Richland Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Olney, Illinois.
- Location
- 900 East Scott Street, Olney, Illinois 62450
- CMS Provider Number
- 145135
- Inspections on file
- 39
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Richland Nursing & Rehab during CMS and state inspections, most recent first.
The facility failed to prevent multiple episodes of resident‑to‑resident physical abuse involving cognitively impaired residents with serious mental health and dementia diagnoses. In one case, a resident awoke to another resident standing over her in bed with gloved hands pressed over her mouth and nose, an event corroborated by staff interviews and the aggressor’s own statements. In a separate episode, a resident with known aggressive behaviors wheeled into another resident’s room, blocked the resident in a corner, and kicked the resident above the knee before a CNA could intervene. Hours later, the same aggressive resident self‑propelled behind another cognitively impaired resident seated at the nurses’ station and slapped her on the back, an event directly witnessed and reported by a CNA. These incidents occurred despite existing care plans and an abuse prevention policy that defined and prohibited such willful physical abuse.
A resident with dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease had physician orders for daily weights, MD notification for specified weight gains, and PRN bumetanide for weight increases. Weight records showed multiple days where the resident’s weight increased beyond ordered thresholds, but there was no documentation that the MD was notified. An LPN reported administering PRN bumetanide after noting a significant weight gain but did not recall notifying the MD, and the NP who followed the resident stated she was not informed of any weight gains during that period. This occurred despite a facility policy requiring prompt notification of the MD and DON when physician orders are not followed.
A resident with dementia, CKD, localized swelling, and interstitial pulmonary disease had a PRN order for bumetanide 1 mg PO to be given for specified weight gains. Weight records showed multiple days when the resident met the ordered parameters, but the MAR documented the dose as not administered on several of those days, as indicated by initials in parentheses. The Regional Clinical Director confirmed that the medication should have been given on those days according to the order, and the resident’s care plan did not address medication administration despite the PRN diuretic order.
A resident with multiple medical conditions was found unresponsive and did not receive CPR because staff were unaware of the resident's code status, despite documentation indicating full code. The care plan and physician orders lacked code status information, and the POLST form was not completed. Staff failed to follow facility policy requiring CPR initiation in the absence of a documented DNR, resulting in the resident not receiving life-sustaining measures.
A resident with multiple complex medical conditions was admitted without a documented code status or advance directive, and the required POLST form was not completed. Staff interviews revealed confusion about responsibility for advance directive completion, and facility policy requiring timely provision and inquiry about advance directives was not followed.
Multiple residents experienced physical abuse from peers, including biting, slapping, and hitting, which led to injuries such as bruising and a hip fracture. Staff and LPNs witnessed these altercations, and documentation confirmed that the facility did not prevent these incidents despite having an abuse prevention policy.
A resident with severe cognitive impairment, high fall risk, and dependence for mobility was left standing unassisted in a hallway while a CNA briefly left to retrieve a walker. During this time, the resident fell and sustained a comminuted fracture to the right arm and elbow. Staff interviews and documentation confirmed that the resident required continuous supervision, and the facility's fall management policy was not followed, leading to the incident.
Several residents did not receive timely assistance with ADLs, particularly toileting, and experienced long call light response times. One resident with severe cognitive impairment and incontinence repeatedly requested help for over half an hour without receiving assistance, resulting in an episode of incontinence and visible distress. Other residents reported similar delays, sometimes attempting self-toileting to avoid accidents. Staff cited insufficient CNA coverage and policies that prevented them from interrupting feeding to assist with toileting, despite facility policies requiring prompt response.
The facility did not provide enough nursing staff to meet residents' needs, resulting in delays in toileting assistance, inadequate supervision during meals, and insufficient monitoring of residents with cognitive impairments. Staff and residents reported that care was not delivered in a timely manner, and documentation confirmed low staffing levels across multiple shifts. These deficiencies led to residents being left unattended, soiling themselves, and experiencing falls due to delayed responses.
Surveyors found that the dining room floor remained unclean for two consecutive days, with dried spills, food debris, dirt, and seeds present despite daily housekeeping routines. The administrator agreed the cleanliness did not meet facility standards, and an LPN noted that housekeeping staff were not consistently sweeping and mopping, sometimes requiring nursing staff to clean instead. Facility policy requires daily and as-needed cleaning, but these procedures were not followed, affecting all residents who dined in the area.
Two residents requiring substantial assistance did not receive timely help with ADLs, including toileting and scheduled showers. One resident with severe cognitive impairment and incontinence was left waiting for over 30 minutes for toileting assistance, resulting in incontinence episodes, while another dependent resident missed multiple scheduled showers over two separate six-day periods, with documentation errors and no evidence of alternative hygiene care provided. Staff interviews confirmed delays and inadequate care due to staffing and scheduling issues.
Multiple residents with dementia did not receive timely, person-centered care, including assistance with toileting and supervision during meals, resulting in distress, incontinence, and unsafe behaviors. Staff were unable to meet residents' needs due to inadequate staffing and inconsistent activity programming, and care plans lacked individualized dementia interventions.
A cognitively impaired resident with Alzheimer's and a history of exit-seeking behaviors was able to leave the Dementia Care Unit unsupervised by accessing an unlocked office and exiting through an unsecured window. Staff were unable to redirect the resident despite multiple attempts, and at the time of the incident, were occupied with other residents. The resident was found by police after sustaining injuries from a fall and was treated at the ER. Investigation revealed that required door alarm checks were not performed daily, alarms were malfunctioning, and the environment was not adequately secured, contributing to the resident's elopement.
The facility did not consistently provide enough nursing staff on the Dementia Care Unit, with only one nurse and one or two CNAs often present despite the high care needs of 25 residents, including those requiring total assistance and behavioral supervision. Staff and family members reported difficulties in obtaining timely care and supervision, and assignment records confirmed multiple shifts with insufficient staffing, contrary to the facility's own policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility, was found by police with injuries, and was transported to the ER. The facility did not notify the resident's POA until after the resident returned from the hospital, failing to provide timely and comprehensive information as required by policy.
A facility failed to adhere to transfer protocols, resulting in falls and injuries for three residents. One resident with cognitive deficits fell due to unlocked wheelchair brakes, sustaining a fractured rib and dislocated shoulder. Another resident with cerebral palsy fell when a CNA did not apply necessary interventions, and a third resident with Parkinson's disease fell when a CNA let go of a gait belt. These incidents highlight a lack of adherence to care plans and proper communication among staff.
