St Clara's Rehab & Senior Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Illinois.
- Location
- 1450 Castle Manor Drive, Lincoln, Illinois 62656
- CMS Provider Number
- 145720
- Inspections on file
- 30
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at St Clara's Rehab & Senior Care during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a high risk for falls was not properly secured during van transport by an LPN, who only locked the wheelchair wheels and did not use the required securement systems. This lapse led to the resident falling and sustaining a subdural hematoma and scapular fracture.
The facility did not provide prescribed skin treatments for two residents, missing multiple applications of ointments and dressings as ordered by physicians. Additionally, blood glucose monitoring was not performed as ordered for a resident with diabetes on two occasions. These deficiencies were confirmed by the DON through review of treatment and medication administration records.
A resident with Type II Diabetes Mellitus did not receive prescribed doses of Insulin Aspart and Humalog at multiple scheduled times, including missed sliding scale doses when indicated by blood glucose readings. The DON and physician confirmed these omissions as medication errors, in violation of facility policy.
A resident developed a stage four pressure ulcer due to the facility's failure to implement specific pressure-relieving interventions. Despite being identified as at risk for pressure ulcers, the facility did not complete the required Braden Scale assessments or provide individualized care to prevent ulcers on the resident's heels. Observations showed the resident's heels were not consistently offloaded, and the pressure-relieving boot was not used as required, leading to the ulcer's deterioration.
The facility failed to ensure proper sanitation and food safety practices, affecting all 96 residents. The dishwashing machine used temperature testing strips that only indicated 160°F, below the required 180°F, and were used weekly instead of daily. Additionally, the facility did not log the cooling of meals containing meat, such as goulash and lasagna, as per their policy, risking foodborne illnesses.
The facility failed to provide appropriate indications for antipsychotic medication use in four residents with dementia and did not attempt a gradual dose reduction (GDR) for one resident. Despite facility policy requiring non-pharmacological interventions first, residents were prescribed Seroquel without documented behaviors justifying its use. Observations showed residents were calm and in no distress, questioning the necessity of the medication. The Director of Nursing confirmed the lack of appropriate diagnoses and the failure to attempt a GDR.
A facility failed to follow proper infection control protocols, including hand hygiene and glove changes during medication administration by an LPN. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds or indwelling medical devices. A CNA performed catheter care without a gown, and the Infection Control Preventionist acknowledged missing EBP implementation for certain residents.
A facility failed to follow proper hand hygiene and glove-changing protocols during catheter care for a resident with an indwelling urinary catheter. The CNA did not wash hands or change gloves before providing care, violating the facility's policy and infection control standards. This was confirmed by the DON, highlighting a deficiency in care procedures.
A resident with a history of hypertension and diabetes was not weighed daily as ordered by the physician, missing five days within a two-week period. The resident experienced a significant weight increase of 15.6 pounds in one day, but the physician was not notified, as confirmed by the DON.
The facility failed to follow its Oxygen Administration policy by not placing an oxygen sign on a resident's door and administering oxygen to another resident without a physician's order. One resident with COPD and acute respiratory failure had a physician's order for continuous oxygen, but no sign was placed on their door. Another resident was receiving oxygen without a physician's order, which was confirmed by the DON.
The facility failed to notify the Ombudsman in writing of resident transfers, as confirmed by the Assistant Administrator. While the Ombudsman was notified of admissions and discharges out of the building, transfers to the hospital were not communicated. This oversight has the potential to affect all 94 residents in the facility.
An LPN failed to ensure proper pressure ulcer wound treatment for a resident, leading to potential cross-contamination by allowing the cleansed wound to touch a soiled incontinence brief.
The facility failed to identify target behaviors for antipsychotic medication use and did not ensure a resident received the lowest effective dose. Additionally, another resident's PRN psychotropic medication order lacked the required 14-day stop date.
