St James Wellness Rehab Villas
Inspection history, citations, penalties and survey trends for this long-term care facility in Crete, Illinois.
- Location
- 1251 East Richton Road, Crete, Illinois 60417
- CMS Provider Number
- 145611
- Inspections on file
- 41
- Latest survey
- March 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St James Wellness Rehab Villas during CMS and state inspections, most recent first.
A leaking ice machine in an unlocked nourishment room on the second floor was not repaired for a week, affecting seven residents with impaired cognition. CNAs reported the issue, but the Maintenance Director was only notified the day before. Residents were observed ambulating in the area, with one resident wandering near the ice machine.
The facility failed to provide timely incontinence care for three residents who required assistance with toileting and hygiene. One resident was found with heavily saturated bed sheets and incontinence products, while another was dependent on staff for toileting but was not changed in a timely manner. A third resident, with memory issues, was also not provided timely care. The staff did not adhere to care plans that required regular checks and changes every two hours.
A facility failed to follow physician orders for wound care for a resident with an unstageable sacral ulcer. The resident was found with a heavily saturated and detached dressing, exposing the ulcer. A CNA did not notify the nurse about the need for a dressing change due to being busy. The wound care physician stated that dressings should be changed daily and as needed when soiled, as per the physician order summary.
Two residents experienced medication administration deficiencies. One resident had a Symbicort inhaler at her bedside without a physician's order for self-administration. Another resident was fed unidentified substances mixed into her food, later revealed to be her medications, without proper administration procedures. These actions were not in compliance with the facility's medication administration policy.
The facility failed to follow physician's orders for catheter care for four residents with a history of UTIs. Observations included catheter bags touching the floor, improper cleaning methods, and missing documentation for urine output. The Director of Nursing confirmed these deficiencies, noting that improper care could lead to infections.
The facility failed to provide proper catheter care for four residents, leading to deficiencies in their care. A resident with a history of UTIs and kidney issues had a catheter bag touching the floor, and staff did not change the bag or tubing as ordered. Another resident with diabetes and kidney disease received inadequate catheter care, with improper cleaning and insufficient hand hygiene. A third resident with urinary retention did not receive proper catheter care, and there was a lack of documentation for urine output and missed medication doses. These deficiencies were confirmed by the DON, who noted a trend of residents developing UTIs and becoming septic.
The facility failed to provide enough clean linens, blankets, towels, and washcloths for its 69 residents, affecting their right to a safe and comfortable environment. Residents and staff reported shortages, with observations confirming insufficient supplies on linen carts and in the laundry area. The DON and other staff were aware of the issue, but no additional supplies were ordered, and the facility lacked a backup supply, impacting care delivery.
A resident with multiple diagnoses developed a DTI on the right heel, which was not documented or communicated to the physician or POA. The Wound Care Nurse noticed the injury but did not notify the doctor or apply treatments. The Nurse Practitioner was unaware of the DTI and the resident's elevated heart rate, indicating a failure in communication and documentation.
A facility failed to provide necessary wound care and manage abnormal vital signs for a resident with Covid-19 and other conditions. The resident's elevated heart rate was not documented or communicated to a physician, and a deep tissue injury on the resident's heel was not treated or reported. The facility's protocols for Covid-19 and skin assessments were not followed, leading to a lack of proper care and documentation.
The facility failed to maintain kitchen sanitation and proper food storage, affecting 80 residents. Observations included outdated and unlabeled food items, excessive sanitizer concentration, and cleanliness issues such as grease and dust. A turkey sandwich was served at an unsafe temperature, and an employee was observed with exposed hair, violating facility policies.
The facility failed to maintain the kitchen dishwasher and sink in good repair, affecting dietary services for 80 residents. The dishwasher was non-functional, and the sink was filled with dirty water, leading to the use of disposable plates. Observations revealed unsanitary conditions with dishware caked with food residue and bugs. The Maintenance Director noted ongoing drainage issues, and the Administrator lacked records of repair approvals. Facility policies on equipment maintenance and sanitation were not followed.
