River View Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elgin, Illinois.
- Location
- 50 North Jane, Elgin, Illinois 60123
- CMS Provider Number
- 145308
- Inspections on file
- 40
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at River View Rehab Center during CMS and state inspections, most recent first.
Two cognitively intact roommates with psychiatric histories, including one with psychotic features and hallucinations and the other with major depressive disorder and a history of criminal behavior, became involved in a verbal and then physical altercation after one resident became annoyed by the other talking and swearing to himself. Liquid was thrown, and the confrontation escalated into a fight that moved into the hallway, where staff observed one resident on the floor with the other on top, punching him in the face. One resident sustained bruising and bleeding to the face requiring ER evaluation, and the other had multiple scratches. The facility’s own investigation, as confirmed by the DON and Administrator, substantiated this as abuse under the facility’s abuse policy, reflecting a failure to prevent resident-to-resident physical abuse.
Two residents who were friends and shared a room were involved in an altercation when one resident, who had major depressive disorder with psychotic symptoms and substance abuse, returned from a community pass appearing anxious and talking loudly. The other resident, who had multiple medical and psychiatric diagnoses including COPD and anxiety disorder, approached the bathroom doorway to try to calm the anxious resident. As the anxious resident exited the bathroom, they pulled the other resident’s hair and struck them on the forehead without provocation. The victim reported being surprised and upset, reported the incident to staff, and had no injury. The incident was substantiated as abuse, despite the facility’s written policy affirming residents’ rights to be free from abuse and to have a safe and secure environment.
A resident with a history of mental health conditions was physically assaulted by another resident after intervening in a dispute. The aggressor, who also had mental health diagnoses, admitted to the altercation, and staff confirmed the incident. The facility's investigation substantiated that abuse occurred, and the administrator acknowledged the failure to maintain a safe environment, violating the facility's abuse prevention policy.
A resident with significant mobility impairments and a history of pressure injuries was not properly assessed or monitored for skin breakdown, resulting in the development of unstageable pressure wounds to the sacrum and right heel. Staff failed to identify, report, and document the wounds in a timely manner, and required skin assessments and care plan updates were not completed as per facility policy.
Surveyors found that staff failed to provide grooming and personal hygiene assistance to four residents who requested and required help with shaving and nail care. Several residents, some with mood disorders, anxiety, schizophrenia, or Parkinsonism, were observed with beards, facial hair, or long, dirty fingernails and reported that CNAs were too busy to assist them. MDS assessments and care plans documented self-care deficits and needs for supervision, setup, or partial assistance with personal hygiene, while the DON confirmed CNAs are responsible for ADLs such as shaving and nail care in accordance with the facility’s ADL policy.
The facility failed to ensure medications were safely stored and administered according to professional standards and facility policy. A resident had a cup of multiple scheduled oral meds left on the bedside table after an RN departed, rather than being directly administered. Several other residents had medications or treatment products kept unsecured in their rooms, including antifungal powder without a physician order, a nasal spray and antacid with orders but not locked, an albuterol inhaler kept at the bedside, and antifungal cream and Medi-honey used without any corresponding orders by a cognitively impaired resident. Facility policy required that all meds, including those brought in by residents or families, be properly labeled and stored in locked medication areas.
A resident who is 74 inches tall and weighs over 240 lbs was observed lying in a 76-inch bed with his feet pressed against the footboard and his face and body pressed against the wall, while an overhead trapeze hung a few inches from his head, limiting his ability to turn and sit up. The resident reported previously requesting a larger bed, repositioning of the bed to allow easier communication with his roommate and television viewing, removal of the trapeze, and use of side rails or enablers for mobility. His care plan called for person-centered care, including specific positioning and head-of-bed elevation related to asthma and comfort, and his EMR showed no refusals of care. The DON stated there was no specific policy or criteria for assigning bariatric beds, that such decisions were made case by case, and that the current bed was considered appropriate, despite limited clearance and lack of available manufacturer measurements at the time of review.
A cognitively intact resident reported that the bottom half of his room window had been broken for an extended period, leaving jagged, sharp glass edges exposed and covered only partially with cardboard, and stated he had told multiple people without any action taken. Surveyors confirmed the broken, unsafe window. The Maintenance Director, employed for two years, reported no work order had been submitted and that he was unaware of the problem, later learning that a housekeeper had informed the housekeeping director about the issue but not him. This occurred despite a facility preventative maintenance policy requiring random rounds to ensure all areas are kept clean and in safe condition.
Two residents with COPD and chronic respiratory conditions did not receive oxygen therapy as ordered, including required humidification and prescribed flow rates. One resident ordered to receive 4 L/min humidified oxygen was repeatedly observed on 4 L/min via nasal cannula without the humidifier properly connected, after being told by staff that tubing for the humidifier was not available. Another resident ordered 3 L/min oxygen as needed was observed on 5 L/min without a humidifier, and reported that staff increase the flow to 5 L/min when she feels short of breath, causing nasal and sinus dryness. An RN reported not knowing about the humidified oxygen order or how to obtain the correct tubing, and the DON stated that oxygen must follow POS orders and that humidifiers should be used at 5 L/min or more.
A resident with a chipped right molar and severe, persistent dental pain was evaluated by a dentist, prescribed abx for a tooth infection, and informed that a root canal or extraction was needed, with follow-up pending insurance approval. The social worker, who was responsible for arranging outside dental referrals, acknowledged being informed of the needed procedure but stopped assisting due to difficulties with the resident’s Medicaid coverage and told the resident to contact the insurer directly. No referral efforts, follow-up, or the prior dental consultation were documented in the EMR, despite an active order allowing dental services and a facility policy requiring ongoing oral assessments, physician notification, and documentation of dental needs.
Surveyors found that multiple residents had expired or visibly spoiled food items stored in their personal refrigerators, and one resident’s refrigerator lacked a thermometer. One resident had expired peach cups, another had expired vegan cream cheese, and a third had milk and a nutritional supplement with illegible dates and curdled contents. Residents reported that staff did not clean or check their refrigerators regularly. The Housekeeping Director and DON stated that housekeepers are responsible for daily refrigerator cleaning and disposal of expired foods, while facility policies require regular cleaning, dating and discarding perishable foods by use-by or expiration dates, and daily checks of personal refrigerators for labeling, temperature recording, and maintaining 34–40°F.
A resident physically assaulted another resident, causing a right medial orbital wall blowout fracture, after a series of threatening and racially charged interactions. Despite staff awareness of the aggressor's behavioral issues and the need for close monitoring, the incident escalated to physical violence before being interrupted by a CNA. Both individuals had complex medical and psychiatric histories, and the facility's abuse prevention policy was not effectively implemented to prevent this event.
