Silvis Center For Nursing Rehab & Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Silvis, Illinois.
- Location
- 1455 Hospital Road, Silvis, Illinois 61282
- CMS Provider Number
- 145703
- Inspections on file
- 31
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Silvis Center For Nursing Rehab & Care during CMS and state inspections, most recent first.
A resident with chronic kidney disease, bladder incontinence, and a compromised immune system developed suprapubic pain, hematuria, dysuria, and dark, foul-smelling urine, but antibiotics were not started until about a week after symptoms began and more than a day after an ESBL-positive urine culture was reported. Nursing notes documented worsening UTI symptoms, yet this information was not communicated effectively to the NP, who waited for culture results before ordering Levaquin. The resident’s toileting and hygiene needs increased from supervision to dependence, but the care plan was not updated to reflect higher incontinence care needs or UTI monitoring, and a family member reported the resident remained in soaked incontinence briefs and was not cleaned adequately.
The facility failed to provide sufficient nursing staff to meet residents’ needs, as shown by repeated reports of prolonged call light response times and unmet care needs. Several residents, including one with a history of falls and another with limited arm function, reported routinely waiting 30–60 minutes or more for assistance with toileting, transfers, and other care, sometimes resulting in incontinence accidents and extended discomfort. Multiple staff, including LPNs and a CNA, described frequent CNA call-ins that were not consistently replaced, shifts with as few as two CNAs for about 50 residents, missed showers, incomplete charting, and an inability to provide timely care due to high patient-to-staff ratios. The DON acknowledged ongoing concerns with call light response and agreed that the length of time some residents waited for toileting assistance was excessive.
The facility failed to ensure two residents received ordered specialist care when transportation was not properly arranged, causing missed pulmonology and neurology appointments. One resident with obstructive sleep apnea, CHF, and lung cancer was prepared for a pulmonology visit, with a CNA arranged to accompany her, but contracted transport services reported no pickup was scheduled and she did not attend. Another resident with confusion, high fall risk, and a history of alcoholism had a neurology consult ordered and scheduled, with referral paperwork faxed and family agreement, yet missed at least one neurology appointment because transportation was not set up, leaving the consult outstanding while the resident later exhibited stroke-like symptoms and was sent to the ER. Staff, including an LPN, the NP, and the DON, acknowledged ongoing transportation issues with outside contracted services.
Multiple residents, family members, and visitors reported that call lights were routinely left unanswered for at least an hour, with some instances extending to an hour and a half. Staff were observed turning off call lights and promising to return without providing assistance. The issue persisted despite facility policies and was only temporarily improved when state agency representatives were present, prompting management and additional staff to assist with call light responses.
The facility did not consistently serve meals as listed on posted menus, frequently substituting planned items with alternatives without prior notice. Multiple residents reported dissatisfaction with the quality, variety, and predictability of meals, and facility records confirmed numerous menu changes affecting all residents. Staff acknowledged difficulties in obtaining menu items, leading to repeated substitutions.
A resident with Parkinson's Disease and anxiety, who frequently exhibited physical and self-injurious behaviors, did not have an updated care plan reflecting her current condition or interventions to reduce injury risk. Staff observed the resident being anxious, aggressive, and sustaining injuries, but the care plan lacked documentation of her behaviors or triggers, and staff confirmed it was not revised to address her needs.
A resident with CHF and severe cognitive impairment did not receive daily weights as ordered, and significant weight gains were not communicated to the physician. Orders for daily weights were inconsistently entered and followed, with multiple days lacking documentation and no evidence of physician notification when weight thresholds were exceeded. The care plan and facility policies did not address daily weight monitoring or CHF-specific care, leading to repeated hospitalizations for CHF exacerbations.
A resident with multiple respiratory and cardiac conditions was not provided with a physician-ordered BiPAP machine for several days after returning from the hospital, despite clear discharge orders. Facility records and assessments did not consistently reflect the need for BiPAP, and the device was not available until days after the resident's return, resulting in hospitalization for respiratory failure.
