Regency Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Springfield, Illinois.
- Location
- 2120 West Washington, Springfield, Illinois 62702
- CMS Provider Number
- 146139
- Inspections on file
- 24
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Regency Care during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and high fall risk were not adequately protected from accidents. One resident, dependent for mobility and transfers, was found on the floor and was forcefully lifted by a CNA from the floor to the bed without a nurse assessment, gait belt, mechanical lift, or assistance from other staff, while audibly expressing pain. The CNA did not report the fall to nursing staff, despite facility policy requiring nurse assessment and use of a full mechanical lift for floor transfers. Another resident, known to be very confused and a frequent wanderer, had documented fall-risk interventions such as a cushion and nonskid footwear but was able to leave bed and was later found on the floor in another resident’s bathroom shower area, complaining of pain and subsequently diagnosed with fractures. Staff interviews confirmed the resident’s ongoing wandering behavior and frequent reminders to sit, indicating that supervision and fall-prevention measures were not effectively implemented.
Multiple residents reported that call lights were not answered promptly, with some waiting up to 30 minutes for assistance. One resident, who required significant help with toileting and hygiene due to fractures and urinary retention, became incontinent after waiting too long for staff response, leading to feelings of humiliation. Resident council meetings and facility records confirmed ongoing concerns about delayed call light responses and unresolved issues.
The facility did not ensure that food served to residents was palatable or maintained at safe and appetizing temperatures. Food was observed to be cold, bland, and overcooked by the time it reached residents, with staff and residents reporting frequent complaints and the need to reheat meals due to delayed tray delivery and insufficient staffing.
Dishware, including trays and covers, were observed to be wet during meal service, causing napkins to become wet and water droplets to potentially fall onto food. Staff confirmed the issue, and the administrator noted insufficient supplies and time for proper drying, as well as the absence of a relevant policy. This affected all residents in the facility.
Staff failed to provide complete and appropriate incontinent and catheter care for several residents, including not cleansing the labia, urethral opening, or catheter tubing, not drying after cleaning, improper glove use, and lack of hand hygiene. These actions were inconsistent with facility policy and were observed in residents with catheters, cognitive impairments, and mobility issues.
Surveyors found that medications were not consistently labeled or securely stored, with several residents observed having medication cups left at their bedside and an unlabeled insulin pen found in a medication cart. Staff confirmed that leaving medications at the bedside was a common practice, and a bottle of Pepto-Bismol was found in a resident's room without a physician's order, all in violation of facility policy.
A resident with a history of falls, moderate cognitive impairment, and urinary retention requiring a catheter was admitted without a baseline care plan being developed and implemented within 48 hours, as required by facility policy. The omission occurred because the nurse completing the admission assessment did not answer the care plan questions in the electronic system, resulting in no interim care plan being generated to address the resident's immediate medical and safety needs.
Two residents did not have updated care plans reflecting their current clinical needs. One resident's care plan lacked documentation of a dialysis fistula site and necessary precautions for the left arm, while another's care plan did not accurately reflect the use of bed rails as observed and documented elsewhere. The facility did not revise care plans as required by policy.
A resident with multiple chronic conditions and moderate cognitive impairment did not receive scheduled showers or adequate grooming assistance, as evidenced by repeated observations of poor hygiene and the resident's own reports. Staff interviews and record reviews revealed missing documentation for showers, inconsistent staff responses, and a lack of facility policy regarding ADL care, resulting in the resident not receiving necessary hygiene support.
A resident with multiple medical conditions was administered oxygen therapy without a physician order or care plan, and staff failed to notify the medical director of the change in condition or the initiation of oxygen. The resident was later sent to the ER for acute hypoxia, but the required physician notification and documentation were not completed as per facility policy.
A resident with a stage 2 pressure injury on the coccyx did not receive the physician-ordered dressing during incontinence care. A CNA changed the resident's adult brief and returned the resident to a wheelchair without applying the required dressing, despite facility policy and wound care orders specifying the need for topical treatment on scheduled days.