A CNA failed to immediately notify a nurse after a resident with a history of stroke, hemiplegia, and moderate cognitive impairment fell in the shower room. The CNA assisted the resident back to the chair and did not report the incident, resulting in a delay in nursing assessment until the resident's family member informed staff later in the day. Facility policy requires immediate nurse notification and assessment after any fall.
A resident with a history of aggressive behavior and substance abuse threatened and intimidated other residents, leading to Immediate Jeopardy. The facility failed to protect residents from mental abuse, resulting in fear and social isolation for some. Staff and residents were intimidated by the aggressor, who repeatedly violated facility rules and made threats of violence.
The facility failed to conduct timely pre-admission screenings and background checks for several residents, including identified offenders, as required by their abuse prevention policy. This oversight potentially compromised the safety of all residents, as checks were either delayed or not completed, and follow-up on critical reports was neglected.
A facility failed to protect residents from abuse, resulting in a resident being sexually and mentally abused by a CNA and exposed to a previously abusive resident. Another resident was involved in multiple physical altercations, hitting several residents. The facility's lack of effective interventions and supervision contributed to these incidents.
The facility failed to report and investigate abuse allegations involving two residents. One resident reported inappropriate touching and comments by a CNA, which was not immediately reported to authorities. Another resident was physically assaulted by a co-resident, but the facility did not substantiate the abuse despite witness accounts. The facility's actions did not align with their abuse prevention policy.
A resident with a history of aggressive behavior was involved in multiple altercations with two other residents, resulting in physical harm. Despite staff intervention and attempts to transfer the resident, the facility failed to prevent further incidents, violating policies on resident safety and abuse prevention.
A resident with multiple health issues was found to have a rash and other care concerns after a holiday visit home. The resident's family reported these issues to the facility, but the grievance was not documented or resolved within the required 72-hour period. The facility's staff failed to follow the grievance policy, resulting in a deficiency.
A resident with multiple diagnoses, including dementia and seborrheic dermatitis, had a rash on her back that was not assessed or treated by the facility for four months. Despite family concerns and staff awareness, there was no documentation of physician evaluation or treatment, and potential allergy causes were not investigated.
A resident with multiple health conditions did not receive proper foot care, including toenail clipping and podiatry examination, as required by the facility's policy. The resident's family discovered severely overgrown toenails and debris between the toes during a home visit, prompting them to perform the necessary care themselves. Facility staff confirmed that the resident had not been seen by a podiatrist for over two years, despite monthly visits to the facility.
A resident with moderate cognitive impairment and multiple health conditions was found with long, discolored fingernails pressing into their palm, and dried food debris in their hand. The Wound Care Nurse noted the issue, and a CNA confirmed that CNAs should trim nails when necessary. The DON stated that nail care should occur during showers, as per facility policy.
A resident with hyponatremia did not receive the prescribed fluid restriction of 1800 ml/day due to a communication breakdown between the nursing and dietary departments. Despite a physician's order, the restriction was not documented on the resident's dietary card, and staff were unaware of the restriction, leading to inadequate care.
The facility failed to provide adequate pressure ulcer care for two residents. One resident's air mattress was set incorrectly, potentially affecting wound healing, while another resident lacked necessary protective devices, leading to reddened heels. Staff were aware of these issues but did not take corrective actions, contrary to care plans and facility policies.
A resident with contractures was not provided with a necessary hand splint, as observed during a survey. The facility's assessment inaccurately reported normal range of motion, and the care plan lacked documentation of the splint, despite physician orders. Staff confirmed the splint had been missing for months, and there was no documentation of its application, violating facility policy.
The facility failed to ensure resident safety by inadequately assessing and supervising residents with cognitive impairments regarding smoking and community pass privileges. A resident with severe cognitive impairment and aggressive behavior was allowed unsupervised community access and smoking, despite assessments indicating the need for supervision. Another resident with a history of smoking in their room was found with smoking materials, contrary to facility policy.
A facility failed to provide appropriate catheter care for a resident with a suprapubic catheter. Despite requiring supervision, the resident primarily managed his catheter care independently, contrary to the care plan and physician orders. Staff acknowledged the resident's self-management, and the DON confirmed a lack of formal training or approval for this practice. The facility's policy for urinary catheters was not provided, indicating a lack of documented guidelines.
A resident with COPD was found with a nasal cannula not connected to the oxygen concentrator, despite a physician's order for oxygen therapy to maintain saturation above 92%. The RN did not verify the connection after placing the cannula back, leading to inadequate respiratory care.
The facility failed to ensure medications were not left at a resident's bedside and that medications were administered on time for three residents. One resident was found with pills left on the dresser, and two others received medications outside the scheduled times. The facility's policy requires medications to be administered at the right time, as prescribed.
A resident with intact cognition was physically assaulted by another resident with paranoid schizophrenia, resulting in the need for emergency medical care. Despite the aggressor's history of unpredictable and aggressive behavior, the facility failed to provide additional supervision or monitoring, leading to the incident. Staff interviews confirmed the lack of specific interventions for the aggressive resident, highlighting a deficiency in the facility's abuse prevention measures.
The facility failed to report multiple incidents of alleged abuse involving a resident with paranoid schizophrenia, whose mental status fluctuated. Incidents included inappropriate touching and aggressive behavior, which were not reported to the state agency as required by the facility's policy. Confusion over reporting responsibilities among staff contributed to the delay in reporting.
A resident reported being sexually abused by another resident who touched her inappropriately while she was seated outside. The incident was reported the next day, and the police were contacted. The resident who committed the act admitted to the behavior, citing alcohol influence, and was subsequently arrested and relocated within the facility. The facility's abuse prevention policy was not effectively enforced to prevent this incident.
A resident with multiple medical conditions and a care plan for behavioral issues recorded a video of IV tubing left on his chest by a nurse. The nurse confronted the resident, attempted to take the phone away, and made physical contact. The resident reported the incident to the police, leading to an internal investigation and a city ordinance ticket for battery issued to the nurse. The facility's Abuse Prevention Program Policy was not upheld, resulting in the deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent abuse between two cognitively intact roommates, resulting in one resident sustaining injuries that required emergency room evaluation. One resident (R1), with diagnoses including bipolar disorder with psychotic features and hallucinations, was known to talk to himself, laugh, and swear in response to auditory and visual hallucinations. On the evening of the incident, R1 was in the shared room talking to himself and responding to his voices while the other resident (R2), who has major depressive disorder, suicidal ideation, alcohol abuse, and a history of criminal behavior, was also in the room watching television. R2 became annoyed by R1’s behavior and told him to keep it down. Accounts differ on who threw liquid first, but both residents reported that liquid was thrown or poured, followed by a physical altercation. According to interviews and progress notes, R1 and R2 began yelling and then physically fighting, moving from their room into the hallway. Staff, including an RN and CNAs, heard a commotion and yelling and then observed R2 lying on the floor in the hallway with R1 on top of him, punching him in the face. Witnesses described the residents “punching and fighting with each other” before staff intervened. R1 later stated he punched R2 in self-defense after R2 threw a cup with liquid and punched him, while R2 stated that R1 came to his side of the room, got in his face, threw water at him, hit the side of his head, gave him multiple swings, pushed him to the floor, got on top of him, and continued punching. As a result of the altercation, R2 sustained bruising to the left temple, bleeding above the eye and lip, and required emergency room evaluation, while R1 had scratches to the right eyelid, chin, and forearm. The facility’s abuse policy defines abuse as physical or mental injury inflicted on a resident other than by accidental means and specifies that resident-to-resident altercations should be reviewed as potential abuse. The DON and Administrator both stated that, based on the facility’s investigation, the allegation of abuse was substantiated and acknowledged that it is the facility’s job to prevent abuse, indicating that the facility did not prevent this resident-to-resident physical abuse incident from occurring.