Multiple residents with complex medical needs experienced significant delays in call light response, assistance with toileting, and medication administration due to insufficient staffing. Residents and their families reported frequent incontinence episodes, missed showers, and staff turning off call lights without providing help. Staff and meeting records confirmed ongoing staffing shortages, high resident acuity, and missed care tasks, while a physician cited poor communication and care continuity. Facility policies for prompt response and timely medication administration were not followed.
The facility failed to maintain the independence of resident council meetings by allowing non-residents to attend without clear documentation of their purpose. Additionally, the facility did not record the names of residents attending or address concerns raised in the meetings, such as environmental and maintenance issues, in subsequent meetings. This oversight affects all 62 residents as their grievances are not being effectively managed.
A facility failed to protect a resident's privacy during nursing care when the door to their room was left open while they were vomiting and complaining of stomach pain to an LPN. The resident's daughter, present in the hallway, noted the need for the door to be closed. The LPN later acknowledged that the door should have been closed to maintain privacy.
A facility failed to reweigh a resident after a significant weight change was recorded, with the resident's weight increasing from 125.8 to 173 pounds within a month. The Registered Dietician questioned the accuracy of the weight, suspecting it was taken with the resident in her wheelchair, and did not make new dietary recommendations. The DON acknowledged the need for reweighing despite the lack of a specific policy.
A facility failed to administer medications on time to five residents due to staffing issues. Medications scheduled for 8 AM were given several hours late, affecting treatments for hypertension, neuropathy, COPD, pain, and anxiety. The delay was caused by an absent agency nurse, leaving only two nurses to cover both skilled and LTC units. The DON's directive to reassign a nurse to the LTC unit was delayed, leading to late medication administration.
The facility failed to respond to call lights in a timely manner for eight residents, with wait times ranging from 5 minutes to over an hour. Staffing cuts following a change in ownership led to increased workloads and stress among staff, contributing to the delays. Residents reported incidents of prolonged waits for assistance, including one who waited nearly two hours after an accident. Staff confirmed the staffing issues, and the DON acknowledged the responsibility to respond promptly.
A resident with severe cognitive impairment slid out of a wheelchair while being assisted by a CNA, resulting in a left leg fracture. The incident occurred during a routine change into a gown, and the resident's pain was not immediately recognized as an injury. The facility's policies lacked specific guidance on safe wheelchair positioning, contributing to the deficiency.
The facility failed to ensure that the Medical Director attended the QA meetings, as required by their policy. The QAPI sign-in sheets for a meeting did not include the Medical Director's signature, which was confirmed by the Administrator. This deficiency has the potential to affect all 72 residents in the facility.
The facility failed to ensure that the designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP) was certified. The Care Plan Coordinator, who has the certification, did not oversee the IPCP, while the Assistant Director of Nursing, who is halfway through certification training, was acting as the IP. This deficiency has the potential to affect all 72 residents in the facility.
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for psychotropic medications for four residents. The facility did not attempt GDRs, identify target behaviors, or document behaviors justifying the use of psychotropic medications. This was confirmed through record reviews and interviews with the Director of Nursing (DON).
The facility failed to perform proper hand hygiene during care for two residents. An RN administered an insulin injection without changing gloves or performing hand hygiene, and a CNA performed catheter care without changing gloves or performing hand hygiene before touching other items and the resident.
A facility failed to incorporate hospital discharge instructions for a cervical neck brace and skin care into a resident's care plan and treatment plan. Despite detailed instructions, skin checks were inconsistently documented and performed, leading to frustration from the resident and their spouse. The DON acknowledged the oversight.
The facility failed to ensure all doors were alarmed, leading to a resident with an electronic monitoring bracelet exiting the building without triggering the alarm. The ambulance door was not regularly checked due to maintenance staff not having the key to reset the alarm, a lapse attributed to changes during the COVID-19 pandemic.
