Seminary Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Galesburg, Illinois.
- Location
- 2345 North Seminary Street, Galesburg, Illinois 61401
- CMS Provider Number
- 145598
- Inspections on file
- 27
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Seminary Manor during CMS and state inspections, most recent first.
A resident with a history of behavioral symptoms and moderate cognitive impairment made sexually explicit comments to another cognitively impaired resident in a dining room, telling her he wanted to see and touch her breasts and making other graphic remarks. The recipient of the comments became upset, sought out staff, and reported the incident, stating she did not want other female residents to be similarly harassed and now actively avoids the other resident. Staff confirmed both residents were oriented, and the facility’s own policy prohibits sexual abuse, including sexual harassment, yet the incident was not substantiated as abuse based on a conclusion that the offending resident lacked capacity, despite acknowledgment that he understood basic social rules and could recognize inappropriate comments.
The facility did not return trust fund balances to discharged or deceased residents within the required timeframe and failed to notify residents or their representatives when trust fund accounts approached or exceeded the SSI resource limit. Multiple residents were affected, with some accounts holding significant balances, and staff confirmed that required notifications and refunds were not completed as per policy.
The facility did not hold required quarterly QAA meetings as outlined in its QAPI Plan, with only two meetings documented in the past year and none during the administrator's absence. This failure potentially affected all 97 residents in the facility.
The facility did not properly identify, monitor, or review antibiotic use for several residents, as required by its infection control and antibiotic stewardship policies. Antibiotics and antifungals were administered for various conditions, but the facility's tracking logs and pharmacist reviews failed to document the medications, their indications, or relevant test results. Staff interviews confirmed that ongoing monitoring and accurate record-keeping were not performed.
A resident had an active PRN order for Alprazolam 0.5 mg for generalized anxiety, despite not having received the medication for over a month. The DON confirmed that the order remained in the medical record and should have been discontinued according to facility policy.
A resident's care plan did not include their diagnoses of Atrial Fibrillation and Diabetes or the use of Eliquis and Humalog Insulin, despite these medications being ordered and administered. The Care Plan Coordinator confirmed these omissions during the review.
A resident did not have compression stockings applied as ordered by their physician. Although the treatment record indicated the stockings were on, observation revealed the resident was not wearing them, and a CNA confirmed the omission and located the stockings in the resident's dresser drawer.
A resident with a history of trauma and multiple psychiatric diagnoses did not have potential trauma triggers or emotional support needs identified in their care plan or medical record. Staff confirmed the absence of this documentation, and the facility lacked a trauma-informed care policy.
Two residents developed severe pressure ulcers due to the facility's failure to implement and update care plans with pressure-relieving interventions. One resident developed an unstageable ulcer on the left heel, while another developed a stage three ulcer on the right heel and an unstageable ulcer on the inner ankle. The facility did not conduct required assessments, update care plans, or notify physicians of changes, resulting in severe pain for the residents.
A resident with Congestive Heart Failure and respiratory conditions experienced multiple instances of oxygen deprivation due to the facility's failure to monitor and maintain a continuous oxygen supply. The resident's portable oxygen tanks were not adequately checked or refilled, leading to severe respiratory distress during a medical appointment and at the facility. Interviews revealed issues with equipment maintenance and a lack of proper procedures, contributing to the resident's distress.
The facility failed to change nebulizer and oxygen equipment as per protocol, with two residents' nebulizer equipment not replaced weekly and found un-bagged, and oxygen tubing for two residents not dated or replaced every seven days. Observations showed oxygen equipment improperly stored and dated, indicating a lapse in respiratory care standards.
The facility failed to disinfect wound care supplies after each use, affecting multiple residents. A resident with diabetes and chronic kidney disease received wound care, but the spray bottle used was not disinfected before being returned to the treatment cart. This bottle was used for multiple residents, contradicting the facility's infection control policies.
The facility failed to document justification for duplicative antidepressant therapy for a resident and for reinstating an antipsychotic for another. One resident was put back on Olanzapine after confirmed agitation, but without documented justification. Another resident was on three antidepressants without documented rationale, despite not being a harm to themselves or others.