Staff failed to follow safe transfer procedures with mechanical lifts, did not provide required supervision during meals for a resident with a recent choking incident, and left an oxygen cylinder unsecured on the floor. Additionally, another resident was transferred without staff maintaining physical contact, increasing the risk of accidents.
A resident requiring hemodialysis did not have consistent assessments of their dialysis access site documented, as required by facility policy. Staff interviews confirmed that assessments should occur every shift and after each dialysis session, but the necessary documentation was missing from the resident's records.
The facility did not complete required assessments, obtain physician orders, or secure informed consent before using bed rails for three residents with varying medical conditions, including hemiplegia, CHF, and cognitive impairment. Bed rail evaluations lacked documentation of alternatives, medical justification, and risk assessment, and staff confirmed that proper diagnoses and documentation were missing.
A resident admitted with pneumonia did not receive a prescribed course of oral Augmentin after hospital discharge because the medication order was not transcribed into the facility's physician orders. The DON confirmed the omission, and the physician indicated that all discharge medications were expected to be continued as written.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols during care for three residents requiring infection control measures. In separate incidents, an LPN did not wear a gown during nephrostomy care, and CNAs provided incontinent care and dressing assistance while only wearing gloves, failing to change gloves or perform hand hygiene between tasks. These actions did not comply with the facility's infection prevention policies.
A facility failed to follow physician orders for timely changing an indwelling urinary catheter for a resident with hydronephrosis. The catheter was changed 10 days late due to an oversight in scheduling, despite the resident being cognitively intact and aware of her care routine. The facility's policy required catheter changes every 30 days, but the lapse in adherence led to a deficiency.
A facility failed to follow a resident's care plan by not providing appropriate footwear during a transfer, resulting in a deficiency. The resident, with severe cognitive impairment and a history of falls, was transferred by a CNA wearing regular socks instead of the required non-skid footwear. The administrator confirmed this was against the care plan.
A resident with moderately impaired cognition reported that a CNA, who was on her phone while in the resident's room, later threw a bowl of soup at her. The resident was not injured, and the soup was not hot. The incident was reported to the BOM, who informed the DON. The CNA was advised to use her phone only during breaks but later left the facility upset and returned to throw the soup. The facility's policy to protect residents from abuse was not upheld, resulting in a deficiency.
A resident with a history of hyper-sexual behavior sexually abused another resident twice in one day, despite being removed from the room after the first incident. The facility failed to adequately supervise the abuser, leading to repeated abuse. The victim, who had severe cognitive impairment, was unable to recall the incident.
Failure to Follow Transfer Policy and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own transfer and fall-prevention policies and to provide adequate supervision, resulting in improper handling of one resident found on the floor and a fall with fracture for another resident. One resident (R2), with diagnoses including sepsis, cerebral infarction, type 2 diabetes, dementia, and cellulitis of the buttock, was severely cognitively impaired, dependent for mobility and transfers, and had documented upper and lower one-sided impairment. R2’s care plan identified a high risk for falls related to stroke history, traumatic brain injury, dementia, prior falls, incontinence, and medication use, with interventions such as a low bed, fall mat, bed/chair alarm, non-skid footwear, and keeping the resident within staff vision when up. R2’s fall assessment documented a high fall risk. Video evidence reviewed by the surveyor showed that on the evening of the incident, a CNA (V5) entered R2’s room where R2’s arm reached toward the CNA, and V5 then picked R2 up from the floor by the shoulders and forcefully placed the resident on the bed. The CNA then pulled on R2’s right leg and shirt to straighten the resident in bed and raised the bed, placing a pillow behind R2. During this transfer, R2 could be heard calling out “Ouch” and moaning. No gait belt, mechanical lift, staff assistance, or nursing assessment was used during this transfer, despite the facility’s transfer policy requiring that a nurse first assess any resident who has fallen and that, if medically appropriate, a full-size mechanical lift be used to transfer a resident from the floor. R2’s progress note later documented that it was reported the