The facility failed to provide sufficient staff to meet the needs of all 78 residents, particularly in providing care for ADLs and supervision during meals. Residents reported not receiving scheduled showers or bed baths due to staffing shortages, and incidents occurred where a resident took food from others' plates due to inadequate supervision. Staff confirmed the staffing issues, noting that while the facility technically had enough staff according to census, they struggled to meet residents' needs.
The facility failed to maintain dignified dining services and uphold resident rights for four residents with cognitive impairments. A resident repeatedly took food from others' plates during meals, despite requiring supervision. Staff were aware but did not prevent the behavior, and the facility lacked a policy for resident rights, indicating a systemic issue in addressing these deficiencies.
The facility failed to provide adequate assistance with activities of daily living and meals for several residents due to staffing shortages. A resident did not receive regular showers or bed baths, while another was left with an unattended meal for an extended period. Staff confirmed the lack of sufficient personnel to provide necessary care, leading to deficiencies in resident hygiene and nutrition.
A facility failed to identify specific medical conditions necessitating the use of a physical restraint for a resident with dementia and other diagnoses. The resident was observed with a seatbelt restraint in a wheelchair during meals, contrary to the care plan that required the restraint to be removed during such activities. Staff interviews revealed uncertainty about the restraint's use, and the facility did not adhere to its policy on restraint documentation and assessment.
A facility failed to conduct a Level II PASARR evaluation for a resident with mental illness, including visual hallucinations and bipolar disorder. The initial Level I PASARR indicated a need for further evaluation, but it was not completed due to staff assumptions about the resident's other medical conditions. The Social Service Director was unaware of the new bipolar diagnosis, leading to non-compliance with PASARR requirements.
A resident with dementia and dysphagia, requiring a mechanically altered diet, was inadequately supervised during mealtime, leading to multiple instances of the resident taking regular consistency food from other residents' plates. Staff acknowledged the resident's history of such behavior, indicating insufficient supervision and adherence to dietary policies.
The facility failed to provide the correct diet for three residents, including one with dysphagia who received improperly prepared broccoli, another with a low BMI who received unminced vegetables, and a third at risk for impaired nutrition who did not receive finger foods as ordered. The Dietary Manager and Registered Dietician acknowledged issues with menu planning and execution.
The facility failed to follow proper infection control practices, as an LPN did not sanitize hands between administering medications to residents, and staff did not adhere to enhanced barrier precautions for a resident with an open wound and urinary catheter. Despite training, staff were unfamiliar with these precautions, and the DON acknowledged the need for further training.
The facility failed to respond promptly to residents' call lights, affecting the dignity and care of three residents. A resident experienced humiliation and pain from sitting in urine and feces due to delayed assistance. Another resident with moderate cognitive impairment reported waiting over an hour for care, worsening pain from existing wounds. A third resident faced similar delays, exacerbating pain in the coccyx area. Staff shortages were a significant issue, with only two CNAs available for 34 residents, leading to extended wait times.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. A resident reported waiting up to an hour and a half for assistance, leading to pain and incontinence. Another resident with moderate cognitive impairment experienced similar delays, exacerbating his discomfort due to existing wounds. Staff interviews confirmed ongoing staffing challenges, particularly on weekends, with insufficient updates to staffing schedules further complicating the issue.
The facility failed to maintain a clean and pest-free kitchen, affecting all 85 residents. Observations included food particles, debris, and dead bugs, including roaches, throughout the kitchen. The Dietary Manager was unaware of these issues, and the pest control measures were inadequate. The facility's cleaning schedule policy was not properly followed, leading to unsanitary conditions.
The facility failed to maintain an effective pest control program, leading to the presence of roaches and bed bugs. A resident was admitted with bed bugs, and the issue worsened when infested clothes were brought in. The facility did not follow its pest control policy due to a missing document, delaying treatment. In the kitchen, ongoing roach issues were exacerbated by cleanliness problems, hindering pest control efforts. Staff reported sightings of bugs, indicating a failure to adhere to pest control procedures.
A resident with severe cognitive impairment was physically abused by another resident with a known history of aggression. Despite previous interventions, the aggressive resident continued to attack, causing fear and insecurity for the victim. The facility failed to manage the aggressive behavior effectively, leading to a deficiency in providing a safe environment.
Failure to Prevent Multiple Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical abuse on the behavioral unit and other units, resulting in multiple altercations. One incident involved a resident with schizoaffective disorder and moderate cognitive impairment who was asleep in bed when she awoke to another resident, also diagnosed with schizoaffective disorder and anxiety disorder, standing over her with gloved hands placed over her mouth and nose and pushing down. The sleeping resident reported that the other resident was trying to kill her and yelled for her to get out of the room. Staff, including an LPN and a CNA at the nurses’ station, heard the yelling, observed the alleged aggressor coming up the hallway wearing medical gloves, and were informed by the victim that the aggressor had tried to cut off her breathing. Multiple staff interviews documented that the alleged aggressor did not deny placing her hands over the other resident’s mouth and nose and, in some accounts, demonstrated how she did it and stated she had planned it because she believed the other resident had taken fentanyl patches. A second incident involved a resident with severe dementia, expressive aphasia, and a history of cerebral infarction, who had care plan interventions for communication deficits and pain assessment. Another resident with dementia, cognitive communication deficit, and a care plan identifying wandering, verbal aggression, physical aggression, and resisting care was observed entering the first resident’s room. A CNA reported seeing the aggressive resident block the other resident in the room with her wheelchair in a corner and, before she could intervene, saw the aggressive resident kick the other resident above the knee. Nursing documentation confirmed that the resident was kicked by another resident, with no injury or complaints of pain noted at that time. A third incident occurred a few hours later and involved the same aggressive resident and another resident with unspecified dementia with behavioral disturbance, Alzheimer’s disease, seizures, generalized anxiety disorder, major depressive disorder, atrial fibrillation, delusional disorder, and chronic heart failure, who was severely cognitively impaired and care planned as at risk of abuse/neglect related to dementia. A CNA sitting at the nurses’ station witnessed the aggressive resident self‑propel her wheelchair behind this resident, who was seated in a wheelchair, and slap her on the back. The CNA separated the residents and notified nursing and administration. Progress notes and the facility’s incident reports documented that the aggressive resident had hit another resident in the back and that these were resident‑to‑resident altercations. Across these events, the facility’s abuse prevention policy defined abuse as the willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and required steps to prevent further potential abuse while investigations were in progress, but the incidents demonstrate that residents were not kept free from physical abuse by other residents.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of significant weight changes for a resident as required by physician orders and the care plan. The resident was admitted with diagnoses including dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease, and had a moderate cognitive deficit per the MDS. The care plan identified a problem of risk for impaired nutrition and hydration, with an intervention to monitor weight and notify the provider of significant weight changes. Physician orders directed staff to obtain daily weights before breakfast and to notify the physician for weight gain greater than 3 pounds in 1 day or 5 pounds in 1 week, and also included an order for PRN bumetanide to be given for specified weight gains. The resident’s January weight records showed multiple instances where the notification parameters were met: a 3‑pound gain in one day on three separate dates and a 5‑pound gain in one week on another date. An LPN stated she noted a 3‑pound weight gain on one of those days and administered the PRN bumetanide but did not remember notifying the physician. The Regional Clinical Director reviewed the resident’s weights and progress notes and was unable to find documentation that the physician had been notified of the weight changes as ordered. The Nurse Practitioner who routinely followed the resident stated she had not been notified of any weight gains during that month and indicated that, if notified, she would have directed staff to administer the PRN bumetanide as ordered. The facility’s policy on obtaining and following physician orders states that if orders are not followed for any reason, the physician and DON will be promptly notified, which did not occur in this case.
