Serenity Estates At Morris
Inspection history, citations, penalties and survey trends for this long-term care facility in Morris, Illinois.
- Location
- 1223 Edgewater, Morris, Illinois 60450
- CMS Provider Number
- 146077
- Inspections on file
- 23
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Serenity Estates At Morris during CMS and state inspections, most recent first.
Multiple residents reported receiving cold meals, both in their rooms and in the dining area. Staff observations confirmed that hot food was not consistently maintained at appropriate temperatures during plating and delivery, with temperature checks showing some items below the standard for palatability. The facility lacked both adequate equipment and a policy to ensure food was served at an appetizing temperature.
A resident who was cognitively intact and dependent on staff for showering was left alone and undressed in the shower room by a CNA, who left to assist another resident and returned about 15 minutes later to find the resident shivering and cold. Facility leadership confirmed that residents should not be left alone or naked during shower care.
Two residents with a history of repeated falls, dementia, and poor safety awareness were observed multiple times without the required non-skid mats on their wheelchair seats, despite care plans specifying this intervention. Staff interviews confirmed the non-skid mats were not consistently used, and facility records showed multiple falls for both residents over several months.
Two cognitively intact residents with complex medical conditions did not receive their prescribed medications in a timely manner after admission due to delays in order entry, lack of staff access to medication storage, and missed opportunities to request STAT pharmacy deliveries. Staff did not follow facility policies for obtaining unavailable medications or notifying physicians about the delays, resulting in missed doses of critical medications.
A resident with dementia and high fall risk was improperly transferred using a mechanical lift, resulting in a fall and head injury. The CNAs involved failed to secure the lift sling properly, causing the resident's wheelchair to tip backward. The facility's policy on safe transfers was not followed, leading to the incident.
A resident with a history of aphasia and hemiplegia suffered fractures due to improper transfer assistance. A new CNA performed a one-person pivot transfer, contrary to the care plan requiring a two-person assist with a mechanical lift. The resident was initially assessed with no injuries but later confirmed to have fractures after expressing pain. Facility staff confirmed the CNA did not follow the safe transfer policy.
The facility failed to maintain sufficient dietary staff, impacting meal preparation for all residents. The Dietary Manager reported staffing shortages, leading to meal schedule changes and mismatches with the menu, affecting residents' meal choices. The facility's staffing schedule showed numerous days with insufficient staff, falling short of the required levels to meet residents' needs.
The facility failed to follow its established menus due to staffing shortages, leading to meal substitutions not aligned with policy. A resident expressed dissatisfaction with the inconsistency, and the Dietary Manager admitted to altering meals because of insufficient staff, which is not permitted by the facility's policy.
The facility failed to maintain proper food safety and sanitation practices, including improper labeling and dating of food items, inadequate sanitization of kitchen equipment, and lack of hair restraints by staff in the kitchen. These deficiencies were observed during meal preparation and storage inspections, posing potential cross-contamination and foodborne illness risks.
The facility failed to implement adequate fall prevention measures for several residents, leading to multiple incidents. A resident on anticoagulants fell out of bed without fall mats in place, another with cognitive impairment had her bed left in a high position against care plan instructions, and a third resident at high fall risk had only one fall mat instead of two. Additionally, exposed metal bed frames posed injury risks, indicating systemic issues in fall prevention and safety measures.
A long-term care facility failed to properly label, store, and dispose of medications, leading to potential safety risks for residents. Insulin pens were found without proper labeling, and controlled substances were improperly stored. Expired medical supplies were not disposed of, and medications were found at residents' bedsides without proper orders or safety assessments. The facility's policies on medication storage and controlled substance accountability were not adhered to, posing a risk of medication errors and potential harm to residents.
The facility failed to follow infection control practices for residents under TBP and during the transportation of dirty linen. A resident with C. difficile was visited by a family member and an occupational therapist without proper PPE or hand hygiene. Another resident under EBP for MRSA had a CNA enter without a gown due to lack of supplies, and the urinary catheter bag was mishandled. Additionally, CNAs failed to change gloves or perform hand hygiene during incontinent care and transported soiled linen improperly.
