Rose Garden Of Pana
Inspection history, citations, penalties and survey trends for this long-term care facility in Pana, Illinois.
- Location
- 900 South Chestnut, Pana, Illinois 62557
- CMS Provider Number
- 145411
- Inspections on file
- 25
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Rose Garden Of Pana during CMS and state inspections, most recent first.
The facility did not schedule an RN to be on duty for at least 8 consecutive hours per day over an 88-day review period, despite having 71 residents. Staffing schedules and daily staffing sheets showed no RN coverage on any of the reviewed days. During the survey, a regional nurse was the only RN present, and CNAs reported that while the DON and regional nurse were in the building, they did not know if they were working the floor as nurses. The regional nurse confirmed that the facility did not have an RN providing services for 8 consecutive hours a day, contrary to the facility’s staffing policy requiring daily RN coverage.
The facility failed to ensure resident dignity and respect related to call light response and toileting needs. Several residents with varying levels of cognition and urinary incontinence reported long waits for call light response, leading to situations where they had accidents or felt compelled to toilet themselves, which made them feel embarrassed or awful. Night-shift staff, including an LPN and multiple CNAs, reported that there were not enough CNAs on the units at night, that management and call nurses did not respond when contacted, and that they nonetheless tried to answer call lights as quickly as possible while recognizing that having to wait and become incontinent would be embarrassing. An Ombudsman rights document referenced by surveyors stated that the facility must support residents' physical and mental health and their sense of satisfaction with themselves at the highest practical level.
A resident with venous and non-pressure wounds and multiple comorbidities had physician orders for daily skin checks and nightly dressing changes with specific wound care procedures, along with care plan requirements for ongoing wound assessment and documentation. Review of TARs over several months showed multiple missed or undocumented daily skin checks and dressing changes. Observation found a wound dressing dated from the prior day with yellow-green drainage, and the resident reported the dressing had not been changed when agency staff worked the previous night. LPNs reported that agency nurses often did not complete ordered treatments and that night-shift dressing changes were inconsistent, contrary to the facility’s wound care policy requiring thorough documentation of wound care and assessments.
A resident with dementia, chronic kidney disease, and heart failure experienced several days of vomiting, decreased intake, and lethargy. Staff did not thoroughly assess the resident's gastrointestinal symptoms or promptly notify the physician or family representative of the change in condition. This delay led to the resident being hospitalized for small bowel obstruction, dehydration, and related complications, requiring advanced interventions.
The facility failed to provide an RN for at least 8 consecutive hours a day, 7 days a week, and did not employ a DON. The administrator confirmed insufficient RN coverage, with only one RN working three days a week. The former DON left in July, and a newly hired DON did not complete employment. The RN on staff worked only on weekends, leaving the facility without adequate RN coverage on multiple days, affecting all 53 residents.
The facility did not post daily nursing staff hours, affecting all 53 residents. Observations over several days revealed no postings of resident census and licensed nursing staff numbers. The administrator was unaware of the lapse, assuming the former DON handled it. An LPN noted it was previously posted on the former DON's office door and should be updated daily.
A facility failed to prevent a severely cognitively impaired resident from wandering unsupervised, leading to multiple incidents where he entered other residents' rooms, causing distress. Despite reports from several residents and documented grievances, the facility lacked a specific policy on resident rights, and interventions were inconsistent.
A facility failed to supervise two residents adequately, leading to incidents of wandering and a fall without proper follow-up. One resident with dementia wandered unsupervised, entering other residents' rooms, while another resident with Alzheimer's fell and sustained injuries without an incident report or updated care plan. Staff interviews revealed a lack of awareness and communication, and the facility's fall prevention policy was not followed.
The facility failed to label, date, and dispose of food items in the refrigerator and freezer, potentially affecting four residents. Items such as pears, thickened juices, and various frozen goods were found improperly stored, contrary to the facility's policy requiring all items to be covered, labeled, and dated. The Dietary Manager admitted to not following the policy, leading to this deficiency.
The facility failed to provide timely Medicare notices to two residents regarding service termination and potential liability for non-covered services. One resident did not receive the required two days' notice before Medicare Part A coverage ended, and another resident's family did not receive evidence of the mailed notice. The facility lacked a policy for beneficiary notification, contributing to this deficiency.
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. A cognitively intact resident reported being struck by a severely cognitively impaired resident with dementia. Another incident involved a verbal argument escalating into physical aggression between two residents, and a third resident reported being elbowed multiple times by the same impaired resident. The facility's policy on abuse prevention was not effectively implemented, contributing to these occurrences.
