopsy orders, indicating a breakdown in communication and follow-through. The resident's condition, including the need for a biopsy if the rash persisted, was not addressed, resulting in ongoing discomfort and potential harm. This lack of coordination and adherence to the care plan highlights the facility's failure to provide appropriate treatment and care according to the resident's needs and physician's directives.
Failure to Prevent Peer-to-Peer Sexual Abuse
Penalty
Summary
The facility failed to protect residents from peer-to-peer sexual abuse, involving a resident with a history of inappropriate sexual behavior. This resident, who was admitted with diagnoses including Alzheimer's Disease and moderate cognitive deficits, engaged in unwanted sexual contact with three other residents who were cognitively impaired and unable to consent. The incidents included touching residents' breasts and making unsolicited sexual comments. Despite being aware of these behaviors, the facility did not implement effective supervision or monitoring to prevent further incidents. The first incident occurred when the resident touched another resident's breast, which was witnessed by a Licensed Practical Nurse. Although the residents were separated immediately, the facility did not establish a plan for effective supervision. Subsequent incidents involved the same resident grabbing another resident's breast and making sexual comments to a third resident. These incidents were reported, but the facility's response was inadequate, as the resident continued to exhibit inappropriate behaviors without sufficient monitoring or intervention. The facility's records indicate that the resident was placed on 15-minute checks, but documentation was inconsistent, and there was no evidence of one-to-one monitoring. Staff reported being unable to adequately supervise the resident due to staffing shortages. The facility's failure to implement and maintain effective interventions allowed the resident to continue engaging in inappropriate behaviors, posing a risk to other residents.
Removal Plan
- The Facility has implemented and educated staff on its Abuse Policy, including effective, individualized interventions for all residents displaying inappropriate sexual behavior.
- All staff and department heads have been educated to ensure if there are reports of inappropriate sexual behaviors, they are to be immediately reported to their Administrator and individualized interventions need to be put in place to prevent further altercations. Education was provided by the Director of Operations and Regional Clinical Director. All licensed staff will be educated prior to their next shift. This will be reviewed and verified by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide reeducation if deficiencies are recognized. All audits and verifications will be provided to QA team.
- The facility has incorporated effective monitoring of residents with sexually inappropriate behaviors to ensure all residents remain free of resident to resident abuse.
- R1 was discharged to a Regional Hospital. Education for effective monitoring of inappropriate behaviors was provided by the Director of Operations and Director of Nursing. All staff will be educated prior to their next shift. This will be reviewed and verified by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide re-education if deficiencies are recognized. All audits and verifications will be provided to QA team.
- All reportables have been reviewed to ensure there are effective interventions in place and care plans are updated.
- R2, R3 and R7 have all had trauma assessments completed and psycho-social follow-up. No negative results noted.
- This will be reviewed and verified by the Director of Operations or Regional Nurse Consultants to ensure all items are in compliance and to provide re-education if deficiencies are recognized. All audits and verifications will be provided to QA team.
- The QA team was notified of the Immediate Jeopardy and the abatement plan that was put into place. The QA team will review the results of the audits, as referenced above, to ensure the plan of correction is effective.
Failure to Notify Representatives of Sexual Abuse Incidents
Penalty
Summary
The facility failed to notify the representatives of two residents about incidents of peer-to-peer sexual abuse. One resident, who was admitted with diagnoses including unspecified dementia and diabetes type 2, was involved in an incident where another resident attempted to lift their shirt. This incident was witnessed by a Licensed Practical Nurse (LPN) but was not reported to the resident's Power of Attorney (POA) or the facility's administrator, who is also the abuse coordinator. Consequently, an abuse investigation was not initiated, and the resident's representative was not informed. In another incident, a resident with severe cognitive impairment was subjected to inappropriate behavior by a male resident who was unclothed and masturbating with the door open. This resident was beckoned to engage in sexual activity, which visibly upset them. A Certified Nursing Assistant (CNA) witnessed the incident and reported it to a charge nurse, but there was no documentation of the incident in the resident's chart, nor was the responsible party notified. The facility's abuse coordinator confirmed that the incident was not reported to her, and therefore, the resident's representative was not informed.