The facility failed to provide written notification to residents, their families, and the ombudsman regarding hospital transfers for six residents with various medical conditions. Despite verbal notifications, there was no documentation of written notices, violating the facility's Bed Hold and Readmission policy.
The facility failed to provide written notification of the bed hold policy to residents or their representatives during hospital transfers. This deficiency affected six residents, all of whom were transferred without receiving the required documentation. The facility's policy mandates informing residents or their representatives of the bed hold policy at the time of transfer, but this was not adhered to, as confirmed by the facility's Administrator and DON.
The facility failed to obtain physician orders for over-the-counter medications and improperly allowed medications to be stored in resident rooms. Six residents were affected, including those with glaucoma, dementia, and Parkinson's disease. Medications were found in rooms without proper authorization or physician orders, contrary to facility policy requiring secure storage and authorized access.
A long-term care facility was found to have multiple deficiencies in infection control practices, including improper hand hygiene and PPE usage. Staff failed to change gloves and sanitize hands during resident care, did not use required PPE for COVID-19 precautions, and improperly disposed of PPE. These actions violated the facility's policies and potentially exposed residents with serious health conditions to infection risks.
The facility failed to provide adequate ADL care for five residents dependent on staff assistance. Observations showed long, jagged fingernails, dry skin, and a lack of regular hygiene care, despite the facility's policy requiring such care. The DON confirmed that care should be provided as needed, and there was no record of residents refusing care.
The facility failed to implement fall interventions for four high-risk residents. One resident was found with non-skid socks and a wheelchair out of reach, while another lacked fall mats by the bed. Staff were unaware of fall interventions for a resident with multiple diagnoses, and a floor mat was misplaced for a cognitively impaired resident. The facility's policy requires interventions to minimize fall risks, which were not followed.
The facility failed to administer oxygen as ordered for two residents. One resident received less oxygen than prescribed, while another had a nasal cannula improperly placed, which was not corrected until a surveyor intervened. The DON confirmed the expectation for staff to ensure proper oxygen administration.
The facility failed to maintain a functioning call light system for two residents, one with dementia and high fall risk, and another with diabetes and limited mobility. Both residents were unable to use their call lights to request assistance, relying on others or physically moving to seek help. Staff acknowledged the issue, but the deficiency persisted.
The facility failed to position a resident's catheter bag correctly, causing backflow of urine, and did not provide timely incontinent care to several residents. A resident with a suprapubic catheter experienced backflow due to improper bag placement, while other residents were found with soiled briefs, indicating delays in care. CNAs cited being busy as a reason for not following the facility's protocol of providing care every two hours.
A resident experienced multiple episodes of vomiting and diarrhea, but the facility failed to notify the physician or document the condition change. The CNA informed a nurse, but the nurse did not recall notifying the doctor, and the resident's condition was not documented in the progress notes. This oversight violated the facility's guidelines for notifying physicians of significant changes in a resident's condition.
Leaking Ice Machine in Unlocked Nourishment Room
Penalty
Summary
The facility failed to repair a leaking ice machine in the nourishment room on the second floor, which affected seven residents who are ambulatory and have impaired cognition. On March 18, 2025, the nourishment room door was found wide open without a lock, and a puddle of water was observed on the floor due to the leaking ice machine. Certified Nursing Assistants reported the leak had been ongoing for a week. On March 19, 2025, the room remained unlocked, and wet bedsheets were used to absorb the leaking water. The Maintenance/Housekeeping Director acknowledged the leak but stated he was only notified the day before. Residents with impaired cognition were observed ambulating in the area, including one resident who was seen wandering in the hallway where the ice machine was located.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for residents who require assistance with toileting and hygiene. This deficiency was observed in three residents. The first resident, R1, was found in bed with heavily saturated bed sheets, incontinence brief, and pad, all stained with urine. R1 reported using the call light for assistance, but the staff turned it off without providing help. R1's care plan indicated a need for substantial assistance with toileting hygiene, yet the staff did not adhere to the plan's interventions, which included checking and changing every two hours. The second resident, R2, was also found heavily saturated with urine and had a bowel movement. R2 was dependent on staff for toileting and personal hygiene, but the staff failed to provide timely care. Similarly, R3 was found in a similar state, with urine saturation and a bowel movement. R3's care plan required regular checks and changes, but the staff waited for R3 to request assistance, despite R3's short-term memory problems. The facility's failure to follow care plans and provide timely incontinence care led to these deficiencies.