A facility failed to implement a resident's chosen DNR status, despite it being documented in the POA paperwork and confirmed by family members. The resident, with multiple diagnoses including dementia, had made the DNR decision prior to cognitive changes. The facility lacked a physician's order for the DNR, and the resident was assumed to be a full code, contrary to the facility's policy on communicating code status.
The facility failed to provide adequate ADL care to two residents, resulting in deficiencies in personal hygiene and toileting assistance. One resident was observed with a crusted substance on her eyelid over several days, indicating her face had not been washed. Another resident was not properly assisted with wiping or handwashing after toileting. The facility's policy requires necessary services for residents unable to perform ADLs.
The facility failed to apply assistive devices as ordered for two residents. One resident with Parkinsonism and dementia did not have the prescribed hand rolls to prevent contractures, and staff used makeshift solutions due to the absence of a restorative program. Another resident with a leg fracture had a CAM boot that was not worn as ordered, with staff misunderstanding the requirement for it to be on at all times except during specific activities.
A resident with severe cognitive impairment and urinary retention was found with an indwelling catheter bag positioned above bladder level, risking a UTI. A nurse indicated the bag might have been left in this position by a therapist, and both the RN and DON confirmed the risk of UTI from improper positioning. Facility policy requires catheter bags to be below bladder level.
A resident with a PICC line was found with a dirty, peeling dressing lacking a date or label, and there was no physician order or documentation for regular dressing changes. The facility's policy requires weekly dressing changes to prevent infection, but this was not followed, as confirmed by the RN and DON.
The facility failed to obtain consents for psychotropic medications for two residents and did not follow pharmacy recommendations. One resident was administered Clonazepam and Mirtazapine without consents, while another received Escitalopram and Olanzapine without consents and had a delayed AIMS test. The facility's policy on medication management and monitoring was not followed.
The facility failed to document their yearly Performance Improvement Projects (PIP) for falls, identified as a problem-prone area. During a QAPI/QAA task, the Administrator and ADON could not provide records of QAPI/QAA meetings or data on interventions for the fall PIP. The ADON had interventions in mind but had not documented them, affecting all 90 residents.
The facility did not conduct QAA meetings quarterly and lacked required members, including the Medical Director, in recent sessions. The last official meeting was in June 2024, and subsequent sessions were introductory, not formal QAA meetings.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at a palatable and acceptable temperature for residents, as evidenced by multiple resident interviews and direct observation. Thirteen residents reported that their meals were served cold, both in their rooms and in the dining room. Residents described the food as 'not really hot,' 'ice cold,' and 'not very edible.' During meal service, it was observed that hot food items were plated under a heating lamp, covered with metal lids, and transported on trays using a free-standing cart covered by a plastic liner. Only one insulated enclosed cart was available for a specific unit, and the facility did not use heating pellets for each plate. Temperature checks conducted by the Dietary Manager after the last meal tray was served showed that the Italian roast beef sandwich was at 104.5°F and potato wedges at 134.9°F, while the standard for palatability was stated by the facility dietitian to be between 110-120°F. The facility lacked a policy regarding the palatability of food, and staff confirmed the absence of necessary equipment to maintain appropriate food temperatures during delivery. These actions and inactions resulted in residents consistently receiving meals at temperatures below acceptable standards.