resident had rolled out of bed onto the floor and was observed lying on the fall mat, with an assessment noting range of motion and neurological status within normal limits and no visible injuries. The facility’s abuse and fall investigations for R2 documented that the nurse on duty (V4, LPN) was not informed by the CNA that R2 had been on the floor, and other CNAs (V6 and V7) reported they were not aware of a fall and had not been asked to assist with a transfer. The Administrator (V1) stated that the incident was not reported by V5, that V5 did not tell the nurse that R2 had fallen or was on the floor, and that the transfer was not done in accordance with policy. R2’s family member reported having a video recorder in the room, observing V5 “very forcefully” handling R2 from the floor to the bed, hearing R2 yell “Ouch,” and submitting the video as a complaint. A second resident (R6) experienced a fall resulting in fractures. R6 had diagnoses including senile degeneration of the brain, hypertensive heart disease with heart failure, CHF, atrial fibrillation, and metabolic encephalopathy, and had a BIMS score of 4, indicating significant cognitive impairment. R6 required partial/moderate assistance with mobility, transfers, and walking, and was care planned as high risk for falls with interventions such as a cushion, nonskid footwear, and a clear pathway. R6’s progress notes documented that a CNA alerted the nurse that R6 was found on the floor in another resident’s bathroom, in the shower area, with the resident’s head and back against the shower wall, legs positioned toward the door, and the resident holding the left shoulder while tearful and complaining of pain in the head, left shoulder, buttocks, and right lower extremity, and verbalizing inability to move. The initial fall investigation for R6 documented that approximately 20 minutes before being found on the bathroom floor, R6 had been assisted to the bathroom and then to bed, with the call light placed within reach. After the fall, R6 complained of pain to the left shoulder, right lower extremity, and buttocks, and would not allow staff to assist off the floor due to pain. Vital signs and neurological checks were within normal limits, and the resident was sent to the emergency room at the request of the power of attorney. A CT scan showed a nondisplaced avulsion fracture of the right ilium and a minimally displaced right distal clavicle fracture. Staff interviews described R6 as very confused and a wanderer who frequently got up on her own despite use of a bucket seat and cushion, and that multiple staff, including kitchen staff, would remind her to sit down. Despite R6’s known wandering behavior and high fall risk, she was able to leave her bed area and be found on the floor in another resident’s bathroom, indicating that supervision and fall-prevention measures were not sufficient to prevent this fall and resulting injury. The facility’s written transfer policy required that when a resident falls to the floor, a nurse must first assess the resident and, if medically appropriate, a full-size mechanical lift must be used to transfer the resident from the floor, or EMS must be called if not medically appropriate. The fall policy required assessment of each resident’s fall risk on admission, quarterly, and with each fall, to guide care planning and monitoring to reduce injury risk. In R2’s case, the CNA did not follow the transfer policy, moved the resident from the floor without a nursing assessment or mechanical lift, and did not report the fall to nursing staff. In R6’s case, despite documented high fall risk and known wandering, the resident was able to ambulate unsupervised to another resident’s bathroom where the fall occurred, resulting in fractures, demonstrating that the facility did not provide adequate supervision or effective implementation of fall-prevention interventions for this resident.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
The facility failed to answer call lights in a timely manner for six residents, resulting in unmet needs and compromised dignity. One resident, who required substantial to maximal assistance for toileting and personal hygiene due to multiple fractures and urinary retention, reported waiting at least 30 minutes or more for staff to respond to her call light. As a result of the delay, she was unable to wait any longer and became incontinent, which she described as humiliating. The facility's policy requires prompt response to call lights and instructs staff to seek assistance if unable to meet a resident's needs immediately. During a resident council meeting, five additional residents reported that call lights were not answered promptly, sometimes taking up to 30 minutes. These residents, most of whom were cognitively intact, expressed ongoing concerns over delayed responses, with some stating that CNAs would check the reason for the call light but leave without resolving the issue. Resident council minutes from previous months documented similar unresolved complaints about delayed call light responses, particularly at night.