Failure to Administer PRN Bumetanide per Physician Order Based on Weight Gain
Penalty
Summary
Surveyors identified a deficiency related to failure to ensure a resident was free from significant medication errors when PRN bumetanide was not administered as ordered. The resident had diagnoses including dementia, chronic kidney disease, localized swelling, and interstitial pulmonary disease, and had a Brief Interview for Mental Status score indicating moderate cognitive deficit. The physician’s order, effective since 12/08/2025, directed administration of bumetanide 1 mg by mouth daily as needed for weight gain of more than two pounds in one day or more than three pounds in five days. The resident’s care plan did not include a problem area related to medication administration. Weight records for the month showed multiple instances of weight gain that met the parameters for bumetanide administration. The vitals/weight report documented specific daily weights demonstrating that the resident met the criteria for bumetanide on several days. Based on these weights, the medication should have been administered on multiple dates, including 1/3, 1/6, 1/7, 1/9, 1/11, 1/16, and 1/22. However, review of the Medication Administration Record showed that on many days the medication entry was marked with initials in parentheses, which the Regional Clinical Director confirmed indicated the medication was not given. The Regional Clinical Director also confirmed that the medication should have been administered whenever the resident had the specified weight gain and that this did not occur on at least 1/6, 1/7, and 1/16, contrary to the physician’s order and the facility’s policy requiring physician orders to be followed or the physician and DON to be notified if not followed.
Failure to Initiate CPR Due to Lack of Code Status Documentation
Penalty
Summary
Facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive, despite the resident being a full code. The resident was discovered without a pulse or respirations by two CNAs, who then notified a Registered Nurse (RN). The RN did not know the resident's code status and did not initiate CPR, assuming the resident was a Do Not Resuscitate (DNR) because there was no documentation in the electronic medical record. However, the resident's progress notes and hospital discharge summary indicated that the resident was a full code. The care plan and physician order summary did not document the code status, and the POLST form was not completed during the resident's 12-day stay at the facility. Multiple staff members, including CNAs and nurses, were unaware of the resident's code status at the time of the incident. The CNAs relied on the RN for direction, and the RN failed to check or confirm the code status before pronouncing the resident deceased. The facility had a system in place to indicate code status with colored stars outside resident rooms and in the electronic medical record banner, but this information was either missing or not utilized. Staff interviews revealed confusion and lack of familiarity with the resident and the facility's protocol for determining and documenting code status. The failure to initiate CPR was contrary to facility policy, which states that in the absence of a documented code status, staff should treat the resident as a full code and begin CPR. The lack of documentation, incomplete admission paperwork, and failure to verify code status led to the resident not receiving life-sustaining measures when found unresponsive. The resident was pronounced dead at the facility without any attempt at resuscitation, and the incident was identified as Immediate Jeopardy due to the failure to provide basic life support as required.
Removal Plan
- V2 (Director of Nursing), V14 (LPN / MDS) and V20 (LPN) were educated by V10 (Regional Clinical Director) on code status policy, death of a resident and change of condition policy, and the CPR policy.
- V4 (Registered Nurse) was educated by V2 on Code status policy, death of a resident, change in condition policy, notifications, and CPR policy.
- V9 (Social Services Director) and V14 completed an audit of all residents to ensure an order for a code status was in place, POLST form was in place and care plan indicates the order appropriately.
- V3 completed an audit of all staff who are CPR certified and schedule a class for the staff who are not.
- V3 reviewed the facility policy on CPR.
- V2 initiated and completed the following in-servicing with all nursing staff on CPR initiation policy including immediate initiation of CPR for all full code residents when unresponsive, documentation of a death, code status when to initiate CPR and change in condition policy.
- V9 (Social Service Director) will be doing ongoing monthly audit to ensure all code status orders remain accurate and current.
- V2 (Director of Nursing) will monitor. Random audits of 3 resident records per week for accuracy of code status and 2 staff interviews to verify knowledge of protocol. Results will be reviewed by V1 (Administrator) and the Quality Assurance Committee monthly.