Resident Left Unattended and Undressed During Shower
Penalty
Summary
A resident with diagnoses including intervertebral disc disorder with radiculopathy, acute respiratory failure with hypoxia, generalized muscle weakness, chronic pain, and dizziness, who was cognitively intact and dependent on staff for showering, reported being left alone and naked in the shower room by a CNA. The resident stated that the CNA turned on the water and left to attend to another resident in a different shower room, returning approximately 15 minutes later to find the resident shivering and cold, unable to wash himself. Facility leadership confirmed that residents should not be left alone or naked in the shower room during care.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement recommended fall prevention measures for residents identified as high risk for falls. Two residents with multiple medical diagnoses, including repeated falls, unsteadiness, lack of coordination, and dementia, were observed multiple times without the required non-skid mats on their wheelchair seats, despite care plans specifying this intervention. Observations on several occasions showed these residents sitting in their wheelchairs or being assisted by staff without the non-skid mats in place. Staff interviews confirmed that the non-skid mats were not consistently used, and one CNA stated she had never seen a non-skid mat on one resident's wheelchair. The facility's fall incident log documented multiple falls for both residents over a period of several months. The care plans for both residents, which were updated following these incidents, included the use of non-skid mats as a specific intervention to address their high risk for falls due to poor safety awareness, dementia, and other medical conditions. Despite these documented interventions, direct observations and staff interviews revealed that the non-skid mats were not in use at the times observed, indicating a failure to follow the established fall prevention measures for these high-risk residents.
Failure to Provide Timely Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that medications were readily available to newly admitted residents, resulting in delays in medication administration for two residents. One resident, who was cognitively intact and had multiple diagnoses including COPD, depression, and chronic respiratory failure, was admitted after the pharmacy's medication order cut-off time. The assigned LPN did not have access to the medication storage and was unaware of the process to obtain medications after hours or request a STAT delivery. As a result, the resident did not receive several scheduled medications on the evening of admission and the following morning, with documentation showing that medications were not delivered until the afternoon of the next day. Another cognitively intact resident with complex medical conditions such as diabetes, congestive heart failure, and stage 4 kidney disease also experienced delays in receiving medications. The resident's medication orders were not entered into the computer until the evening of the day after admission, and medications were not administered until the following day. The resident missed multiple doses of oral medications and insulin, and family members had to retrieve medications from the previous care setting due to the delay. There was no documentation that physicians were notified about the delays in medication administration. Facility policies required immediate action when medications were unavailable, including notifying the physician and obtaining alternative orders or emergency deliveries. However, staff did not follow these procedures, and there was a lack of communication and timely action to ensure that newly admitted residents received their prescribed medications as ordered.
Unsafe Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in an accident. The resident, who has a history of dementia, weakness, Meniere's disease, and hearing loss, was identified as high risk for falls. The care plan specified the use of a mechanical lift with two staff members for transfers. During a transfer from a wheelchair to a bed, the resident's wheelchair was lifted along with the resident, causing the wheelchair to tip backward and the resident to fall, hitting his head on the floor. The incident occurred because the mechanical lift sling was not securely attached to the metal hook, and the staff were focused on the issue with the wheelchair rather than ensuring all hooks and slings were properly secured. The incident was witnessed by two CNAs who were conducting the transfer. One CNA was operating the lift controls while the other was positioned on the side of the resident, leaving no one behind the wheelchair to prevent it from tipping. The resident's wife, who was not present during the incident, reported finding the resident on the floor with a bruise on his head. The resident was sent to the hospital and diagnosed with a scalp hematoma before being discharged back to the facility. The facility's policy on safe resident handling and transfers was not adhered to, as it requires ensuring all slings are securely placed and the resident is positioned safely during transfers.
Failure to Provide Safe Transfer Assistance
Penalty
Summary
The facility failed to provide safe transfer assistance for a resident, resulting in an acute nondisplaced bimalleolar fracture and a nondisplaced oblique fracture of the distal fibula. The resident, who has a medical history of aphasia, hemiplegia, and hemiparesis following a cerebral infarction, was being transferred from an electric wheelchair to a bed via a pivot transfer when the incident occurred. The transfer was conducted by a CNA who was new to the facility and performed the transfer alone, despite the resident's care plan indicating that a two-person assist with a mechanical lift was required. The resident was lowered to the ground after becoming weak during the transfer, and subsequent assessments initially did not reveal any obvious injuries. The resident later expressed pain in the right lower extremity and was sent to the emergency room, where initial evaluations did not indicate fractures. However, continued pain led to further X-rays, which confirmed the fractures. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, revealed that the CNA was not familiar with the facility's procedures and did not seek assistance for the transfer, which was against the facility's policy for safe resident handling and transfers. The policy clearly states that two staff members must be utilized when transferring residents with a mechanical lift.