Failure to Prevent Resident-to-Resident Physical Abuse in Shared Room
Penalty
Summary
The facility failed to protect a resident from abuse by another resident in accordance with its abuse prevention policy. On January 11, 2026, two residents who were friends and shared a room were involved in an altercation in their shared room. One resident (R8), who had diagnoses including major depressive disorder severe with psychotic symptoms, alcohol and cocaine abuse, COPD, and asthma, returned from a community pass appearing anxious and talking loudly. The other resident (R5), who had diagnoses including major depressive disorder, COPD, history of malignant neoplasm of the breast, history of healed femur fracture, history of alcohol abuse, cannabis abuse, and anxiety disorder, approached the bathroom doorway in an attempt to calm R8. As R8 exited the bathroom, R8 pulled R5’s hair and hit R5 on the forehead without provocation. R5 reported being surprised and upset by R8’s actions and immediately left the room to seek staff assistance. R5 stated that there was no injury from the incident. The Administrator confirmed that the incident between the two residents was substantiated as abuse, with R8 identified as the perpetrator and R5 as the victim. The facility’s own Abuse Prevention and Reporting policy, dated February 2, 2026, affirms residents’ rights to be free from abuse and to have an environment that promotes resident safety and security. Despite this policy, the incident occurred, resulting in a substantiated finding of abuse involving one of the residents reviewed for abuse in the survey sample.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse by another resident. On 11/10/2025, one resident (R3) entered a room to visit another resident (R9), where R8 (R9's roommate and R2's girlfriend) told R3 to leave. When R2 attempted to intervene, R3 became upset and physically assaulted R2 by grabbing and punching him in the neck. The incident was witnessed by staff, and the local police were called. The facility's investigation substantiated that abuse occurred, and it was acknowledged by the administrator that the environment was not kept safe for R2. R2 had a history of mental health diagnoses, including schizoaffective disorder, depressive type, personality disorder, schizophrenia, post-traumatic stress disorder, disorder of psychological development, and suicidal ideation, but was noted to have intact cognition at the time of the incident. R3, who also had mental health diagnoses, admitted to the physical altercation. The facility's abuse policy states that residents have the right to be free from all forms of abuse, but this policy was not upheld in this instance, resulting in a substantiated case of resident-to-resident physical abuse.
Failure to Assess and Document Pressure Wounds Prior to Becoming Unstageable
Penalty
Summary
The facility failed to properly assess, report, and document a resident's acquired pressure wounds before they became unstageable. The resident, who had multiple diagnoses including paraplegia, degenerative nervous system disease, and impaired mobility, was dependent on staff for activities of daily living, including toileting and transfers. Although the resident's admission Braden scale assessment indicated a risk for pressure injuries, the care plan and subsequent MDS did not reflect this risk, and no pressure injuries were documented during the look-back period. The resident's family member reported that the resident had a history of pressure injuries prior to admission, and was only informed weeks after admission that new, extensive wounds had developed. The wound care nurse identified a new sacral-coccyx wound during an assessment for a different healed wound, noting it was full-thickness but did not classify the wound type or document the tissue present, as she was waiting for the wound physician's assessment. The wound was not reported by staff prior to this identification, despite facility policy requiring daily skin observation and prompt reporting of abnormalities. The wound physician later assessed the resident and found both the sacral wound and a new right heel wound to be unstageable, with the sacral wound containing 40% necrotic tissue and the heel wound presenting as a deep tissue injury with a blood-filled blister. Documentation showed that the resident's comprehensive care plan was not updated to reflect the risk for skin breakdown until after the wounds were identified. Scheduled weekly skin assessments were not consistently documented, with the last recorded assessment occurring a week before the wounds were discovered. Facility policy required immediate assessment and documentation of any skin breakdown, including detailed wound descriptions, but these steps were not followed prior to the wounds becoming unstageable.
Failure to Provide Needed Grooming and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide needed ADL care, specifically grooming and personal hygiene, to multiple residents who required assistance. One resident with bipolar disorder, anxiety disorder, major depressive disorder, and Parkinsonism was observed in the morning with a beard and mustache, stated he preferred to be clean shaven, and reported that CNAs did not have time to shave him. His MDS showed moderate cognitive impairment and a need for partial/moderate assistance with personal hygiene, and his care plan documented a self-care deficit requiring assistance with ADLs to maintain his highest level of functioning. Another resident with major depressive disorder was observed with hair on her chin and above her lip, stated she wanted to be shaved, and had an MDS indicating she was cognitively intact but needed setup or clean-up assistance with personal hygiene; her care plan also identified a self-care deficit and need for ADL assistance. A third resident with major depressive disorder, anxiety disorder, and Parkinsonism was observed with long fingernails on both hands and a black substance underneath. She stated she wanted her nails cut and that CNAs usually did this but had been too busy the last time she asked. Her MDS showed she was cognitively intact and required supervision or touching assistance with personal hygiene, and her care plan documented a self-care deficit and need for ADL assistance. A fourth resident with bipolar disorder, paranoid schizophrenia, and generalized anxiety disorder was observed with a beard, stated he wanted to be shaved, and reported that staff were too busy to shave him; his MDS showed he was cognitively intact and needed setup or clean-up assistance with personal hygiene, and his care plan also reflected a self-care deficit and need for ADL assistance. The DON stated that CNAs are responsible for ADLs such as shaving and nail care during showers and as needed, and the facility’s ADL policy emphasized maintaining personal hygiene, including shaving and self-manicure.