Failure to Formulate or Offer Advance Directive Upon Admission
Penalty
Summary
The facility failed to formulate or offer to formulate an advance directive for one resident upon admission, despite the resident having multiple significant medical diagnoses, including cerebral infarction due to embolism, acute respiratory failure with hypoxia, acute on chronic diastolic heart failure, type 2 diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, and unspecified intellectual disabilities. The resident's face sheet and physician order summary did not include a code status or advance directive, and the care plan lacked a focused area addressing the resident's choices regarding advance directives. The POLST (Physician Order for Life-Sustaining Treatment) form was not completed at the time of admission, and there was confusion among staff regarding who was responsible for ensuring its completion. Interviews with facility staff revealed a lack of clarity and communication about the process for obtaining and documenting code status and advance directives. The administrator was unaware of the facility's policy on when POLST forms should be completed, and the social services director indicated a preference for residents to arrive with a completed POLST from the hospital. The social services director also noted that the resident was difficult to assess due to behaviors and a low BIMS score, and had not reviewed all hospital paperwork or ensured the POLST was completed. The nurse practitioner confirmed that no discussion had occurred with the resident's family regarding code status, and that in the absence of a POLST, the resident was automatically considered a full code. Facility policy required that written information about advance directives be provided to residents prior to or upon admission, and that staff inquire about the existence of any written advance directives. However, these procedures were not followed for this resident, resulting in a lack of documented code status or advance directive for 12 days after admission. Multiple staff members expressed uncertainty about their roles and responsibilities in this process, contributing to the deficiency.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving three out of six residents reviewed for abuse. In one incident, a resident with unspecified dementia and anxiety was bitten on the wrist by another resident with severe dementia, behavioral disturbances, and other neurological and psychiatric diagnoses. The biting incident resulted in a bruise, and in response, the first resident grabbed the other by the shirt and slapped them on the face. Staff witnessed the altercation, and documentation confirmed the physical interactions and resulting injuries. Another incident involved a resident with dementia and behavioral disturbances who was struck on the shoulder by a recently admitted resident with severe cognitive impairment and a history of traumatic brain injury, bipolar disorder, and major depressive disorder. The striking occurred as the first resident was walking by the second resident's room, leading to a loss of balance and a fall that resulted in a right hip fracture. Witnesses, including CNAs and a wound care nurse, confirmed the sequence of events and the resulting injury. The resident who initiated the physical contact stated they were trying to prevent the other from entering their room. The facility's abuse prevention policy defines abuse as the willful infliction of injury or intimidation resulting in physical harm or mental anguish. Despite this policy, the incidents described demonstrate that the facility did not effectively prevent resident-to-resident abuse, as evidenced by physical altercations resulting in injuries such as bruising and a hip fracture. The report includes direct observations and statements from staff and residents involved in the incidents.
Failure to Provide Adequate Supervision During Ambulation Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when the facility failed to provide proper supervision during ambulation for a resident with severe cognitive impairment and a high risk for falls. The resident had multiple diagnoses, including unsteadiness on feet, dementia, and a history of fractures. The care plan and assessments indicated that the resident was dependent for mobility, required maximum assistance from two staff members, and was not safe to ambulate or stand unassisted. Despite these documented needs, the resident was left standing in the hallway while a CNA briefly left to retrieve a walker, during which time the resident fell and sustained a comminuted fracture to the right arm and elbow. Interviews with staff confirmed that the resident was unsteady, impulsive, and should not have been left alone while standing or walking. The CNA involved stated that he attempted to get the resident to sit back in the wheelchair and then moved a few feet away to get the walker, at which point the resident stumbled and fell into the handrail. Other staff, including LPNs, the DON, and the facility administrator, all acknowledged that the resident required continuous supervision and should not have been left unassisted during ambulation or while standing. The facility's fall management policy required individualized interventions and supervision for residents at high risk for falls, including the use of assistive devices and staff assistance as necessary. The failure to follow these protocols and provide adequate supervision directly resulted in the resident's fall and subsequent injury. Documentation and staff interviews consistently indicated that the resident's needs for supervision were well known but not adhered to at the time of the incident.
Failure to Provide Timely ADL Assistance and Call Light Response, Compromising Resident Dignity
Penalty
Summary
The facility failed to ensure timely assistance with activities of daily living (ADLs), specifically toileting, and did not respond promptly to call lights, compromising the dignity of several residents. One resident with severe cognitive impairment and frequent incontinence was observed repeatedly requesting help to use the bathroom over a 35-minute period, both verbally and by seeking out staff, but did not receive assistance. During this time, staff members, including CNAs and a patient aid, informed the resident that they could not help due to being occupied with feeding other residents, and the resident ultimately experienced an episode of incontinence in a public area, becoming visibly upset and distressed. Other residents also reported excessive wait times for call lights to be answered, with some stating they had to attempt self-toileting to avoid accidents, despite requiring assistance. Multiple residents described call light response times as too long, sometimes up to an hour, particularly during meal times or when staffing was reduced. Staff interviews confirmed that there were not enough CNAs on duty to meet residents' needs in a timely manner, and that they were instructed not to interrupt feeding to provide toileting assistance. Facility policies reviewed by the surveyor required prompt response to residents' requests for toileting assistance and call lights, and prohibited practices that compromise resident dignity. Despite these policies, staff actions and statements indicated that care was delayed due to staffing shortages and prioritization of other tasks, resulting in residents' needs not being met in a manner that promotes dignity and respect.
Failure to Provide Sufficient Nursing Staff for Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to monitor and deliver timely care to residents, as evidenced by multiple direct observations, interviews, and record reviews. During a lunch period on the Alzheimer's unit, a resident with severe cognitive impairment and incontinence repeatedly requested assistance to use the bathroom but was told by staff that they could not help her immediately due to being occupied with feeding other residents. The resident became visibly upset, cried out for help, and ultimately soiled herself after waiting for an extended period without assistance. Other residents were observed wandering unsupervised, attempting to exit the facility, and eating food from other residents' plates, indicating a lack of adequate supervision and timely care. Staff interviews confirmed that the unit was short-staffed due to a CNA leaving early, leaving only two CNAs and a patient aid (PA) present. Staff consistently reported that this level of staffing was insufficient to meet residents' needs in a timely manner, especially during busy periods such as mealtimes. Staff also described being unable to stop feeding residents to provide other necessary care, and noted that administrative and nursing staff were not available to assist during these times. The PA stated she was not permitted to provide direct care, further limiting the available support. The nurse manager and DON acknowledged the chaotic environment and agreed that more staff would be beneficial, particularly during meals and evenings. Additional documentation and interviews revealed similar staffing concerns on other units and shifts, including night shifts where a nurse was shared between two units and only two CNAs were present. Staff described delays in responding to alarms, providing incontinence care, and assisting residents with activities of daily living. One resident experienced a fall when staff were occupied elsewhere and alarms were not heard in time. Multiple staff members and residents reported that care was not provided in a timely manner due to inadequate staffing, and assignment sheets confirmed the low staffing levels. The facility's own policy stated that adequate staffing would be maintained to meet residents' needs, but this was not observed in practice.
