St Paul's Senior Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Belleville, Illinois.
- Location
- 1021 West E Street, Belleville, Illinois 62220
- CMS Provider Number
- 146122
- Inspections on file
- 40
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at St Paul's Senior Community during CMS and state inspections, most recent first.
A resident with a stage 4 coccyx pressure ulcer, total dependence for ADLs, and continuous incontinence was care planned and ordered to be turned/repositioned at least every two hours, have moisture barrier applied with each incontinent episode, and receive specific daily wound care. Over several hours of observation, the resident remained in a wheelchair without repositioning or incontinence checks, and reported that staff did not check, change, or turn her every two hours and that she had not had a pressure ulcer before admission. A CNA confirmed residents should be turned and changed every two hours but stated it was hard to complete rounds due to staffing, while the ADON and IP said they expected two-hour checks, changes, and repositioning and acknowledged there was no formal turning/repositioning policy, only a general protocol for residents with wounds.
The facility failed to serve meals at safe and palatable temperatures when turkey wraps, vegetables, and sweet potato fries were prepared and distributed without proper temperature control or documentation. The dietary director identified that turkey wraps were above the required cold-holding temperature and placed them in the freezer, but they remained above 41°F when later checked. On a nursing unit, a dietary aide found hot items below the required hot-holding temperature, briefly returned them to the oven, and then served multiple residents without rechecking temperatures. A subsequent sample tray showed the entrée and sides at temperatures below facility standards for both hot and cold foods, and the food temperature log lacked required reheating temperatures despite a policy mandating corrective actions and documentation when items are out of range.
A resident with paraplegia, cognitively intact and independent with eating on a carbohydrate-controlled diet, reported that meals were consistently cold and lacked flavor. A test tray taken after meal service showed hot food items, including beef tacos, broccoli, and rice, were below the facility’s preferred 120°F standard, and the broccoli was mushy and light green. Resident Council minutes documented ongoing concerns about cold and overly spicy food. The DON acknowledged an expectation that staff follow the facility’s policy requiring daily monitoring of food temperatures to ensure palatability.
The facility did not post daily nurse staffing information in a prominent, accessible location for residents and visitors. Staff reported that nursing assignments were kept near the employee time clock or on individual papers rather than being publicly displayed in the lobby or on resident units. The ADON and DON acknowledged that staffing information was not posted where residents or visitors could see it and that there was no policy in place for nurse staffing posting. This deficiency had the potential to affect all 99 residents in the facility.
A resident with paraplegia and neurogenic bladder experienced pain and catheter displacement after a CNA failed to follow proper catheter care procedures, including pulling on the catheter tubing and not securing the leg strap correctly. The incident resulted in a hospital visit and was attributed to inadequate staff competency in catheter management.
Three residents with complex medical needs reported that food was often cold, unappetizing, and sometimes late. Direct observation found hot food items, such as gravy, were not kept at the required temperature, and staff confirmed food was not maintained in the warmer as expected. Resident council minutes and grievances documented ongoing concerns about cold food.
Two residents with special dietary needs reported that alternative menu items were frequently unavailable, with one resident stating that requests for alternatives were routinely denied and another not requesting alternatives due to past unavailability. Staff confirmed that certain alternative foods were sometimes out of stock, and no facility policy on alternative menus was provided when requested.
Two residents did not consistently receive diets as ordered or the full number of menu items due to the facility running out of food or not preparing all items for special diets. Staff confirmed that individuals on mechanical soft or pureed diets often received only two items instead of the three or four listed on the menu, and grievances documented issues such as incomplete meals, lack of protein, and repeated menu items.
The facility failed to provide adequate respiratory care for several residents, leading to significant health issues. One resident with COPD did not receive ordered nebulizer treatments, resulting in chest pain and decreased oxygen saturation. Another resident was found without a nasal cannula, despite needing continuous oxygen therapy, and was left alone with critically low oxygen levels. Additional residents experienced issues with oxygen management, including empty tanks and incorrect flow rates. The staff's failure to follow policies and communicate effectively contributed to these deficiencies.
The facility failed to maintain the dignity of three residents, leading to feelings of embarrassment and frustration. One resident was left in soiled conditions for over 30 minutes, while another was instructed to soil herself due to inadequate staffing. A third resident, the President of the Resident Council, reported feeling belittled by staff. These incidents highlight the facility's failure to uphold its Resident Rights Policy.
A facility failed to provide adequate staffing, impacting resident care. One resident was left in a soiled state due to delayed staff response, while another experienced a delay in oxygen concentrator checks. A third resident was told to soil herself due to insufficient staff. Staffing records confirmed only one CNA was available on a unit, contrary to usual staffing levels. The facility lacked a formal staffing policy, relying on state guidelines.
A resident with multiple medical conditions was unsafely transferred using a full body mechanical lift by a single CNA due to staffing shortages. The CNA did not lock the wheelchair, leaving the resident free-swinging in the air, contrary to the facility's policy and lift device manual, which recommend two assistants for safe operation.
Two residents experienced inadequate incontinent care, affecting their dignity and hygiene. A resident with multiple medical conditions was left soiled for over 30 minutes, and a CNA failed to perform proper peri-care. Another resident with end-stage renal disease was instructed to soil herself due to staffing issues, impacting her dignity. The facility did not adhere to proper care procedures, compromising resident care.
A resident with COPD and acute respiratory failure did not receive continuous oxygen therapy as ordered, due to staff oversight and equipment malfunction. The resident's oxygen concentrator was found off and beeping, and staff failed to maintain the prescribed oxygen level. The resident's daughter also noted incorrect oxygen settings on separate occasions, indicating a systemic issue with oxygen administration in the facility.