Insufficient Dietary Staffing Affects Meal Preparation
Penalty
Summary
The facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Services, impacting meal preparation for all residents receiving oral nutrition. The Dietary Manager, identified as V9, reported that the facility was short-staffed, with only two staff members, including herself and the cook, available on certain days. This staffing shortage led to changes in the meal schedule, such as switching meals between days and serving meals that did not match the menu, which affected the residents' ability to choose their meals. For instance, a resident, R205, expressed dissatisfaction with receiving meals that did not match the menu, such as being served tuna salad on white bread instead of toast. The facility's staffing issues have persisted for at least two months, with the Dietary Manager having to adjust meal plans and even the facility's Administrator assisting in the kitchen due to insufficient staff. The facility's staffing schedule highlighted numerous days with insufficient staff, totaling 33 out of 111 days. The facility's assessment tool indicated a need for a specific number of dietary staff to meet residents' needs, but the current staffing levels fell short of these requirements. The Dietary Manager emphasized the importance of feeding residents on time and the challenges posed by the lack of staff, which sometimes led to meal substitutions and disruptions for the residents.
Failure to Follow Menu Due to Staffing Shortages
Penalty
Summary
The facility failed to adhere to its established menus, which are required to meet the nutritional needs of residents, as observed during a survey. The Dietary Manager, identified as V9, admitted to altering the menu due to insufficient staffing levels. On a specific Monday, the planned meal of chicken enchiladas was replaced with pulled pork, pasta salad, and pea salad because the preparation time for enchiladas was too long for the available staff, which consisted of only two people instead of the required five. This substitution was not in line with the facility's policy, which does not allow for menu changes due to staffing issues. Additionally, a resident expressed dissatisfaction with the meal changes, stating that meals often did not match the menu, which affected their sense of choice. Further observations revealed that on another day, the lunch served did not match the menu, with chicken enchiladas being served instead of the planned Hawaiian Pork Sliders. The Dietary Manager acknowledged that meal substitutions had occurred on other occasions due to staffing shortages, and even the facility's Administrator had to assist in the kitchen. The facility's policy on menu substitutions only allows for changes when a product is unavailable or for special requests, not for staffing shortages. This inconsistency in meal service highlights the facility's failure to follow its own menu policies, impacting the residents' dining experience.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation practices in the kitchen, affecting all residents who receive oral nutrition. During a lunch service, a cook was observed placing a thermometer probe on a visibly dirty serving table and then using it to check the temperature of food without sanitizing it. The cook also dropped a lid on the kitchen floor and continued to use the same oven mitts to handle food trays, and later dropped a thermometer on the floor, cleaning only the probe but not the digital display, which then touched food. These actions were identified as potential cross-contamination risks. Additionally, the facility did not ensure proper labeling and dating of food items in storage. Several items in the walk-in refrigerator, freezer, and dry storage were found without labels or dates, including diced chicken, egg products, yogurt, grape salad, ice cream cake, cookies, baking powder, and powdered sugar. Some items were also found to be expired, such as pie crusts and baking powder. The Dietary Manager acknowledged that all food items should be labeled and dated to ensure safety and prevent foodborne illness. The facility also failed to enforce the use of hair restraints in the kitchen. Two CNAs entered the kitchen during meal preparation without wearing hairnets, posing a risk of physical contamination of food by hair. The Dietary Manager confirmed that all staff entering the kitchen should wear hair restraints to prevent contamination. The facility's policies on labeling, dating, and hair restraints were not followed, contributing to the deficiencies observed.