A resident with Alzheimer's and severe cognitive impairment fell, sustaining injuries, but the facility failed to update the care plan with new fall prevention interventions. The incident was not documented in the EMR, leading to a lack of awareness and follow-up by the care plan coordinator and resident care coordinator, contrary to facility policy.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) to be on duty for at least 8 consecutive hours each day, as required by regulation and the facility’s own staffing policy, for all 88 days reviewed in December 2025, January 2026, and February 2026. Review of working schedules and daily staffing sheets showed that no RN was scheduled on any day from 12/01/25 through 12/31/25, from 01/01/26 through 01/31/26, and from 02/01/26 through 02/26/26. During the survey, the Regional Nurse (V4) was the only RN present in the building, and the facility’s CMS-671 dated 02/23/26 documented that 71 residents resided in the facility. During interviews on 02/26/26, two CNAs (V23 and V22) reported that the DON (V2) and the Regional Nurse (V4) were in the facility but did not know whether they were working on the floor as nurses. At 9:45 AM on the same day, the Regional Nurse (V4) confirmed that the facility did not have an RN providing services for 8 consecutive hours a day. The facility’s policy titled “Staffing, Sufficient, and Competent Nursing,” revised August 2022, states that an RN must provide services at least eight consecutive hours every 24 hours, seven days a week, and may be scheduled for more than eight hours depending on resident acuity. Despite this policy and the presence of 71 residents, the required RN coverage was not provided during the entire review period.
Failure to Ensure Dignity Related to Call Light Response and Incontinence
Penalty
Summary
Surveyors identified a failure to ensure dignity and respect related to call light response for four residents. One resident with moderately impaired cognition and frequent urinary and occasional stool incontinence reported that when staff did not answer her call light and she had to go to the bathroom, she sometimes had accidents that did not feel good and embarrassed her. Another resident with intact cognition and frequent urinary incontinence due to taking a diuretic stated she was always incontinent but, when she had to wait, she thought about other residents who also needed help and were not getting it. A third resident with intact cognition and occasional urinary incontinence reported that it took a long time for night shift to answer her call light, so she would get up and go to the bathroom on her own. A fourth resident with intact cognition and occasional urinary incontinence stated that if she had to wait a long time to use the toilet and had an accident, it made her feel awful. Staff interviews further described conditions contributing to delayed call light response. A night-shift LPN reported that they usually staffed 2 to 3 CNAs for three units (100, 200, 400) and 1 CNA for the memory care unit at night, and stated that this was not enough CNAs to get everything done and that 1 CNA was not enough on the unit. A CNA reported that management did not answer when staff tried to contact them, including call nurses, and stated that night shift did not have enough staff and that they needed 5 CNAs on nights, including 2 on the memory unit. Additional CNAs stated they tried to answer call lights as soon as possible and acknowledged that, if they themselves had urinated on themselves while waiting for a call light to be answered, they would feel embarrassed. The Ombudsman Residents' Rights document cited by surveyors stated that the facility must provide services to keep residents' physical and mental health and sense of satisfaction with themselves at their highest practical levels.
Failure to Consistently Complete and Document Ordered Wound Care and Skin Checks
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and daily skin checks as ordered for a resident with multiple comorbidities and documented venous and non-pressure wounds. The resident, cognitively intact and dependent on staff for most ADLs, had care plan interventions requiring ongoing wound assessment and documentation, including weekly measurements and monitoring for signs of infection. Physician orders directed daily skin checks on day shift with CROPs documentation on the TAR each Friday, and nightly dressing changes to the right anterior lower leg with specific cleansing and dressing procedures. Review of the Treatment Administration Records (TARs) for December, January, and February showed multiple dates where daily skin checks and ordered dressing changes were not documented as completed. On observation, the resident was seen in a wheelchair with a right lateral ankle dressing dated the previous day and showing a moderate amount of yellow/green drainage, and the resident reported that the dressing, usually changed by night shift, had not been changed the prior night when agency staff were working. Interviews with LPN staff indicated that many agency nurses do not complete ordered treatments, with one LPN stating she found dressings unchanged two days after she had last performed them, and another describing dressing changes on night shift as “hit or miss,” particularly when agency staff were on duty. The regional nurse stated she expects dressings to be changed as ordered. The facility’s wound care policy requires detailed documentation of wound care, including type of care, date and time, assessment data, resident tolerance, and any problems or refusals, which was not consistently reflected in the TARs for this resident.