Failure to Safely Store and Administer Medications
Penalty
Summary
The deficiency involves the facility’s failure to safely store and administer medications in accordance with professional standards and its own policies. One resident was found resting in bed with a pill cup of scheduled 10 AM medications left on the bedside table, including Plavix (for heart arrhythmia), Lasix and Metoprolol (for high blood pressure), Loratadine, a multivitamin, folic acid, Gabapentin (for lumbar radiculopathy), and Venlafaxine (for anxiety disorder). The administering RN acknowledged leaving the medications at the bedside and later stated he should not have done so because another resident could take them or the resident might take them at an off-schedule time. The DON stated that medications should never be left at the bedside and explained that medications must be taken by the intended resident at the scheduled time. Additional observations showed multiple residents with medications or treatment products stored unsecured in their rooms. One resident had an antifungal powder at his TV that he reported using as needed, but there was no corresponding physician order. Another resident recovering from a respiratory infection had a nasal spray and a bottle of antacid at the bedside; both items had physician orders, but they were not stored in locked medication areas. A third resident had an albuterol inhaler on the bedside table and reported using it when needed, with a physician order present. A fourth resident, who was moderately cognitively impaired per a recent MDS, had an unlabeled antifungal cream and Medi-honey on the bedside table, reported that the cream was not hers and that she used the Medi-honey on her hands, and had no physician orders for either product. The facility’s medication administration policy required that medication storage areas be locked when not in use and that all medications, including those brought in by residents or families, be properly labeled and stored in designated locked areas.
Failure to Provide Appropriately Sized and Configured Bed for Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident's needs and preferences by not providing an appropriately sized and configured bed. Surveyors observed the resident, who is 74 inches tall and weighs 240.6 lbs, lying in a 76-inch bed with his feet pressed against the footboard and the right side of his face and body pressed against the wall. The bed was positioned perpendicular to his roommate's bed, with one side flush against the wall and his feet facing his roommate. An overhead trapeze was hanging approximately three inches above his head, and the resident reported being unable to turn or sit up comfortably because of the limited space and the trapeze striking his face when upright. The resident stated he had requested a larger (longer and wider) bed, repositioning of the bed to be parallel to his roommate's bed so they could talk and he could watch television without turning his neck, removal of the trapeze, and installation of side rails or enablers to assist with bed mobility. Review of the resident's care plan showed directives for person-centered care to afford him as much initiative, control, and self-determination as possible, including elevating the head of the bed to 90 degrees to prevent shortness of breath related to asthma, encouraging correct positioning for comfort and to prevent muscle and joint strain, and offloading his heels to prevent pressure injury. At the time of the survey, the EMR did not document any behaviors or refusal of interventions. The DON stated the facility had no specific policy or criteria for providing bariatric beds and that such beds were assigned on a case-by-case basis without defined height or weight parameters. The DON reported that, based on her recent assessment, the resident's current bed was appropriate for his height and weight and that he did not require a different type of bed, but she and the ADON were unable to provide the bed's measurements or manufacturer guidelines, despite the bed label indicating a total length of 76 inches, leaving only approximately two inches of clearance for the resident's height.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Broken Window
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when it did not address a resident’s broken window over an extended period. A cognitively intact resident reported that the bottom half of his room window had been broken for the past two years, with jagged and sharp glass edges exposed and only a piece of cardboard covering part of it. The resident stated he had informed multiple people about the broken window but no action was taken, and he stopped feeding birds out of concern about cutting his hands on the glass. Surveyor observation confirmed the broken window with exposed sharp edges. The Maintenance Director, who had been employed at the facility for two years, stated he had never seen a work order for the resident’s window and that the resident had not reported the issue to him, suggesting the damage might have occurred before his employment. Later, the Maintenance Director reported that a housekeeper had told the housekeeping director about the broken window a week earlier but had not informed him. The facility’s Preventative Maintenance Program policy states that random rounds are to ensure all facility areas are kept clean and in safe condition, but the broken window in the resident’s room remained unrepaired despite this policy.
Failure to Follow Oxygen Therapy Orders and Provide Required Humidification
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy as ordered, including required humidification, for residents with COPD and other respiratory conditions. One resident with COPD, dependence on supplemental oxygen, and congestive heart failure had a physician’s order for 4 L/min humidified oxygen to maintain oxygen saturation above 92%. Surveyors observed this resident on multiple occasions receiving 4 L/min oxygen via nasal cannula from a concentrator without the humidifier properly connected. Initially, the concentrator had a humidifier canister but no tubing connecting it to the oxygen source, and the resident reported staff told her they did not have the tubing. On a later observation, the resident again received 4 L/min oxygen without humidity, and the humidifier canister had been removed. The resident stated she had previously connected her nasal cannula directly to the humidifier instead of the concentrator due to lack of proper tubing, resulting in her not receiving oxygen. The RN stated he did not know the resident had an order for humidified oxygen and was unsure where to obtain the tubing, and the DON confirmed that if the order specifies humidified oxygen, the resident should receive humidified oxygen and that lack of humidity can cause nasal dryness and irritation. A second resident with COPD and chronic respiratory failure with hypoxia had a physician’s order for oxygen at 3 L/min via nasal cannula as needed to keep oxygen saturation above 92%. During observation, this resident was receiving oxygen at 5 L/min via nasal cannula directly from the concentrator without a humidifier or adaptor. The resident reported that the higher oxygen flow dries out her nose and affects her sinuses and stated that staff increase her oxygen flow from 3 L/min to 5 L/min when she feels short of breath. The DON stated that oxygen settings are based on physician orders in the POS and that humidifiers should be used for oxygen rates of 5 L/min or more. The facility’s oxygen therapy policy directs staff to give oxygen per physician order, but observations and interviews showed that staff did not consistently follow the ordered parameters or provide humidification as required.
Failure to Assist Resident in Obtaining Needed Emergency Dental Services
Penalty
Summary
The deficiency involves the facility’s failure to assist a resident in obtaining needed emergency dental services despite ongoing severe tooth pain and documented need for a root canal or extraction. The resident reported right molar pain rated 9 out of 10, with symptoms beginning months earlier when the tooth began to chip. During a routine dental visit, the resident was informed that a root canal extraction procedure was needed to manage the tooth pain. An infectious disease progress note documented that the resident had a right lower tooth infection, was prescribed Amoxicillin 500 mg TID for seven days, and still had persistent pain with a chipped tooth, with a root canal pending insurance approval and a need to follow up with the dentist. The resident stated that the tooth had become more chipped and increasingly uncomfortable, especially when eating, and that he repeatedly tried to follow up with the social worker for assistance with the dental referral but was still waiting for an update. The social worker acknowledged being responsible for assisting residents with outside dental referral services and confirmed he was informed months earlier about this resident’s needed dental procedure. He stated that due to difficulties related to the resident’s Medicaid insurance, he stopped assisting with the referral because he was unsure how else to help and instead told the resident to contact his insurance directly. The social worker did not document any referral attempts in the EMR, did not include the dental consultation assessment or extraction referral from the earlier dental visit, and did not discuss the resident’s dental needs with the administrator. The EMR contained an active order allowing the resident to receive dental and other specialist services as deemed necessary, but there were no further progress notes showing staff follow-up or assistance with the resident’s dental care needs. The facility’s policy on routine dental care required ongoing oral health assessments, physician notification of dental treatment needs, and inclusion of dental findings in the medical record, but the documented actions and omissions show that these processes were not carried out for this resident’s dental problem.