Delayed UTI Treatment and Failure to Update Incontinence Care Plan
Penalty
Summary
The facility failed to ensure timely initiation of antibiotic treatment and appropriate care planning for a resident with signs and symptoms of a urinary tract infection (UTI). The resident had chronic kidney disease, hypertensive chronic kidney disease, bladder incontinence related to impaired mobility, and was undergoing cancer treatments with a compromised immune system. The facility’s algorithm for antimicrobial management of UTIs required treatment when new or marked incontinence, suprapubic pain, hematuria, and other symptoms were present, and the resident’s care plan directed staff to monitor and document for UTI signs such as pain, burning, blood-tinged urine, foul-smelling urine, and changes in behavior or eating patterns. On one date in December, the nurse practitioner assessed the resident, who complained of fatigue, cough, and suprapubic pain, and ordered a urinalysis. The following day, nursing documentation showed hematuria and suprapubic pain, and the urinalysis revealed dark brown urine, extra turbid clarity, protein, blood, and leukocytes. Over the next days, nursing notes documented dark brown, odorous urine, suprapubic pain, dysuria, and incontinence, and the urine was sent for culture and sensitivity. The final culture, completed several days later, showed ESBL-producing Klebsiella pneumoniae and Proteus mirabilis, and the resident was placed on contact isolation. However, the nurse practitioner stated she waited for culture results before starting antibiotics and was not informed that additional symptoms and worsening signs were being documented by nursing staff. The nurse practitioner ordered Levaquin after reviewing the culture results, and the first dose was administered approximately seven days after the resident’s urinary symptoms were first identified and more than 28 hours after the positive ESBL culture result was reported. During this period, the resident experienced suprapubic pain, burning with urination, blood and odor in the urine, and incontinence of dark brown odorous urine. The resident’s family member reported that the resident was not being cleaned adequately, sat in soaked incontinence briefs for too long, and required more help toward the end of her stay. The Minimum Data Set assessments showed a decline from supervision/touching assistance for toileting and hygiene to dependence and substantial/maximal assistance for toilet transfers, but the care plan at discharge did not reflect increased care needs for toileting, hygiene, or UTI monitoring. The DON confirmed the resident had a rapid decline after the December UTI, that care plan interventions for incontinence and toileting were not updated to match her increased dependence, and that there was no documentation to show the change in condition or altered incontinence care and monitoring needs.
Failure to Provide Sufficient Nursing Staff Resulting in Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, as evidenced by prolonged call light response times and unmet care needs. The facility census showed 73 residents, and the facility assessment stated staffing was adequate based on resident population, acuity, and regulatory requirements. However, multiple residents reported waiting extended periods after activating call lights, including reports of waiting 30 minutes to an hour or more for assistance, particularly with toileting and transfers. One resident with a history of falls, dizziness, and passing out stated that call lights sometimes took an hour to be answered. Another resident council president reported frequent staffing and call light concerns, including waiting from 11:00 PM to 12:00 AM for help to the bathroom, resulting in accidents and describing the experience as humiliating and painful. Staff interviews corroborated these concerns and described chronic understaffing. An LPN reported that on one occasion there were only two CNAs for 50 residents, leading to missed showers and long waits for assistance, and that a resident complained of waiting over an hour to go to bed and have a call light answered. Another LPN stated there were not enough nurses and staff to complete required tasks or charting, and that the patient-to-nurse ratio made it impossible to provide adequate help. A CNA reported daily CNA call-ins that were not always replaced, especially on second shift, resulting in residents waiting longer to be changed and cleaned up and increased frustration for some residents. During observation, a resident with a flaccid arm was seen waiting with a call light on for help with incontinence care and reported having accidents while waiting. The DON acknowledged awareness of call light concerns and agreed that 30 minutes was too long for someone to be expected to hold their bladder, noting that staff call-offs increased during that time of year.