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide appropriate fall interventions and maintain a hazard-free environment for several residents, leading to multiple incidents. One resident, admitted with a history of falls and on anticoagulants, was found on the floor with a head injury and skin tear after rolling out of bed. Despite being at high risk for falls, the resident did not have fall mats in place, which were part of the prescribed interventions. The staff admitted to forgetting to replace the fall mat, and the resident had experienced multiple falls since admission. Another resident with severe cognitive impairment and a history of falls was observed with her bed in a high position, contrary to her care plan that required the bed to be in a low position at night. The resident expressed confusion about her bed preference, and staff inconsistently managed the bed height, leaving it high even after providing care. The Director of Nursing was initially unaware of the resident's fall interventions, indicating a lack of communication and adherence to care plans. A third resident, with a history of repeated falls and a subdural hematoma, was found with only one fall mat beside her bed, despite being at high risk for falls. Staff acknowledged that two fall mats should be in place if the bed is not against a wall, but this was not implemented. Additionally, another resident's bed had exposed metal frames, posing a risk of injury, which the Assistant Director of Nursing confirmed should not occur. These findings highlight a systemic issue in the facility's fall prevention and environmental safety measures.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly label, store, and dispose of medications, leading to potential safety risks for residents. Several insulin pens were found without proper labeling, including opened and expired pens that were not discarded, as observed with residents R269, R155, R254, R206, and R60. Additionally, controlled substances such as clonazepam and hydrocodone were improperly stored, with some blister packs taped, which could lead to contamination. The medication room refrigerator was not maintained properly, with excess ice buildup and missing temperature logs, indicating a lack of oversight in medication storage conditions. Expired medical supplies were found in the medication room, including catheterization trays and IV administration set tubing, which were not disposed of despite being past their expiration dates. This oversight was acknowledged by the LPN, who was unaware that medical supplies had expiration dates. Furthermore, medications were found at residents' bedsides without proper orders or safety assessments, as seen with residents R357, R359, R63, R64, and R304. These medications included nasal sprays, creams, and wound cleansers, which were accessible to residents without supervision or proper documentation. The facility's policies on medication storage and controlled substance accountability were not adhered to, as evidenced by the lack of proper labeling, storage, and disposal of medications. The Director of Nursing and other staff members were unable to provide clear answers or demonstrate knowledge of the facility's expectations regarding medication management. This lack of compliance with established protocols poses a risk of medication errors and potential harm to residents, as medications were not securely stored or properly monitored.
Infection Control Lapses in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to infection control practices for residents under Transmission Based Precautions (TBP) and during the transportation of dirty linen. This deficiency was observed in four residents who were part of a sample of 28. For instance, a resident diagnosed with enterocolitis due to Clostridium difficile was placed under contact isolation. However, a family member and an occupational therapist entered the resident's room without wearing the required personal protective equipment (PPE) and did not follow proper hand hygiene protocols. The family member was not instructed on the necessary precautions, and the occupational therapist used alcohol-based hand sanitizer instead of washing hands with soap and water, which is ineffective against C. difficile. Another resident with a Foley catheter and wounds was under Enhanced Barrier Precautions (EBP) due to the risk of Methicillin Resistant Staphylococcus Aureus (MRSA). Despite this, a certified nurse assistant (CNA) entered the resident's room without a gown because the isolation bin was not stocked with gowns. The CNA handled the urinary catheter bag, which was improperly placed on the ground, without wearing the appropriate PPE. The Director of Nursing (DON) and other staff members acknowledged the need for proper PPE and hand hygiene but failed to ensure compliance. Additionally, there were lapses in the handling and transportation of soiled linen. A CNA performed incontinent care on a resident without changing gloves or performing hand hygiene afterward. The CNA also transported soiled briefs and linen to the soiled utility room without placing them in a garbage bag. Another incident involved a CNA who did not change gloves or wash hands during the process of changing a resident's wet brief and pants. These actions were contrary to the facility's policies on handling soiled linen and hand hygiene, which require proper disposal and hand hygiene to prevent the spread of infection.