Failure to Serve Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to serve palatable food to its residents, as evidenced by multiple observations, interviews, and record reviews. During a meal service observation, food temperatures were initially within safe ranges on the steam table, but by the time trays were delivered to residents, the food had cooled significantly, with sampled items measuring between 106 and 124 degrees Fahrenheit and described as cold, lukewarm, dry, tough, and bland. Staff interviews revealed that food is often reheated for residents due to delays in tray delivery, attributed to insufficient staffing. There was no facility policy on ensuring food palatability. Resident council meeting minutes over several months documented ongoing complaints about food being overcooked, cold, and inconsistently served at appropriate temperatures. Residents and staff confirmed these issues, with one resident explicitly stating the food is usually cold and unpalatable, and a CNA acknowledging frequent complaints about cold food and the need to reheat trays. Observations included instances where residents received cold food after returning from therapy, requiring staff to warm up their meals. The deficiency affected all 87 residents in the facility, as documented in the facility's application for Medicare and Medicaid.
Failure to Properly Dry Dishware Before Use
Penalty
Summary
The facility failed to ensure that dishware, including trays and dish covers, were properly dried before use during meal service. During kitchen service, trays and dish covers were observed to be wet, resulting in napkins becoming wet and water droplets from the dish covers potentially dropping onto the food. A dietary aide confirmed the trays were wet, and the cook indicated that the dishware likely was not shaken out enough to dry. The administrator acknowledged a lack of sufficient supplies and time between meals to allow for proper drying and also stated that there was no policy in place regarding palatable food or drying dishes. This deficiency had the potential to affect all 87 residents residing in the facility, as documented in the facility's application for Medicare and Medicaid.
Failure to Provide Complete Incontinent and Catheter Care
Penalty
Summary
The facility failed to provide complete and appropriate incontinent and catheter care for five residents, resulting in deficiencies related to the prevention of urinary tract infections (UTIs). Direct observations revealed that staff did not follow established protocols for perineal and catheter care, such as cleansing the labia, urethral opening, and catheter tubing, or ensuring proper drying after cleaning. In one instance, a resident with an indwelling urinary catheter and a history of urinary retention was not properly cleaned around the catheter site, and the drainage bag was positioned above the bladder, contrary to policy. The resident was subsequently treated for a UTI. Other residents with significant medical histories, including morbid obesity, Parkinson's disease, and cognitive impairments, were also observed receiving incomplete care. Staff failed to clean all necessary areas, did not change gloves between soiled and clean tasks, and neglected hand hygiene after providing care. In some cases, staff did not use appropriate personal protective equipment (PPE) while on enhanced barrier precautions, and did not follow proper procedures for cleaning and drying the perineal and anal areas. Supplies and techniques used, such as reusing washcloths and not rinsing or drying the skin, were inconsistent with facility policy. Facility policies required thorough cleaning of the perineal area, including the external genitalia and anal area, with separate strokes and clean sections of washcloths, as well as rinsing and drying. However, staff actions deviated from these protocols, as evidenced by multiple instances where residents were not properly cleaned, dried, or protected from cross-contamination. These failures were confirmed by interviews with staff and review of facility policies, which outlined the correct procedures that were not followed during care.
