Pleasant View Luther Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ottawa, Illinois.
- Location
- 505 College Avenue, Ottawa, Illinois 61350
- CMS Provider Number
- 145801
- Inspections on file
- 26
- Latest survey
- November 15, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pleasant View Luther Home during CMS and state inspections, most recent first.
A resident with impaired mobility and poor balance, assessed as a moderate fall risk, was left unsupported on the toilet during personal hygiene care after being transferred with a sit-to-stand lift. The CNA removed the lift sling and raised the enabler bar, leaving the resident unable to maintain balance, which resulted in a fall to the floor.
A resident experiencing depression and emotional distress following a separation and impending divorce did not receive psychosocial service interventions. The Social Service Director confirmed that the resident was not assessed for his feelings, was not included in any psychosocial programming, and that no such programs were available, with residents only attending general activities.
Two residents experienced improper handling of a bed bug infestation, with staff failing to consistently bag and remove all clothing and personal items, provide showers before room transfers, or document the incident and treatment. Staff interviews revealed confusion about procedures, and observations showed unbagged items left in affected rooms, contrary to facility policy and pest control recommendations.
A resident with a history of falls and cognitive impairment sustained a C1 fracture after tripping over another resident's wheelchair in a crowded dining area. Staff confirmed that the space was too narrow for safe ambulation and the resident's walker was not accessible, despite care plan interventions requiring its use. The facility did not identify or address environmental hazards or update fall prevention strategies after previous incidents.
A resident with dementia and major depressive disorder had her Zoloft dose reduced without her POA's knowledge or consent. The POA discovered the change after noticing the resident's emotional state and reviewing medication records. Facility documentation did not show consent for the dose reduction, and staff confirmed that notification and consent should have been obtained.
A resident's representative filed a grievance after finding the resident in bed, soaked in urine and not provided breakfast. Despite communicating concerns to a Resource Nurse and Social Service, the representative did not receive any follow-up or notification regarding the investigation or resolution of the grievance, contrary to facility policy requiring timely communication of grievance outcomes.
A resident who was frequently incontinent and required extensive ADL assistance did not receive timely incontinence care, resulting in the resident being found soaked in urine by a family member. Staff interviews confirmed that the resident was not checked or changed for an extended period, despite care plan interventions to keep the resident dry and prevent skin breakdown.
The facility failed to comply with its policies on hair restraints, food storage, and chemical storage, potentially affecting 76 residents. Kitchen staff did not fully cover their hair, and several food items were found unlabeled and undated. A Sanitizer chemical was improperly stored in the Dry Food Storage Room.
The facility did not ensure that its staff were trained in Hospice and End of Life Care for residents receiving hospice services. A RN and an LPN lacked the necessary education, and the administrator admitted the training was not assigned or completed. The RN confirmed she had not received such training since her hire.
A facility failed to follow proper infection control practices during a pressure ulcer dressing change for a resident. An RN did not perform hand hygiene or change gloves appropriately, using the same soiled gloves to cleanse the wound, apply ointment, and handle personal items and surfaces. The RN also disposed of garbage and moved an overbed table without sanitizing hands, contrary to the facility's infection control protocols.
The facility failed to follow its policy for changing and labeling oxygen tubing and humidifier bottles weekly for two residents. One resident had a humidifier bottle dated over a week old and undated tubing, while another had both the humidifier bottle and nasal cannula undated. The DON confirmed the policy requirement.
A facility failed to obtain written physician orders from Hospice providers for a resident with a terminal prognosis. Hospice orders were often given verbally, and facility nurses entered them into the EHR without written documentation. This led to confusion among staff, as one nurse was unaware of the correct method to administer Ativan. The lack of written orders and clear communication contributed to the deficiency in care.
A facility failed to document a clinical rationale for extending a PRN psychotropic medication order for a resident. The policy requires PRN orders to be limited to 14 days unless a rationale is documented. A resident had an order for Alprazolam for 30 days without a documented rationale. An LPN confirmed the extension was made without written justification.
The facility failed to ensure proper coordination and documentation of hospice services for residents, affecting three individuals with Alzheimer's Disease. Necessary hospice care plans, prescribers' orders, and clinical notes were missing from medical records. Communication between hospice and facility staff was primarily verbal, leading to insufficient documentation.