Failure to Properly Secure Resident During Transport Resulting in Serious Injury
Penalty
Summary
The facility failed to follow its established procedures for the safe transportation and supervision of a resident, resulting in a significant accident. Specifically, a Licensed Practical Nurse (LPN) who was newly trained and licensed to drive the facility van transported a resident from the emergency room back to the facility. The LPN did not properly secure the resident in the van, only locking the wheelchair wheels and neglecting to use the required securement systems. The LPN admitted to this lapse, stating that he believed the short distance justified the omission. As a result, when the van accelerated from a stop, the resident rolled backward and fell, striking his head on the rear door of the van. The resident involved had a complex medical history, including a left above-knee amputation, hemiplegia, diabetes, dementia, and a history of falls, and was identified as being at high risk for falls and injury. Following the incident, the resident was diagnosed with a left subdural hematoma and a minimally displaced left scapular fracture. Documentation and interviews confirmed that the LPN had received training on securing residents but failed to implement these procedures during the transport, directly leading to the resident's injuries.
Failure to Provide Physician-Ordered Skin Treatments and Blood Glucose Monitoring
Penalty
Summary
The facility failed to provide skin treatments as ordered by the physician for two residents who were being monitored for skin alterations. For one resident, the treatment administration records showed that emollient ointment was not applied to the bilateral upper extremities on five occasions, and barrier cream was not applied to the buttocks on three occasions, despite physician orders. For the second resident, skin preparation to the left heel was missed on two occasions, triple antibiotic ointment and dressings to the left forearm were missed once, and petroleum dressing and related wound care to the left arm were missed on three occasions. These omissions were verified by the Director of Nursing through review of the treatment administration records. Additionally, the facility failed to obtain blood glucose levels as ordered by the physician for one resident with a diagnosis of Type II Diabetes Mellitus. The medication administration records indicated that blood glucose testing was not performed as ordered before meals and at bedtime on two specific occasions. The Director of Nursing confirmed these omissions during record review. These failures represent non-compliance with the facility's own policies for wound care and blood glucose monitoring.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer insulin as ordered for a resident with Type II Diabetes Mellitus. According to the Medication Administration Records (MARs) and physician orders, the resident was prescribed both Insulin Aspart and Humalog insulin to be given subcutaneously before meals, with additional sliding scale dosing based on blood glucose levels. The MARs documented multiple instances where the resident did not receive the prescribed doses of Insulin Aspart and Humalog at the specified times. Additionally, on at least one occasion, the sliding scale dose of Insulin Aspart was not administered when the resident's blood sugar reading indicated it was required. Interviews with the resident's physician and the Director of Nursing confirmed that the insulin doses were missed and that this constituted a medication error. The facility's own policy requires medications to be administered accurately and according to physician orders, but this was not followed in the resident's case, as evidenced by the documented omissions in the MARs.
Failure to Implement Pressure Ulcer Prevention Leads to Stage Four Ulcer
Penalty
Summary
The facility failed to develop and implement specific pressure-relieving interventions for a resident, leading to the development and worsening of a pressure ulcer. The resident, who was admitted with no pressure ulcers, was identified as being at risk for pressure ulcers based on the Braden Scale assessments conducted shortly after admission. Despite this, the facility did not complete the required weekly Braden Scale assessments for four weeks post-admission, as per their Wound and Ulcer Policy. Additionally, the care plan lacked individualized interventions to prevent pressure ulcers on the resident's heels, despite the noted risk. The resident's condition deteriorated from a blister to a stage four pressure ulcer on the right heel, requiring surgical debridement. Observations revealed that the resident's heels were not consistently offloaded while in bed, and the pressure-relieving boot was not used as required when the resident was out of bed. The resident reported pain and expressed that staff did not promptly address complaints of discomfort, leading to a delay in identifying the pressure ulcer. Interviews with facility staff, including the Registered Nurse/Infection Preventionist and the Wound Physician, confirmed that the necessary interventions to relieve pressure on the resident's heels were not implemented. The pressure-relieving boot was misplaced for at least two days, and the resident's heels were observed resting directly on the floor and mattress, contrary to the physician's recommendations. These failures contributed to the worsening of the resident's pressure ulcer, highlighting a significant deficiency in the facility's pressure ulcer prevention and management practices.
