Sharon Health Care Willows
Inspection history, citations, penalties and survey trends for this long-term care facility in Peoria, Illinois.
- Location
- 3520 North Rochelle, Peoria, Illinois 61604
- CMS Provider Number
- 14E888
- Inspections on file
- 43
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Sharon Health Care Willows during CMS and state inspections, most recent first.
The facility failed to prevent multiple incidents of resident-to-resident physical and sexual abuse involving individuals with known behavioral and psychiatric histories. A resident with schizophrenia and bipolar disorder reported being slapped and later having her breast and back touched without consent in a dining room by a peer with a documented history of inappropriate sexual behavior, with staff witnessing the contact and the resident’s verbal objections. In separate events, a resident with a criminal history of violent offenses admitted to striking another resident in the mouth, and another resident with schizoaffective disorder, daily yelling behaviors, hallucinations, and potential for physical aggression punched a peer in the mouth, causing a lip laceration and swelling, all occurring in common areas despite known risks.
The facility failed to notify local police of several resident-to-resident abuse incidents. In one event, a resident struck another in the face with a closed fist, causing a lip laceration, and police were not contacted. In another, a resident hit a peer in the mouth in a dining room and admitted doing so, yet law enforcement was not notified. In a separate incident, a resident reported that a peer touched her breast and lower side without consent, with no documentation of police notification. The Administrator confirmed that police are only contacted when there is a serious injury, resulting in these physical and sexual abuse allegations not being reported to law enforcement.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents who required supervision while smoking were left unsupervised on the patio during a scheduled smoke break, resulting in an altercation. Care plans and facility policy specified the need for staff monitoring, but interviews and documentation confirmed that no staff were present at the time, and that this lack of supervision had occurred previously.
Multiple residents with cognitive and psychiatric conditions were involved in physical altercations, including hitting and pushing, resulting in injuries such as a wrist fracture and facial scratches. These incidents occurred in common areas like hallways and dining rooms, and were witnessed by staff, but residents were not adequately protected from physical abuse by peers.
A resident with multiple medical conditions and a history of falls slipped on a wet floor after attempting to get up unassisted to use the bathroom. Although a CNA noticed the spill and instructed the resident not to get up, the CNA left the room to get cleaning supplies without ensuring supervision or activating the call light. The resident fell and sustained a fractured femur requiring surgery. The facility failed to provide adequate supervision and promptly address the environmental hazard, resulting in significant injury.
A resident with a history of PTSD reported repeated sexual harassment and inappropriate gestures from another resident with a known history of such behaviors. Despite multiple reports to the administrator and staff, the facility's response was limited to redirection, with no documentation or effective intervention, resulting in continued distress for the affected resident.
A resident with a history of inappropriate sexual behavior repeatedly made sexual gestures and verbal advances toward another cognitively intact resident, who reported distress and a history of PTSD. Despite multiple reports to the Administrator and staff, the incidents were not documented or reported to the state agency as required by facility policy.
A resident with a history of PTSD reported repeated sexual harassment and gestures from another resident to the administrator and staff over several months, but no investigation or documentation was completed as required by facility policy.
A resident was struck on the back of the head by another resident in the dining room after a dispute over wheelchair positioning. Staff and security witnessed the incident, and documentation confirmed that the physical contact constituted abuse as defined by facility policy.
Multiple residents with cognitive and psychiatric conditions were involved in repeated physical altercations, including hitting, biting, and tipping wheelchairs, resulting in injuries such as bruises and lacerations. Staff were not always able to intervene in time to prevent harm, and some residents were involved in multiple incidents. The facility did not effectively prevent episodes of physical abuse among residents.
Several residents with behavioral and cognitive disorders engaged in physical altercations, including hitting, biting, and tipping wheelchairs, due to the facility's failure to implement adequate monitoring and behavioral interventions. Despite known histories of aggression and care plans outlining the need for supervision and redirection, staff did not consistently intervene or increase monitoring, resulting in repeated episodes of physical abuse.
Two residents, both cognitively intact and with histories of aggression, were involved in a physical altercation resulting in one resident sustaining a nasal fracture. The incident occurred on the facility's patio, and the aggressor was taken to jail by police. The facility's abuse prevention policy failed to prevent this incident.