The facility failed to post Ombudsman contact information on resident floors, affecting all 77 residents. Residents were unaware of how to contact the Ombudsman, and the only poster was located on the first floor, where no residents reside. The Community Ombudsman had not visited in over a year and had difficulty reaching the Activity Director.
The facility failed to make the Survey Binder, containing prior survey results, accessible to residents. Residents were unaware of the binder's existence and location, which was found placed out of reach and view behind picture frames on a high ledge. Additionally, the binder lacked recent survey results, affecting all 77 residents.
The facility failed to provide written notifications to residents or their representatives regarding hospital transfers, affecting six residents. The administrator confirmed reliance on verbal notifications, contrary to policy requirements for written communication. This deficiency could impact all 77 residents.
The facility failed to provide the Bed Hold Policy to residents or their representatives during emergency hospital transfers, affecting six residents. The policy requires notification before hospitalization and at the time of transfer, but documentation showed no evidence of compliance. The Social Security Director confirmed that notifications were not provided as required.
A resident with dementia was sexually abused by another resident with a history of problematic behaviors in an LTC facility. The incident involved inappropriate touching and resulted in the victim feeling frightened and requiring hospital examination. Despite known risks, the facility failed to prevent the incident, leading to an Immediate Jeopardy situation.
A facility failed to implement its abuse prevention program, resulting in incidents of inappropriate sexual behavior between two residents. Despite policies requiring abuse screenings and reporting, these were not conducted or escalated, leaving residents vulnerable. The facility's inaction and lack of communication led to a deficiency in protecting residents' safety and rights.
A facility failed to report and investigate potential resident-to-resident sexual abuse involving two cognitively impaired residents. A CNA observed inappropriate behavior and reported it to an RN, who did not escalate the issue to the Abuse Coordinator, believing the residents could consent. The facility's policy on immediate reporting was not followed, and the administrator later confirmed the residents could not consent due to dementia.
A resident with Alzheimer's and other health issues, requiring assistance for ambulation, fell and fractured her femur due to a CNA's failure to use a gait belt as per facility policy. The incident led to a decline in the resident's condition and subsequent death. The CNA admitted to not using the gait belt, which was required for safety.
A facility failed to immediately report an allegation of physical abuse by a CNA towards a resident. The incident was reported the next morning, violating the facility's policy requiring immediate notification to the Administrator or Abuse Coordinator.
Failure to Implement Safety Interventions During Toileting Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement appropriate safety interventions for a resident identified as being at moderate risk for falls. The resident, who had impaired mobility and poor sitting/standing balance, was transferred to the toilet using a sit-to-stand mechanical lift. During personal hygiene care, the Certified Nursing Assistant (CNA) removed the lift sling and raised the enabler bar to provide more room, leaving the resident unassisted on the toilet. The resident was unable to maintain posture and balance, resulting in a fall to the floor. The facility's policies required that the harness safety strap be securely fastened and that the resident be properly supported during transfers and toileting. However, the CNA unhooked the resident from the lift and did not reapply the top harness before attempting to move the resident's feet onto the sit-to-stand lift. The CNA confirmed that the resident was unable to balance or stand without assistance, and that the enabler bars were intended for residents who could stand independently. The lack of proper support and supervision directly led to the resident's fall.
Failure to Provide Psychosocial Services for Resident in Emotional Distress
Penalty
Summary
The facility failed to provide psychosocial service interventions for a resident who was experiencing significant emotional distress due to a recent separation and impending divorce after more than 40 years of marriage. The resident reported feeling very depressed and stated that he would act out at times because he did not know how to handle his personal situation. He also indicated that the only interactions he had with the Social Service Director or other staff were when he was in trouble, and that no one had asked him about his feelings or what he was going through. The Social Service Director confirmed that the resident was not included in any psychosocial programming, had not been assessed regarding his feelings about the divorce, and that there were no psychosocial programs available in the facility, with residents only participating in general activities.
