St Anthony's Nsg & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Rock Island, Illinois.
- Location
- 767 30th Street, Rock Island, Illinois 61201
- CMS Provider Number
- 145387
- Inspections on file
- 43
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at St Anthony's Nsg & Rehab Ctr during CMS and state inspections, most recent first.
The facility failed to ensure reasonable access to and privacy in telephone communication when it removed landlines and relied on shared unit cell phones that were often unanswered or inaccessible. At times there was no receptionist to answer ringing phones, and a unit landline was nonfunctional while the unit cell phone sat unattended in the nurse’s station. The ADON and administrator stated that each floor had one cell phone for both staff and resident use and that nurses were supposed to carry it, but they could not explain staff absences from the reception desk. Family members of two residents reported repeated problems reaching staff by phone, including unanswered calls, and an RN stated that the phone system was problematic and that residents could see staff text messages and other communications about other residents when using the shared cell phone.
A resident at moderate risk for skin impairment, who was severely cognitively impaired and dependent on staff for all care, did not have pressure-relieving interventions, repositioning schedules, or pressure ulcer care documented in the care plan, despite facility policies requiring comprehensive prevention and early intervention. The resident developed a facility-acquired coccyx pressure ulcer that progressed from a stage 3 wound with tunneling to an unstageable/stage 4 ulcer with visible bone and osteomyelitis, as documented by wound notes and a wound physician’s debridement and bone scraping. Nursing staff were unable to locate an initial wound assessment or clear onset date, and subsequent documentation described copious drainage, bone particles in the wound bed, and the need for IV antibiotics and debridement.
The facility lacked a full-time DON for several months, leaving an LPN in an assistant role to manage nursing needs without clear departmental leadership, which contributed to poor communication and documentation. In one case, a resident’s SLP notes continued to reference a G-tube and restricted oral intake, while nursing notes showed the G-tube had been pulled out and enteral feedings discontinued, and the SLP reported not being informed of this change. In another case, a dependent resident developed an in-house Stage 3 coccyx pressure ulcer with tunneling and osteomyelitis, but the wound nurse, an LPN, could not locate the initial wound assessment and dated the onset based on when she took over the position rather than when the ulcer actually developed.
The facility operated for several months without a DON, leaving an ADON who is an LPN to manage nursing needs and contributing to poor communication between nursing and therapy. The Administrator acknowledged ongoing communication problems, including no defined process for sharing therapy recommendations and no nursing access to therapy documentation. In this context, a resident’s G-tube was pulled out, enteral feeding orders were discontinued, and only site care was provided, yet speech therapy records continued to reflect that a feeding tube was in place with recommendations for puree diet and therapeutic feedings with the SLP only. The SLP later reported believing the tube remained in place and not being informed of its removal, illustrating the communication breakdown surrounding the resident’s G-tube management.
Surveyors found that resident rooms were maintained at unsafe, uncomfortable temperatures, with readings as low as the mid-50s despite residents wearing multiple layers of clothing, coats, and hats and reporting feeling cold. Temperature logs showed occupied rooms ranging from the mid-50s to upper-60s over several days. The building was heated by two steam boilers, but only one was operational, and the structure’s age, high ceilings, old windows, and multiple elevators allowed significant cold air infiltration, contributing to the facility’s inability to maintain adequate room temperatures.
A resident with multiple respiratory and cardiac conditions was admitted with physician orders for Albuterol nebulizer treatments every six hours. Facility records and interviews confirmed that the ordered nebulizer treatments were not transcribed or administered, and the resident reported not receiving the medication during their stay.
A resident with severe cognitive impairment and multiple risk factors for pressure injuries was not properly assessed for skin breakdown. Staff failed to document and stage superficial open areas found on the buttocks, and a stage 2 pressure injury later developed on the shoulder. Required wound assessments and documentation were not completed according to facility policy.
A resident with a history of a Stage IV sacral pressure ulcer was admitted without a timely skin assessment or initiation of wound care orders. The resident received no wound treatment for several days, and the care plan was not updated to address the worsening wound or the resident's non-compliance. The wound deteriorated significantly, developing necrosis and infection, and required multiple debridements.
The facility failed to document that staff received education on the benefits and risks of the COVID-19 vaccine. A review of consent forms showed three staff members were vaccinated, but there was no evidence of education provided, as required by the facility's policy. This oversight could impact all 82 residents.