Failure to Maintain Clean and Sanitary Dining Room Environment
Penalty
Summary
The facility failed to maintain the dining room floor in a clean and sanitary condition for all residents who dined in the Center and East Halls Dining Room. Over the course of two consecutive days, surveyors observed multiple dried liquid spots, including what appeared to be dried milk and other clear or semi-clear substances, as well as debris such as food particles, dirt, and maple tree seeds scattered throughout the dining room floor. These observations were made despite the presence of housekeeping staff, and the same spills and debris remained unaddressed from one day to the next. The administrator acknowledged that the cleanliness observed did not meet the facility's standards. Interviews with staff revealed concerns about the adequacy and consistency of cleaning practices. A housekeeper described the daily cleaning routine, which included cleaning tables, sweeping, mopping, and taking out trash, and stated that the current staffing level was sufficient. However, an LPN reported that housekeepers were not routinely sweeping and mopping as expected, leading nursing staff to sometimes clean areas themselves. Facility policy requires daily cleaning and immediate attention to spills or soiling, but these procedures were not followed, resulting in a failure to provide a clean, safe, and homelike environment for residents.
Failure to Provide Timely ADL Assistance and Scheduled Showers
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents who required substantial help, resulting in unmet care needs. One resident with severe cognitive impairment, frequent incontinence, and a care plan requiring substantial assistance with toileting repeatedly requested help to use the bathroom over a 33-minute period. Despite her visible distress and repeated verbal requests to multiple staff members, she was not assisted in a timely manner. Staff were observed prioritizing feeding other residents and charting over responding to her toileting needs, and the resident ultimately urinated on herself while waiting for assistance. Interviews with staff confirmed that staffing shortages and task prioritization contributed to the delay, and documentation indicated that the resident was found with soiled clothing and incontinence products after the incident. Another resident, who was dependent on staff for bathing and required two-person assistance with transfers, did not receive scheduled showers for two separate six-day periods. The resident reported not having received a shower in two to three weeks, despite a physician's order for twice-weekly showers. Documentation errors were identified, with a CNA admitting to mistakenly recording showers that did not occur. There was also no documentation to support claims that the resident received bed baths during the missed shower periods. Staff interviews revealed that showers were often scheduled late at night, which may have contributed to missed care, but the resident denied refusing showers. The facility's own bathing policy requires regular and as-needed bathing assistance, but this was not followed for the residents in question. Staff and management acknowledged that the expected frequency of showers was not met and that residents should have been offered alternative hygiene care when showers were missed. The deficiencies were substantiated through direct observation, resident and staff interviews, and review of care plans and documentation.
Failure to Provide Person-Centered Dementia Care and Services
Penalty
Summary
The facility failed to provide necessary person-centered care and services to residents with dementia, as evidenced by multiple direct observations and staff interviews. During a continuous observation of the Alzheimer's unit dining area, a resident with severe cognitive impairment repeatedly requested assistance to use the bathroom but was not promptly assisted by staff, resulting in visible distress and incontinence. Staff were observed prioritizing other tasks, such as feeding residents and documenting, and stated they were not allowed to interrupt these duties to assist with toileting. The resident's care plan did not include progressive, person-centered interventions specific to her dementia diagnosis. Another resident with moderate dementia and behavioral disturbances was observed wandering the hallways and eating food from other residents' plates, despite being on a mechanical soft diet. Staff redirected her only after she had already consumed food from multiple plates. The care plan for this resident also lacked individualized, progressive interventions tailored to her dementia-related needs. Staff interviews confirmed that residents frequently wander into other rooms and that there are insufficient activities and supervision to engage and monitor them effectively. A third resident with severe cognitive impairment was observed handling dirty dishes and smearing food on her hands without appropriate staff intervention until after the fact. Staff interviews and record reviews revealed that staffing levels were inadequate to meet residents' needs in a timely manner, and that activity programming was inconsistent and often disrupted. The care plans for all three residents reviewed did not reflect person-centered, progressive interventions for dementia care, and the facility's own dementia protocol was not followed as required.
Unsupervised Elopement of Cognitively Impaired Resident Due to Lapses in Supervision and Environmental Security
Penalty
Summary
A cognitively impaired, ambulatory resident with a diagnosis of Alzheimer's disease and a history of exit-seeking behaviors was able to leave the facility's Dementia Care Unit unsupervised and unwitnessed. The resident exited the building, walked approximately one block away, fell in the street, sustained a skin tear over the left temporal region and abrasions on both hands, wrists, and elbows, and then entered an unlocked private vehicle. The resident was found by an off-duty police officer, who noted confusion and inability to provide his address or explain his whereabouts. The resident was subsequently transported to the emergency room for evaluation and treatment of his injuries. The resident's care plan and elopement evaluation had previously identified him as being at risk for elopement, with interventions such as redirection, notification of staff, diversional activities, and 30-minute checks. Despite these interventions, staff were unable to effectively supervise the resident on the day of the incident. Staff interviews and documentation revealed that the resident had been displaying increased exit-seeking and challenging behaviors throughout the day, including attempts to open doors, requests for keys, and verbal aggression. Staff attempted various redirection techniques, but these were unsuccessful. At the time of the elopement, staff were occupied with other residents, and the resident was able to access an unlocked office, open a window, and push out the screen to exit the building without triggering door alarms. Further investigation found that the facility had several environmental and procedural lapses that contributed to the incident. The office door providing access to the window was left unlocked, and the window was unsecured. Additionally, the north exit door's alarm system was not functioning properly, allowing doors to be opened without alerting staff. Maintenance logs showed that door alarms were not being checked daily as required by facility policy, and staff were unaware of this requirement. Staffing levels were also cited as a concern, with staff reporting that increased supervision was not possible due to the number of residents and the level of care required on the unit.
Removal Plan
- R1 was placed on 30-minute checks.
- R1's Care Plan was updated to reflect elopement interventions.
- V9 ensured the office door from which R1 was believed to have accessed a window to elope was locked.
- V5 installed a self-locking doorknob, replaced the window screen and secured the window.
- All residents identified at risk for elopement care plans were updated with interventions, as well as the facility's Elopement Binder by V9.