Improper Medication Storage and Administration Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and administration practices. An opened Basaglar insulin pen was found in the medication cart without a resident label, name, or date of opening, and the responsible RN stated the label must have fallen off. Several residents were observed with cups of medications left on their bedside tables, including one resident who had seven pills left in a cup after the scheduled administration time, and another who reported that the nurse routinely leaves morning medications at the bedside for later consumption. Staff interviews confirmed that it is common practice to leave medications at the bedside for residents to take on their own. Additionally, a bottle of Pepto-Bismol was found in a resident's room without a physician's order for its use. Facility policies require that medications be stored securely in properly labeled containers and that medications are not left at the bedside except in rare, care-planned circumstances. The observed practices did not align with these policies, as medications were not consistently labeled, stored securely, or administered directly to residents as required.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident with a history of falling and moderate cognitive impairment. The resident was admitted with diagnoses including a history of falls, chronic confusion, moderate memory loss, and urinary retention requiring a urinary catheter. Despite the facility's policy requiring a baseline care plan to be completed and implemented within 48 hours of admission, the electronic medical record did not contain a care plan addressing the resident's medical and safety needs. The administrator confirmed that the interim care plan was not created because the nurse responsible for the admission assessment did not complete the necessary care plan questions in the computer program.
Failure to Maintain Updated, Resident-Centered Care Plans
Penalty
Summary
The facility failed to maintain updated, resident-centered care plans that addressed the current needs of two residents. For one resident with end-stage renal disease and dependence on hemodialysis, the care plan did not include documentation of the left upper arm fistula site or instructions to avoid using the left arm for blood pressure measurements or blood draws, despite this information being present in other clinical records. The care plan only referenced general interventions such as fluid restriction, oral hygiene, medication administration, and monitoring for changes in mental status, but omitted critical details specific to the resident's dialysis access site. For another resident with hemiplegia, hemiparesis following a stroke, and epilepsy, the care plan documented the use of 1/4 side rails bilaterally to promote bed maneuverability. However, the resident's bed rail evaluation and direct observation indicated the use of bilateral 1/2 bed rails, and staff confirmed the resident attempted to use them during repositioning. The facility's policy required care plans to be evaluated and modified at least quarterly or with significant changes in condition, but the care plans for both residents were not updated to reflect their current needs and interventions.
Failure to Provide Scheduled Showers and Grooming Assistance
Penalty
Summary
A resident with diagnoses of congestive heart failure, chronic kidney disease, and osteoarthritis, and who was assessed as having moderate cognitive impairment, was not provided with adequate assistance for activities of daily living, specifically bathing and grooming. The resident required partial to moderate staff assistance for bathing and dressing, as documented in her care plan and Minimum Data Set. Over several days of observation, the resident was repeatedly noted to have greasy, matted hair and reported not having received a shower or bath for an extended period. The resident expressed discomfort and a desire for her hair to be washed, indicating that she only received limited hygiene care focused on her groin area. Interviews with staff revealed inconsistencies and a lack of documentation regarding the resident's showers. The CNA assigned to the resident stated that showers were scheduled on specific evenings but denied responsibility for the resident's care on those days. The LPN responsible for auditing shower records found no documentation of showers for the resident for the months reviewed and acknowledged that it appeared the resident had not received a shower since admission. When questioned, staff retroactively completed shower sheets, some indicating refusals, but these were not contemporaneous records. The facility administrator confirmed the absence of a policy for showers or ADL care and acknowledged that the lack of documentation and the resident's appearance suggested showers were not provided as scheduled.
Failure to Notify Physician and Document Oxygen Therapy Initiation
Penalty
Summary
The facility failed to clarify pre-operative instructions, document, and notify the physician of a change in condition while providing medical treatment without an order for one resident. The resident, who had diagnoses including atrial fibrillation, hypertension, and malignant neoplasm of the colon, was cognitively intact and did not have any care plan or physician order for oxygen therapy. Despite this, the resident was observed receiving oxygen via concentrator in her room, and staff reported she had been using oxygen at night for some time, though no order was found in her chart. On multiple occasions, the resident was seen with an oxygen concentrator in use, and at one point was noted to have blue-tinged lips and low oxygen saturation, prompting staff to administer oxygen and send her to the emergency room, where she was diagnosed with acute hypoxia. Documentation revealed that the medical director was not notified of the resident's change in condition or the initiation of oxygen therapy, as required by facility policy. The medical director confirmed there were no orders for oxygen and that she was not informed of the resident's condition changes or hospital transfer. Facility policy required prompt physician notification of significant changes in resident condition, including the commencement of new treatments such as oxygen therapy. However, staff failed to notify the physician in a timely manner, and the administrator acknowledged that the expected protocol was not followed. The lack of documentation, failure to obtain physician orders, and inadequate communication regarding the resident's condition and treatment changes led to the identified deficiency.