Failure to Arrange Transportation for Specialist Appointments
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received ordered specialist care when transportation was not arranged, resulting in missed pulmonology and neurology appointments. One resident with obstructive sleep apnea, congestive heart failure, and right lower lobe lung cancer had a scheduled pulmonology appointment documented on the facility’s calendar. Nursing progress notes show that on the day of the appointment the resident was prepared, a CNA had been arranged to accompany her, but no transportation arrived. Contracted transportation companies reported they did not have the resident scheduled for pickup, and the appointment had to be rescheduled. The LPN caring for the resident confirmed that the resident missed the pulmonology appointment solely due to transportation not being set up. Another resident, admitted with high fall risk related to confusion, deconditioning, gait/balance problems, poor safety awareness, and a history of falls, had a neurology referral ordered by the nurse practitioner due to confusion. Documentation shows the referral paperwork was faxed, the family was notified and agreed with the plan, and a neurology appointment was scheduled and entered on the facility’s calendar. The resident’s family later reported that the resident missed neurology appointments because the facility could not get him to the appointments and that he was charged no-show fees. Nursing notes and staff interviews confirm at least one missed neurology appointment due to transportation not being set up and that the consult order remained outstanding after several days. The nurse practitioner also confirmed there were transportation issues that caused the resident to miss a needed neurology appointment, and that during the stay the resident experienced signs and symptoms of stroke and went to the emergency room.
Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer resident call lights in a timely manner, as evidenced by multiple resident and visitor interviews, grievance log entries, and direct observations. Residents consistently reported waiting at least an hour, and sometimes up to an hour and a half, for staff to respond to activated call lights. Several residents stated that staff would turn off the call light and promise to return, but then failed to provide the requested assistance. Family members and visitors corroborated these accounts, noting that call lights often remained unanswered for extended periods and that they sometimes had to seek out staff multiple times to obtain help. The facility's own grievance log documented complaints about delayed call light responses, with conclusions indicating staff re-education or counseling, but residents reported no improvement over time. The facility's policy requires that call lights be accessible at each resident's bedside, toilet, and bathing area, and that all staff are responsible for responding to activated call lights. Despite this, interviews revealed that timely responses were not the norm, except during periods when state agency representatives were present in the facility. During these times, residents and visitors observed that call lights were answered much more quickly, with management and additional staff visibly assisting. The issue was described as ongoing by both residents and the facility ombudsman, who personally witnessed call lights remaining unanswered for over an hour.
Failure to Consistently Serve Meals According to Posted Menus
Penalty
Summary
The facility failed to consistently serve meals according to the posted menus, as required by regulations. Multiple residents reported that the meals served often did not match what was listed on the menu, with frequent substitutions and changes occurring without prior notice. Residents expressed frustration over the lack of variety, repeated substitutions, and the perception that cost-saving measures were prioritized over their dietary needs. Specific examples included changes such as substituting grilled cheese with deli meat sandwiches, replacing breakfast meats with eggs, and altering side dishes and desserts without explanation. Review of facility records confirmed numerous instances where the planned menu items were substituted with different foods across several weeks. These substitutions included changes to main entrees, side dishes, and desserts for multiple meals, often resulting in residents receiving meals that did not align with the posted or planned menus. The Dietary Manager's job summary indicated responsibility for planning menus with the dietitian, ensuring menus meet nutritional needs, and maintaining sufficient inventory, but the observed practices did not align with these responsibilities. Interviews with residents and facility staff further corroborated the inconsistency in meal service. Residents consistently reported dissatisfaction with the quality, quantity, and predictability of meals since a new company took over food service operations. The facility administrator acknowledged that dietary staff sometimes could not obtain the necessary food items and had to make substitutions, but did not perceive this as a frequent issue. The facility census indicated that all 76 residents were potentially affected by these deficiencies.