- V5 installed a self-locking doorknob on the north hall shower room, and secured the window so as not to allow opening.
- V5 and V13, Corporate Regional Director, confirmed the north exit door did not automatically open with 15 seconds of pressure.
- V9 completed Elopement Assessments on all residents of the Dementia Care Unit.
- V14, Minimum Data Set Coordinator, completed a Care Plan audit on all residents of the Dementia Care Unit to ensure Care Plans addressed elopement risk.
- V13 reviewed the Resident Supervision Policy with no changes made.
- V2 and V15, LPN/Assistant DON, completed staff education on resident supervision with all staff.
- V13 completed education for V5 regarding window and door security.
- V5 will complete window and door audits daily for one week, twice weekly for two weeks.
- V2 will complete a Facility Activity Audit to identify exit seeking behavior of residents daily for one week, twice weekly for two weeks, and weekly for 4 weeks.
- V9 will complete an audit of the Elopement Binder to ensure it is up to date according to Elopement Assessments daily for one week, twice weekly for two weeks, and weekly for four weeks.
Inadequate Staffing on Dementia Care Unit
Penalty
Summary
The facility failed to provide adequate nursing staff on the Dementia Care Unit, which affected all 25 residents living on that unit. The Director of Nursing (DON) confirmed that the standard staffing pattern was one nurse and two CNAs per shift, but acknowledged that this was not always achieved due to CNA call-ins. Staff interviews revealed that the unit was often staffed with only one nurse and one or two CNAs, which was insufficient given the residents' high level of care needs, including incontinence, mechanical lift transfers, total feeding assistance, and behavioral supervision. Staff also reported that requests for increased staffing were denied by corporate administration. Family and staff interviews further documented the impact of inadequate staffing, including difficulty finding staff to assist with resident care and supervision, and instances where family members were called to help manage resident behaviors. Assignment sheets confirmed that on multiple occasions, only one CNA and a shared nurse were present on the Dementia Unit during overnight shifts. The facility's own staffing policy required adequate staffing to meet resident needs and regulatory requirements, but documented staffing levels did not consistently meet these standards.
Failure to Timely Notify POA After Resident Elopement and Injury
Penalty
Summary
The facility failed to promptly notify a resident's Power of Attorney (POA) and provide a comprehensive report following an elopement incident. The resident involved had diagnoses including Alzheimer's Disease and Hypertensive Heart Disease with Heart Failure, was severely cognitively impaired, and had a documented history of wandering and exit-seeking behaviors. The care plan included interventions such as redirecting the resident, notifying staff of exit-seeking tendencies, providing diversional activities, and conducting 30-minute checks. On the date of the incident, the resident was found by an off-duty police officer approximately 0.2 miles from the facility, sitting in a vehicle with visible injuries including a laceration on the left eyebrow and abrasions on the hands, wrists, and elbows. The resident was disoriented, unable to state his address, and was subsequently transported to the emergency department for evaluation. Medical records confirmed the injuries and noted that the resident had escaped from the memory care unit, tripped, and fallen on the street before being returned to the facility. The facility did not notify the resident's POA until after the resident had returned from the emergency department, several hours after the elopement and subsequent injuries occurred. The POA reported being upset about not being informed when the facility first became aware of the elopement and not receiving full details of the event. Facility policy required prompt assessment and notification of a resident's designated medical contact in the event of a change in condition, which was not followed in this case.
Failure to Follow Transfer Protocols Leads to Resident Falls
Penalty
Summary
The facility failed to safely transfer residents according to their Transfer Assessments and Care Plans, resulting in falls and injuries. One resident, who had severe cognitive deficits and required substantial assistance for transfers, fell during a transfer from the toilet to a wheelchair. The resident's wheelchair brakes were not properly locked, leading to a fall that resulted in a fractured rib and dislocated shoulder. The resident had a history of impulsive behavior and agitation, which contributed to the incident. Another resident, diagnosed with cerebral palsy and requiring maximal assistance for transfers, fell when a CNA attempted to transfer her without applying necessary interventions such as shoes, socks, and a leg brace. The resident's legs gave out during the transfer, and she was lowered to the floor by the CNA. The resident was not injured, but the failure to follow the care plan and use appropriate equipment was evident. A third resident, with moderate cognitive deficits and Parkinson's disease, fell during a transfer to a bedside commode. The CNA assisting the resident let go of the gait belt to adjust the resident's oxygen tubing, resulting in the resident losing balance and falling. The resident sustained minor injuries, including skin tears. The CNA was unaware that the resident required assistance from two staff members for transfers, highlighting a lack of adherence to the care plan and proper communication among staff.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of all 78 residents, particularly in providing care for Activities of Daily Living (ADL) and supervision during meals. This deficiency was observed through multiple instances where residents did not receive scheduled showers or bed baths due to staffing shortages. For example, one resident, who is dependent on two-person assistance for transfers, reported not receiving a shower for over a month and only occasionally receiving bed baths. Another resident, also requiring substantial assistance, similarly reported not receiving regular showers or bed baths, with staff confirming that showers were missed due to insufficient staffing. Additionally, the facility failed to provide adequate supervision during meal times, leading to incidents where a resident with cognitive impairments took food from other residents' plates. This lack of supervision resulted in residents not receiving their dietary requirements, as seen when one resident's meal was taken by another, and the replacement meal did not meet the original dietary specifications. Staff acknowledged the issue, noting that additional help would be beneficial to ensure residents receive proper assistance during meals. The facility's Director of Nursing and several Certified Nurse Assistants confirmed the staffing issues, noting that the facility technically had enough staff according to census but still struggled to meet residents' needs. The documentation discrepancies, such as incorrect charting of shower tasks, further highlighted the staffing inadequacies. The facility's policy mandates regular showers and adequate staffing to meet residents' needs, yet these were not consistently met, as evidenced by the observations and interviews conducted during the survey.