A resident sustained a burn from a vape pen due to unsupervised smoking, contrary to the facility's policy requiring supervision. Additionally, the facility failed to conduct quarterly smoking assessments for several residents, only performing them annually. This oversight in policy adherence contributed to the incident and lack of monitoring of residents' smoking habits.
A resident was subjected to inappropriate conduct by a staff member, a Registered Nurse, who sent the resident an explicit photo and messages. The resident, who is cognitively intact, reported the incident, and the staff member admitted to sending the photo, citing a lack of friends outside of work. The facility's investigation confirmed the misconduct, leading to the staff member's termination.
A resident with Dementia was prescribed Quetiapine/Seroquel without appropriate indication, as required by facility policy. Despite the medication, the resident's behavior of constant yelling was not reduced, and the dosage was acknowledged to be higher than usual. Observations confirmed the resident's frequent calls for help, indicating insufficient use of non-pharmacological interventions.
A resident received twice the prescribed dosage of Seroquel for a month due to a transcription error by a nurse. The hospice physician had ordered 50mg three times daily, but the resident was given 100mg three times daily. The error was discovered through a review of the MAR, and no adverse effects were noted.
An LPN failed to change gloves during wound care for a resident with a pressure ulcer, violating infection control protocols. The LPN removed a soiled dressing, cleansed the wound, applied barrier cream, and placed a new dressing without changing gloves or performing hand hygiene. The DON confirmed the expectation for glove change and hand hygiene after removing soiled dressings.
The facility did not have the survey binder with State Agency survey results readily available for residents to review. During an annual survey, the binder could not be located, and Resident Council members were unaware of its existence or their right to review it. The administrator confirmed the binder was not accessible, impacting all 82 residents.
A facility failed to change a resident's indwelling catheter monthly as ordered and did not consistently monitor urinary output, leading to a urinary tract infection. The resident, with a neurogenic bladder, had no documented catheter changes during their stay, and sporadic urinary output records. This resulted in the resident being hospitalized with a UTI, hypoxia, and pneumonia.
A resident's family reported a missing ring, a valuable heirloom, to an LPN, who informed the AIT. Despite facility policy requiring immediate reporting of such incidents, the AIT did not notify the state agency or local authorities, citing no follow-up from the family.
The facility did not follow its abuse prevention policy by failing to conduct a background check on a contracted maintenance consultant with a known criminal history. The Operations Manager, aware of the consultant's criminal past, did not pursue necessary checks, citing the consultant's status as a contractor. This oversight potentially affects all 89 residents in the facility.
A CNA's unprofessional conduct, including loud arguments and inappropriate language in front of residents, led to a deficiency in maintaining a respectful and dignified environment. Despite resident complaints and documented incidents, the behavior persisted, causing discomfort and insecurity among residents.
The facility failed to maintain an effective pest management program, affecting all 80 residents. Multiple reports from residents and staff indicated the presence of large roaches in various areas, including shower rooms and hallways. A facility-wide tour confirmed these sightings. The facility's pest control efforts were inadequate, with terminated agreements and incomplete documentation from pest control companies, leading to ongoing pest issues.
The facility failed to provide consistent care and treatment for several residents, including improper wound care and mishandling of scabies treatment. One resident did not receive consistent wound care and repositioning, while another received incorrect doses of Ivermectin for suspected scabies. Additionally, a resident's scabies test was delayed, and another resident's wound care was not consistently provided. These deficiencies highlight a lack of adherence to treatment plans and necessary assessments.
A facility failed to implement isolation precautions for a resident suspected of having scabies. Despite a physician's order for strict contact precaution isolation, there was no signage or PPE in the resident's room. The resident, who had new bites, was observed outside their room, and the DON confirmed the resident was on contact precautions without a confirmed diagnosis.
A resident reported being treated roughly by a CNA, but the facility failed to follow its abuse policy by not suspending the accused CNA during the investigation. Instead, the CNA was moved to another floor, and the investigation remained incomplete. The resident's report was met with skepticism due to perceived inconsistencies and a report of the resident's confusion.
A resident with a history of mental health issues and substance use eloped from the facility unsupervised and returned exhibiting signs of intoxication. The facility failed to document the incident, notify the physician, or implement necessary interventions to prevent future elopements, despite staff awareness of the resident's tendencies.