Failure to Follow Bed Bug Infection Control Protocols
Penalty
Summary
The facility failed to follow recommended guidelines for infection prevention and control in response to the presence of bed bugs in the rooms of two residents. Staff discovered bed bugs in one resident's room, and although clothing was bagged and removed on one occasion, there were inconsistencies in the handling of personal items and the timing of room treatment. On a previous occasion, not all clothing or items in drawers were removed, and staff questioned whether proper treatment was performed, as another live bed bug was found later. The pest exterminator did not arrive until several days after the initial report, and during this period, one resident was isolated in the room while the other was moved to a different room. Observations revealed that personal items such as shoes, socks, and toiletries were left unbagged in the affected rooms, contrary to the facility's own policy and the pest exterminator's recommendations. Staff interviews indicated a lack of consistent education and communication regarding the proper procedures for handling bed bug infestations. Some staff were unaware of the need to shower residents before moving them out of infested rooms, and there was confusion about the appropriate steps to take when bed bugs were found. Additionally, there was no documentation in the residents' medical records regarding the discovery of bed bugs or the treatment provided. The facility's policy required that all clothing and personal items be bagged, residents be showered and dressed in clean clothing from outside the room, and that personal belongings not leave the room until deemed bed bug free. However, these procedures were not consistently followed, as evidenced by staff and resident reports, lack of documentation, and direct observation of unbagged items remaining in the rooms. The failure to adhere to established protocols contributed to the ongoing presence of bed bugs and inadequate infection control practices.
Failure to Prevent Fall Due to Environmental Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to identify and address environmental hazards and did not implement effective fall prevention interventions for a resident with a known history of falls. The resident, who was assessed as a high fall risk due to Alzheimer's, vascular dementia, muscle weakness, and other conditions, required assistance with activities of daily living and was supposed to use a walker for support. On the day of the incident, the resident attempted to leave the dining room table, but the space was too narrow due to the placement of another resident's large wheelchair and a water cooler. The resident's walker was not accessible, and he attempted to step over the wheelchair, resulting in a fall that caused a head injury and a C1 (neck) fracture. Multiple staff interviews confirmed that the dining room layout did not provide adequate space for safe ambulation, especially for residents with mobility aids. The resident had a documented history of previous falls, and the care plan included interventions such as ensuring the use of a walker and anticipating the resident's needs. However, the care plan had not been updated with new interventions following recent falls, and environmental hazards in the dining area were not addressed. The facility's fall prevention policy required identification and mitigation of environmental risk factors, but these measures were not effectively implemented, directly contributing to the resident's accident.
Failure to Notify POA of Antidepressant Dose Change
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) regarding a change in the resident's antidepressant medication. The resident, who has diagnoses of dementia and major depressive disorder, had her Zoloft dose decreased from 75 mg to 50 mg without the knowledge or consent of her POA, who is also her daughter. The POA discovered the change after returning from vacation and noticing the resident was tearful and emotional. Upon reviewing the medication record, the POA found the dose reduction and stated she had not consented to it. The medication was later returned to the original dose at the POA's request, and subsequently increased with her consent. Review of the resident's psychotropic consent forms showed that the dose reduction to 50 mg was not documented, nor was there any record of the POA's consent for this change. The facility's resource nurse confirmed that the POA should be notified and consent obtained for any medication changes. The lack of notification and consent for the medication adjustment constituted a failure to follow required procedures for informing a resident's representative of significant changes.
Failure to Notify Resident Representative of Grievance Resolution
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's representative of the resolution of a grievance. The resident's daughter and Power of Attorney (POA) arrived at the facility and found the resident in bed, soaked in urine, with a strong urine odor in the room, and the resident had not been gotten up or fed breakfast. The POA communicated her concerns to the Resource Nurse via text and in person, expressing her desire to file a grievance and requesting follow-up. Despite this, the POA reported that she did not receive any communication from the facility regarding the findings or resolution of her grievance for nearly a month. The Resource Nurse confirmed receiving the grievance and acknowledged that an update should have been provided within 24 hours, but no follow-up communication was made to the POA. The Social Service staff completed a grievance form and documented the concern, but also did not notify the POA of the facility's response or findings. The facility's grievance policy requires that the resident or their representative be informed of the investigation's findings and corrective actions within seven working days, which was not done in this case.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of urine and required extensive assistance with activities of daily living did not receive timely incontinence care. The resident's facility assessment indicated a need for assistance with toileting and transfers. On the morning in question, the resident's daughter arrived to find the resident still in bed, soaked with urine, and attempting to get out of bed. The room had a strong urine odor, and the daughter was upset that the resident had not been toileted. Interviews with staff revealed that the night shift CNA last offered toileting at 2:30 AM, which the resident refused, and did not check on the resident again before the end of the shift. The day shift CNA reported only peeking into the resident's room at intervals without checking if the resident was wet or offering toileting assistance. The resident was not checked or changed until the daughter arrived and found the resident in a soiled state. The care plan for the resident included interventions to keep the resident dry and prevent skin breakdown, but these were not followed as documented.