Failure to Maintain Dignified Dining Services and Resident Rights
Penalty
Summary
The facility failed to provide dignified dining services and maintain resident rights for four residents with cognitive impairments, including dementia and communication deficits. One resident, who was unable to complete a mental status interview, repeatedly took food from other residents' plates during meal times. This resident, who required supervision or assistance with eating, was observed taking ham from the plates of three other residents, all of whom also had cognitive impairments and required dietary accommodations. The incidents occurred despite the presence of staff, who were aware of the resident's behavior but did not prevent it. The facility lacked a policy for resident rights, and staff were observed attempting to address the situation only after the food was taken. In one instance, a Certified Nurse Aide offered a replacement meal to a resident whose food was taken, but the replacement did not match the original dietary order. The facility's staffing policy indicated that adequate staffing should be maintained to meet residents' needs, yet the repeated incidents suggest a failure to adequately supervise and protect residents during meals. The facility administrator confirmed the absence of a policy for resident rights, highlighting a systemic issue in addressing and preventing such deficiencies.
Inadequate Assistance with ADLs and Meals Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically eating and bathing, for several residents. Resident R55, who is cognitively intact but dependent on assistance for bathing, reported not receiving a shower for over a month due to staffing shortages. Despite being scheduled for showers twice a week, documentation showed multiple instances where the activity did not occur, and staff confirmed the lack of sufficient personnel to provide the necessary care. R55 expressed a willingness to receive bed baths but noted that these were also infrequent. Resident R63, with severely impaired cognition, also did not receive regular showers or bed baths as required. The care plan indicated a need for substantial assistance, yet documentation and staff interviews revealed that showers were often missed due to inadequate staffing. R63 reported not remembering the last time he received proper bathing care, and observations noted poor hygiene, including oily hair and body odor. Staff acknowledged the challenges in providing care due to the limited number of CNAs available during night shifts. Residents R71 and R52 experienced issues with meal assistance. R71, who requires supervision and assistance with eating, was left with her meal covered and unattended for an extended period, resulting in her not eating until a new tray was provided. Similarly, R52, who is dependent on assistance for eating, waited over an hour before receiving help with his meal. The facility's policy on maintaining adequate staffing was not adhered to, leading to these deficiencies in resident care.
Failure to Properly Assess and Document Restraint Use
Penalty
Summary
The facility failed to properly identify specific medical conditions or symptoms that necessitated the use of a physical restraint for a resident, referred to as R71, who was part of a sample of 50 residents. R71, who has diagnoses including dementia, type 2 diabetes mellitus, and anxiety disorder, was observed with a seatbelt restraint while in a wheelchair. The Minimum Data Set (MDS) for R71 indicated that restraints and alarms were not used, yet the care plan documented the use of a seatbelt due to cognitive decline and safety risks. The care plan also specified that the restraint should be removed during activities of daily living, dining, and leisure activities, but observations showed that the seatbelt was not undone during meals, and R71 did not attempt to remove it herself. Observations over several days revealed that R71's seatbelt remained fastened during meal times, and she did not make any movements towards her food or the seatbelt. Interviews with staff, including a Certified Nurse Aide and the Administrator, indicated uncertainty about when the seatbelt should be undone and whether R71 could remove it on command. The facility's policy on restraint use emphasized the need for ongoing documentation and assessment, including recording the duration of restraint use and attempts to reduce its use. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and assessment for R71's restraint use.
Failure to Conduct Level II PASARR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a mental illness diagnosis was referred to the appropriate state-designated authority for a Level II PASARR evaluation. The resident, identified as R48, was admitted with diagnoses of visual hallucinations and bipolar disorder. The initial Level I PASARR form indicated a need for a Level II evaluation due to the mental health conditions. However, the Level II evaluation was not conducted because the facility staff believed the diagnoses were related to other medical conditions such as Parkinson's disease and Lewy body disease. The Social Service Director (SSD) was unaware of the new bipolar disorder diagnosis and did not initiate a new Level I screen or the necessary Level II evaluation. The facility's policy requires coordination with the PASARR program to ensure appropriate placement of residents with serious mental disorders. Despite this policy, the staff did not notify the SSD of the new bipolar diagnosis, leading to a failure in conducting the required Level II PASARR evaluation. This oversight resulted in non-compliance with the PASARR requirements for residents with mental health conditions, as the resident did not receive the necessary evaluation to determine the need for specialized services.
Inadequate Supervision During Mealtime for Resident with Special Dietary Needs
Penalty
Summary
The facility failed to provide adequate supervision to a resident, identified as R28, during mealtime, which led to multiple incidents of the resident taking food from other residents' plates. R28, who has diagnoses including dementia, anxiety disorder, and dysphagia oropharyngeal phase, requires a mechanically altered diet and supervision or assistance with eating. Despite these needs, R28 was observed on several occasions taking regular consistency food, specifically ham, from other residents' plates and consuming it, which is not suitable for her dietary requirements. These incidents occurred over a period of time during a single mealtime, indicating a lack of adequate supervision. Staff members, including a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN), acknowledged that R28 has a history of taking food from other residents and requires constant redirection. The facility's policy on consistency modified diets emphasizes the need for individualized diets based on residents' chewing and swallowing abilities, which was not adhered to in R28's case. Additionally, the facility's staffing policy states that adequate staffing should be maintained to meet residents' needs, which was evidently not sufficient in this instance, as R28 was able to repeatedly access inappropriate food items without proper intervention.
Failure to Adhere to Dietary Orders for Residents
Penalty
Summary
The facility failed to provide the diet as ordered for three residents, leading to deficiencies in meeting their nutritional needs. Resident 28, who has dementia and dysphagia, was observed receiving broccoli pieces that were not mechanically soft as per her dietary order. This inconsistency in food preparation could potentially impact her ability to safely consume her meals. Resident 71, who has dementia and a BMI less than 20, also received broccoli pieces that were not minced as required for her mechanical soft diet. The Dietary Manager acknowledged that the spreadsheet used for meal preparation did not differentiate between regular and mechanical soft diets, leading to the oversight. This failure to adhere to dietary orders could affect the resident's nutritional intake and overall health. Resident 66, who is at risk for impaired nutrition and hydration, did not receive finger foods as ordered. Instead, she was served mashed potatoes and gravy, which are not suitable as finger foods. The Dietary Manager admitted that the facility lacked a finger food menu, and the Registered Dietician was unaware of this issue. This lack of appropriate menu planning and execution could hinder the resident's ability to maintain adequate nutrition.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during resident care, as observed in the actions of a Licensed Practical Nurse (LPN) and other staff members. The LPN did not wash or sanitize her hands between administering medications to multiple residents, even after handling used medication and water cups by their rims. This lapse in hand hygiene was acknowledged by the LPN, who admitted to being nervous and unaware of her failure to sanitize. The Director of Nursing confirmed that hand sanitization between residents is a standard practice expected of the nursing staff. Additionally, the facility did not implement enhanced barrier precautions for a resident with an open wound and an indwelling urinary catheter, despite signage indicating the need for such precautions. Both a Wound Care Nurse and a Certified Nursing Assistant performed care without donning protective gowns, contrary to the facility's policy. Although both staff members had received training on enhanced barrier precautions, they were unable to explain the principles or demonstrate proper adherence. The Director of Nursing acknowledged the need for further training on infection control procedures and enhanced barrier precautions.