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to follow physician orders for wound treatment and dressing changes for a resident with multiple diagnoses, including type 2 diabetes mellitus, unspecified dementia, and an unstageable pressure ulcer in the sacral region. On March 19, 2025, the resident was observed with a heavily saturated wound dressing that was dated the previous day and had become detached, exposing the unstageable sacral ulcer. The surrounding area was wet with exudates, and a leaking rectal tube was noted near the exposed wound. A CNA changed the resident's brief but did not notify the nurse about the need for a dressing change due to being busy with other assignments. The wound care physician confirmed that the dressing should be changed daily and as needed when soiled to prevent potential skin breakdown. The physician order summary indicated that the sacral area should be cleansed with normal saline, medihoney applied, and covered with a dry dressing every day and as needed if the dressing becomes loose or soiled. The facility's failure to adhere to these orders resulted in the deficiency.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper physician orders for self-administration of medication and accurate medication administration as prescribed. One resident, who has multiple medical diagnoses including chronic obstructive pulmonary disease and asthma, was found with a Symbicort inhaler at her bedside without a physician's order or an updated care plan authorizing self-administration. This indicates a lack of compliance with the facility's policy that requires specific authorization from the attending physician for residents to self-administer medication. Another resident, with diagnoses including type 2 diabetes mellitus and unspecified dementia, was observed being fed by a restorative aid with unidentified substances mixed into her pureed bread. The assistant director of nursing initially identified the substance as a sugar substitute, but it was later revealed by the primary nurse that the substances were actually the resident's medications, mixed into the food due to the resident's refusal to take them with applesauce. This practice was not in line with the facility's medication administration policy, which states that the person who prepares the dose must be the one to administer it, and highlights a failure to ensure medications are administered as prescribed.
Failure to Implement Physician's Orders for Catheter Care
Penalty
Summary
The facility failed to implement physician's orders for four residents with a history of urinary tract infections (UTIs). For one resident, the catheter bag and tubing were observed touching the floor, and the urine was dark and cloudy. Despite the resident's complaints of pain, the nurse did not change the catheter bag or tubing as per the physician's order. Another nurse provided catheter care using only normal saline instead of soap and water, and there was leakage and a brown substance around the catheter. The nurse practitioner confirmed that the catheter should have been changed when clinically indicated, as per the physician's order. Another resident with multiple diagnoses, including diabetes and chronic kidney disease, received catheter care with only normal saline, contrary to the physician's order to use soap and water. The resident's electronic medication administration records (EMARs) showed missing documentation for urine output and failure to change the catheter securement device. The Director of Nursing verified these findings and acknowledged that improper catheter care could lead to UTIs. A third resident with a suprapubic catheter also received care with only normal saline, and the dressing was not changed as required. The EMARs revealed missing documentation for urine output and a missed dose of Bactrim, an antibiotic. The Director of Nursing noted that the failure to administer the medication could have contributed to the resident's UTI. A fourth resident, who was discharged to a hospital and later died, had missing documentation for urine output, and the Director of Nursing suggested that poor catheter care could have contributed to the UTIs and sepsis observed in the residents.
Inadequate Catheter Care Leads to Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide proper catheter care for four residents, leading to deficiencies in their care. Resident R3, who had a history of urinary tract infections, acute kidney failure, and other urinary issues, was observed with a catheter bag and tubing touching the floor, which was against the facility's catheter care policy. Despite R3's complaints of pain and the presence of dark, cloudy urine, the nursing staff did not change the catheter bag or tubing as per the physician's orders. Additionally, the nurse did not use soap and water for catheter care, which was required by the facility's policy, and there was a lack of documentation regarding R3's urine output. Resident R4, diagnosed with diabetes, chronic kidney disease, and urinary tract infections, also received inadequate catheter care. The nurse used only normal saline instead of soap and water to clean the catheter, and there was insufficient hand hygiene during the procedure. The facility's records showed a lack of documentation for urine output and failure to change the catheter securement device as ordered by the physician. These lapses in care were verified by the Director of Nursing, who acknowledged that such failures could lead to urinary tract infections. Resident R2, with a history of diabetes and urinary retention, received improper catheter care as well. The nurse did not use soap and water as required, and there was a failure to change the suprapubic dressing as per the physician's orders. Additionally, there was a lack of documentation for urine output and a missed dose of prescribed medication, Bactrim DS, which was crucial for treating R2's urinary tract infection. The Director of Nursing confirmed these deficiencies and noted a trend of residents developing UTIs and becoming septic, which could be attributed to the poor catheter care provided by the facility.