Non-compliance with Food Safety and Storage Policies
Penalty
Summary
The facility failed to adhere to its policies regarding hair restraints, food storage, and chemical storage, which could potentially affect the safety and quality of food consumed by 76 of the 77 residents. Observations revealed that several kitchen staff members, including the Culinary Services Director, did not have their hair completely covered while in the kitchen, contrary to the facility's Use of Hair Restraints Policy. Staff members were seen with hairnets or caps that did not fully cover their hair, with tendrils, bangs, and beards left exposed. Interviews with the staff confirmed that they were aware of the requirement to cover all hair while in the kitchen. Additionally, the facility did not comply with its Storage Procedures and Date Marking Policies. Several food items in the Freezer, Walk-in Cooler, and Bakery Freezer were found without labels or dates, including individually wrapped meatloaf portions, a bag of rice, a pitcher of lemonade, sliced potatoes, sub sandwiches, and bags of cookies. Furthermore, a container of Sanitizer chemical was improperly stored in the Dry Food Storage Room, which is against the facility's policy that prohibits storing chemicals in food storage areas. The Kitchen Manager acknowledged the misplacement of the Sanitizer and the lack of labeling on the cookies.
Lack of Hospice and End of Life Training for Staff
Penalty
Summary
The facility failed to ensure that its staff were educated and competent in providing Hospice and End of Life Care for nine residents receiving hospice services. The Hospice Agreement for Nursing Facility, Inpatient and Inpatient Respite Care Services required that employees be familiar with the needs of hospice patients and competent in their care. However, training transcripts for a Registered Nurse and a Licensed Practical Nurse did not indicate that they had completed the necessary Hospice or End of Life education. The facility administrator acknowledged that the training was not assigned or completed for these staff members upon their hiring. Additionally, the Registered Nurse confirmed that she had not received any Hospice or End of Life training since her date of hire.
Inadequate Infection Control During Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during the care of a resident with a pressure ulcer. Specifically, a Registered Nurse (RN) did not perform hand hygiene or change gloves appropriately during a dressing change for a resident with a pressure ulcer located in the coccyx area. The RN used the same soiled gloves to cleanse the wound and apply ointment and dressings, and then proceeded to handle personal items and other surfaces without performing hand hygiene. This included retrieving a marker from her pocket, signing and dating the dressing, and placing the marker back into her pocket without changing gloves or sanitizing hands. Furthermore, the RN continued to handle various items and surfaces with soiled gloves, including gathering treatment supplies, wiping scissors, and cleaning the overbed table. The RN also disposed of the garbage and moved an overbed table into another resident's room without performing hand hygiene. The Director of Nursing confirmed that hand hygiene should be performed between soiled and clean tasks and after removing gloves, which was not adhered to in this instance.
Failure to Change and Label Oxygen Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R25 and R127, by not adhering to the policy of changing and labeling oxygen tubing and humidifier bottles weekly. For R25, the physician's orders required oxygen to be administered at 1-3 liters per minute via nasal cannula, with the tubing and humidifier bottle to be changed and labeled every Sunday night shift. However, on February 25, 2025, the humidifier bottle was dated February 16, 2025, and the oxygen tubing was not dated. Similarly, for R127, the orders specified oxygen at 2 liters per minute with the same weekly change and labeling requirement. On the same day, the humidifier bottle and nasal cannula for R127 were found undated. The Director of Nursing confirmed that the facility's policy mandates weekly dating and changing of these items.