Failure to Remove Expired Food and Monitor Resident Refrigerators per Policy
Penalty
Summary
Surveyors identified that the facility failed to remove expired food items from resident refrigerators and failed to ensure thermometers were present, as required by facility policy. During an initial tour, one resident’s refrigerator contained two 15 oz cups of peaches that had expired on June 14, 2025; the resident stated that a cleaning staff member checks his refrigerator but not on a daily basis. Another resident’s refrigerator contained a partially consumed container of vegan cream cheese that had expired on May 15, 2025; this resident reported not having seen staff clean her refrigerator in days. A third resident’s refrigerator contained an 8 oz carton of milk and a 6 oz carton of a fortified nutritional supplement with smudged, illegible expiration dates; the contents of both cartons appeared white and curdled, and there was no thermometer inside the refrigerator. This resident stated that the facility does not check the temperature or contents of his refrigerator. The Housekeeping Director and the DON both reported that housekeepers are responsible for cleaning resident refrigerators daily and discarding expired foods. Facility policies on food brought in by family or visitors and on food storage from outside sources require regular cleaning of refrigerators, dating and discarding perishable foods per use-by or expiration dates, and daily staff checks of personal refrigerators for proper labeling, temperature recording, and storage between 34–40 degrees, as well as monitoring for food disposal needs.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
A resident's right to be free from physical abuse was not protected when another resident became physically aggressive, resulting in a serious injury. The incident occurred late at night when one resident entered another's room, used racial slurs, and physically assaulted him by punching him in the face and choking him. The altercation was only interrupted when a CNA, alerted by the sounds of the struggle, entered the room. The victim sustained a right medial orbital wall blowout fracture, as confirmed by hospital CT scan records. Prior to the physical altercation, the aggressor had been sending threatening and racially charged text messages to the victim, demanding information unrelated to the victim. Despite the known behavioral issues and the need for staff to monitor the aggressor closely, the incident escalated to physical violence. Staff interviews indicate that the aggressor was observed heading toward the victim's hallway, and staff were aware of the need to keep an eye on him, but the assault still occurred. Both residents involved had multiple medical and psychiatric diagnoses, with the aggressor having a history of anxiety disorder and PTSD, and the victim having schizophrenia, bipolar disorder, and substance abuse issues. The facility's abuse prevention policy states that residents have the right to be free from abuse, including physical abuse, but the events leading up to and during the incident demonstrate a failure to prevent resident-to-resident abuse, resulting in significant harm.
Failure to Immediately Notify Nurse and Assess Resident After Fall
Penalty
Summary
A direct care staff member (CNA) failed to follow facility policy and procedures by not immediately notifying a nurse after a resident experienced a fall in the shower room. The CNA assisted the resident, who has a history of cerebral infarction, hemiplegia, and moderate cognitive impairment, with a shower. During the process, the resident slid off the shower chair after attempting to sit down while still soapy. The CNA picked the resident up and returned him to the chair without calling for a nurse or conducting an immediate assessment as required by facility policy. The CNA asked the resident if he wanted the incident reported, but the resident declined. The CNA then continued with the shower, dressed the resident, and returned him to his room, again asking if he wanted the fall reported, to which the resident again said no. The CNA did not inform the nurse on duty about the fall and proceeded with other duties. The incident was only discovered later in the day when the resident told his sister, who then informed the evening nurse. The nurse subsequently assessed the resident and found no injuries. Facility policy requires that after a fall, the CNA must call for a nurse immediately and not move the resident until assessed. The nurse on duty during the morning shift was not made aware of the fall, and the required immediate assessment did not occur. The resident's care plan identified him as at risk for falls due to his medical conditions and need for assistance with transfers and showers. The delay in notification and assessment constituted a failure to provide appropriate treatment and care according to orders and the resident’s needs.
Failure to Protect Residents from Mental Abuse
Penalty
Summary
The facility failed to protect residents from mental abuse, resulting in Immediate Jeopardy for three residents. One resident reported feeling fearful and socially isolated due to threats from another resident, who had a history of verbally aggressive behavior and criminal activity. This resident had been threatened with violence if he reported drug-related activities involving the aggressor. The facility's records showed multiple incidents of the aggressor possessing drugs and alcohol, being verbally aggressive, and disobeying facility rules. Another resident experienced mental anguish after being threatened with physical harm and death by the same aggressor. This resident was initially hesitant to speak about the incidents due to fear of retaliation. The aggressor had entered the resident's room uninvited and made threats while under the influence of substances. The facility's staff and other residents were also intimidated by the aggressor, who had a history of threatening behavior and substance abuse. A third resident was too afraid to speak to surveyors about the aggressor, who had hidden alcohol and drugs in the resident's room. The resident feared retaliation if he reported these activities. The facility's staff, including the administrator and assistant administrator, were also threatened by the aggressor, leading to a heightened sense of fear and insecurity within the facility. The facility's abuse prevention policy was not effectively implemented, resulting in the failure to protect residents from mental abuse.
Removal Plan
- R1 was placed on 1:1 monitoring.
- The police will be called for assistance every time R1 violates community restriction. R1 will be discharged per court order.
- An order of protection will be filed on R1, by R2, R3, and R6 pending their consent.
- Recent abuse in-services/education will be continued on all newly hired employees and agency nurses.
- The resident admission process was reviewed with the Admissions Director and Social Services and will be implemented per facility guideline. It will ensure that resident background checks are being completed. The background checks will also be reviewed to ensure that appropriate interventions are put into place for the safety of all residents.
- Should a resident become noncompliant with facility protocols and guidelines, the resident will be counseled by staff. If the resident continues to be noncompliant, he/she will be sent out for psychiatric evaluation and will be served a discharge notice as deemed appropriate. Should he/she become harmful to other residents, he/she will be placed on 1:1 monitoring.