Failure to Update Care Plan for Resident with Physical Behaviors
Penalty
Summary
The facility failed to revise and update the care plan for a resident with a history of Parkinson's Disease and anxiety, who frequently exhibited physical behaviors resulting in self-harm and aggression towards staff. Despite the facility's policy requiring prompt assessment and care plan updates following changes in a resident's condition, the resident's care plan did not document her behavioral issues, known triggers, or interventions to reduce the risk of injury. Observations showed the resident was anxious, angry, and physically aggressive, including an incident where she sustained an open laceration and another where she struck a staff member while being assisted. Interviews with facility staff, including the nurse practitioner and the MDS coordinator, confirmed that the resident's mental state had declined and that the care plan had not been updated to reflect her current behaviors or needs. The lack of an updated care plan meant that staff were not provided with guidance on managing the resident's physical behaviors or preventing injury, despite multiple incidents and staff awareness of her triggers and risks.
Failure to Complete and Communicate Daily Weights for CHF Resident
Penalty
Summary
The facility failed to ensure that daily weights were completed as ordered for a resident with congestive heart failure (CHF), and did not identify or communicate significant weight increases to the physician. The resident, who had severe cognitive impairment and multiple comorbidities including CHF, COPD, and respiratory failure, was admitted with explicit hospital discharge instructions for daily weight monitoring and prompt reporting of weight gains. Despite these orders, daily weights were inconsistently documented, and significant weight changes were not communicated to the physician as required. Review of the electronic medical record and eMAR revealed multiple gaps in weight documentation, including days when weights were not recorded and periods when incorrect orders were entered, resulting in missed daily weights. On several occasions, the resident experienced notable weight gains that met the threshold for physician notification, but there was no evidence that the physician was informed. The care plan for CHF did not include specific interventions for daily weights or physician notification of weight changes, and the facility lacked a policy addressing CHF care or daily weight monitoring. Interviews with staff and the resident's physician confirmed concerns about the lack of consistent daily weight monitoring and communication. The physician reported receiving weight updates only once and expressed frustration with the lack of follow-through on orders. The DON acknowledged the importance of daily weights for CHF management and expected staff to complete them as ordered, but also confirmed the absence of a facility policy specific to CHF or daily weights. These failures resulted in the resident being transferred to the hospital multiple times for CHF exacerbations.
Failure to Provide Timely BiPAP Respiratory Support as Ordered
Penalty
Summary
The facility failed to provide a resident with a physician-ordered BiPAP machine for respiratory support, despite multiple hospital discharge orders specifying the need for BiPAP at specific settings. The resident, who had a history of acute diastolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, acute and chronic respiratory failure with hypoxia, primary pulmonary hypertension, obstructive sleep apnea, and severe cognitive impairment, was admitted and readmitted to the facility several times. Each time, hospital discharge documentation included orders for BiPAP at night, but the facility's admission assessments and electronic medication and treatment administration records did not consistently reflect these orders, and the BiPAP was not made available to the resident in a timely manner. The resident's family provided a CPAP machine from home, but after a hospitalization, the discharge orders were changed to BiPAP, which was not immediately available upon the resident's return to the facility. There was a delay of several days before the BiPAP machine was delivered by the DME provider, during which time the resident did not have access to the prescribed respiratory support. Documentation showed inconsistent entries regarding the use of CPAP or BiPAP, and the care plan did not reflect BiPAP use until well after the resident's return from the hospital, despite clear orders from the hospital for its use. Interviews with the resident's power of attorney, physician, and the facility's Director of Nursing confirmed that there was confusion and a lack of clarity regarding the respiratory device orders, as well as delays in obtaining the correct equipment. The physician and DON acknowledged that the BiPAP should have been available from the initial admission based on the hospital orders, and that the orders should have been clarified and entered into the eMAR. The failure to provide the BiPAP as ordered resulted in the resident being hospitalized for respiratory failure due to not using the BiPAP machine.