Failure to Obtain Written Hospice Orders
Penalty
Summary
The facility failed to ensure that Hospice providers supplied written physician orders for a resident receiving Hospice services. The Hospice's agreement allowed nurses to receive and transcribe physician orders, which were to be countersigned by the facility's Director of Nursing or another nurse. However, for the resident in question, the facility did not have written documentation of medication order changes, aspiration risk orders, or instructions for administering medications. The resident's care plan indicated they were admitted to Hospice services with a terminal prognosis related to Alzheimer's Disease and Severe Protein Malnutrition, and they expired without the facility having complete Hospice documentation. Interviews with facility staff revealed that Hospice orders were often given verbally, and it was the responsibility of the facility nurses to enter these orders into the Electronic Health Record. The facility's Director of Nursing and Registered Nurses acknowledged that verbal orders were taken without written documentation, and the Hospice nurses did not leave progress notes or plans of care at the facility. This lack of written documentation led to confusion among the nursing staff, as one nurse admitted to not knowing the correct method of administering Ativan to the resident. The absence of written orders and clear communication between the Hospice and facility staff contributed to the deficiency in care provided to the resident.
Lack of Documentation for Extended PRN Psychotropic Medication
Penalty
Summary
The facility failed to document a clinical rationale for extending a PRN psychotropic medication order for a resident. The facility's policy requires that PRN orders for psychotropic medications be limited to 14 days unless the prescriber provides a documented rationale for extending the order. In this case, a resident had an order for Alprazolam, a psychotropic medication, to be administered as needed for anxiety for 30 days, three times per day. However, the clinical record did not include a documented rationale for extending the order beyond the standard 14 days. A Licensed Practical Nurse confirmed that the order was extended to 30 days without a written rationale, suggesting it was done to prevent the order from dropping off after 14 days.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure that hospice services were properly coordinated and documented for residents receiving hospice care. Specifically, the facility did not have the necessary hospice care plans, prescribers' orders, or clinical/progress notes available in the medical records for three residents under hospice care. This deficiency was identified during a review of hospice care management for a sample of 38 residents, affecting three residents with Alzheimer's Disease, one of whom had a terminal prognosis and expired during the review period. Interviews with facility staff and hospice personnel revealed that communication between the hospice and the facility was primarily verbal, with hospice nurses not leaving their notes at the facility. The Director of Nursing acknowledged that hospice orders were sometimes given verbally, and the Administrator admitted to having insufficient information in the facility's records. The hospice registered nurse confirmed that new orders or changes in care needs were communicated verbally, and there was uncertainty about whether the hospice office provided the facility with the necessary records.
Ombudsman Contact Information Not Visible to Residents
Penalty
Summary
The facility failed to ensure that the Ombudsman contact information was visible to residents on the second, third, and fourth floors. This deficiency was identified through observations, interviews, and record reviews. Residents from these floors attended a Resident Group meeting and expressed their unawareness of who the facility Ombudsman is, how to contact them, and reported not seeing any Ombudsman postings on their respective floors. The only Ombudsman poster was found at the entrance on the first floor, where no residents reside. Additionally, the Community Ombudsman reported not having visited the facility for over a year and mentioned unsuccessful attempts to contact the Activity Director, who did not return calls. The Activity Director claimed that the Community Ombudsman visits periodically but has not attended Resident Council Meetings. This lack of visibility and communication regarding the Ombudsman potentially affects all 77 residents residing in the facility.
Inaccessible Survey Binder and Missing Records
Penalty
Summary
The facility failed to ensure that the Survey Binder, which includes all prior survey results conducted by the State Agency, was easily accessible to residents. This deficiency was identified during a Resident Group meeting where several residents expressed their unawareness of the existence of such records and their location. The facility's policy states that residents have the right to see reports of all inspections from the last five years, but the residents reported not having seen this information or knowing where to find it. Upon investigation, it was found that the Survey Binder was placed on the upper level of the receptionist desk, approximately four and a half feet from the floor, and obscured behind two picture frames. This placement made it difficult, if not impossible, for residents, particularly those in wheelchairs, to see or reach the binder. Additionally, the binder was missing several recent survey results, including complaint or facility-reported incidents from the past year. The administrator confirmed the binder's location and acknowledged its inaccessibility to residents.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the reasons for their transfer to a hospital. This deficiency was identified for six residents who were transferred to the hospital for various reasons, including falls, changes in condition, and medical emergencies. The facility's policy requires that residents and their representatives be notified in writing and in a language they understand before a transfer or discharge occurs. However, in these cases, there was no documentation indicating that such written notifications were provided. The administrator confirmed that the facility does not provide written transfer forms to residents or their representatives, relying instead on verbal notifications. This practice was found to be inconsistent with the facility's own policy and regulatory requirements. The lack of written notification has the potential to affect all 77 residents residing in the facility, as it does not comply with the necessary procedures for informing residents and their representatives about transfers or discharges.