Failure to Apply Ordered Dressing to Pressure Ulcer
Penalty
Summary
A certified nursing assistant (CNA) was observed removing an incontinent resident's adult diaper and failing to apply a dressing to a pressure ulcer located on the resident's coccyx, despite physician orders specifying that a control gel formula dressing should be applied topically to the area on designated days. The CNA acknowledged that a bandage is normally placed on the sore but did not do so at the time, instead placing a new adult diaper and returning the resident to a wheelchair without the required dressing. The wound nurse confirmed that dressings are to be in place as ordered for pressure sores and referenced having performed the treatment the previous day. Facility policy requires adherence to nursing standards for wound management and the initiation of appropriate treatment protocols for pressure ulcers.
Failure to Prevent Accidents and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure safe transfer practices, adequate supervision during meals, and proper storage of oxygen cylinders for three residents. In one instance, a resident with hemiplegia and moderate cognitive impairment, who was dependent on staff for transfers, fell during a full mechanical lift transfer when the sling strap became unhooked. Observations revealed that staff did not double-check or pull down on the sling loops during subsequent transfers, and the administrator confirmed that aides should have been double-checking the straps and steadying the sling, which was not done. Another resident, who had a history of pneumonia and congestive heart failure and was cognitively intact, was observed eating unsupervised in his room despite a physician's order requiring supervision at all meals in the dining room. This resident had recently experienced a choking incident that required intervention. Additionally, an unsecured oxygen cylinder was found on the floor in the resident's room on multiple occasions, contrary to facility policy requiring cylinders to be kept in a cart, rack, or chained to the wall. A third resident, who was at risk for falls and required substantial assistance for transfers, was transferred using a full body mechanical lift without staff holding onto her while she was suspended in the air. The resident was moved across the room while swinging freely, and staff acknowledged that they did not maintain physical contact with the resident during the transfer, which was inconsistent with expected safety practices.
Failure to Consistently Assess and Document Dialysis Access Site
Penalty
Summary
The facility failed to consistently assess the dialysis access site for a resident with a diagnosis of dependence on renal dialysis. Documentation in the resident's electronic medical record showed that assessments of the left upper arm fistula were only recorded on two specific dates, with no documentation of assessments between those dates or after the most recent dialysis session. The facility's policy requires monitoring of the dialysis site every shift and upon return from dialysis for signs of bleeding and redness, but this was not reflected in the resident's records. Interviews with facility staff confirmed that assessments of the fistula site should be performed and documented at least every shift and after each dialysis session. However, the responsible LPN was unable to locate any such documentation for the resident in the medication or treatment records. The administrator also acknowledged that the required assessments and documentation were not present, indicating a failure to follow established protocols for monitoring dialysis access sites.
Failure to Assess, Obtain Orders, and Consent for Bed Rail Use
Penalty
Summary
The facility failed to conduct complete assessments, obtain physician orders, and secure informed consent for the use of bed rails for three residents. For one resident with hemiplegia and hemiparesis following a stroke, the bed rail evaluation did not document any alternatives considered, the medical reason for bed rail use, or the associated risks. The care plan indicated the resident required assistance with bed mobility using side rails, and observation confirmed the resident was in bed with half bed rails raised. A certified nurse aide stated the resident used the rails when being turned. Another resident with pneumonia and congestive heart failure had a bed rail evaluation that also failed to document alternatives, medical reasons, or risks, and there was no physician order for bed rail use in the medical record. This resident was observed in bed with side rails raised. A third resident with a history of falling and moderate cognitive impairment had a bed rail evaluation listing confusion as the reason for bed rails, which staff later stated was not an appropriate diagnosis for their use. There was no consent or physician order documented for this resident, who was also observed with side rails raised. Facility policy requires assessment, physician order, and consent prior to bed rail use, but these steps were not followed for the residents reviewed.