Failure to Provide Sufficient Nursing Staff and Timely Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports of delayed response to call lights, missed or delayed care, and medication administration outside of scheduled times. Several residents with significant medical needs, including hemiplegia, diabetes, heart failure, cognitive impairment, and recent surgery, reported waiting 30 minutes to over an hour for assistance with toileting and other personal care. Some residents experienced incontinence while waiting for help, leading to feelings of humiliation and frustration. One resident resorted to emptying his own urinal due to lack of timely staff response, and another's spouse reported frequent delays resulting in accidents. Resident council meeting minutes over several months documented ongoing concerns about inadequate staffing, long call light wait times, missed showers, and staff turning off call lights before providing assistance. Residents consistently expressed that there were not enough CNAs to meet their care needs, and staff confirmed that frequent call-offs and reduced nurse staffing contributed to the inability to complete required tasks, such as providing showers and timely assistance. Staff also reported that high-acuity residents often required two-person assistance, further straining available resources. Medication administration was also affected by staffing shortages, with documentation showing that medications were given significantly outside of scheduled times. A physician noted poor communication and frequent staff turnover, stating that patients were not receiving appropriate care and that it was difficult to reach facility leadership. The DON acknowledged ongoing complaints about call light response times and attributed the issue to staffing cuts and changes in facility management structure. Facility policies required prompt response to call lights and timely medication administration, but these standards were not met.
Deficiency in Resident Council Meeting Protocols
Penalty
Summary
The facility failed to uphold the residents' rights to organize and participate in resident council meetings independently. The report highlights that non-residents, such as family members and facility staff, were present at these meetings without clear documentation of their invitation or purpose. Additionally, the facility did not record the names of residents attending the meetings, which is a crucial aspect of maintaining transparency and accountability. This lack of proper documentation and adherence to protocol undermines the independence of the resident council. Furthermore, the facility did not adequately address or resolve concerns raised during the resident council meetings. Specific grievances, such as issues with environmental services and maintenance, were noted in the minutes but lacked follow-up or resolution in subsequent meetings. The failure to document the names of residents with concerns and the absence of a clear plan to address these issues indicate a significant oversight in the facility's grievance handling process. This deficiency potentially affects all 62 residents in the facility, as their concerns are not being effectively managed or resolved.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during nursing care. On March 18, 2025, at noon, a resident was observed with their room door open while they were vomiting and complaining of stomach pain to an LPN. The resident's daughter was present in the hallway and noted that the door should have been closed to maintain privacy. When questioned, the LPN acknowledged that the door should have been closed to protect the resident's privacy.
Failure to Reweigh Resident After Significant Weight Change
Penalty
Summary
The facility failed to reweigh a resident after a significant weight change was recorded. The medical record for a resident documented a weight of 125.8 pounds on November 3, 2024, which then increased to 173 pounds on November 22, 2024, and remained the same on December 1, 2024. A progress note dated December 27, 2024, indicated that the Registered Dietician did not make any new dietary recommendations due to questioning the accuracy of the weight, suspecting it might have been taken with the resident in her wheelchair. The Director of Nursing acknowledged that the resident should have been reweighed after the significant weight gain recorded on November 22, 2024, despite the absence of a specific policy, as good nursing judgment should have prompted staff to verify the weight change.
Medication Administration Delays Due to Staffing Issues
Penalty
Summary
The facility failed to ensure timely administration of medications to five residents, resulting in significant delays. Each resident's medication administration record (MAR) indicated that medications scheduled for 8 AM were administered several hours late, with delays ranging from three to over four hours. Residents reported changes in their medication schedules, expressing concerns about the late administration. The medications involved included those for hypertension, neuropathy, chronic obstructive pulmonary disease, pain management, and anxiety, all of which were crucial for managing the residents' health conditions. The delay in medication administration was attributed to staffing issues on the morning of February 1, 2025. An agency nurse scheduled to work did not show up, leaving only two nurses to cover both the skilled and long-term care units. The Director of Nursing (DON) directed that one nurse from the skilled unit, which had fewer residents, assist in the long-term care unit. However, this transition did not occur until almost 11 AM, resulting in the late administration of medications. The facility's policy requires medications to be administered within an hour of the scheduled time, which was not adhered to in this instance.