Failure to Report Peer-to-Peer Sexual Abuse
Penalty
Summary
The facility failed to report incidents of peer-to-peer sexual abuse involving three residents to the Administrator, who is also the facility's Abuse Coordinator. In one incident, a Licensed Practical Nurse (LPN) witnessed a resident attempting to lift another resident's shirt at the nurse's station. Despite observing this behavior, the LPN did not report the incident to the Administrator, and no abuse investigation was initiated. The resident involved in this incident had a history of inappropriate behaviors, including exposing himself and making inappropriate comments, as documented in his care plan. In another incident, a Certified Nursing Assistant (CNA) observed a resident lying unclothed on his bed, masturbating with the door open, and making sexual comments to another resident passing by. The CNA redirected both residents and informed a charge nurse, but the incident was not reported to the Administrator. The residents involved in these incidents had cognitive impairments, with one being moderately impaired and the other severely impaired. The facility's Abuse Prevention Policy requires staff to report any incidents or suspicions of abuse immediately to the Administrator, which was not followed in these cases.
Inadequate Behavioral Interventions for Resident
Penalty
Summary
The facility failed to provide effective behavioral interventions for a resident, identified as R1, who exhibited inappropriate sexual behaviors towards other residents and staff. R1, who was admitted with diagnoses including Alzheimer's Disease and Adjustment Disorder, displayed moderate cognitive deficits and was ambulatory. The incidents began shortly after R1's admission, with the first reported incident involving unwanted contact with another resident, R2. Despite being separated and assessed, R1 continued to exhibit inappropriate behaviors, including touching another resident, R3, and making sexually inappropriate comments and gestures towards staff. The facility's response to R1's behaviors included medication adjustments and increased supervision orders, such as 15-minute checks. However, documentation revealed significant lapses in the implementation of these interventions, with numerous instances of missing documentation for the 15-minute checks. Staff interviews indicated that R1 was not consistently monitored as required, and there was a lack of sufficient staffing to provide the necessary one-to-one monitoring. Staff members reported feeling unable to adequately protect other residents from R1's behaviors due to these staffing challenges. The facility's Behavioral Assessment, Intervention, and Monitoring Policy required immediate safety strategies to protect residents from harm, but the report indicates that these measures were not effectively implemented. R1's behaviors continued to escalate, leading to multiple incidents of inappropriate contact with other residents and staff. The facility's failure to provide adequate supervision and intervention for R1's behaviors resulted in a deficiency in ensuring the safety and well-being of all residents.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its 45 residents, particularly in ensuring that residents received showers and assistance with care. Observations and interviews revealed that residents often experienced delays in receiving help, especially at night, and some residents, like R5, had to attempt transfers without assistance, leading to falls. The documentation showed that scheduled showers were frequently missed or not recorded for multiple residents, including R5, R4, R6, and R7, indicating a systemic issue with staffing and care provision. Interviews with staff and residents highlighted the severity of the staffing shortage. A Licensed Practical Nurse (LPN) and several Certified Nursing Assistants (CNAs) reported that the facility was often operating with only two or three CNAs, which was insufficient to meet the needs of residents, many of whom required total assistance with activities of daily living (ADLs) and had behaviors necessitating one-on-one supervision. The staff expressed that they were stretched thin, with some CNAs working alone in heavy workload areas and struggling to complete their duties, including providing showers and timely incontinence care. The facility's administration acknowledged the staffing issues, with the Administrator and Social Services Director frequently assisting on the floor. However, the Director of Nursing (DON) was noted to be less involved in direct care. The facility's wages were reportedly not competitive, contributing to difficulties in attracting and retaining staff. The lack of a specific policy for handling call-ins further exacerbated the staffing challenges, leading to instances where only one or two CNAs were available for extended periods, as documented in the nursing and CNA schedules.
Staffing Shortages Lead to Inadequate ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADL) for five out of seven residents reviewed. Residents were not receiving scheduled showers, and there was a lack of documentation for showers or refusals on multiple occasions. For instance, one resident, who is totally dependent on staff for ADLs, had no documentation of showers or refusals for several scheduled days. Another resident, who is cognitively intact but requires assistance with transferring, reported not receiving showers as scheduled and experienced a fall while attempting to transfer independently due to delayed staff response. The report highlights staffing shortages as a significant issue contributing to the deficiency. Interviews with staff and family members revealed that the facility was often short-staffed, with only a few CNAs available to assist residents. This shortage led to delays in responding to call lights and providing necessary care, such as transferring assistance and incontinence care. Staff members, including the administrator and social services director, were observed assisting on the floor, but the shortage persisted, impacting the quality of care provided. Family members expressed concerns about the lack of staff and the impact on resident care, noting instances where residents were left in wet clothing for extended periods. Staff interviews confirmed the challenges faced due to insufficient staffing, with CNAs struggling to complete their duties and maintain proper documentation. The facility's policy requires documentation of shower refusals and interventions, but this was not consistently followed, contributing to the deficiency in care.
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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