The facility's kitchen failed to maintain proper sanitation and food safety standards, with issues including improperly mixed sanitizing solutions, uncovered trash bins near food prep areas, and unsanitary handling of ice. The sanitizing solution was found to be outside the acceptable range, and trash cans were left open and near food preparation areas. Additionally, the ice scoop was stored in an unsanitary manner, and a resident was observed using it with bare hands. These deficiencies could potentially affect all 115 residents.
The facility failed to update care plans for two residents with mental health disorders. One resident with schizophrenia experienced hallucinations but had no documented behaviors or non-pharmacological interventions in their care plan. Another resident with schizoaffective disorder exhibited yelling behaviors, yet their care plan also lacked documentation of targeted behaviors and interventions. These deficiencies were confirmed by the RN Care Plan Coordinator.
The facility failed to implement a range of motion (ROM) program for three residents with functional limitations, as required by their Restorative Program Policy. These residents, observed with limitations in their range of motion, did not have individualized care plans addressing these needs. A CNA confirmed that these residents were not receiving any active or passive ROM therapies, indicating a failure to adhere to the facility's policy.
A facility failed to implement non-pharmacological interventions and did not document or track behaviors for a resident prescribed psychotropic medications. Despite the resident reporting hallucinations, the medical record lacked documentation of behaviors or interventions, contrary to facility policy. A nurse confirmed the absence of necessary documentation.
A resident's wound care was compromised when an RN failed to sanitize scissors between uses, leading to potential cross-contamination. The RN used the same unsanitized scissors to cut dressings for multiple wounds, despite the presence of fecal matter on the drape beneath the resident. This breach of infection control protocols occurred during a scheduled dressing change, observed by another RN and the Infection Control Preventionist.
The facility failed to protect residents from physical abuse in two incidents. In one case, a resident was kicked by another, causing a fall. In another, a resident with Schizophrenia and Bipolar Type pushed another resident to the ground. Despite the facility's abuse prevention policy, these incidents occurred, indicating a deficiency in safeguarding residents.
Failure to Prevent Resident-to-Resident Physical and Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to prevent physical and sexual abuse among residents with known behavioral and psychiatric histories. One resident with schizophrenia and bipolar disorder reported being slapped in the face in the dining room and later stated that another resident had grabbed her breast there. A CNA heard the resident yell for the other resident to stop touching her and observed the peer touching her breast and lower back. The same day, the peer resident walked behind her, made a suggestive verbal remark, and attempted to kiss the top of her head, prompting the resident to yell and staff to intervene. The peer resident’s care plan documented a history of inappropriate sexual behavior, yet the incidents occurred in a common area where contact and sexualized behavior were observed by staff. Additional incidents of physical abuse occurred between other residents with documented behavioral risks. In one event, a resident with a criminal history including domestic battery, aggravated battery, and battery admitted to hitting another resident in the mouth with an open hand after complaining about the other resident’s statements; staff heard the victim yell that she had been hit and then separated the two. In another event in a dining room, a resident with schizoaffective disorder, daily yelling behaviors, hallucinations, and a history of potential physical aggression punched another resident in the mouth with a closed fist, causing a lip laceration and swelling. Staff statements and care plans confirmed that this resident frequently yelled out, could be physically aggressive, and was resistant to redirection, yet the assault still occurred in a common area where both residents were present.