Failure to Assess and Notify Change in Condition Resulting in Delayed Hospitalization
Penalty
Summary
The facility failed to properly assess a resident who experienced a change in condition, specifically regarding symptoms of nausea, vomiting, and decreased oral intake. The resident, who had a history of dementia, chronic kidney disease, and congestive heart failure, was observed by staff and family to be unusually lethargic and to have episodes of vomiting over several days. Despite these symptoms, nursing staff did not perform a thorough assessment, such as checking the resident's abdomen for bowel sounds or distention, nor did they document the time of the last bowel movement. Communication among staff was inconsistent, with some staff unaware of the resident's gastrointestinal issues, and there was a lack of prompt notification to the physician regarding the resident's change in condition. Additionally, the facility did not notify the resident's physician or representative in a timely manner as required by policy when the resident's condition changed. The delay in assessment and notification resulted in the resident being hospitalized with a diagnosis of small bowel obstruction, dehydration, and other complications, requiring nasogastric decompression and multiple attempts at intravenous access for fluid resuscitation. The facility lacked a specific policy for gastrointestinal assessment, and staff interviews revealed gaps in communication and follow-through on reporting and assessing significant changes in the resident's health status.
Deficiency in RN Coverage and Lack of DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, and did not employ a Director of Nursing (DON). This deficiency was identified through interviews, observations, and record reviews. The facility's administrator confirmed the lack of a DON and insufficient RN coverage, with only one RN working three days a week. The facility's management team document indicated the DON position was vacant, and during the survey period, no DON or RN was observed on duty. The facility's Licensed Practical Nurse (LPN) stated that the former DON's last day was in July, and a newly hired DON left after only two hours without completing employment paperwork. The RN on staff, identified as V15, worked only on Fridays, Saturdays, and Sundays, with documented absences on multiple days in October, leaving the facility without RN coverage for 8 hours a day on those days. The facility's nurse staffing policy requires sufficient licensed and unlicensed nursing staff to maintain residents' well-being, but this policy was not adhered to, affecting all 53 residents in the facility.
Failure to Post Daily Nursing Staff Hours
Penalty
Summary
The facility failed to ensure that the daily nursing staff hours were posted and easily visible to residents, affecting all 53 residents residing in the facility. Over several days, from 10/28/2024 to 10/31/2024, the survey team observed that there were no postings documenting the resident census and the number of licensed nursing staff. The administrator, identified as V1, was unaware that the postings were not being made, believing that the former Director of Nursing (DON) had been responsible for posting the nurses' schedules at the nurses' station. An LPN, identified as V5, confirmed that the postings used to be on the former DON's office door and should be updated daily by the person responsible for the schedule.
Facility Fails to Prevent Wandering Resident from Invading Others' Privacy
Penalty
Summary
The facility failed to protect residents' private spaces from a wandering resident, identified as R48, who was observed multiple times moving unsupervised throughout the facility. R48, who is severely cognitively impaired with a BIMS score of 99, was seen entering other residents' rooms and common areas without staff intervention. This behavior was noted on several occasions, including attempts to exit through a secured door and entering dietary areas. R48's care plan indicated he required supervision and had a history of physical and verbal aggression related to dementia. Several residents, including R11, R36, R14, and R12, reported incidents where R48 entered their rooms uninvited, causing distress and fear. R11, who is cognitively intact and suffers from multiple health issues, expressed fear of potential harm due to her frailty. R36 recounted an incident where R48 mistakenly claimed his room and another where R48 took his tea. R14 and R12 also reported similar intrusions, with R14 having to use her call light to get assistance when R48 began undressing in her room. The facility's resident council meeting minutes and grievance records indicated ongoing concerns about resident safety and privacy due to R48's wandering. Despite these issues, the facility lacked a specific policy on resident rights, and staff interventions appeared inconsistent. R48's wife suggested a more structured approach to his care, but the facility's response was limited, with temporary 1:1 supervision only implemented during state surveys or medication changes.