Failure to Conduct Timely Background Checks for Resident Safety
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing pre-admission screenings for six residents, potentially affecting the safety of all 179 residents. The facility's policy requires that an electronic name-based background check be ordered within 24 hours of admission, and if the resident is identified as an offender, a fingerprint-based criminal history check must be completed within 72 hours. However, for residents R4, R10, R11, R12, R13, and R1, these checks were either delayed or not completed at all. For instance, R4, R11, and R12 had no checks completed, while R10 and R13 had their National Sex Offender Registry checks completed only on the day of the survey. R12 and R13 were identified offenders with serious convictions, yet their fingerprint-based checks were delayed. Additionally, R1's case highlights a significant oversight, as the facility failed to follow up on the results of R1's criminal analysis security report, which was crucial for determining the resident's risk level and implementing appropriate safety interventions. The administrator acknowledged the importance of knowing the risk level of identified offenders to ensure resident safety but admitted that the facility did not follow up on R1's report. This lack of timely and thorough background checks and follow-up actions represents a breach of the facility's policies designed to protect residents from abuse, neglect, and exploitation.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual and mental abuse by staff and other residents. A resident was inappropriately touched by a CNA in the shower and received lewd comments about her body. Additionally, the resident was exposed to another resident who had previously sexually abused her, causing her emotional distress and leading her to discharge herself against medical advice. The facility's investigation substantiated these incidents, revealing that the CNA had sent inappropriate messages to the resident and had inappropriately touched her during a shower. The facility also failed to protect residents from physical abuse by other residents. One resident was involved in multiple physical altercations with other residents, hitting several individuals over a period of time. Despite the resident's history of aggressive behavior and criminal background, the facility did not implement effective interventions to prevent further incidents. The facility's investigation confirmed these incidents of physical abuse, but no adequate measures were taken to prevent recurrence. The facility's abuse prevention policy was not effectively enforced, as evidenced by the repeated incidents of abuse and the lack of appropriate interventions. The facility's failure to separate the alleged perpetrators from the victims and to provide adequate supervision and monitoring contributed to the ongoing risk of abuse. The report highlights the facility's inability to protect residents from abuse and to ensure their safety and well-being.
Removal Plan
- R5 was given an immediate discharge to St [NAME] Hospital, R5 no longer a resident of River View.
- R6 was reassessed on Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors (Sexual Misconduct) and educated on Appropriate behavior.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report and thoroughly investigate allegations of abuse as per their policy, involving two residents. One resident, R1, reported that a CNA, V8, made inappropriate comments and touched her inappropriately during a shower. R1's daughter, V23, was informed of the incident and contacted the facility, but the facility initially only reported verbal abuse to the authorities. The physical abuse allegation was not reported until days later, and the resident was not sent to the hospital for examination immediately after the allegation. Another incident involved R7, who reported being physically assaulted by another resident, R5. Despite witness statements and a physician's order to send R5 to the ER for physical aggression, the facility did not substantiate the abuse, citing R5's unsteady gait as the reason for the altercation. The facility's investigation did not align with the witness accounts, which indicated that R5 had indeed hit R7. The facility's abuse prevention training program and policy require immediate reporting and thorough investigation of abuse allegations, including notifying the police and the Department of Public Health. However, in both cases, the facility failed to adhere to these protocols, resulting in delayed reporting and inadequate investigation of the incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving three residents. Resident 1, who has diagnoses including hypertension, morbid obesity, and diabetes, was involved in multiple altercations. On one occasion, Resident 1 kicked Resident 2, who has a history of stroke and diabetes, in the buttocks and later backed her wheelchair into Resident 2, leading to a physical confrontation where Resident 2 pulled Resident 1's hair, and Resident 1 scratched Resident 2's arm. Staff and witnesses confirmed the aggressive behavior, and police were called to intervene. In another incident, Resident 1 was involved in an altercation with Resident 3, who has epilepsy and schizoaffective disorder. Resident 3 accidentally bumped into Resident 1's wheelchair, prompting Resident 1 to retaliate by hitting Resident 3 in the head with a plastic cup multiple times. Witnesses observed the altercation, and staff intervened to separate the residents. Resident 1's care plan noted a history of aggressive behavior, and the facility had been attempting to transfer her to another facility without success. The facility's policy on abuse mandates that residents have the right to be free from physical abuse, yet the incidents involving Resident 1 demonstrate a failure to uphold this policy. Despite interventions and assessments, Resident 1's aggressive behavior persisted, resulting in harm to other residents. The facility's inability to manage Resident 1's behavior and ensure a safe environment for all residents constitutes a significant deficiency in care.
Failure to Resolve Grievance in a Timely Manner
Penalty
Summary
The facility failed to adhere to its grievance policy by not resolving a grievance within the stipulated 72-hour timeframe. A resident, who has multiple diagnoses including multiple sclerosis, dementia, and bipolar disorder, was found to have a red rash covering her back. The resident's daughter raised concerns about her mother's care, including improper incontinence care, long toenails, and the rash, after taking her home for the holidays. Despite these concerns being communicated to the facility, there was no documentation of a physician's assessment for the rash or any follow-up on the family's request for a meeting to discuss the resident's care. The daughter of the resident sent an email to the Psychiatric Rehabilitation Services Director (PRSD) on December 26, 2024, detailing the issues observed during the resident's time at home. The email was forwarded to the Director of Nursing (DON) and the Assistant Administrator, but no grievance form was filled out, and no meeting was scheduled to address the concerns. The facility's policy requires that all grievances be documented and resolved within 72 hours, but this was not done in this case. Interviews with facility staff revealed a lack of communication and follow-up regarding the grievance. The PRSD admitted to not filling out a grievance form and was unsure if the grievances were resolved. The DON confirmed that no grievance form existed for the resident and that no meeting had been set up with the family. The facility's failure to document and address the grievance in a timely manner constitutes a deficiency in following their established grievance policy.
Failure to Assess and Treat Resident's Rash
Penalty
Summary
The facility failed to ensure a resident received assessment and treatment for a rash that was identified four months prior. The resident, who has multiple diagnoses including multiple sclerosis, dementia, and seborrheic dermatitis, was admitted to the facility with a red rash noted on her face and back. Despite this, there is no documentation showing that the rash on the resident's back was assessed by a physician or that any treatment was provided. The resident's cognitive impairment prevented her from communicating any symptoms related to the rash, and the facility staff, including a CNA and a Wound Care Nurse, acknowledged the presence of the rash but did not ensure it was evaluated by a physician. The resident's family discovered the rash during a home visit and expressed concerns to the facility, which were forwarded to the Director of Nursing and Assistant Administrator. However, as of the date of the report, there was still no documentation of an assessment or treatment for the rash. The Wound Care Nurse mentioned that the resident had previously indicated a possible corn syrup allergy as the cause of the rash, but there was no confirmation or follow-up on this potential allergy, nor was there any indication that dietary staff were informed. This lack of action and documentation highlights the facility's failure to provide appropriate care and treatment according to the resident's needs and medical orders.