Linen Shortage in Facility Compromises Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of clean linens, blankets, towels, and washcloths for its 69 residents, compromising their right to a safe, clean, comfortable, and homelike environment. Multiple residents reported a shortage of essential items such as bed pads, wash rags, and Kleenex, with some stating that linens were not changed regularly. Observations confirmed the lack of sufficient linens on the facility's linen carts and in the laundry area, where only a minimal number of sheets, blankets, and other items were available. Staff interviews corroborated the residents' claims, with several CNAs and LPNs acknowledging the shortage and its impact on their ability to provide proper care, such as giving showers and changing bed linens. The Director of Nursing (DON) and other staff members, including the Maintenance Director and Housekeeping Director, were aware of the linen shortage but indicated that no additional supplies had been ordered or purchased. The facility's Laundry Services Policy mandates maintaining a sufficient inventory of clean linen to meet residents' needs, yet this was not adhered to. The DON expressed uncertainty about the availability of funds to address the issue, and staff reported that linens were sometimes disposed of due to being stained, though not intentionally discarded. The lack of a backup supply of linens, blankets, and towels was acknowledged by the facility's Administrator, highlighting a systemic issue in inventory management and resource allocation.
Failure to Notify POA and Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the Power of Attorney (POA) and physician of changes in condition for a resident with multiple diagnoses, including vascular dementia and schizophrenia. The resident was admitted to the facility with a moderate cognitive impairment and later developed a Deep Tissue Injury (DTI) on the right heel, which was not documented or communicated to the physician or family. The Director of Nursing acknowledged the lack of documentation and notification, which could have led to further complications such as infection or sepsis. The Wound Care Nurse first noticed the DTI on the resident's right heel but did not notify the doctor or apply any protective treatments, only placing socks on the resident. The Nurse Practitioner was unaware of the DTI and the resident's elevated heart rate, which could indicate a progressing infection. The facility's records showed no wound care orders or notifications to the POA or provider regarding the skin alteration, indicating a failure in communication and documentation of the resident's condition changes.
Failure to Provide Wound Care and Manage Vital Signs for Resident with Covid-19
Penalty
Summary
The facility failed to provide necessary wound care treatment and manage abnormal vital signs for a resident diagnosed with Covid-19, vascular dementia, schizophrenia, and other conditions. The resident, who had moderate cognitive impairment, was admitted to the facility and later transferred to the hospital. The Director of Nursing acknowledged that the resident's elevated heart rate was not documented or communicated to a physician or nurse practitioner, which was a deviation from the expected protocol for residents with Covid-19. The Wound Care Nurse identified a deep tissue injury (DTI) on the resident's right heel but did not notify the physician or apply any protective treatments, as the area was not open. The nurse also failed to inform the resident's family or power of attorney about the DTI. The Licensed Practical Nurse who was responsible for the resident's care did not document the elevated heart rate or notify the physician, which could have led to further complications. The Infection Preventionist confirmed that the facility's Covid protocol required vital signs to be taken every four hours and documented every shift, but there was no standard form for Covid screening. The Nurse Practitioner was unaware of the resident's DTI and elevated heart rate, which could have indicated a progressing infection. The facility's protocols for acute condition changes and pressure/skin breakdown were not followed, as there was no documentation or reporting of the resident's condition changes or skin assessments.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a manner that prevents foodborne illness, affecting 80 residents receiving dietary services. During a kitchen tour, it was observed that the dry storage contained a labeled powder with an outdated label. The walk-in cooler had several unlabeled and undated food items, including personal employee food items, which were not stored according to the facility's policy. The sanitizer solution in a red sanitizing bucket was tested at 400 ppm, exceeding the facility's policy requirement of 200 ppm. Additionally, the kitchen had visible cleanliness issues, such as grease and dust on the stove vents, greasy grime on the metal wall behind the stove, and yellow crusts and dead bugs on shelves containing dishware. Further observations revealed that a dietary aide served a turkey sandwich at 64.8 degrees Fahrenheit, which is above the facility's policy requirement of maintaining perishable foods at 41 degrees Fahrenheit or below. The Dietary Manager acknowledged that food items should be labeled with delivery, open, and use-by dates to prevent foodborne illness. It was also noted that employees' food stored in the kitchen refrigerator must adhere to the same labeling and storage standards. The Assistant Dietary Director was observed with exposed hair, contrary to the facility's policy requiring full hair coverage to prevent contamination.