Deficiencies in Dishwashing and Food Cooling Practices
Penalty
Summary
The facility failed to ensure proper sanitation and food safety practices in their dietary department, which could potentially affect all 96 residents. The facility used a high-temperature dishwashing machine that requires a rinse cycle temperature of at least 180 degrees Fahrenheit for proper sanitation. However, the dietary manager, V4, admitted to using temperature testing strips that only indicate a temperature of 160 degrees Fahrenheit, which is below the required temperature. Furthermore, these strips were only used once a week instead of daily, as the facility relied on the machine's digital thermometer for daily checks. This practice does not ensure that the dishes are sanitized at the required temperature. Additionally, the facility did not adhere to its own policy for cooling hot foods to prevent foodborne illnesses. The policy requires that food be cooled from 135 degrees to 70 degrees Fahrenheit within two hours and then to 41 degrees Fahrenheit within an additional four hours, with temperatures recorded on a log. However, the facility's logs for January and February 2025 only documented the cooling of pork loin, while other prepared meals containing meat, such as goulash and lasagna, were not monitored or logged for proper cooling. The dietary manager confirmed the absence of cool down logs for these meals, indicating a failure to ensure food safety standards were met.
Inappropriate Use of Antipsychotic Medications and Lack of GDR in Residents with Dementia
Penalty
Summary
The facility failed to provide appropriate indications for the use of antipsychotic medications for four residents diagnosed with dementia and did not attempt a gradual dose reduction (GDR) for one resident. The facility's policy on psychotropic medication requires that these medications be used only when necessary and that non-pharmacological interventions be attempted first unless contraindicated. However, the facility did not adhere to these guidelines, as evidenced by the lack of appropriate diagnoses for the use of Seroquel/Quetiapine in residents R2, R5, R54, and R82. Resident R2 was admitted with severe dementia and other conditions, and was prescribed Seroquel for unspecified dementia without behavioral disturbance. Observations showed R2 was calm and in no distress, indicating a lack of justification for the antipsychotic use. Similarly, Resident R5, with a diagnosis of unspecified dementia and other disorders, was on Seroquel despite no documented behaviors warranting its use. Observations of R5 showed calmness and no distress, further questioning the necessity of the medication. Resident R54, diagnosed with Parkinson's disease and dementia, was on Seroquel without documented behaviors justifying its use, and a GDR was not attempted despite policy requirements. The physician rejected a GDR request without providing clinical rationale. Resident R82, with severe cognitive impairment, was also on Seroquel for unspecified dementia without behavioral disturbance. Observations showed R82 was pleasant and in no distress, indicating the medication might not be necessary. The Director of Nursing confirmed the lack of appropriate diagnoses and the failure to attempt a GDR for R54.
Infection Control Deficiencies in Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, particularly in hand hygiene and glove usage during medication administration. An LPN was observed applying gloves and then touching various surfaces, including medication cart keys and a medication drawer, before administering eye drops and an intramuscular injection to residents without changing gloves or performing hand hygiene. The LPN acknowledged the potential for germ transmission due to this practice. The Infection Control Preventionist confirmed that gloves should be changed and hand hygiene performed before administering invasive medications. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. One resident with a stage two pressure wound did not have EBP signage or PPE available in or outside their room. Another resident with an indwelling urinary catheter also lacked EBP signage and PPE. A CNA performed catheter care without using a gown, and the CNA was unaware of the EBP requirements. The Infection Control Preventionist confirmed the oversight and acknowledged the need for EBP for residents with catheters and wounds. The deficiencies highlight lapses in the facility's infection control practices, particularly in the use of PPE and adherence to EBP protocols. The Infection Control Preventionist admitted to missing the implementation of EBP for certain residents, which should have been in place due to their medical conditions. These oversights were identified during the survey, indicating a need for improved infection control measures and staff education on EBP requirements.
Failure in Hand Hygiene and Glove Protocol During Catheter Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols during urinary catheter care for a resident with an indwelling urinary catheter. The resident, who was admitted with a diagnosis of Neuromuscular Dysfunction of Bladder and had a care plan indicating the use of a urinary catheter due to Benign Prostatic Hyperplasia, Obstructive Uropathy, and Neurogenic Bladder, was supposed to receive catheter care every shift as per the physician's order. However, during an observation, a Certified Nursing Assistant (CNA) did not wash her hands or change gloves before providing catheter care, which is a violation of the facility's Catheter Care/Incontinent Care policy and the Infection Prevention and Control Standard. The CNA entered the resident's room with personal protective equipment and necessary supplies, placed them on the overbed table, and proceeded to perform catheter care without changing gloves or washing hands from the time of entry until leaving the room. This action was verified by the Director of Nursing, who confirmed that the CNA should have performed hand hygiene and changed gloves before providing care. This oversight in following standard precautions and facility policy led to the deficiency noted in the report.