Failure to Notify Police of Resident-to-Resident Physical and Sexual Abuse Allegations
Penalty
Summary
The facility failed to notify local law enforcement of multiple allegations of physical and sexual abuse between residents. An incident report dated 12/29/25 documented that at 9:15 a.m. one resident (R5) hit another resident (R6) in the face with a closed fist, causing a cut on R6’s lip, and the form showed that police were not notified. Another incident report dated 1/27/26 documented that at 1:10 p.m. in the North dining room, one resident (R3) hit another resident (R4) in the mouth with an open hand; staff separated the residents after R4 alerted them, and R3 admitted to hitting R4, but the report documented that police were not notified of this physical altercation. A separate incident/accident report dated 2/6/26 documented that R4 reported a peer (R7) touched her breast and lower side without her consent, and this form contained no documentation that local police were notified of the unwanted touching. On 2/9/26 at 10:30 a.m., during an interview, the Administrator (V1) confirmed that the facility does not notify police of any physical or sexual incidents unless there is a serious injury, corroborating that law enforcement was not contacted for these reported incidents of resident-to-resident physical and sexual abuse.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Supervise Residents During Scheduled Smoking Breaks
Penalty
Summary
The facility failed to monitor, supervise, and follow its own policy to ensure a safe smoking environment for two residents who were identified as requiring supervision while smoking. Both residents had care plans specifying the need for staff supervision and assistance during smoking breaks to maintain safety. Despite these documented requirements, on the date of the incident, both residents were left unsupervised on the facility's patio during a scheduled smoke break, which resulted in an altercation between them. Multiple interviews with other residents and staff confirmed that no staff were present on the patio at the time of the incident, and that this lack of supervision had occurred during previous smoke breaks as well. The facility's Smoking Safety Policy and Procedure required that patients in the supervised smoking program receive assistance and monitoring to maintain safety. Scheduled smoke breaks were assigned to specific staff members, but on the day of the incident, the designated staff member was not present due to being called away for another task. Staff interviews acknowledged that supervision was not provided as required, and that both residents involved were not independent smokers and should have been monitored according to their care plans and facility policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from episodes of physical abuse perpetrated by other residents. Several incidents were documented in which residents with cognitive and psychiatric diagnoses engaged in physical altercations, resulting in injuries. In one instance, a female resident with schizoaffective disorder and intact cognition was struck on the jaw by a male peer with Alzheimer's disease and moderate cognitive impairment while she was in her wheelchair in the hallway. Witness statements confirmed that the male resident became agitated, yelled, and hit the female resident with a closed fist. No injuries were noted, and the resident denied pain or discomfort at the time. Another incident involved a cognitively intact female resident with multiple psychiatric diagnoses who was pushed to the ground by a male resident with moderate cognitive impairment during a struggle over snacks in the dining room. The female resident sustained a displaced fracture of the distal radial metaphysis in her right wrist, as confirmed by x-ray. Witnesses, including a registered nurse, observed the altercation and confirmed that the male resident pushed the female resident after both attempted to take possession of the snack. The injured resident later reported significant pain in her wrist. Additional altercations were documented, including an incident in which a female resident attempted to take another resident's belongings, resulting in a physical confrontation where one resident was pushed and then struck in the face. Another event involved a resident being pushed to the ground after reaching for another resident's cup. These repeated episodes of resident-to-resident physical abuse occurred despite the facility's abuse prevention policy, which affirms residents' rights to be free from abuse and outlines the facility's commitment to preventing mistreatment. The documented incidents demonstrate a failure to prevent and protect residents from physical abuse by peers.
Failure to Prevent Resident Fall Due to Inadequate Supervision and Environmental Hazard
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including Bipolar Disorder, COPD, metabolic encephalopathy, and a right artificial shoulder joint, experienced a fall resulting in a fractured femur. The resident was assessed as having intact cognition but exhibited delusions and impulsive behaviors, and required supervision for all activities of daily living and toileting. The care plan identified the resident as being at risk for falls, with a history of wheelchair use and independent ambulation. On the night of the incident, the resident attempted to get up from bed to use the bathroom and slipped on a wet floor caused by a spilled cup of water. A CNA observed the water on the floor and instructed the resident not to get up while she left the room to obtain cleaning supplies. Despite these instructions, the resident attempted to stand and subsequently fell, sustaining a comminuted and displaced distal femur fracture that required surgical intervention. The CNA later acknowledged that she should have ensured someone stayed with the resident or activated the call light until the hazard was addressed. Facility policy required routine assessment of the care environment for extrinsic risk factors and prompt corrective action to prevent falls. However, the failure to provide adequate supervision and to immediately address the environmental hazard directly contributed to the resident's fall and injury. The incident investigation identified the wet floor and the resident's impulsivity as contributing factors, and staff interviews confirmed that supervision was insufficient at the time of the event.
Failure to Protect Resident from Ongoing Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by repeated incidents involving inappropriate sexual gestures and verbal sexual advances from another resident. One resident, who is cognitively intact and has a history of PTSD due to childhood sexual trauma, reported that another cognitively intact resident with a documented history of inappropriate sexual behaviors persistently made sexual gestures and explicit sexual comments towards her. These behaviors included making suggestive hand gestures, verbalizing sexual intentions, and making inappropriate remarks in the presence of others. The affected resident reported these incidents multiple times to the facility administrator and other staff members, expressing distress and discomfort. Despite these reports, the administrator acknowledged being aware of the ongoing inappropriate behaviors but did not document the complaints or take effective action beyond instructing staff to redirect the offending resident. Staff interviews confirmed that the inappropriate behaviors were witnessed and reported to facility leadership, yet the response was limited to redirection without further intervention or documentation. The facility's own Abuse Prevention Program defines such conduct as sexual abuse, including sexual harassment and coercion, but the policy was not effectively implemented to protect the resident from ongoing abuse.