Failure to Maintain Kitchen Equipment in Good Repair
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the dishwasher and sink, in good repair, affecting dietary services for 80 residents. On December 3, 2024, the Dietary Manager was unable to operate the dishwasher due to it not working, and the adjacent sink was filled with dirty water. The Assistant Dietary Manager confirmed that the dishwasher and sink had been malfunctioning since June, requiring the use of a shop vac to remove water from the sink. Dishes were either washed in a three-compartment sink or served on disposable plates. Observations revealed that shelves containing dishware, declared clean, were caked with yellow crusts, dried food, and small dead black bugs. The Maintenance Director, who had been with the facility for a month, stated that the dishwasher had been repaired, but the drainage problem persisted, preventing its use. The Administrator did not have records of repair quotes or work orders dating back to June but approved repairs for the floor to be dug up and pipes replaced on December 4, 2024. Previous work requests and service requests indicated ongoing issues with the dishwasher and drainage system, with some repairs pending approval or completion. The facility's policies on equipment maintenance and sanitation were not adhered to, as evidenced by the unsanitary conditions and malfunctioning equipment.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents, their families or Power of Attorney (POA), and the ombudsman regarding the reasons for hospital transfers. This deficiency was identified in six residents who were transferred to the hospital for various medical conditions, including sepsis, gastrointestinal bleeding, syncope, chest pain, worsening confusion, and urinary tract infections. Despite verbal notifications to some family members, there was no documentation of written notices provided to the residents, their POAs, or the ombudsman. For instance, one resident with severe cognitive impairment was transferred to the hospital for sepsis and a gastrointestinal bleed. Although the resident's daughter was verbally informed of the transfer, there was no written notice provided. Similarly, another resident with severe cognitive impairment was transferred for syncope, and while the family was verbally informed, no written documentation was provided. In another case, a resident experiencing chest pain was transferred to the hospital, and although the POA was notified by voicemail, there was no written notice documented. The facility's failure to provide written notifications is a violation of their Bed Hold and Readmission policy, which requires informing residents or their representatives of the policy at the time of admission and transfer. The policy also mandates written notification at the time of transfers, which was not adhered to in these cases. The facility's administration acknowledged the lack of written documentation and the omission of notifying the ombudsman.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the bed hold policy at the time of transfer to a hospital or during therapeutic leave. This deficiency was identified for six residents who were reviewed for discharge. The facility's policy requires that residents or their designated representatives be informed of the bed hold policy at the time of admission and at the time of transfer to a hospital or for therapeutic leave extending beyond 24 hours. However, the facility did not provide the required documentation to the residents or their Power of Attorney (POA) at the time of their hospital transfers. For instance, one resident with multiple diagnoses, including multiple sclerosis and dementia, was transferred to the hospital for evaluation due to a change in condition. Despite the transfer, there was no documentation of the bed hold policy being communicated to the resident or their POA. Similarly, another resident with severe cognitive impairment was transferred to the emergency room for evaluation, but again, no bed hold documentation was provided. This pattern was consistent across all six residents reviewed, indicating a systemic issue in the facility's adherence to its own policy. The facility's Bed Hold and Readmission Policy, dated November 2016, outlines the requirement for written notification of the bed hold policy to be provided at the time of transfer. However, interviews with the facility's Administrator and Director of Nursing revealed that they were not providing this written documentation to residents, families, or the ombudsman when residents were sent to the hospital. This lack of compliance with the policy resulted in the deficiency noted in the report.