Failure to Provide Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, including toenail clipping and examination by a podiatrist, as per the facility's foot care policy. The resident, who has multiple diagnoses including multiple sclerosis, dementia, and osteopenia, was found to have severely overgrown toenails and debris between her toes during a visit home with her family. The resident's daughter reported cutting the toenails and cleaning the feet herself due to the condition observed. The facility's policy requires that residents be seen by a podiatrist at least yearly, but records show that the resident had not been seen by a podiatrist for over two years. Interviews with facility staff revealed that CNAs are not permitted to cut residents' toenails, and the responsibility lies with nursing staff or podiatry. However, there was no documentation to show that the resident received toenail care from nursing staff or was seen by a podiatrist. The facility's Director of Nursing confirmed that the podiatrist visits monthly, yet the resident was not included in these visits, and there was no chart or service notes available for the resident from the podiatry group.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to ensure proper care and assistance for a resident with moderate cognitive impairment and multiple health conditions, including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, and vascular dementia. The resident required substantial to maximum assistance with daily activities. During an observation, it was noted that the resident's left hand was contracted, and the fingernails were very long and discolored due to residue underneath. The nails were pressing into the palm, and dried food debris was present in the hand. The Wound Care Nurse acknowledged the poor condition of the resident's fingernails and mentioned that the podiatrist was scheduled to address the issue. However, a CNA stated that CNAs are responsible for trimming residents' nails when they become long to prevent dirt accumulation and potential self-injury. The Director of Nursing confirmed that resident fingernails should be checked, cleaned, and trimmed during showers, as per the facility's policy. The policy emphasizes the importance of nail care for cleanliness, infection prevention, and safety.
Failure to Implement Fluid Restriction for Resident
Penalty
Summary
The facility failed to implement a fluid restriction for a resident (R30) who was diagnosed with hyponatremia, among other conditions. Despite a physician's order dated 10/17/24 for a fluid restriction of 1800 ml/day, the restriction was not enforced. The resident expressed concerns that the staff were not monitoring his fluid intake, and a CNA confirmed that there was no fluid restriction noted on the resident's meal card or in the system. The dietary card also showed no fluid restriction, indicating a lack of communication and documentation. Interviews with facility staff revealed a breakdown in communication between the nursing and dietary departments. The RN stated that the dietary department was informed of the fluid restriction, but the Dietary Manager indicated that the restriction was removed after the resident's hospital visit. The dietary supervisor did not receive a copy of the renewed order upon the resident's return from the hospital. This failure to communicate and document the fluid restriction order led to the resident not receiving the prescribed care, which could potentially exacerbate his condition of hyponatremia.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident R57, who has multiple health issues including multiple sclerosis, diabetes, and stage 4 pressure ulcers, was observed with an air mattress set incorrectly at a pressure level suitable for a 320-pound individual, despite weighing only 75.4 pounds. This incorrect setting was noted over several days and was not adjusted, potentially impacting the healing of her chronic wounds. Staff, including CNAs and the Wound Care Nurse, were aware of the incorrect setting but did not take action to adjust it, and the Director of Nurses acknowledged that the mattress settings should be checked and set according to the resident's weight. Resident R20, who has conditions such as COPD, diabetes, and vascular dementia, was found lying in bed with his heels directly on the mattress and no protective devices in place, despite his care plan indicating the need for foam boots to prevent pressure ulcers. His left heel was observed to be reddened, and his fingernails were pressing into his palm due to contractures. Staff confirmed that heel protector boots should have been used, and the facility's policy emphasized the use of positioning devices to prevent pressure sores. The lack of appropriate interventions for both residents highlights a failure in adhering to care plans and facility policies for pressure ulcer prevention.
Failure to Provide and Document Splint Use for Resident with Contractures
Penalty
Summary
The facility failed to accurately assess and provide appropriate care for a resident with contractures, specifically neglecting to ensure the presence of a hand splint for a dependent resident. The resident, who was admitted with multiple diagnoses including vascular dementia and contractures, was observed without a splint on his contracted left hand. Despite the resident's complaints of pain during repositioning and the absence of a splint, the facility's restorative assessment inaccurately documented that the resident's range of motion was within normal limits and did not indicate the use of a splint or brace. Further investigation revealed that the resident's care plan lacked documentation of the left upper extremity splint, despite physician progress notes indicating the need for a resting hand splint. The facility's order for the splint was delayed, and there was no documentation of splint application for the past three months. Staff interviews confirmed that the splint had been missing for 1-2 months, and the facility's policy required documentation of splint application, which was not adhered to. This oversight in care and documentation led to the deficiency identified by the surveyors.
Failure to Ensure Resident Safety in Smoking and Community Pass Privileges
Penalty
Summary
The facility failed to accurately assess and implement safety measures for residents regarding smoking and community pass privileges. Resident R33, diagnosed with paranoid schizophrenia and severe cognitive impairment, was allowed to sign out on a community pass despite exhibiting aggressive behavior and poor judgment, such as drinking from a bleach bottle. The facility's assessments indicated that R33 was capable of outside pass privileges, but staff acknowledged that his behaviors, including aggression and rummaging through garbage, were not adequately considered in the assessment process. Additionally, the facility did not enforce appropriate smoking supervision for residents with cognitive impairments. Resident R33, with a smoking risk assessment score indicating the need for supervision, was observed smoking unattended. Staff admitted that due to R33's aggressive behavior, enforcing smoking supervision was deemed unfeasible, despite the assessment's recommendation. Similarly, Resident R90, with a history of smoking in his room and a severe cognitive impairment, was found smoking unsupervised outside, contrary to the facility's smoking policy. Resident R91, who had a history of smoking in his room, was also found to have smoking materials in his possession, despite assessments indicating the need for supervision. The facility's policy required holding smoking materials for residents not considered independent smokers, yet R91 was allowed to keep his own smoking materials. These failures in assessment and supervision highlight the facility's inability to ensure a safe environment for residents, particularly those with cognitive impairments and behavioral issues.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter, identified as R30. R30 was admitted to the facility with multiple diagnoses, including spina bifida and neuromuscular dysfunction of the bladder, and requires supervision through maximal assistance for care. Despite having a care plan that mandates catheter care every shift and monitoring of the suprapubic site, the facility did not adhere to these interventions. Observations and interviews revealed that R30 primarily managed his catheter care independently, including cleaning and emptying the catheter, contrary to the care plan and physician orders. The staff, including CNAs and the RN, acknowledged that R30 self-managed his catheter care, with minimal intervention from the facility staff. The Director of Nursing (DON) confirmed that R30 preferred to manage his catheter care to maintain independence, but there was no formal training or approval for him to do so. The DON was unaware of R30's self-care practices and discouraged him from handling the catheter himself. Additionally, the facility's policy and procedure for urinary catheters were requested but not provided, indicating a lack of documented guidelines for catheter care. This deficiency in catheter care was identified during a survey, highlighting the facility's failure to ensure proper catheter management and adherence to the care plan and physician orders.