Failure to Report Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to report allegations of potential resident-to-resident sexual abuse to the Administrator and the state agency as required. One resident, who is cognitively intact and has a documented history of inappropriate sexual behaviors, repeatedly made sexual gestures and verbal advances toward another cognitively intact resident. The affected resident reported feeling upset and stated that the behavior was ongoing, including explicit gestures and repeated verbal requests for sex, which she had asked to stop multiple times. She also disclosed a history of PTSD related to childhood sexual trauma. Despite reporting these incidents to the Administrator and other staff members on multiple occasions, the only action taken was to redirect the offending resident, and no formal documentation or external reporting occurred. Multiple staff members, including a restorative aide, social services, and a housekeeper, witnessed or were informed of the inappropriate behaviors and comments but did not escalate the reports to the Administrator or the state agency as required by the facility's abuse prevention policy. The Administrator acknowledged being aware of the allegations but did not document the reports or notify the state agency. The facility's policy mandates immediate reporting of abuse allegations to the state agency and the resident's representative, but this protocol was not followed in this case.
Failure to Investigate Resident's Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct an investigation after a resident reported ongoing sexual harassment and inappropriate sexual gestures from another resident. The affected resident, who has a history of PTSD due to childhood sexual assault, stated that the other resident repeatedly made sexual gestures and verbal propositions, despite being told to stop. The resident reported these incidents to the facility administrator and other staff members multiple times over several months, but no documentation or investigation was initiated in response to these allegations. The administrator confirmed that the resident had reported the inappropriate behavior on several occasions but admitted that neither documentation nor an investigation was completed. The facility's Abuse Prevention Program Policy requires that all allegations of abuse, including sexual harassment, be documented and investigated. However, in this case, the required procedures were not followed, and there was no evidence of any attempt to interview involved parties or review relevant documentation as outlined in the policy.
Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
A deficiency occurred when a resident was not protected from abuse by another resident in the facility's dining room. According to the facility's Incident Investigation Report and nursing progress notes, one resident wheeled up to a table where another resident was sitting. The seated resident expressed that the other resident kept running into his wheelchair and, in response, struck the other resident on the back of the head with an open hand. Staff and security present in the dining room witnessed the incident, and the event was documented by the nurse on duty and reported to the facility administrator. The facility's Abuse Prevention Program policy defines abuse as any physical or mental injury inflicted upon a resident other than by accidental means. The incident involved physical contact that resulted in harm, which meets the facility's definition of abuse. The report confirms that the residents were separated following the altercation, and the incident was verified by both the administrator and the nurse on duty.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from episodes of physical abuse over a period of several months, as evidenced by repeated incidents of resident-to-resident aggression resulting in physical harm. In numerous documented cases, residents with cognitive impairments, such as dementia or severe memory problems, were involved in altercations where they were either the aggressor or the victim. These incidents occurred in various locations throughout the facility, including hallways, dining rooms, and resident rooms, and involved behaviors such as hitting, punching, biting, and tipping wheelchairs. In several cases, residents sustained injuries such as lacerations, bruising, and bleeding, and some required evaluation at a hospital. The report details that staff were present or nearby during many of these incidents but were not always able to intervene in time to prevent physical harm. For example, in one case, a resident with impaired cognition was struck multiple times in the face by another resident before staff could separate them. In another instance, a resident was punched in the face and fell to the ground after an unprovoked attack in the dining room. There were also situations where residents with known behavioral issues or histories of aggression were not adequately monitored or redirected, leading to repeated altercations with peers. The residents involved often had significant psychiatric or neurocognitive diagnoses, such as dementia, schizoaffective disorder, or anxiety disorders, which contributed to their behaviors and vulnerability. The facility's own documentation and staff interviews confirm that these incidents were not isolated and that some residents were involved in multiple episodes of aggression, both as victims and perpetrators. Despite the facility's stated policy to protect residents from abuse and maintain a secure environment, the frequency and nature of these events demonstrate a failure to prevent physical abuse among residents.