Failure to Implement Resident's DNR Status
Penalty
Summary
The facility failed to honor a resident's right to have their chosen Advanced Directives status of Do Not Resuscitate (DNR) implemented. This deficiency was identified for one resident, who was admitted with multiple diagnoses including encephalopathy, frontotemporal neurocognitive disorder, convulsions, type 2 diabetes, hypertension, anxiety, and dementia. The resident's family members confirmed that the resident had made the decision for a DNR status prior to experiencing cognitive changes, and this was documented in the Power of Attorney (POA) paperwork provided to the facility. However, the facility did not have a physician's order for the resident's DNR status, and the Director of Nursing stated that without a POLST or physician's DNR order, the resident is assumed to be a full code. The Assistant Director of Nursing acknowledged that physician orders are required for code status on admission and that the resident's code status, as part of the POA, should have been followed. Despite the POA forms being scanned into the Electronic Medical Record, the physician orders did not contain directives regarding the resident's resuscitation status. The facility's policy on Communication of Code Status emphasizes the importance of adhering to residents' rights to formulate Advanced Directives and implementing procedures to communicate a resident's code status to necessary individuals, which was not followed in this case.
Deficiencies in ADL Care for Two Residents
Penalty
Summary
The facility failed to provide adequate ADL care to two residents, resulting in deficiencies in personal hygiene and toileting assistance. One resident, who was admitted with multiple diagnoses including a fracture, anxiety, and cognitive impairment, required substantial assistance with personal hygiene. Despite this, the resident was observed over several days with a crusted substance on her eyelid, indicating that her face had not been washed. The CNAs responsible for her care admitted to not washing her face, and the Director of Nursing acknowledged that ADLs should be performed daily, with a visual assessment to determine residents' needs. Another resident, diagnosed with Parkinson's disease and other conditions, was dependent on staff for toileting hygiene. During an observation, a CNA assisted the resident with toileting but failed to wipe the resident after a bowel movement or offer handwashing. The CNA later acknowledged the importance of assisting residents with wiping and handwashing. The Director of Nursing confirmed that CNAs are expected to ensure residents' hygiene is maintained and to encourage handwashing to prevent contamination. The facility's policy states that residents unable to perform ADLs should receive necessary services to maintain hygiene.
Failure to Apply Assistive Devices as Ordered
Penalty
Summary
The facility failed to ensure the proper application of anti-contracture devices and a Controlled Ankle Movement (CAM) Boot as ordered for two residents. Resident R160, diagnosed with Parkinsonism, weakness, and dementia, had a physician's order for hand rolls to reduce the risk of contractures. However, observations over several days showed that R160's right hand was consistently in a fist form without the prescribed splint. Interviews with staff revealed that there was no restorative program in place, and makeshift solutions like rolled-up washcloths were used instead of the ordered hand rolls. Resident R354, admitted with a displaced bimalleolar fracture and other mobility issues, had a physician's order for a CAM boot to be worn at all times except during range of motion exercises and bathing. Despite this, the CAM boot was observed off while the resident was in bed, contrary to the physician's order. Interviews with CNAs and the Occupational Therapist indicated a misunderstanding of the order, with staff believing the boot was only necessary when the resident was in a chair. The Director of Nursing confirmed that the boot should be on at all times, except during specific activities as per the order.
Improper Catheter Positioning Risking UTI
Penalty
Summary
The facility failed to maintain proper catheter care for a resident, leading to a potential risk of urinary tract infection (UTI). A male resident with severe cognitive impairment and a diagnosis of urinary retention was observed with an indwelling catheter bag positioned above the bladder level while seated in a wheelchair. This improper positioning caused urine to pool in the catheter tubing. A registered nurse acknowledged that the catheter bag might have been left in this position by a therapist and confirmed that such positioning could lead to a UTI. The Director of Nursing also stated that the catheter bag should be kept below the bladder level to prevent potential UTIs. The facility's policy on indwelling catheter use and removal specifies that the catheter should be secured to facilitate urine flow, prevent kinks, and be positioned below the bladder level.