Failure to Protect Resident From Sexual Harassment by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual harassment by another resident, as required by its abuse prohibition policy. The facility’s policy, revised 11/28/19, states that residents must be protected from all forms of abuse, including sexual abuse and sexual harassment. One resident (R1) had a documented history and care plan problem area for multiple behavioral symptoms, including delusions, exit seeking, physical and verbal behaviors toward others, rejection of care, and making inappropriate comments toward female staff during care. R1’s cognitive status was documented as moderately impaired with a score of 10/15 on the MDS. Another resident (R2), with a cognitive score of 11/15 and no care plan problem areas indicating a history of making false allegations, reported that R1 made sexually explicit comments to her. On the morning of 1/8/26, R2 and R1 were both in the north dining room early, as R1 often went there for coffee and R2 had not been sleeping well and was also up early. R2 reported that R1 told her he wanted to see and touch her breasts in a sexual manner and made other graphic remarks. R2 stated she told R1 to stop talking to her that way, and he stopped immediately. R2 became upset, wheeled herself through the hallway looking for staff, and called out for help to report that R1 was making inappropriate comments and that she did not want other female residents to be harassed. Staff, including a CNA and an RN, responded to R2’s call, and R1 was escorted away from the area. During subsequent interviews, R2 consistently recalled the incident and reiterated that she was upset by R1’s comments and now makes a point to avoid him. Staff who knew both residents stated that both R1 and R2 were oriented to time, place, and purpose. The administrator later determined that the incident was not substantiated abuse based on a conclusion that R1 lacked capacity to understand his actions, despite also acknowledging that R1 understood basic social rules, could recognize that certain comments were inappropriate, and could follow simple directions or redirections. The facility’s determination that abuse was not substantiated, in the context of a credible report of sexually explicit comments and R1’s known history of inappropriate verbal behaviors, reflects the failure to ensure R2’s right to be free from sexual harassment by another resident.
Failure to Timely Refund Resident Trust Funds and Notify of SSI Resource Limit Exceedance
Penalty
Summary
The facility failed to return resident trust fund balances within the required 30-day period after discharge or death for 46 residents. Record review and interviews confirmed that multiple residents had remaining balances in their trust fund accounts that were not refunded in accordance with facility policy and state/federal regulations. Documentation showed that these balances ranged from small amounts to over a thousand dollars, and there was no evidence that the funds were returned to the residents or their representatives within the specified timeframe. The facility's own admission contract and trust fund policy require timely refunds, but these were not followed, as confirmed by both the administrator and business office staff. Additionally, the facility did not provide required notifications when resident trust fund balances approached or exceeded the Supplemental Security Income (SSI) resource limit. Three residents had trust fund balances that exceeded the SSI resource limit, but there was no documentation that the residents, their legal representatives, or social services were notified as required by facility policy. The business office manager was unaware of the SSI resource limit, and the administrator confirmed the lack of notification. These failures were identified through review of facility records and interviews with staff.
Failure to Hold Required Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct quarterly Quality Assessment and Assurance (QAA) meetings as required by its QAPI Plan, which specifies that the committee must meet on a quarterly basis. Record review showed that only two QAA sign-in sheets were available for the past year, dated March and April, with no documentation of meetings prior to March. The administrator confirmed that QAA meetings were not held during her temporary absence starting in July, and no additional sign-in sheets could be located. This lapse in holding required QAA meetings has the potential to affect all 97 residents residing in the facility, as documented on the CMS form 671.
Failure to Monitor and Review Antibiotic Use for Multiple Residents
Penalty
Summary
The facility failed to identify, monitor, and review antibiotic use for all five residents reviewed for antibiotic stewardship, as required by their Infection Control and Antibiotic Stewardship policies. The policies specify that the Infection Control Committee is responsible for surveillance, review, and analysis of infections, as well as maintaining a system for reporting and evaluating antibiotic use. However, the facility's Infection Tracking Logs for multiple months did not include required information such as the antibiotics administered, their indications for use, or the results of relevant cultures and laboratory tests for several residents who were receiving antibiotics or antifungals. For example, one resident was on a maintenance dose of Macrodantin for a history of urinary tract infections without a documented stop date, and this was not tracked in the Infection Tracking Log or evaluated by the pharmacist. Another resident received Macrobid prophylactically and later multiple courses of Levofloxacin for urinary tract infections, but the logs did not document the antibiotics, their indications, or the results of diagnostic tests. Additional residents received various antibiotics and antifungals for conditions such as cough, skin eruptions, pneumonia, and cystitis, but the facility failed to document these treatments and their appropriateness in both the Infection Tracking Log and the Pharmacist's Summary of Recommendations. Interviews with facility staff confirmed that ongoing monitoring of residents on prophylactic antibiotics was not performed after initial initiation, and that the tracking system was incomplete and inaccurate. The Assistant DON/Infection Preventionist acknowledged that the logs did not track culture or test results, were not comprehensive, and that the pharmacist's reviews were not inclusive of all antibiotic or antifungal use. The Administrator also stated that the facility struggled with entering and ensuring the accuracy of required infection information in the new tracking system.