Failure to Provide Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the Bed Hold Policy to residents or their representatives during emergency hospital transfers, as required by their own policy. This deficiency was identified for six residents who were transferred to the hospital for various reasons, including falls, changes in condition, and passing a large clot. The facility's policy, dated December 4, 2020, mandates that a Notice of Bed Hold and Readmission Policy be provided before hospitalization or leave, with a second notice given at the time of transfer or within 24 hours of an emergency. However, documentation for residents R1, R5, R6, R11, R31, and R127 showed no evidence that such notices were provided during their respective hospital transfers. Interviews and record reviews revealed that the facility's Social Security Director acknowledged that residents only sign a bed hold contract upon admission and not with each hospital transfer or discharge. This practice contradicts the facility's stated policy and was confirmed by the inability to produce any bed hold notifications for the affected residents. The facility's CMS 671 Form indicated that 77 residents currently reside in the facility, suggesting that the failure to provide bed hold notifications could potentially affect all residents in the facility.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with dementia from sexual abuse by another resident, who also had dementia and a known history of problematic behaviors such as pacing, wandering, disrobing, and aggression. This incident occurred when the second resident placed his hand down the first resident's pants and performed aggressive sexual motions, resulting in the first resident feeling frightened and requiring a hospital examination where a minor tear near her vagina was noted. The incident was observed by a CNA during routine room checks, who then separated the residents and reported the incident. The first resident, who was severely cognitively impaired, had diagnoses including Alzheimer's Disease, Anxiety Disorder, Depression, and Unspecified Dementia with Agitation. The second resident, who was moderately cognitively impaired, had diagnoses including Vascular Dementia, Unspecified Dementia, Anxiety Disorder, and Major Depression Disorder. The second resident's care plan included monitoring for behaviors such as pacing, wandering, disrobing, and aggression. Despite these known risks, the facility did not adequately prevent the incident from occurring. The facility's policy on abuse and neglect emphasized the residents' right to be free from abuse, including sexual abuse, and required steps to be taken to ensure residents' protection when there is a suspicion of incapacity to consent to sexual activity. However, the facility failed to implement these policies effectively, as evidenced by the incident and the lack of prior intervention despite previous similar occurrences. The facility's failure to protect the resident from abuse resulted in an Immediate Jeopardy situation.
Removal Plan
- A head-to-toe assessment was completed on R1 and 1:1 monitoring was initiated for R2.
- Local police were contacted.
- R1 was sent out to the local hospital for evaluation and returned from the hospital with findings of a vaginal abrasion.
- R2 was maintained on 1:1 monitoring.
- Head-to-toe assessments were completed for each female resident residing on the memory care unit with no findings.
- Further staff interviews conducted with those who worked on the memory care unit with no findings of sexual abuse between R1 or R2 or any other residents.
- R1 was moved to a new room on a different floor.
- Care plan training for IDT for care planning requirements for actual/potential resident to resident abuse completed.
- Care plan updates completed on R1 and R2.
- Head to toe assessments conducted on all residents for signs and symptoms of abuse.
- Completion of the trauma abuse screening assessments on all residents to assess for signs and symptoms of abuse.
- Training took place on utilizing the Abuse and Neglect of a resident policy which includes exploitation and the prevention, detection and reporting expectations for all types of abuse. Training of all staff to be completed in person, or a call to that team member. Administrator was in-serviced by Regional Operations Director. Any team member who has not completed the training will not be able to work until training is completed.
- Administrator or designee will randomly interview four residents for any potential abuse allegations.
- Administrator or designee will interview four staff members to verify their understanding of the identification and reporting of abuse requirements.
- Results from the interviews will be reviewed by the QAPI Committee for any additional recommendations.