Failure to Ensure Reasonable Access to and Privacy in Telephone Communication
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when it eliminated landlines and relied on shared cell phones that were often unanswered or inaccessible. A paramedic reported that dispatch could not reach anyone at the facility’s cell phone after landlines were removed. On one survey day, there was no receptionist at the front desk for over 20 minutes while the phone rang unanswered, and a housekeeper confirmed there was no receptionist that day and that the previous day’s receptionist did not arrive until midday. On the second floor, the landline was nonfunctional and the unit cell phone was left inside the nurse’s station while a CNA sat outside in the hallway area. The ADON stated each floor had one cell phone for staff and resident use, that nurses were supposed to carry the phones, and that a receptionist should be present from 8:00 AM to 8:00 PM to transfer calls, but could not explain the absence of a receptionist that morning. The Administrator stated that there was always supposed to be someone at the reception desk during daytime hours to answer calls and transfer them to the unit cell phones, and confirmed that after 8:00 PM there was no one to answer the phone and callers only reached a recording with options to leave messages for various departments. He also confirmed that police, paramedics, and fire stations did not have the unit cell phone numbers and could not call them directly after hours. Family members of two residents reported repeated problems reaching staff by phone, including calls that went unanswered at night and during the day, and stated that staff did not answer the unit cell phones. An RN reported that the phone system was a problem, that families complained about calls not being answered, and that the single shared cell phone on each floor was used for staff texting with physicians and other communications that residents could see when they used the phone, exposing information about other residents. The facility’s Resident Rights policy stated that residents were to be treated with dignity, respect, and fairness while safeguarding their rights, safety, and access to services.
Failure to Prevent and Properly Manage Facility-Acquired Pressure Ulcer With Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to implement and document appropriate pressure ulcer prevention and management for a resident identified as being at moderate risk for skin impairment. The facility’s own policies required comprehensive skin assessments, risk evaluations, pressure-relieving interventions, timely reassessment with any change in condition, and prompt notification of the nurse supervisor, medical provider, and wound nurse when new wounds or deterioration occurred. Despite Braden assessments indicating moderate risk, the resident’s care plan did not include pressure-relieving interventions, repositioning schedules, or documentation of pressure ulcer care. The resident was severely cognitively impaired and dependent on staff for all care, yet there was no initial assessment documented for when the coccyx pressure ulcer developed, and the wound nurse later stated she could not locate this initial assessment and had only documented that the pressure ulcer developed in July when she assumed her role. Over time, the resident developed a facility-acquired coccyx pressure ulcer that progressed from a stage 3 pressure injury with tunneling to an unstageable/stage 4 wound with osteomyelitis. Wound documentation on one date described a stage 3 full-thickness coccyx ulcer with a 2.2 cm tunnel and noted that the wound was acquired in-house with an unknown onset. A subsequent wound evaluation by a wound physician documented mechanical debridement of the coccyx wound, bone scraping to confirm osteomyelitis, copious bright red bleeding requiring direct pressure and calcium alginate with blood-stop granules, and instructions to keep the resident supine with direct pressure to the wound bed. Later nursing notes described bone particles visible in the wound bed and copious serosanguineous drainage. The resident ultimately required IV vancomycin for wound infection and debridement, and the wound nurse confirmed that the coccyx ulcer was a facility-acquired stage 3 pressure ulcer and that the resident grimaced or pulled away during dressing changes and debridements.
Lack of DON Oversight Leading to Communication and Documentation Failures
Penalty
Summary
The facility failed to ensure the nursing department was directed by a qualified full-time Director of Nursing (DON), resulting in a lack of direction and communication within nursing and therapy regarding resident care needs. The Administrator reported the facility had been without a DON for several months, and the Assistant Director of Nursing, an LPN, stated the former DON left approximately eight months prior and the position had not been replaced. The Administrator also stated there were communication issues between departments, that nursing staff did not have access to therapy documentation, and that there was no defined process for communicating therapy recommendations. For one resident with a history of a gastrostomy tube (G-tube), speech therapy documentation over a two‑month period indicated the resident had a feeding tube in place and recommended puree consistencies with therapeutic feedings only with the Speech Language Pathologist (SLP). Nursing progress notes documented that the resident had pulled out the G-tube and that enteral feeding orders were discontinued, with only G-tube site care continued. The SLP later stated that at the time of the resident’s discharge from therapy, the SLP believed the feeding tube remained in place and had not been informed that the resident had pulled out the G-tube and that it was not reinserted. In a separate case, wound documentation for another resident showed an in-house acquired Stage 3 pressure ulcer to the coccyx with tunneling and subsequent bone debridement and treatment, including involvement of a wound doctor and infectious disease due to osteomyelitis and kidney failure considerations. The wound nurse, an LPN, confirmed the pressure ulcer developed at the facility and that the resident was dependent on staff for all care, but was unable to locate the initial assessment from when the pressure ulcer developed, stating she documented the pressure ulcer as developing in July only because that was when she assumed the wound nurse role. These findings demonstrate missing leadership and oversight in the nursing department, as well as gaps in communication and documentation related to resident care and assessments.