Delayed Response to Call Lights Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that call lights were responded to in a timely manner for eight residents, as observed and reported during interviews and record reviews. The facility's Call Light Policy mandates prompt responses when the call system is activated, yet residents reported waiting times ranging from 5 minutes to over an hour. One resident specifically recounted an incident where they waited 1 hour and 55 minutes for assistance after an accident involving diarrhea. Another resident described a fall incident where help was delayed, requiring a roommate to yell down the hall for assistance. These delays were attributed to staffing issues following a change in facility ownership, which resulted in reduced staff numbers and increased stress among the remaining staff. Interviews with staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed that staffing cuts had occurred after the facility changed ownership, leading to increased workloads and longer response times to call lights. The Director of Nursing acknowledged that all staff are responsible for responding to call lights and that they should be answered promptly. The Monthly Resident Council Minutes also documented residents' concerns about call lights not being answered in a timely manner, further highlighting the ongoing issue of inadequate response times to residents' needs.
Failure to Ensure Safe Wheelchair Positioning Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe positioning in a wheelchair for a resident, resulting in the resident sliding out of the wheelchair and sustaining a fracture of her left leg. The resident, who had severe cognitive impairment and was dependent on staff for various activities of daily living, was being assisted by a CNA to change into a gown when the incident occurred. The CNA reported that the resident began sliding out of the wheelchair, and despite attempts to reposition her, the CNA had to lower the resident to the floor. The resident's medical history included severe cognitive impairment, dementia, and a history of falling, among other conditions. After the incident, the resident complained of pain in her left leg, which was initially not identified as an injury. Over the following days, the resident continued to experience significant pain, leading to the eventual discovery of a medial tibial plateau fracture through a portable x-ray. The family initially refused the x-ray due to concerns about the resident's stress levels but later consented to a portable x-ray after further discussions. Interviews with staff revealed inconsistencies in the handling of the incident and the assessment of the resident's condition. The CNA involved could not recall if the wheelchair was locked or if the footrests were in place, and there was a lack of clarity regarding the thoroughness of the initial assessment by the nurse. The facility's policies on safe lifting and positioning did not provide specific guidance on proper body mechanics in a wheelchair, contributing to the deficiency.
Medical Director's Absence from QA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director attended the Quality Assurance (QA) meetings, as required by their policy. The facility's QAPI (Quality Assurance Performance Improvement) program mandates monthly and quarterly meetings, with the Medical Director and Leadership team collaborating on day-to-day decisions. However, the QAPI sign-in sheets for a meeting held on 3/19/2024 did not include the signature of the Medical Director. This was confirmed by the Administrator during an interview on 05/22/24, who acknowledged that the Medical Director did not attend the QA meeting on 3/19/24 or review the QA information. This deficiency has the potential to affect all 72 residents in the facility.
Failure to Ensure Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), responsible for the Infection Prevention and Control Program (IPCP), was certified. The job description for the IP includes responsibilities such as attending Infection Control Committee meetings, completing infection surveillance reports, advising on isolation protocols, and participating in the Quality Assurance Committee. However, upon entrance to the facility, it was found that the current IP was not clearly designated, and the Care Plan Coordinator, who has the certification, did not oversee the IPCP. Instead, the Assistant Director of Nursing, who is halfway through the certification training, was acting as the IP without having completed the necessary certification. This deficiency has the potential to affect all 72 residents in the facility. The Administrator provided a list of key personnel that did not include the name of the current IP. The Care Plan Coordinator confirmed having the certification but stated they did not manage the IPCP. The Assistant Director of Nursing, who is currently acting as the IP, admitted to not having completed the certification. This lack of a certified IP overseeing the IPCP indicates a failure in the facility's compliance with infection control standards, potentially impacting the health and safety of all residents.