Inadequate Supervision and Fall Management in LTC Facility
Penalty
Summary
The facility failed to adequately supervise and manage the care of two residents, leading to multiple incidents of wandering and a fall without proper follow-up. One resident, diagnosed with dementia and other conditions, was observed wandering unsupervised throughout the facility, entering other residents' rooms, and exhibiting aggressive behavior. Despite documented interventions in the care plan, such as 15-minute checks and 1:1 supervision when agitated, these measures were not consistently implemented. The resident's wife reported that the facility only provided 1:1 supervision temporarily and often lost track of the resident's whereabouts. Another resident, with a diagnosis of Alzheimer's disease and other conditions, experienced a fall that resulted in a head injury and skin tears. The incident was not documented in the facility's risk management system, and no incident report was completed. Consequently, the care plan was not updated with new fall prevention interventions, and no root cause analysis was conducted. The facility's policy requires immediate assessment and documentation of falls, as well as the implementation of new interventions, but these procedures were not followed. Interviews with facility staff revealed a lack of awareness and communication regarding the incidents. The Care Plan Coordinator and Resident Care Coordinator were unaware of the fall due to the absence of an incident report, and the Administrator acknowledged the failure to complete necessary documentation. The facility's Fall Prevention policy outlines specific responsibilities and procedures for managing falls, but these were not adhered to, resulting in inadequate care and supervision for the residents involved.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to properly label, date, and dispose of food items stored in the refrigerator and freezer, which had the potential to affect four residents reviewed for expired food. During an initial walkthrough of the kitchen, several items were found improperly stored, including pears with an open date, thickened juices without open or use-by dates, and various frozen items with freezer burn that were undated and unlabeled. The facility's policy requires all items in refrigerators and freezers to be covered, labeled, and dated, but this was not adhered to. The Dietary Manager acknowledged the practice of keeping fruit in the refrigerator for a week and was unsure about the requirement for dating opened thickened juices. The manager also stated that any undated, unlabeled, or freezer-burned items should be discarded, which was not done. The facility's storage policy mandates that leftovers be stored in covered, labeled, and dated containers, but this procedure was not followed, leading to the deficiency.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Medicare written notices to residents regarding the right to an expedited review of a service termination and potential liability for non-covered services. Specifically, for two residents reviewed, the facility did not issue the Notice of Medicare Non-Coverage (NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) in a timely manner. Resident 17 was not given at least two days' notice before the end of Medicare Part A coverage, as the SNF ABN was signed on the last day of coverage. Resident 44's Medicare A coverage ended without the facility providing the NOMNC, and there was no evidence that the SNF ABN was mailed and received by the resident's family. The facility's staff, including the Regional Director and Social Service Director, acknowledged the expectation of providing at least two days' notice before the end of Medicare Part A coverage. However, the facility lacked a policy for beneficiary notification, which contributed to the oversight. The absence of a documented policy and evidence of notification for Resident 44 highlights the facility's failure to comply with the required notification procedures, resulting in a deficiency in beneficiary protection notification.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident R11, who is cognitively intact, reported being struck in the back by another resident, R48, who is severely cognitively impaired and diagnosed with dementia. This incident occurred when R48 attempted to push R11's walker, and upon being told to stop, R48 became upset and hit R11. The incident was not witnessed by staff, and although no physical injuries were noted, R11 expressed fear of R48 following the altercation. Another incident involved residents R36 and R48, where a verbal argument escalated into physical aggression. R36, who is nearly cognitively intact, pushed R48 with his hip, leading to R48 grabbing R36, who then hit R48 in the head. This altercation was partially witnessed by staff, who intervened to separate the residents. R48, who has a disorganized thought process and is easily overstimulated, was involved in this altercation due to his wandering behavior and poor safety awareness. Additionally, resident R37 reported being elbowed multiple times by R48, causing her concern for her safety. This incident was witnessed by a staff member who intervened to redirect R48. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving R48 and other residents. The facility's failure to adequately monitor and manage R48's behavior contributed to these occurrences, highlighting a deficiency in ensuring resident safety and preventing abuse.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update a resident's care plan with new fall prevention interventions following a fall with injury. The resident, who has diagnoses including Alzheimer's disease and severe cognitive impairment, experienced a fall on 9/30/24, resulting in a head laceration and skin tears. Despite the incident, the care plan was not updated to reflect the fall or include new interventions, and no root cause analysis was conducted. The incident was not documented in the electronic medical record (EMR) risk management program, which led to the care plan coordinator being unaware of the fall. The facility's policy requires that an incident report be completed for each fall, but this was not done. Consequently, the resident care coordinator did not investigate the fall or add any interventions to the care plan. The facility's policies on comprehensive care planning and fall prevention were not followed. The care plan coordinator and the resident care coordinator both stated that they expect nurses to complete incident reports for falls, but this expectation was not met in this case. The lack of documentation and follow-up resulted in a failure to address the resident's fall and implement necessary interventions.
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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