Lack of DON Oversight and Poor Nursing–Therapy Communication on G-Tube Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure the nursing department was directed by a qualified Director of Nursing (DON), resulting in a lack of direction and communication within nursing and therapy regarding resident care needs. The Administrator reported that the facility had been without a DON for several months and acknowledged communication issues between departments, including the absence of a defined process for communicating therapy recommendations and the lack of nursing staff access to therapy documentation. The Assistant Director of Nursing, an LPN, stated that the former DON had left approximately eight months earlier and that the position had not been replaced, leaving her to manage nursing needs to the best of her ability. For one resident reviewed for G-tube management, speech therapy documentation over a period of time recorded that the resident had a feeding tube in place and recommended puree consistencies with therapeutic feedings only with the Speech Language Pathologist (SLP). However, nursing progress notes documented that the resident had pulled out her G-tube, that enteral feeding orders were discontinued by a nurse practitioner, and that G-tube site care was initiated. The SLP later stated that at the time of the resident’s discharge from therapy, the SLP believed the feeding tube was still in place and had not been informed that the G-tube had been removed and not replaced, demonstrating a breakdown in communication about the resident’s G-tube status and care needs.
Failure to Maintain Safe and Comfortable Resident Room Temperatures
Penalty
Summary
The facility failed to maintain resident room temperatures at a comfortable, safe level for multiple residents during a period of substandard indoor temperatures. Surveyors measured room temperatures for three residents on the second floor, finding readings between 59.9 and 62.4 degrees using an infrared thermometer. One resident was observed in a wheelchair wearing multiple layers of clothing and a knitted hat and stated he was cold and that his room had been cold for the past week. Another resident was seated in an easy chair wearing multiple layers of clothing, a coat, and a hat and also stated he was cold. A third resident was seated on his bed in multiple layers of clothing and stated it was cool in his room. Facility temperature logs for occupied rooms over several days documented random room temperatures ranging from 54 to 68 degrees. The facility’s heating system consisted of two steam boilers, with only one boiler functioning at the time of the survey. The Administrator stated that the working boiler had the capacity to heat the entire building but acknowledged the facility had been having trouble maintaining air temperatures inside the building for about a week due to sub-zero wind chills. The Maintenance Director reported that the building is over 100 years old, with high ceilings, large old windows, and multiple elevators that allow cold air to enter without restriction, and that one boiler was shut down due to the need for major repairs. He stated that he had taken temperatures in all resident rooms twice daily and that resident room temperatures had ranged from 54 to 68 degrees. These conditions occurred despite the facility’s policy on emergency procedures for heat loss, which directs staff to quickly assess loss of heating and determine if remediation is possible or if partial or full evacuation is necessary.
Failure to Administer Physician-Ordered Nebulizer Treatments
Penalty
Summary
A resident with a history of acute respiratory failure with hypoxia, pneumonia, COPD with acute exacerbation, chronic systolic heart failure, atrial fibrillation, and hypertension was admitted to the facility with hospital discharge orders for Albuterol nebulizer treatments every six hours. The facility's Medication Administration Policy requires accurate administration of all medications as ordered. Review of the resident's medical record, order summary, and medication administration records showed no documentation that the prescribed nebulizer treatments were administered. The resident reported not receiving any nebulizer treatments during their stay and stated that they requested discharge due to not receiving necessary medication. The facility nurse practitioner confirmed that the nebulizer treatment orders were neither transcribed nor administered as ordered.