Failure to Administer Prescribed Antibiotic Following Hospital Discharge
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis of pneumonia did not receive a physician-prescribed antibiotic following hospital discharge. The hospital discharge plan and medication report specified that the resident was to receive amoxicillin-clavulanate (Augmentin) orally every twelve hours for three days. However, the facility's physician orders for March did not include this medication, resulting in the resident not receiving the prescribed antibiotic. The Director of Nursing confirmed that the hospital discharge orders for Augmentin were not transferred to the admitting orders, which led to the omission. The attending physician stated that the expectation was for the facility to transcribe and continue all hospital discharge medications as written.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for three residents who required Enhanced Barrier Precautions (EBP) and personal protective equipment (PPE) during care. In one instance, a resident with a history of sepsis, hydronephrosis, and a methicillin-susceptible staphylococcus aureus infection received nephrostomy care from an LPN who did not wear a gown, despite EBP signage and supplies being present outside the room. The LPN acknowledged that a gown should have been worn during the procedure. In another case, two CNAs provided incontinent care to a resident with morbid obesity, urinary tract infections, and an indwelling catheter due to hydronephrosis, while only wearing gloves and not utilizing other required PPE under EBP. The CNAs used soiled gloves to perform multiple care tasks, including dressing the resident and handling clean items, and did not perform hand hygiene after glove removal or upon leaving the room. The care provided was also incomplete, as certain areas were not cleaned or dried as required. A third resident, dependent on staff for toileting and with a history of Parkinson's disease and falls, was assisted by a CNA who donned gloves but failed to change them between soiled and clean tasks. The CNA used the same gloves to clean the resident after a bowel movement and then to dress the resident, without performing hand hygiene after glove removal or before leaving the room. The facility's own hand hygiene protocol requires hand cleaning before and after resident contact, after glove removal, and after contact with body fluids, which was not followed in these instances.
Failure to Timely Change Indwelling Urinary Catheter
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely change of an indwelling urinary catheter for a resident. The resident, who is cognitively intact and has a diagnosis of hydronephrosis with renal and ureteral calculous obstruction, reported that her catheter bag is regularly emptied, but she was unsure about the frequency of catheter changes. The facility's policy and physician orders required the catheter to be changed every 30 days or as needed. However, there was a lapse in following this schedule, as the catheter was changed 10 days late. The Director of Nurses confirmed that the catheter was due for a change on November 18, but the order was discontinued and subsequently changed on November 21. The next scheduled change was incorrectly set for December 31, resulting in a delay. The facility's catheter protocol mandates that catheter changes be recorded on treatment sheets and nurse's notes, but the oversight led to a deviation from the prescribed schedule, highlighting a failure in maintaining consistent catheter care as per the physician's directive.
Failure to Provide Appropriate Footwear During Resident Transfer
Penalty
Summary
The facility failed to adhere to a resident's care plan by not providing appropriate footwear during a transfer, leading to a deficiency in accident prevention. The resident, identified as R4, was admitted with diagnoses including heart failure, Alzheimer's disease, and dementia, and was documented as severely cognitively impaired, requiring moderate staff assistance with transfers. According to R4's care plan, she was at risk for falls and required specific footwear, such as properly fitting shoes or non-skid socks, during ambulation or mobilization. However, on December 23, 2024, a Certified Nursing Assistant transferred R4 from her bed to a wheelchair using a gait belt while she was wearing regular socks that were not non-skid. R4 was then left in her recliner without the proper footwear. The facility administrator acknowledged that the fluffy socks worn by R4 were not in accordance with her care plan.