Failure to Discontinue Unnecessary PRN Psychotropic Medication
Penalty
Summary
The facility failed to discontinue a PRN (as needed) psychotropic medication, Alprazolam 0.5 mg, for one resident as required by facility policy and procedures. The resident had an active physician order for Alprazolam to be administered twice daily as needed for generalized anxiety, with the last documented administration occurring over a month prior to the survey. Despite the lack of recent use, the medication order remained active in the resident's medical record. The Director of Nursing confirmed that the PRN order for Alprazolam was still present and acknowledged it should have been discontinued in accordance with facility protocols to prevent unnecessary medication use.
Care Plan Omission for Anticoagulant and Insulin Therapy
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's medical needs. Specifically, for one resident, the care plan did not include the diagnoses of Atrial Fibrillation and Diabetes, nor did it address the administration of Eliquis, a blood thinner, and Humalog Insulin, both of which were ordered by the physician and being administered according to the Medication Administration Record. The Care Plan Coordinator confirmed that these diagnoses and medications were missing from the resident's care plan and acknowledged the oversight during the surveyor's review.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
A deficiency occurred when a resident did not receive leg compression stockings as ordered by their physician. The physician's orders specified that Tubi Grips (compression stockings) were to be applied to both lower extremities in the morning and removed at bedtime. The resident's treatment administration record indicated that the Tubi Grips were on, but during an observation in the activity area, the resident was found without Tubi Grips, socks, or shoes. A certified nurse aide confirmed responsibility for applying the Tubi Grips, acknowledged that the resident was not wearing them, and verified that the stockings were available in the resident's dresser drawer but had not been applied as required.
Failure to Identify and Address Trauma Triggers in Resident Care Plan
Penalty
Summary
The facility failed to provide trauma-informed care for one resident with a history of significant trauma, including childhood separation, time in an orphanage, sexual assault, and experiencing a tornado. The resident's diagnoses included Generalized Anxiety Disorder, Psychotic Disturbance, Mood Disturbance, Major Depressive Disorder, and Hallucinations. Despite this history, the resident's social assessment and care plan did not identify or document any potential triggers or emotional support needs related to past trauma. Interviews with facility staff confirmed that the care plan and medical record lacked this information, and it was also noted that the facility did not have a policy on trauma-informed care.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement adequate pressure ulcer prevention and treatment protocols for two residents, R1 and R2, leading to the development and worsening of pressure ulcers. R1, who was admitted with a left femur fracture and other mobility issues, developed an unstageable pressure ulcer on the left heel six days after admission. The facility did not conduct weekly Braden Scale assessments as required, and R1's care plan was not updated to include interventions for the newly developed pressure ulcer. Additionally, R1's wound was incorrectly categorized as a stage one pressure injury, and there was a lack of consistent wound assessment and documentation. R2, who was severely cognitively impaired and diagnosed with chronic congestive heart failure and cerebrovascular disease, developed a stage three pressure ulcer on the right heel and an unstageable pressure ulcer on the inner ankle. The facility failed to update R2's care plan with pressure-relieving interventions after R2 was identified as high risk for pressure ulcers. Furthermore, there was inadequate documentation and notification to the physician regarding the condition and treatment of R2's pressure ulcers, resulting in severe pain for R2. The facility's staff, including the wound nurse and care plan coordinator, admitted to being behind on assessments and care plan updates. There was also a lack of communication with the physician regarding changes in the residents' wound conditions. These deficiencies highlight the facility's failure to adhere to its own pressure ulcer prevention and treatment protocols, leading to the development and worsening of pressure ulcers in residents R1 and R2.