Failure to Identify and Assess Pressure Injuries in High-Risk Resident
Penalty
Summary
The facility failed to identify and properly assess pressure injuries in a resident who was admitted with severe cognitive impairment, was dependent on staff for all care, and was at high risk for pressure injuries due to conditions such as severe protein-calorie malnutrition, anemia, Alzheimer's Disease, and incontinence. Upon admission, the resident had no open wounds, but was always incontinent and required frequent repositioning and assistance with mobility. Despite these risk factors, the facility did not document any open wounds at admission. On 6/4/25, nursing progress notes indicated the presence of two small superficial open areas on the resident's buttocks, but there was no documentation of measurements, staging, or a thorough assessment of these wounds. Later, on 6/24/25, a new stage 2 pressure injury was identified on the resident's right shoulder, with measurements recorded. Interviews with staff confirmed that skin checks should have been performed regularly and that wounds should have been identified and documented before advancing to stage 2. The facility's own policy required detailed documentation of wound type, stage, location, size, and other characteristics, which was not followed in this case.
Failure to Initiate Admission Skin Assessment and Wound Care Orders
Penalty
Summary
The facility failed to initiate a skin assessment upon admission, did not implement admission wound care orders, and did not develop an appropriate wound care plan for a resident with a known sacral pressure wound. Upon transfer from another facility, the resident had a history of a Stage IV sacral pressure ulcer, with documentation from the previous facility indicating the wound was being treated and managed. However, after admission, no skin assessment was completed within the required timeframe, and wound care orders were not initiated until several days later, resulting in a lapse in treatment. During the period without wound care, the resident received no wound treatment, and there was no documentation of a skin assessment until a wound physician evaluated the resident days after admission. The wound had significantly deteriorated by the time it was assessed, with the presence of thick, adherent black necrotic tissue (eschar) and an increase in wound size. The care plan was not updated or revised to reflect the worsening condition, changes in treatment, or the development of infection, despite multiple debridements and ongoing wound management needs. Interviews with facility staff confirmed that the required admission skin assessment was not completed, and the initial care plan did not address the resident's non-compliance with wound care interventions or include necessary pressure relief equipment. The resident's medical history included multiple comorbidities such as diabetes, paraplegia, and neurogenic bladder, which increased the risk for skin breakdown. The lack of timely assessment, failure to implement wound care orders, and inadequate care planning contributed to the progression of the resident's pressure ulcer to a severe, necrotic state.
Lack of Documentation for COVID-19 Vaccine Education
Penalty
Summary
The facility failed to document that staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccination. This deficiency was identified during a review of employee COVID-19 consent forms, which showed that three staff members received the COVID-19 vaccination, but there was no documentation indicating they or any other staff received the necessary education. The facility's policy, last revised on 10/14/24, mandates that educational materials about the benefits, risks, and availability of vaccines be provided to all employees. However, the Assistant Director of Nursing and Infection Preventionist confirmed the absence of such documentation, which has the potential to affect all 82 residents in the facility.
Failure to Prevent Smoking-Related Injury and Conduct Assessments
Penalty
Summary
The facility failed to prevent a resident from sustaining a smoking or vape-related burn and did not complete quarterly Smoking Assessment Evaluations for several residents. One resident, identified as R46, sustained a burn on his right forearm, which he attributed to his vape pen. Despite the facility's policy requiring smoking to be supervised and assessments to be conducted quarterly, R46 was able to smoke unsupervised, leading to the injury. The resident's care plan noted his non-compliance with the smoking policy, as he would leave the unit unattended to smoke at undesignated times. Additionally, the facility did not complete the required quarterly smoking assessments for residents R33, R46, R51, and R79. The facility's policy mandates that these assessments be conducted upon admission, quarterly, and with any change in condition. However, the facility was only conducting these assessments annually, as confirmed by the administrator. This lack of adherence to the policy contributed to the oversight in monitoring the residents' smoking habits and ensuring their safety.
Resident Subjected to Inappropriate Conduct by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member. A cognitively intact resident, identified as R33, reported receiving an inappropriate nude photo and messages from a staff member, V8, who is a Registered Nurse. The incident was documented in a facility-reported incident report, where R33 showed a staff member a picture of a woman's naked vagina and messages sent from V8's phone number. The messages were inappropriate and included a reference to a 'holocaust victim.' R33 expressed that while he was not overly upset, the messages were inappropriate and should not have occurred. Upon investigation, V8 initially denied sending the explicit photo but later admitted to sending it to R33, acknowledging it was inappropriate. V8 stated she sent the photo because she does not have many friends outside of work. The facility's investigation concluded that V8 was guilty of sending the explicit photo, and she was subsequently terminated from her position. The report highlights a failure in the facility's responsibility to ensure residents are free from abuse, as outlined in their Abuse and Neglect Prevention policy.