Failure to Implement Abuse Prevention Program
Penalty
Summary
The facility failed to implement its abuse prevention program effectively, leading to a deficiency in protecting residents from sexual abuse. Two residents, R1 and R2, were involved in incidents where R2 was observed engaging in inappropriate sexual behavior towards R1. Despite R1 being severely cognitively impaired and R2 being moderately cognitively impaired, the facility did not conduct the required abuse and neglect screenings since their admissions. The facility's policy mandates such screenings upon admission and quarterly, but these were not performed, leaving the residents vulnerable. The incidents included R2 attempting to lay in bed with R1 and being found in a compromising position with R1, which was witnessed by a CNA. The CNA reported these incidents to a nurse, but the nurse did not escalate the reports to the Abuse Coordinator as required by the facility's policy. This lack of reporting and follow-up allowed the situation to persist without appropriate intervention or preventive measures, such as room changes or increased supervision. Furthermore, the facility's staff, including the Social Service Director and the Administrator, were not informed of the incidents in a timely manner, which hindered their ability to take corrective actions. The facility's failure to adhere to its own policies and procedures for abuse prevention and reporting resulted in a deficiency, as the residents' safety and rights were compromised. The facility did not take adequate steps to protect the residents during the investigation, and the lack of communication and documentation contributed to the ongoing risk of abuse.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to identify and report a potential allegation of resident-to-resident sexual abuse involving two residents, R1 and R2, both of whom have cognitive impairments. The incident was first observed by a Certified Nursing Assistant (CNA), V4, who witnessed R2 attempting to undress R1. This was reported to the Registered Nurse (RN), V5, on duty, but no further action was taken to report the incident to the Abuse Coordinator or to investigate the matter further. The facility's policy requires immediate reporting of such allegations to the Abuse Coordinator, which was not followed in this case. A subsequent incident occurred where V4 observed R2 with his hand down the front of R1's pants, which was again reported to V5. Despite this, V5 did not report the incident to the Social Service Director/Abuse Coordinator, V3, and instead believed that the residents could consent to the interaction due to their perceived enjoyment. V5's personal beliefs about the residents' ability to consent, despite their cognitive impairments, led to a failure to follow the facility's policy on reporting and investigating potential abuse. The facility's administrator, V1, confirmed that the incidents were not reported as required and acknowledged that the residents were not capable of consenting due to their dementia. The facility's final report stated that consent could not be determined due to the residents' cognitive conditions, and the facility decided to act as if abuse had been substantiated. However, the lack of immediate reporting and investigation of the incidents represents a significant deficiency in the facility's handling of potential abuse cases.
Failure to Ensure Resident Safety During Assisted Ambulation
Penalty
Summary
The facility failed to ensure resident safety during assisted ambulation, resulting in a serious incident involving a resident who was at moderate risk for falls. The resident, diagnosed with Alzheimer's Disease, General Anxiety Disorder, Chronic Kidney Disease, Muscle Weakness, and a Displaced Intertrochanteric Fracture of the Left Femur, required partial to maximum assistance for ambulation. During an incident, the resident was being assisted by a CNA without the use of a gait belt, which was against the facility's policy. The resident tripped over a threshold and fell, leading to a fractured femur. The CNA admitted to not using a gait belt, acknowledging that it should have been used. Following the fall, the resident was taken to the emergency room and diagnosed with a left hip fracture. The resident underwent surgery and returned to the facility with increased confusion and required cueing, indicating a decline in condition. The resident was later admitted to hospice care and subsequently passed away. The death certificate listed aspiration pneumonia due to congestive hypertensive cardiovascular disease as the cause of death, with the femur fracture due to the fall and chronic kidney disease as significant contributing conditions. The resident's physician confirmed that the fall and fracture exacerbated the resident's decline and contributed to the subsequent death.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to immediately report allegations of employee-to-resident physical abuse to the Administrator/Abuse Coordinator for one resident. The incident involved a Certified Nursing Assistant (CNA) who allegedly punched a resident in the stomach. The CNA who witnessed the conversation about the abuse did not report it immediately to the appropriate authorities. Instead, she texted the Clinical Scheduler's phone after her shift ended, which was not checked until the following morning. This delay in reporting violated the facility's policy, which mandates immediate notification of abuse allegations to the Administrator or Abuse Coordinator. The incident occurred during mealtime when one CNA mentioned to another that she had punched a resident in the stomach to stop the resident's aggressive behavior. The CNA who heard this did not report it immediately due to fear and being new on the job. The Clinical Scheduler, who received the text message the next morning, then informed the Director of Nursing (DON) and the Administrator. The facility's policy clearly states that any team member who receives a complaint of abuse must notify their direct supervisor and the Coordinator of Abuse Prevention immediately, which did not happen in this case.
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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