Delayed Response to Call Lights Affects Resident Dignity and Care
Penalty
Summary
The facility failed to respond to residents' requests for assistance in a timely manner, impacting the dignity and quality of life for three residents. Resident R3, who is cognitively intact and requires a mechanical lift for transfers, experienced significant delays in receiving assistance, leading to discomfort and humiliation from sitting in urine and feces. R3 reported waiting up to four hours for assistance on weekends, causing pain in the coccyx area and anxiety about when help would arrive. Resident R6, with moderate cognitive impairment and requiring substantial assistance for transfers, also experienced delays in care. R6 reported waiting over an hour for call lights to be answered, which exacerbated pain due to existing wounds and the inability to reposition independently. R6 emphasized the need for more staff, particularly on weekends, to address these delays. Resident R7, who is cognitively intact and at risk for pressure ulcers, faced similar issues with delayed responses to call lights. R7 reported waiting up to an hour for assistance, which worsened pain in the coccyx area. Staff shortages were noted as a significant issue, with only two CNAs available to care for 34 residents on certain days, leading to extended wait times for residents needing assistance.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, as evidenced by multiple instances of delayed response to call lights and inadequate care. Resident R3, who is cognitively intact and requires assistance with transfers, reported waiting up to an hour and a half for assistance, leading to pain and incontinence. On one occasion, R3's call light was observed to be unanswered for nearly an hour, and R3 expressed that the lack of staff was a consistent issue, particularly on weekends. Resident R6, who has moderate cognitive impairment and requires substantial assistance, also reported waiting over an hour for care, which exacerbated his discomfort due to existing wounds. Similarly, Resident R7, who is at risk for pressure ulcers, stated that the facility's staffing issues resulted in long waits for care, including the application of necessary creams to manage his condition. These delays in care were attributed to insufficient staffing, particularly on weekends, as noted by both residents and staff members. The facility's staffing records and interviews with staff members, including the Director of Nursing and Certified Nursing Assistants, confirmed the ongoing staffing challenges. The facility's policy requires adequate staffing to meet residents' needs, but the actual staffing levels often fell short, with call-ins and unfilled positions exacerbating the issue. The facility's failure to update staffing schedules accurately further complicated the situation, leading to inadequate care and unmet resident needs.
Facility Fails to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean, sanitary, and pest-free condition, which has the potential to affect all 85 residents. During a kitchen tour, several issues were observed, including the absence of paper towels at the handwashing sink, jelly packets, and cereal pieces on the storeroom floor, and food particles, dust, dirt, and debris scattered throughout the kitchen. Dead bugs, including roaches, were found on a paper bait trap and behind the oven. Additionally, bones were found on the floor under a metal table, and a towel under a leaking sink was brown and speckled. The Dietary Manager, V5, stated that the morning and evening staff are responsible for cleaning the kitchen, but was unaware of the bugs, debris, and bones on the floor. The facility's pest control measures were inadequate, as V1, the Temporary Administrator, acknowledged the presence of roaches in the kitchen and stated that the pest control company had been spraying routinely. However, the Pest Control Employee, V17, noted that cleanliness was an issue and that bugs would not be attracted to bait with food particles present. The facility's cleaning schedule policy, dated February 2012, requires a comprehensive cleaning schedule to be posted and monitored, but V5 admitted to discarding the old schedule after creating a new one. Despite the expectation for the kitchen to be cleaned continuously, the facility failed to adhere to its cleaning and sanitation policies, resulting in unsanitary conditions.
Pest Control Deficiency Due to Ineffective Program and Cleanliness Issues
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and bed bugs, which could potentially affect all 85 residents. The issue began when a resident was admitted with bed bugs, and the problem was exacerbated when the resident's family brought in clothes infested with bed bugs. Despite initial attempts to isolate the issue by moving the resident's roommate and conducting tape tests, the facility did not follow its policy due to the inability to locate it on the server. The pest control company was eventually called to treat the affected rooms, but the treatment was delayed. In the kitchen, the facility had ongoing issues with roaches, as evidenced by food debris and dead bugs found on the floor and behind equipment. The pest control company had been conducting routine treatments, but the problem persisted due to cleanliness issues. The pest control employee noted that the presence of food particles hindered the effectiveness of the bait traps. Despite assurances from the pest control company that a new treatment plan would resolve the issue, the facility continued to struggle with maintaining a clean environment, which contributed to the pest problem. Interviews with staff revealed that the facility had a history of pest issues, with staff reporting sightings of bugs in the kitchen and dish room. The facility's pest control policy required routine inspections and monitoring, but the lack of cleanliness and delayed response to pest sightings indicated a failure to adhere to these procedures. The facility's inability to promptly address the pest issues and maintain a clean environment led to the deficiency noted in the report.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent physical abuse of a resident by another resident with a known history of aggression. Resident 1, who has severe cognitive impairment, was physically abused by Resident 2, who also has severe cognitive impairment and a history of aggressive behavior. Resident 2, who was admitted with diagnoses including Moderate Dementia with Agitation and Intermittent Explosive Disorder, exhibited aggressive behavior towards Resident 1 on multiple occasions. These incidents included slapping, choking, and hitting Resident 1, which were witnessed by staff and reported by Resident 1's family. Despite previous interventions, Resident 2 continued to exhibit aggressive behavior towards Resident 1, leading to two documented incidents of physical abuse. The facility's records and staff interviews confirmed that Resident 2 had physically attacked Resident 1 on at least two occasions, causing fear and insecurity for Resident 1. The facility's failure to effectively manage Resident 2's aggressive behavior and protect Resident 1 from abuse constitutes a deficiency in providing a safe environment for its residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