Failure to Monitor and Report Significant Weight Changes
Penalty
Summary
The facility failed to adhere to a physician's order for daily weights for a resident, identified as R347, who was part of a sample of 33 residents reviewed for daily weights. The resident had a medical history that included essential hypertension, benign prostatic hyperplasia, atherosclerosis of the aorta, and type 2 diabetes mellitus. The physician's order, dated 2/4/25, required daily weights with a directive to notify the provider if there was a weight increase of more than three pounds in 24 hours or five pounds in one week. However, the facility did not weigh the resident on five separate days within a two-week period, specifically on 1/22, 1/24, 1/26, 1/27, and 1/28/2025. On 1/31/25, the resident's weight was recorded as 233.7 pounds, and on 2/1/25, it was documented as 249.4 pounds, indicating a significant increase of 15.6 pounds. Despite this substantial weight gain, there was no evidence that the physician was notified, as confirmed by the Director of Nursing (V3) during an interview on 2/4/25. This oversight in communication and failure to follow the physician's order for daily weights and notification of significant weight changes constituted a deficiency in the facility's care for the resident.
Failure to Follow Oxygen Administration Policy
Penalty
Summary
The facility failed to adhere to its Oxygen Administration policy by not placing an oxygen sign on the door of a resident with COPD and acute respiratory failure. The resident, who was admitted with these diagnoses, had a physician's order for continuous oxygen to maintain oxygen saturation above 92%. However, during an observation, it was noted that there was no oxygen sign on the resident's door, which was later confirmed by the Director of Nursing. Additionally, another resident was found to be receiving oxygen at two liters per nasal cannula without a physician's order, as required by the facility's policy. The Director of Nursing verified that there was no current physician order for this resident's oxygen use, acknowledging that the facility should have obtained an order prior to administering oxygen.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify in writing, and maintain a copy in the medical record, notification to the Ombudsman of residents that were reviewed for notices before transfers. This deficiency was identified during an interview and record review, where it was found that multiple residents had been discharged or transferred without the Ombudsman being notified. The Assistant Administrator confirmed that while the Ombudsman was notified of resident admissions and discharges out of the building, they were not notified of transfers to the hospital. This failure has the potential to affect all 94 residents residing in the facility.
Improper Pressure Ulcer Wound Treatment
Penalty
Summary
The facility failed to ensure proper pressure ulcer wound treatment for one resident, leading to potential cross-contamination. During an observation, an LPN provided wound care for a resident with a stage II pressure ulcer on the coccyx area. The LPN cleansed the wound but allowed the resident to roll back onto an incontinence brief, causing the cleansed wound to touch the soiled brief. The LPN then prepared medication and dressing, rolled the resident back onto their side, applied the treatment, and repositioned the resident back onto the incontinence brief. The LPN confirmed that the resident should not have been allowed to roll back onto the brief after cleansing the wound.
Failure to Justify Antipsychotic Medication Use and Ensure PRN Stop Date
Penalty
Summary
The facility failed to identify target behaviors to warrant the use of an antipsychotic medication and did not ensure a resident received the lowest effective dose of psychotropic medication. Specifically, a resident with diagnoses including unspecified dementia with psychotic disturbance, anxiety disorder, and depression was prescribed Seroquel. Despite a pharmacy recommendation to reduce the dose from 50 mg to 25 mg, the dose was increased back to 50 mg due to the resident and their power of attorney's refusal, without any documented behaviors justifying the increase. Observations and interviews confirmed that the resident did not exhibit behaviors warranting the use of the antipsychotic medication, and behavior tracking logs did not document any behaviors to justify the medication's use. The facility's staff, including the Regional Director of Operations and the Assistant Administrator, verified the lack of documented behaviors and acknowledged that psychotropic medications cannot be increased based on family preference alone. Additionally, the facility failed to ensure that PRN psychotropic medication had a 14-day stop date for another resident diagnosed with unspecified dementia, gastro-esophageal reflux disease, anxiety disorder, hallucinations, and hypertension. The resident's electronic medical record documented a physician's order for Lorazepam to be given as needed for anxiety, but the order was indefinite and did not include the required 14-day stop date. This was confirmed by the Regional Nurse Consultant, who acknowledged the oversight.
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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