Inappropriate Use of Antipsychotic Medication for Resident with Dementia
Penalty
Summary
The facility failed to provide an appropriate indication for the use of an antipsychotic medication for a resident diagnosed with Dementia. The resident, identified as R21, was prescribed Quetiapine/Seroquel, an antipsychotic medication, initially at a dose of 100mg twice daily, which was later increased to 100mg three times daily. The facility's policy on psychotropic medications requires that such drugs are only administered when necessary to treat a specific condition, with documented clinical justification. However, the report indicates that the use of Seroquel did not effectively reduce the resident's behavior of constant yelling, which was the primary behavior being addressed. The resident's care plan noted behaviors such as verbal aggression, yelling out exaggerated claims, and attention-seeking actions, but these behaviors were not sufficiently managed by the medication. The Director of Nursing acknowledged that the medication had not reduced the resident's yelling behavior and that the dosage was higher than usual. Observations over two days confirmed the resident's frequent calls for help, indicating that the non-pharmacological interventions were not effectively utilized or documented as required by the facility's policy.
Significant Medication Error Due to Transcription Mistake
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was prescribed an antipsychotic medication. The error involved a resident who was observed frequently calling out for help. The hospice physician had ordered Seroquel 50mg to be administered three times per day. However, due to a transcription error by a nurse, the resident received Seroquel 100mg three times per day, resulting in the resident receiving twice the prescribed dosage from January 27, 2025, to February 27, 2025. The error was discovered when reviewing the Medication Administration Record (MAR), which indicated the incorrect dosage was administered for a month. The Director of Nursing confirmed the error and noted that the nurse responsible for the transcription error had already been terminated for unrelated reasons. Despite the error, no adverse effects were noted at the time of discovery.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for a resident with a pressure ulcer. A Licensed Practical Nurse (LPN) did not change gloves after removing a soiled dressing from the resident's right buttock wound. The LPN proceeded to cleanse the wound, apply barrier cream, and place a new dressing without changing gloves or performing hand hygiene, which is against the standard infection control procedures outlined in clinical nursing guidelines. The resident's electronic medical record indicated a physician's order to cleanse the wound with normal saline, apply barrier cream, and cover with border gauze daily and as needed until healed. During an observation, the LPN confirmed not changing gloves after removing the soiled dressing. The Director of Nursing later confirmed that the expectation was for the LPN to change gloves and perform hand hygiene after removing the soiled dressing, highlighting a lapse in adherence to infection control protocols.
Survey Binder Not Accessible to Residents
Penalty
Summary
The facility failed to make the survey binder, which contains the results of State Agency surveys, readily available and in a conspicuous place for residents to review. This deficiency was identified during the facility's annual survey conducted by the State Agency on February 25 and 26, 2025, when the survey binder could not be located. Interviews with members of the Resident Council revealed that they were unaware of the existence of the survey binder and their entitlement to review the survey results. The facility's administrator confirmed that the binder was not readily available to residents, affecting all 82 residents residing in the facility.
Failure to Change Catheter and Monitor Output Leads to UTI
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency. The resident, who had a neurogenic bladder, was ordered to have their 16 French indwelling catheter changed every month and as needed. However, there was no documentation in the resident's Treatment Administration Records indicating that the catheter was ever changed during their stay at the facility. Additionally, the facility did not consistently monitor the resident's urinary output, as required, with only sporadic entries found in handwritten day sheet notes. This lack of monitoring and catheter care contributed to the resident developing a urinary tract infection, which was treated with antibiotics. The deficiency was further highlighted when the resident was sent to the emergency room due to symptoms of hypoxia, pneumonia, and a urinary tract infection associated with the indwelling catheter. The Director of Nursing confirmed the absence of documentation for catheter changes and was unaware of any issues with the resident's catheter. The resident's doctor emphasized the importance of changing the catheter monthly to prevent infections, which were evident in this case. The failure to adhere to the physician's orders and monitor the resident's condition adequately resulted in the resident's hospitalization for further treatment.