Failure to Implement Gradual Dose Reductions and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for psychotropic medications for four residents. The facility did not attempt GDRs, identify target behaviors, or document behaviors justifying the use of psychotropic medications. This was confirmed through record reviews and interviews with the Director of Nursing (DON). For instance, one resident was on Olanzapine for dementia-related behaviors without any documented target behaviors or attempts at GDR. The nurse practitioner disagreed with the pharmacist's recommendation for a trial discontinuation, citing the resident's tolerance to the medication and lack of worsening behaviors. Another resident, diagnosed with unspecified depression, reported that their antidepressant was ineffective. Despite this, no GDR attempts were made for the Trazodone prescribed. The DON confirmed that assessments were not conducted due to management and pharmacy changes, and a Performance Improvement Plan (PIP) was in place to address this issue. Similarly, a third resident on Quetiapine for major depressive disorder had no identified target behaviors or personalized non-pharmacological interventions documented in their care plan. A fourth resident with multiple diagnoses, including bipolar disorder and schizoaffective disorder, was on several psychotropic medications without any documented GDR attempts or identified target behaviors. The pharmacist recommended a GDR for Citalopram, but the nurse practitioner disagreed, citing potential exacerbation of the resident's psychiatric condition. The DON confirmed the lack of documented GDRs and personalized care plan interventions for this resident as well.
Failure to Perform Proper Hand Hygiene
Penalty
Summary
The facility failed to perform proper hand hygiene during care for two residents. In the first instance, a Registered Nurse (RN) put on gloves before entering a resident's room, touched a computer and medication cart with gloved hands, and then administered an insulin injection without changing gloves or performing hand hygiene. In the second instance, a Certified Nurse Assistant (CNA) performed catheter care on a resident without changing gloves or performing hand hygiene before touching the resident's bedside table, redressing the resident, and adjusting the resident's position in bed. The CNA later acknowledged the failure to follow proper hand hygiene protocols.
Failure to Incorporate Hospital Discharge Instructions into Care Plan
Penalty
Summary
The facility failed to incorporate hospital discharge instructions for a cervical neck brace and skin care into the care plan and treatment plan for a resident (R65). The resident was admitted with diagnoses including a displaced fracture of the second cervical vertebra, a left pubis fracture, and multiple rib fractures. Despite the hospital's detailed instructions for collar and skin care, these were not included in the resident's care plan or Treatment Administration Record (TAR). Observations and interviews revealed that skin checks were not consistently documented or performed, leading to frustration from both the resident and their spouse. The hospital instructions specified that the cervical collar should be worn at all times, with skin checks and cleaning to be performed 2 to 3 times daily. However, the TAR showed multiple instances where skin checks were not documented. The resident and their spouse reported that skin checks were only performed twice since admission. The Director of Nursing acknowledged that the hospital instructions should have been incorporated into the resident's care plan and treatment plan, but this was not done, resulting in a failure to monitor and care for the resident's skin integrity as required.
Failure to Maintain Door Alarms
Penalty
Summary
The facility failed to ensure that all doors were alarmed at all times, as required by their Elopement Precautions Policy. This failure was highlighted by an incident involving a resident identified as R39, who was found outside the building on the sidewalk in the parking lot. The investigation revealed that R39, who was wearing an electronic monitoring bracelet, exited the building through the ambulance door without triggering the alarm. The security footage showed that R39 left his room in a wheelchair and exited the building without any delay or alarm sounding. Staff members did not react to any noise, indicating that the alarm did not go off as it should have. Further review of the facility's door monitoring logs for April and May 2024 showed that the ambulance door was not being checked regularly. The Director of Nursing (V2) confirmed that maintenance staff had stopped checking this door because they did not have the key to reset the alarm once it went off. This lapse in procedure was attributed to changes made during the COVID-19 pandemic. Despite the alarm working immediately after the incident and since then, the failure to check and maintain the alarm system on the ambulance door led to the deficiency and the potential risk for residents who wander.
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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