Failure to Ensure Continuous Oxygen Supply for Resident
Penalty
Summary
The facility failed to adequately monitor and ensure a continuous supply of oxygen for a resident diagnosed with Congestive Heart Failure and other respiratory conditions. The resident, who was cognitively intact, was admitted with a need for continuous supplemental oxygen. However, the facility did not maintain the resident's oxygen supply as ordered by the physician, leading to multiple instances where the resident was without oxygen for significant periods. This resulted in the resident experiencing severe respiratory distress, including chest pain and shortness of breath. The report details specific incidents where the resident's portable oxygen tank ran out, both during a medical appointment and at the facility. During a visit to a nephrologist, the resident's oxygen tank was empty, causing the resident's oxygen saturation to drop to 80 percent, and the resident exhibited symptoms of cyanosis and slurred speech. The facility's transport staff was not adequately trained or equipped to handle the resident's oxygen needs, leading to a delay in providing a replacement tank. Another incident occurred during dinner at the facility, where the resident's oxygen tank again ran empty, and it took an extended period for staff to provide a new tank. Interviews with staff and family members revealed a lack of proper procedures and equipment maintenance, contributing to the resident's distress. The facility's oxygen tanks were reported to be old and unreliable, with some gauges not functioning correctly. Additionally, there was no consistent schedule for checking and refilling the oxygen tanks, and the resident's care plan did not address their oxygen needs. The facility's failure to ensure a continuous oxygen supply and perform necessary assessments after these incidents highlights significant deficiencies in the care provided to the resident.
Failure to Maintain Proper Respiratory Care Protocols
Penalty
Summary
The facility failed to adhere to its own protocols for respiratory care, specifically regarding the timely replacement and proper storage of nebulizer and oxygen equipment. For two residents, the nebulizer mask and tubing were not changed every seven days as required. One resident's nebulizer equipment was found on a nightstand, un-bagged, and dated over a month prior, while a registered nurse confirmed the equipment should be changed weekly and stored in a bag between uses. Additionally, the oxygen tubing for two residents was not replaced every seven days, as evidenced by the tubing being dated several months prior or having no date at all. Further observations revealed that oxygen tubing and nasal cannulas for two residents were found on the floor, connected to oxygen tanks, and running without proper dating. These residents were not present in their rooms at the time of observation, and when seen later, they were using oxygen tanks with tubing that also lacked date markings. These findings indicate a failure to maintain proper respiratory care protocols, potentially compromising the residents' health and safety.
Failure to Disinfect Wound Care Supplies
Penalty
Summary
The facility failed to ensure that wound care supplies were disinfected after each resident's wound care, which has the potential to affect multiple residents receiving wound care. The facility's Standard Precautions policy and Wound Care policy emphasize the importance of following standard precautions during wound care to prevent the transmission of infectious agents. However, during an observation, it was noted that the wound cleanser spray bottle used for a resident's wound care was not disinfected before being returned to the treatment cart. This spray bottle was used for multiple residents, which contradicts the facility's policy and increases the risk of cross-contamination. The deficiency was observed during the wound care of a resident with diagnoses including insulin-dependent diabetes and chronic kidney disease. The resident's treatment involved cleaning and dressing a pressure ulcer on the left buttock. After the wound care was completed, the wound nurse returned the spray bottle to the treatment cart without disinfecting it. The Director of Nurses confirmed that these bottles are considered community property and are used for multiple residents' wound care, further highlighting the facility's failure to adhere to its own infection control policies.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to document justification for the use of duplicative antidepressant therapy for one resident and failed to document the justification for reinstating an antipsychotic for another resident. One resident was initially prescribed Olanzapine for dementia with delusions and agitation, but the medication was discontinued following a pharmacy review due to a lack of documented behaviors justifying its use. However, the resident was later put back on Olanzapine after exhibiting agitation and accusations of missing clothing, which were confirmed to be true events rather than delusions. Despite this, the facility did not document the justification for reinstating the antipsychotic medication. Another resident was prescribed three different antidepressants: Mirtazapine, Bupropion HCL, and Sertraline. The Director of Nursing, responsible for managing psychotropic medications, was unable to provide a documented reason for the resident taking multiple antidepressants, and it was confirmed that the resident was not a harm to themselves or others. This lack of documentation for the use of multiple antidepressants constitutes a deficiency in the facility's management of psychotropic medications.
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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