Failure to Report Misappropriation of Resident's Jewelry
Penalty
Summary
The facility failed to report an allegation of misappropriation of jewelry to the state agency or local law enforcement for a resident. The facility's policy mandates that any suspected acts of misappropriation should be reported immediately to the nursing home Administrator/Designee and subsequently to the state agency and local authorities. However, in this case, the Administrator In Training (AIT) did not report the missing ring to the state agency or local authorities after being informed by the Licensed Practical Nurse (LPN) that the resident's family member had reported the ring missing. The incident involved a resident whose family member noticed a missing ring, which was a valuable and irreplaceable family heirloom, on the day the resident was sent to the hospital. The family member reported the missing ring to the LPN, who then notified the AIT, designated as the Abuse Coordinator. Despite this notification, the AIT did not take further action to report the incident to the appropriate authorities, citing a lack of follow-up from the family as the reason for inaction.
Failure to Conduct Background Check on Contracted Employee
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing a background check on a contracted maintenance consultant with a known criminal history. The facility's policy mandates that all prospective healthcare employees undergo a criminal history background check to ensure a safe environment for residents, staff, and visitors. However, the Operations Manager did not pursue the necessary background checks, including fingerprinting, for the maintenance consultant, citing that as a contracted consultant from another company, the facility was not required to perform these checks. This oversight has the potential to affect all 89 residents currently residing in the facility. Interviews and record reviews revealed that the Human Resources personnel, responsible for overseeing employee and consultant background checks, were unaware if the maintenance consultant's background and fingerprint results were completed. The consultant's pre-employment background check authorization indicated a criminal conviction, and the health care worker registry did not list the consultant. Additionally, the consultant's employee file was missing the Fee App or Eligibility to work documentation. Despite being aware of the consultant's criminal history, the Operations Manager did not take further action to ensure compliance with the facility's background check policy.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the residents' rights to a dignified existence and self-determination by not providing an environment of respect and dignity. This deficiency was evident in the behavior of a Certified Nursing Assistant (CNA), identified as V7, who engaged in unprofessional conduct in the presence of residents. Multiple residents reported incidents where V7 was involved in loud arguments and used inappropriate language with other staff members, causing discomfort and a sense of insecurity among the residents. The facility's Resident Council Minutes and Grievance/Complaint Reports documented several instances of V7's disruptive behavior. Residents expressed their concerns during council meetings, highlighting V7's tendency to yell and curse in front of them. Despite these complaints, the behavior persisted, with V7 being involved in multiple altercations, including a physical confrontation with another CNA, V13, in the facility lobby. These incidents were not only disruptive but also violated the facility's policies on maintaining a respectful and safe environment for residents. Interviews with residents further corroborated the reports of V7's inappropriate conduct. Residents described feeling uncomfortable and unsafe due to V7's actions, which included yelling, cursing, and engaging in confrontations with other staff members. The Director of Nursing acknowledged being unaware of the full extent of the incidents until recently, despite previous counseling sessions with V7. The failure to address these issues promptly and effectively contributed to the deficiency in maintaining a respectful and dignified environment for the residents.
Ineffective Pest Management Program
Penalty
Summary
The facility failed to maintain an effective pest management program, which has the potential to affect all 80 residents residing in the facility. Multiple residents and staff members reported sightings of large roaches, some with wings, in various areas of the facility, including shower rooms, soiled linen rooms, hallways, and individual rooms. These reports were corroborated by a facility-wide tour, during which a cockroach with parasites was observed in a hallway. Residents expressed concerns about being bitten by these pests, and staff members noted that the insects were more prevalent at night. The facility's pest control efforts were found to be inadequate. The facility had terminated an agreement with a pest control company in February 2024 due to a significant bill and had not effectively engaged another service provider. Documentation from a second pest control company was incomplete, and the company could not be contacted. A third pest control company had only provided a quote for future services and had not yet performed any pest control activities at the facility. This lack of a consistent and effective pest control program contributed to the ongoing pest issues within the facility.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to implement appropriate care for residents, as evidenced by the lack of wound care and other treatments for several residents. One resident, identified as R1, had multiple wounds that were not treated consistently over several months. The resident's treatment records showed numerous instances where wound care, weighing, and application of barrier cream and extensor brace were not conducted as ordered. Additionally, the resident was observed lying in bed for extended periods without repositioning, despite being at high risk for pressure ulcers. Another resident, R2, was suspected of having scabies, but the treatment and follow-up were mishandled. The resident received incorrect doses of Ivermectin, and there was a delay in administering the correct dose. Furthermore, the resident's records lacked documentation of ongoing skin assessments and the results of a scabies test, which was ordered but not completed in a timely manner. Similarly, R4 also had suspected scabies, but the medication was not administered as ordered, and there was confusion regarding the scabies test. The resident reported new bites and expressed concern about the lack of confirmed diagnosis and treatment. Additionally, R6's records indicated that wound care was not consistently provided for various wounds, including pressure ulcers. The facility's failure to adhere to treatment plans and conduct necessary assessments contributed to the deficiencies identified in the care of these residents.