Failure to Prevent Physical Abuse by CNA
Penalty
Summary
The facility failed to prevent physical abuse for a resident, identified as R2, who was involved in an incident with a Certified Nurse Assistant (CNA), V3. R2, who has moderately impaired cognition and requires assistance for mobility and dressing, reported that V3 was on her phone while in her room and later threw a bowl of soup at her. R2 did not sustain any injuries from the incident, and the soup was not hot. R2 had previously been in an abusive relationship but declined services and intervention at the time of the incident. The Business Office Manager (BOM), V5, was informed by R2 about V3's behavior, including being on the phone while in R2's room. V5 reported this to the Director of Nurses (DON), V2, who found V3 on her phone in the sunroom and advised her to use her phone only during breaks. Despite this, V3 was later reported by therapy staff for being on her phone during incontinent care. V3 left the facility upset after being spoken to about her phone use and returned later to throw soup at R2. The facility's Administrator, V1, and other staff were informed of the incident and assessed R2, finding no injuries. V3 was placed on a do-not-return list with the staffing agency. The facility's policy states that all residents have the right to be free from abuse, but the incident with V3 indicates a failure to uphold this policy, resulting in a deficiency in protecting residents from abuse.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R5, from sexual abuse by another resident, R1. On September 8, 2024, R5 was sexually abused twice by R1, an incident that was witnessed by a Certified Nurse Assistant (CNA), V5. Despite removing R1 from the room after the first incident, R1 was left unsupervised and re-entered the room to abuse R5 a second time. The abuse was reported to the Licensed Practical Nurse (LPN), V6, who was the manager on duty, and subsequently to the facility administrator, V1. R1 had a history of hyper-sexual and flirtatious behavior, with a previous incident of sexual abuse in February 2024. At that time, R1 was prescribed Provera, which was later discontinued but restarted after the incident with R5. R1's care plan included interventions to anticipate and meet his needs, provide positive interaction, and remove him from situations as necessary to protect others. However, these interventions were not effectively implemented, leading to the repeated abuse of R5. R5, who had severe cognitive impairment and impaired physical mobility, was unable to defend himself or recall the incident. The facility's policy on abuse prohibition clearly states that all residents have the right to be free from sexual abuse, and any suspected abuser should have no further contact with the resident involved or any other resident. The failure to adequately supervise R1 and protect R5 from further abuse constituted a significant deficiency in the facility's duty to ensure resident safety.
Removal Plan
- Nurse managers and Administrator interviewed all residents for abuse.
- Facility completed head to toe assessment on all residents by Nurse managers.
- All resident charts have been reviewed by the facility Administrator, DON, Nurse Managers and Social Service Director.
- The resident identified for exhibiting inappropriate behaviors is in a private room directly across from the nurse's station for supervision and 1:1 when choosing to exit his private room.
- Primary Care Physician reviewed chart and medications, ordered 5mg tablet of Provera daily and was initiated.
- Primary Care Physician requested a psychiatry consult.
- Facility Pharmacy consultant completed Medication Regimen Review and Chart Review.
- Facility sent referrals with resident's approval to multiple facilities for the resident to reside.
- The facility Social Service Director reassessed the resident's PTSD Screen for DSM-5/Trauma Informed Care, PHQ-2 to 9 Evaluation, Brief Interview for Mental Status (BIMS) Evaluation.
- Administrator provided education to each department manager regarding the facility Abuse and Neglect Policy.
- Department managers provided education to all staff regarding the facility Abuse and Neglect Policy.
- The Director of Nursing or designee will review behavior notes and progress notes of all residents to identify inappropriate behaviors and notify Administrator.
- The Administrator updated care plan of the resident identified for exhibiting inappropriate behaviors and staff were educated.
- Administrator provided education regarding the updated care plan for resident identified for exhibiting inappropriate behaviors to each department manager.
- Administrator and department managers provided education to all staff of the Care Plan revisions and updates.
- Administrator provided education to all department managers regarding resident's care plan.
- The Interdisciplinary Team (IDT) has reviewed, discussed and approved the Immediate Jeopardy Removal Plan.
- Administrator will monitor to ensure compliance of interventions put in place by auditing.
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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