Failure to Ensure Proper Oxygen Therapy for Resident
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident who required oxygen therapy. During an observation, a resident was found sitting in bed with the head of the bed elevated, complaining of shortness of breath. The resident's nasal cannula was hanging off the side of the bed and not attached to the oxygen concentrator, which was turned on. The resident mentioned removing the cannula to blow her nose. A registered nurse checked the resident's oxygen saturation, which was 89% on room air, and placed the nasal cannula back in the resident's nose. However, the nurse did not verify that the cannula was connected to the concentrator to ensure oxygen delivery. The resident had a physician's order for oxygen at 3 liters per minute via nasal cannula as needed to maintain oxygen saturation above 92%. The Director of Nursing stated that if a resident requires oxygen, staff should ensure the nasal cannula is connected to the concentrator and check the resident's oxygen saturation. The resident's care plan indicated a need for oxygen therapy due to chronic obstructive pulmonary disease, with instructions to maintain oxygen saturation above 92%. The facility's policy on oxygen therapy required adherence to physician orders, which was not followed in this instance.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were not left at a resident's bedside and that medications were administered on time for three residents. One resident was found asleep with a medication cup containing four oblong pills on the dresser at the end of his bed. The nurse responsible admitted that medications should not be left at the bedside and confirmed that the resident had not yet received any medications that day. The resident's care plan did not include a plan for self-administration of medications, and the facility's policy requires that medications be administered in accordance with the physician's order, including the right time. Additionally, the facility failed to administer medications at the scheduled times for two other residents. One resident received gabapentin and depakote two hours after the scheduled time, and another resident received medications outside the one-hour window allowed by the facility's policy. The Director of Nursing confirmed that medications should not be given two hours late to maintain efficacy. The facility's Medication Administration Policy emphasizes the importance of administering medications at the right time, as prescribed by the physician.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident, R1, from physical abuse by another resident, R2, resulting in R1 requiring emergency medical care. R1, who had intact cognition, was assaulted by R2, who had a diagnosis of paranoid schizophrenia and exhibited fluctuating mental status with inattention and disorganized thinking. Despite R2 being identified as an offender requiring closer supervision, the facility did not implement additional monitoring or supervision beyond the standard for other residents. This lack of appropriate supervision allowed R2 to physically assault R1, causing injuries that required hospital treatment. Interviews with staff revealed that R2 had a history of aggressive behavior, including altercations with staff and other residents. Staff members reported that R2's behavior was unpredictable and that he had previously pushed or slapped staff members. Despite these incidents and R2's escalating behavior, there was no specific care plan or interventions in place to monitor R2 more frequently than other residents. The facility's failure to provide adequate supervision and monitoring for R2, despite his known aggressive tendencies, directly contributed to the incident of abuse against R1.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report multiple incidents of alleged abuse involving residents to the state agency, as required by their Abuse Prevention Program Policy. The incidents involved inappropriate touching and aggressive behavior by a resident diagnosed with paranoid schizophrenia, whose mental status fluctuated. One incident involved a resident grabbing another resident's buttocks in the dining room, which was reported to a registered nurse but not further reported to the state agency. Another incident involved the same resident being found touching a peer in their room, which was reported to a nurse practitioner but not escalated further. Additionally, there was an incident where the resident hugged and groped another resident, which was not reported to the administrator due to confusion over reporting responsibilities between two registered nurses. Further incidents included the resident walking in the hallway without underpants, attempting to kiss another resident, and entering another resident's room while naked, which resulted in physical aggression towards a certified nursing assistant. Although the police were called for this incident, the inappropriate touching and other incidents were not reported to public health authorities until months later. The facility's policy requires immediate reporting of any potential abuse, neglect, or mistreatment to the administrator, which was not adhered to in these cases. The administrator acknowledged the failure to report these incidents in a timely manner, attributing it to staff not following the reporting protocol.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. On the evening of August 21, 2024, a resident (R1) reported that another resident (R2) approached her while she was seated in her wheelchair on the front porch. R2 expressed romantic interest, which R1 declined, stating she only considered him a friend. Despite this, R2 proceeded to touch R1's right breast, leaving her stunned. R1 did not report the incident until the following morning, at which point the facility contacted the local police department. R1, who has a history of major depressive disorder and Huntington's disease, was assessed after the incident and found to have no physical injuries. She expressed feelings of anger and disgust towards R2 but stated she felt safe in the facility. R1's care plan includes psychotropic medication to manage her depressive symptoms, and she was offered ongoing support following the incident. R2, who has a history of depression and alcohol abuse, admitted to touching R1's breast over her shirt while under the influence of alcohol. He was subsequently arrested and relocated within the facility to limit his interactions with R1. The facility's abuse prevention policy emphasizes the residents' right to be free from abuse, including sexual abuse, defined as non-consensual sexual contact. Despite this policy, the incident occurred, highlighting a failure to protect R1 from abuse. Staff interviews revealed that R2 had no prior history of sexually inappropriate behavior, and the incident was unexpected. The facility took steps to separate R2 from R1 and restrict his movements within the facility following the incident.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse by a staff member. The incident involved a resident with multiple medical conditions, including paraplegia, sepsis, and multiple stage four pressure ulcers, who was cognitively intact and used a motorized wheelchair for mobility. The resident had a care plan for behaviors that included verbal aggression and recording staff without authorization. On the morning of May 18, 2024, the resident recorded a video of IV tubing left on his chest by a nurse, which led to a confrontation when the nurse noticed the recording and attempted to take the phone away from the resident, making physical contact in the process. The resident later reported the incident to the police and the facility, leading to an internal investigation and a city ordinance ticket for battery issued to the nurse involved. The resident's video showed the IV tubing draped across his chest and the nurse loudly demanding that he stop recording. The nurse's hand was seen coming towards the phone, and the video ended abruptly. The resident demonstrated how the nurse made contact with his hand and phone but denied any injury. The nurse documented the incident, stating that she was trying to block her face from being recorded and did not know it was part of the resident's care plan to video. The facility's Psychiatric Rehab Services Director and the Administrator were informed of the incident, and the police officer who reviewed the video confirmed the nurse's actions and issued a city ordinance ticket for battery. The facility's Abuse Prevention Program Policy states that residents have the right to be free from abuse, neglect, and mistreatment. Despite this policy, the incident occurred, and the facility's internal investigation confirmed the resident's allegations. The nurse involved was not aware of the resident's care plan allowing video recording, which contributed to the confrontation and subsequent physical contact. The police officer's involvement and the issuance of a city ordinance ticket highlighted the severity of the incident and the need for the facility to address the deficiency in ensuring residents' safety from abuse by staff members.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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