Failure to Implement Isolation Precautions for Suspected Scabies
Penalty
Summary
The facility failed to implement isolation precautions as ordered for a resident suspected of having scabies. The Scabies Policy requires the use of gloves and gowns when providing direct care to residents suspected or confirmed to have scabies, along with implementing contact precautions. Despite a physician's order placing the resident on strict contact precaution isolation, observations on July 29 revealed the absence of contact precaution signage and personal protective equipment in the resident's room. The resident expressed confusion about the lack of adherence to isolation protocols, noting new bites on various parts of their body. Additionally, the resident was observed at the nurse's station, indicating a breach in isolation protocol. The Director of Nursing confirmed the resident was on contact precautions, although a test to confirm the diagnosis was not obtained.
Failure to Implement Abuse Policy During Investigation
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by the handling of an incident involving a resident who reported being treated roughly by a Certified Nursing Assistant (CNA). The facility's policy mandates that any employee accused of abuse should be immediately removed from the facility to protect the resident during the investigation. However, in this case, the alleged perpetrator, a CNA, was not suspended but merely moved to another floor, despite the resident's report of the CNA grabbing her face and chin. The facility's investigation was still incomplete at the time of the report, and the CNA continued to work in the facility during the investigation period. The incident involved a resident who reported the rough treatment to another CNA during the third shift. The resident's Power of Attorney and physician were notified, and an investigation was initiated. Despite the resident's report and the concern expressed by another CNA, the facility administrator decided not to suspend the accused CNA due to perceived inconsistencies in the resident's story and a report from the resident's granddaughter about the resident's increasing confusion. This decision was made even though the facility's policy clearly states that accused employees should be removed pending the outcome of the investigation.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to accurately assess a resident at risk for elopement and did not implement necessary interventions, resulting in the resident eloping from the facility unsupervised. The resident, who had a history of mental health issues and substance use, was found by a city bus driver sleeping on a park bench and was returned to the facility exhibiting signs of intoxication. Despite this incident, there was no documentation of the event in the resident's record, no notification to the physician, and no medications were held as per the facility's policy. The resident's care plan did not reflect his repeated statements about wanting to leave the facility or his risk of elopement. Staff interviews revealed that the resident had previously left the facility with a friend and returned in an impaired state, yet no formal interventions were put in place to prevent future elopements. The resident was able to use the elevator freely, which facilitated his unsupervised departure from the facility. The facility's policies on elopement and drug-free environment were not followed, as evidenced by the lack of documentation and appropriate response to the resident's behavior. Staff members were aware of the resident's tendencies and previous incidents but did not take adequate measures to ensure his safety. The facility's failure to address these issues led to the resident's unsupervised elopement and subsequent return in a compromised state.
Removal Plan
- An elopement binder is kept at the front desk identifying those residents who may pose a risk for attempted elopement or wandering out of the facility.
- All Staff are being re-educated on: Elopement/Elopement risks amongst residents (including wandering), Managing behaviors and effective interventions, Resident Drug Free Environment. This training is being conducted with employees in the building as they report to work until all employees have received the training (including any agency staff on duty). This training has also been uploaded to the nursing staff agency the facility occasionally uses so that all staff coming to the facility will be required to complete the education before their first/next scheduled shift at the facility.
- All current residents are being re-evaluated for elopement risk and care plans updated accordingly with any new interventions. New residents are evaluated upon admission and then re-evaluated as changes are indicated. Interventions and risks are reviewed and revised accordingly minimally at care plan reviews, more often as indicated.
- In order to assure ongoing compliance, the Administrator and/or designee shall conduct an audit of 10 residents per week to assure that all elopement assessments are up-to-date and current care plan interventions in place. Any issues shall be addressed immediately and corrected with findings reviewed at the quarterly QAPI meeting. Behavior Committee meetings to be held one time per month to review residents requiring behavioral monitoring, use of antipsychotics and GDRs being conducted, elopement risks/factors, etc.
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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