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to implement adequate behavioral interventions and supervision to prevent episodes of physical abuse among residents with known behavioral and cognitive disorders. Multiple incidents occurred in which residents with histories of aggression, psychiatric diagnoses, or cognitive impairment engaged in physical altercations with peers. In several cases, staff did not initiate increased monitoring, such as 15-minute checks or one-to-one supervision, despite documented increases in aggressive behaviors and prior incidents. One resident with anxiety, delusional disorder, and a criminal background was involved in multiple altercations, including attempting to kiss and biting a peer, and later engaging in a physical fight with another resident. Despite escalating behaviors and recommendations for medication review, staff did not implement increased monitoring prior to the altercation. Another resident with schizoaffective disorder and a history of physical aggression tipped another resident's wheelchair on two separate occasions, causing the other resident to fall. Staff were expected to monitor and redirect these residents but failed to do so effectively, resulting in repeated incidents. Additional incidents included a resident with Alzheimer's disease and wandering behaviors colliding with another resident, leading to a physical altercation, and a resident striking a peer in the face after being agitated by disruptive wheelchair behavior during meals. In each case, the residents involved had care plans that identified their behavioral risks and outlined interventions such as redirection and monitoring. However, staff did not consistently implement these interventions, and the lack of proactive supervision and timely behavioral management contributed to the occurrence of physical abuse between residents.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to prevent a physical altercation between two residents, resulting in one resident sustaining a nasal fracture and other injuries. The incident involved two residents, both of whom were documented as cognitively intact. One resident had a history of verbal aggression escalating to physical threats, while the other had a history of physical aggression towards peers. On the day of the incident, a Certified Nursing Assistant (CNA) was alerted to a fight on the patio, where one resident was found on top of the other, hitting him in the face. The injured resident was subsequently transported to the Emergency Department for evaluation and treatment of a nasal fracture. The facility's abuse prevention policy emphasizes the protection of residents from abuse by anyone, including other residents. However, the altercation occurred despite this policy, indicating a failure in its implementation. The police were involved, and the aggressor was given the option of going to jail or the hospital, ultimately being taken to jail. The facility's reports document the incident and the injuries sustained, but do not provide information on preventive measures that were in place or actions taken to prevent such incidents.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation standards in its kitchen, as evidenced by several observations and interviews. The sanitizing solution used to clean food preparation surfaces was found to be improperly mixed, with one instance measuring only 10 ppm and another exceeding 200 ppm, both outside the acceptable range of 100-200 ppm. Additionally, the facility did not consistently document the checks of the sanitizing solution, as required by their procedures. This lack of proper sanitation practices was confirmed by the Dietary Manager, who acknowledged the discrepancies in the solution's concentration and the absence of recorded checks. The facility also failed to adhere to its waste disposal policy, which mandates that trash bins be covered and kept away from food preparation areas. Observations revealed multiple open trash cans in the kitchen, some placed near food preparation areas such as the steam table and grill. The Dietary Manager and a Dietary Aide confirmed the absence of lids for these trash cans, with the aide noting that lids had not been used in the five years of their employment. This oversight in waste management practices was further compounded by the unsanitary condition of the kitchen floor, which was observed to be dirty, sticky, and littered with debris, including a yellow slime-like substance and a brown gritty material. Furthermore, the facility's handling of ice was found to be inadequate, as the ice scoop used for kitchen purposes was stored in an unsanitary manner. The scoop was left open to air on a cart with unknown particles and debris, and a resident was observed using the scoop with bare hands to fill a personal cup. The Dietary Manager confirmed that this was the only scoop used for kitchen ice purposes and attempted to address the issue by placing the scoop on a tray. These deficiencies in sanitation and food safety practices have the potential to affect all 115 residents living in the facility.