Medication Storage and Physician Order Deficiencies
Penalty
Summary
The facility failed to obtain physician orders for over-the-counter medications and allowed medications to be stored in resident rooms without proper authorization. This deficiency was observed in six residents, each with varying medical conditions and cognitive statuses. For instance, one resident with glaucoma had a bottle of eye vitamin and mineral supplement in their room without a physician's order. Another resident with chronic obstructive pulmonary disease had Nystatin topical powder on their bedside table, despite having a physician's order for its use, there was no order permitting the medication to be stored in the room. In another case, a resident with dementia had two bottles of eye drops on their bedside dresser, which they used daily, but there was no physician's order for these specific eye drops, nor permission for them to be stored in the room. Additionally, a resident with Parkinson's disease had a nasal spray in their room, which they used, but again, there was no order allowing the medication to be stored in the room. Another resident with morbid obesity and major depressive disorder had Nystatin powder and Terconazole vaginal cream on their bedside table without an order for room storage. The facility's Director of Nursing stated that residents must be alert and oriented to have medications stored in their rooms, requiring an assessment and a physician's order. However, this protocol was not followed, as evidenced by a resident with dementia who had a nasal spray in their room without any orders for self-administration or storage. The facility's policy mandates that medications be stored securely and only accessible by authorized personnel, which was not adhered to in these instances.
Infection Control Deficiencies in PPE and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to standard infection control practices, as evidenced by multiple instances of improper hand hygiene and personal protective equipment (PPE) usage. A Certified Nurse's Assistant (CNA) was observed providing incontinence care to a resident without changing gloves or cleaning hands after handling soiled items, which is against the facility's hand hygiene policy. Similarly, a nurse failed to use the required PPE, such as a face shield or N95 mask, when entering rooms of residents under contact and droplet precautions for COVID-19. The nurse also improperly disposed of PPE in the hallway instead of in the resident's room, and continued to wear the same mask while attending to other residents. In another instance, a wound care nurse did not change gloves or perform hand hygiene between different stages of wound care, potentially leading to cross-contamination. This was observed during wound care for multiple residents, including those with COVID-19 and other serious health conditions. The nurse also placed clean wound care supplies on potentially contaminated surfaces without using a barrier, further violating infection control protocols. Additionally, there was a lack of proper disposal facilities for PPE in rooms, leading to improper disposal practices. The facility's policies on hand hygiene and transmission-based precautions were not followed, as evidenced by the lack of signage for Enhanced Barrier Precautions (EBP) and improper handling of PPE. Residents with serious health conditions, such as chronic wounds and COVID-19, were not adequately protected due to these lapses in infection control. The facility's failure to implement and adhere to its own policies contributed to the deficiencies observed during the survey.