Failure to Maintain PICC Line Dressing
Penalty
Summary
The facility failed to adhere to its policy on maintaining a Peripherally Inserted Central Catheter (PICC) line for a resident, identified as R62, who was part of a sample of 28 residents reviewed for central line catheter care. R62, a male resident with intact cognition, was admitted with diagnoses including Sepsis, Right Lower Limb Cellulitis, and Osteolysis. On observation, R62 was found with a left upper arm double lumen PICC line that had a dirty, peeling dressing with no date or label. The resident expressed uncertainty about whether the facility had ever changed his PICC line dressing. Further investigation revealed that there was no physician order to change R62's PICC line dressing, and the Medication Administration Record (MAR) lacked documentation of weekly dressing changes. The Registered Nurse (V5) confirmed the absence of an order and documentation for dressing changes. The Director of Nursing (V2) stated that PICC line dressings should be changed weekly and as needed, with proper dating and labeling to prevent central line-associated bloodstream infections (CLABSI). The facility's policy, reviewed and revised shortly before the incident, mandates weekly dressing changes or as needed to minimize infection risks, with physician orders specifying dressing type and change frequency.
Failure to Obtain Consents and Follow Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consents for psychotropic and antidepressant medications for two residents, R156 and R308, and did not follow pharmacy recommendations. R308, who had multiple diagnoses including major depressive disorder and anxiety, was administered Clonazepam and Mirtazapine without signed consents or documented verbal consents in the electronic medical record. The facility's administrator and director of nursing acknowledged the absence of consents and highlighted the potential risks of administering psychotropic medications without them. Additionally, the facility's policy required that residents and their representatives be educated on the risks and benefits of psychotropic drug use, which was not adhered to in these cases. For R156, who had diagnoses including Alzheimer's Disease and unspecified psychosis, the facility did not have medication consents for Escitalopram and Olanzapine. Furthermore, the facility failed to complete the AIMS test as recommended by the pharmacist until the survey was conducted. The assistant director of nursing confirmed that the AIMS test should have been completed within a day of the pharmacy's recommendation. These oversights indicate a failure to comply with the facility's policy on psychotropic medication management and monitoring.
Lack of Documentation for Falls PIP
Penalty
Summary
The facility failed to provide documentation or evidence of their yearly Performance Improvement Projects (PIP) for falls, which they had identified as a problem-prone area. This deficiency was discovered during a QAPI/QAA task conducted with the surveyor, where the Administrator and Assistant Director of Nursing (ADON) were unable to locate any records of QAPI/QAA meetings or information regarding the facility's PIP. Additionally, there was no tracking or trending data available to demonstrate which interventions were implemented to address the fall PIP or their effectiveness in reducing falls within the facility. The facility's QAPI Feedback policy outlines the importance of collecting feedback from staff, residents, and family members to conduct structured investigations and analyses of problems affecting quality of care, quality of life, and resident safety. However, the lack of documentation and data collection indicates a failure to adhere to this policy. The ADON mentioned having interventions in mind but had not documented them, as she had only recently taken over the QAPI responsibilities. This lack of documentation and systematic data collection potentially affects all 90 residents residing in the facility.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to hold Quality Assessment and Assurance (QAA) meetings on a quarterly basis and did not have the appropriate committee members present at these meetings. During an interview and record review, it was revealed that the Medical Director did not participate in the last QAPI meeting since the Assistant Director of Nursing (ADON) took over two weeks prior. The Administrator provided sign-in sheets for the QAA meetings, with the last meeting held in June 2024. The ADON provided two sign-in sheets dated September 26, 2024, and October 3, 2024, which were not QAA meetings but rather introductory sessions on QAPI for staff. These sign-in sheets did not include the Medical Director's attendance. According to the facility's policy, the QAA committee should include the Director of Nursing and the Medical Director or their designee and meet at least quarterly.
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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