Failure to Update Care Plans for Residents with Mental Health Disorders
Penalty
Summary
The facility failed to update the care plans for two residents, both of whom were diagnosed with mental health disorders. The first resident, who was alert and oriented, had schizophrenia and was on multiple medications for anxiety and depression. Despite the resident's admission of experiencing hallucinations that prompted self-harm thoughts, the care plan did not document any targeted behaviors or non-pharmacological interventions. This oversight was confirmed by the Registered Nurse Care Plan Coordinator. The second resident had schizoaffective disorder and altered mental status but was not on any psychological medications. This resident exhibited behaviors such as yelling and slamming doors, which were observed by the surveyor and confirmed by a Certified Nurse Aid. However, the care plan for this resident also lacked documentation of targeted behaviors and non-pharmacological interventions. The Registered Nurse Care Plan Coordinator verified this deficiency as well.
Failure to Implement Range of Motion Program for Residents
Penalty
Summary
The facility failed to implement a range of motion (ROM) program for residents with functional limitations, as required by their own Restorative Program Policy. This deficiency was identified for three residents, who were observed to have limitations in their range of motion but did not have individualized care plans addressing these needs. Resident 8 was observed in a contracted fetal position, with documented impairments in bilateral lower extremities, yet lacked a care plan for ROM interventions. Similarly, Resident 47, who relied on staff for mobility and had impairments in bilateral lower extremities, reported not receiving any exercises or ROM assistance, and her care plan also lacked documentation for ROM interventions. Resident 90, diagnosed with Huntington's Disease and Primary Osteoarthritis, was observed with spastic movements and contracted arms, indicating limitations in both upper and lower extremities. Despite these observations, her care plan did not include a ROM program to address these limitations. The Rehabilitation Aide/CNA confirmed that these residents were not on the list for restorative care and were not receiving any active or passive ROM therapies. This oversight indicates a failure to adhere to the facility's policy of providing appropriate treatment and services to maintain or improve residents' abilities.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions and did not identify, document, or track behaviors for a resident who was prescribed psychotropic medications. The facility's policy on psychotropic medication requires that each medication is tracked for behaviors, mood, and depression, and that non-pharmacological approaches are attempted before resorting to medication. However, for one resident with schizophrenia, there was no documentation of behaviors or non-pharmacological interventions in the medical record, despite the resident being prescribed multiple psychotropic medications, including Lorazepam, Zoloft, Risperidone, Olanzapine, and Trazodone. Observations made over several days showed the resident without any noted behaviors, but during an interview, the resident reported experiencing hallucinations that prompted self-harm thoughts. The medical record lacked documentation of these behaviors or any non-pharmacological interventions. A registered nurse confirmed the absence of targeted behaviors and interventions in the resident's medical record, and a certified nurse aide mentioned that behaviors are typically charted in their online system, which was not reflected in this case.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control during a resident's wound care, leading to potential cross-contamination. The resident, who had multiple wounds on the right leg, was receiving treatment for skin integrity issues related to urinary incontinence and limited mobility. During a scheduled dressing change, a registered nurse (RN) used unsanitized scissors to cut dressings for the resident's wounds, despite the presence of fecal matter on the disposable drape beneath the resident. The RN did not sanitize the scissors between uses, which were used to cut both the hip/thigh and calf dressings, and also reused a piece of calcium alginate that had fallen onto the contaminated drape. The RN acknowledged the oversight, admitting that she did not consider sanitizing the scissors during the wound care process. The facility's policy required adherence to universal precautions and clean techniques for wound care, but these were not followed. The incident was observed by another RN and the facility's Infection Control Preventionist, who were present during the procedure. The failure to maintain a clean field and sanitize equipment during wound care posed a risk of wound contamination for the resident.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents involving residents. In the first incident, a resident was involved in a physical altercation on the patio area, where one resident kicked another, causing the latter to fall. Witnesses confirmed the altercation, and the facility's administrator acknowledged the incident. In the second incident, a resident with a diagnosis of Schizophrenia and Bipolar Type physically assaulted another resident in the dining room. The aggressor lifted the victim from a chair and pushed them to the ground, although no injuries were reported. The facility's administrator confirmed the details of the altercation, noting the aggressor's potential delusional state. The facility's policy on abuse prevention, updated shortly before these incidents, emphasizes the residents' right to be free from abuse and outlines the types of abuse, including physical abuse, which involves inflicting injury that requires medical attention. Despite this policy, the facility did not prevent the physical altercations between residents, resulting in a failure to protect them from abuse. The incidents were documented in the facility's incident investigation reports, and the police were notified in the second case. However, the facility's actions were insufficient to prevent these occurrences, highlighting a deficiency in protecting residents from abuse by other residents.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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