Deficiency in Providing ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for five residents who were dependent on staff assistance. Observations revealed that several residents had long, jagged fingernails, dry flaking skin, and in some cases, a brown substance under their nails. These residents, including those with severely impaired cognition and those requiring moderate assistance, did not receive the necessary personal hygiene care. For instance, one resident was observed with long nails and dry skin, despite being dependent on staff for personal hygiene, and another resident had not received a shower or bed bath in over a month due to staffing issues. The Director of Nursing (DON) acknowledged that nail and skin care should be provided as needed, and there was no documentation of residents refusing care. The facility's policy on ADL care, which includes hygiene, bathing, dressing, grooming, and oral care, was not adhered to, leading to the observed deficiencies. The lack of proper care was attributed to insufficient staffing, as noted by a resident who expressed frustration over not receiving regular hygiene care.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall interventions for four residents identified as high risk for falls. One resident was observed standing next to his bed with his wheelchair out of reach and wearing only socks that were not non-skid, despite a care plan indicating the need for proper footwear. Another resident was found in bed without fall mats on the floor, contrary to the care plan that required mats to be in place when the resident is in bed. The Director of Nursing confirmed that these interventions should have been in place. Additionally, a resident with multiple diagnoses, including hemiplegia and cognitive deficits, was observed wearing regular socks without skid protection and without shoes, with staff unaware of the fall interventions in place for him. Another resident with severely impaired cognition had a floor mat placed four feet away from his bed, which was not repositioned after being moved by a CNA. The facility's policy requires staff to identify and implement relevant interventions to minimize the risk and consequences of falls, which was not adhered to in these cases.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R5 and R10, as per their physician's orders. R5 was observed on two occasions with oxygen administered at 2 liters per minute through a nasal cannula, despite the physician's order indicating a requirement for 4 liters per minute continuously with 100% humidity. This discrepancy was confirmed by the Director of Nursing (DON) upon reviewing R5's electronic health records. Similarly, R10 was found with his nasal cannula around his neck instead of in his nostrils, and it was not corrected until a state surveyor pointed it out. The staff member, V6, expressed uncertainty about how long R10 had been without oxygen, and the situation was later trivialized by V6 and a nurse, V9, who laughed about the oversight. R10's physician's order specified the use of a nasal cannula at 2 liters per minute as needed for shortness of breath every shift. The DON acknowledged the expectation for nurses to ensure the correct administration of oxygen, including verifying the rate and placement of the nasal cannula.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly for two residents, leading to a deficiency in resident care. One resident, who has diagnoses including metabolic encephalopathy, dementia, and is at high risk for falls, reported that her call light had not been working for some time. She relied on her roommate to call for assistance, as her own call light did not activate when tested by the surveyor. Despite informing staff about the issue, the call light remained non-functional, and the resident's care plan emphasized the need for a working call light due to her dependency on staff for personal care and hygiene. Another resident, with conditions such as diabetes mellitus and an acquired absence of the right leg below the knee, also lacked access to a functioning call light. His call light was found to be cut short and unavailable for use, forcing him to physically seek assistance by moving down the hallway. The staff, including a CNA and the DON, acknowledged the resident's need for a call light, but it remained unavailable during the survey period. This deficiency highlights the facility's failure to maintain an accessible and operational call light system for residents, compromising their ability to request assistance when needed.
Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to properly position a resident's indwelling catheter bag during a wound care dressing change. The catheter drainage bag was placed on the bed instead of below the bladder, leading to backflow of urine in the catheter tubing. The resident, who had a suprapubic indwelling catheter, was diagnosed with multiple conditions including spinal stenosis, pressure ulcers, quadriplegia, and a history of urinary tract infections (UTIs). The facility's policy requires the catheter drainage bag to be positioned lower than the bladder to prevent backflow and potential UTIs. Additionally, the facility did not provide timely incontinent care to several residents. One resident was observed with a heavily soiled brief and had been trying to get assistance since early morning. Despite turning on the call light, the resident did not receive timely care, and a CNA acknowledged the delay. The Director of Nursing confirmed that delayed incontinent care could lead to UTIs and skin infections. Other residents were also found with urine-soaked briefs, indicating a lack of timely incontinent care. CNAs admitted to being busy with other residents and not being able to provide care every two hours as required. The facility's protocol mandates scheduled toileting and incontinent care every two hours, but this was not consistently followed, leading to deficiencies in resident care.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a physician of a resident's change in condition, specifically for one resident who experienced vomiting and diarrhea. On the evening of August 30, 2024, the resident began vomiting and having diarrhea, which continued until the following morning. A CNA reported these episodes to a nurse, who did not recall notifying the resident's doctor. The nurse practitioner and physician were also unaware of the resident's condition, which would have prompted them to order lab tests and medication. The facility's guidelines require immediate notification of a physician when there is a significant change in a resident's condition. However, there was no documentation in the resident's progress notes indicating that the physician or nurse practitioner was informed. The Director of Nursing and the Administrator were also unaware of the resident's condition, which was not documented in the electronic health record beyond a large bowel movement. This lack of communication and documentation led to a failure in following the facility's notification procedures.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