The facility failed to properly store and label food, affecting all 103 residents. Observations revealed multiple instances of unlabeled and undated food items, including cheese, rice, eggs, and expired yogurt, across various kitchen units and resident refrigerators. Despite a policy requiring labeling, the Dietary Manager confirmed the oversight, posing a risk of contamination.
The facility did not submit the required PBJ data for the 4th quarter of 2024, affecting all 103 residents. The report showed low weekend staffing, RN coverage for 8 hours/day, and licensed nurse coverage for 24 hours/day, leading to a one-star staffing rating. The Administrator stated the data was sent to the corporate office but not to CMS due to a new employee. The facility also lacked a policy for PBJ data submission.
A facility failed to notify a resident's family of a pneumonia diagnosis, despite the resident's daughter filing a grievance about not being informed of x-ray results. The daughter, who was concerned about her mother's symptoms, was not notified until she visited the facility. The responsible LPN received a write-up and re-education on family notification policies.
Two residents reported that staff frequently used personal cell phones during care, leading to confusion and irritation. Despite repeated concerns raised in Resident Council Meetings, the facility lacked a policy on cell phone use, violating resident rights to dignity and respect.
A facility failed to provide proper incontinent care and infection control, leading to a UTI in a resident. Observations showed CNAs not changing gloves or performing hand hygiene between tasks, and residents reported delays in receiving care. Staff interviews revealed a lack of consistent adherence to hygiene protocols, and the facility lacked a specific policy on incontinent care.
The facility failed to follow infection control practices, particularly in glove changing and hand hygiene, during care for three residents. CNAs did not change gloves or perform hand hygiene between tasks, violating the facility's policies. This was observed during peri-care for residents with multiple health conditions, including urinary tract infections.
A resident with Alzheimer's Disease, chronic pain syndrome, and vascular dementia requiring substantial assistance for transfers sustained bilateral femur fractures due to a Certified Nurse's Aide (CNA) attempting a solo transfer against the care plan's 2-person assist directive. The incident occurred late in the evening, and the absence of proper equipment like a gait belt or sit-to-stand device was noted. The facility's documentation highlighted non-adherence to the care plan and transfer protocols. Medical professionals confirmed the severity of the injuries, with osteopenia complicating surgical intervention, leading to the resident's death.
Failure to Provide Timely Turning and Incontinence Care for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely turning/repositioning and incontinence care to prevent the worsening and development of pressure ulcers for one resident at very high risk. The resident had diagnoses including a stage 4 sacral pressure ulcer, osteoarthritis of both hands, and peripheral vascular disease, and was dependent on staff for all ADLs with continuous bowel and bladder incontinence. Her care plan identified impaired skin integrity related to a coccyx pressure injury, pain, incontinence, decreased mobility, and poor circulation, and noted that she sometimes refused repositioning. Interventions in the care plan and physician orders included assistance with turning/repositioning at least every two hours, application of moisture barrier with each incontinent episode, floating heels, use of heel protectors, and specific daily wound care and dressing changes for the coccyx wound, with ongoing monitoring and documentation of wound characteristics. Despite these identified needs and interventions, observations over several hours showed the resident sitting in her wheelchair without any repositioning or incontinence checks. The resident reported that she did not have a pressure ulcer before admission and stated that staff did not check, change, or turn her every two hours. A CNA acknowledged that residents should be turned, repositioned, and changed every two hours but reported difficulty completing rounds due to feeling there was not enough staff. The ADON and Infection Preventionist both stated they expected residents to be checked, changed, and repositioned at least every two hours, and the ADON reported there was no formal turning and repositioning policy, only a general protocol to turn residents with wounds every two hours to relieve pressure.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures for multiple residents during a lunch meal service. On the day of survey, the dietary director (V3) reported that turkey wraps with sweet potato fries, mixed vegetables, and pudding were being served. V3 stated that all wraps were temperature-checked before being placed in coolers and would be re-checked on the units, and calibrated the surveyor’s thermometer to 32.5°F, indicating a 0.5°F adjustment. At 11:47 AM, the turkey wraps measured 49.8°F, and V3 placed them in the freezer, stating that hot food would be sent out first so it could be placed in ovens while the cold food was brought to proper temperature. At 12:07 PM, after time in the freezer, the wraps were rechecked at 45°F and returned to the freezer. At 12:14 PM, food arrived on the 2 South unit and the dietary aide (V4) began preparations to serve. V4 checked the mixed vegetables at 132°F and the sweet potato fries at 134.5°F, stated these were not warm enough, and placed them back in the oven. V4 checked the turkey wraps at 43.4°F at 12:20 PM and left them out over ice. At 12:25 PM, V4 began serving the meal to residents, including R1, R6, R7, R8, and R9, without rechecking any food temperatures. At 1:00 PM, a sample tray taken after all residents were served showed the following temperatures: turkey wrap 43.2°F, mixed vegetables 102°F, sweet potato fries 97.6°F, pureed wrap 65.7°F, pureed vegetables 103.8°F, and pureed sweet potato fries 114.5°F. The facility’s Food Holding Temperature Log for 2 South documented an entrée at 43.4°F, vegetable at 132°F, and starch at 134°F, with no reheating temperatures recorded, despite the log and the facility’s policy requiring hot foods to be 140°F and above, cold foods 41°F and below, and documenting corrective actions and new temperatures when reheating or chilling is required.
Failure to Provide Palatable Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food was appetizing and served at a palatable temperature for one resident reviewed for food and nutritional services. The resident, who was cognitively intact, had paraplegia, was independent with eating, and was on a carbohydrate-controlled diet, reported that the food was always cold and lacked flavor. A test tray conducted after the last resident tray was served showed that the beef tacos measured 110°F, the broccoli 107°F, and the rice 101°F, which were below the facility’s preferred standard of 120°F or greater for hot foods on room trays at the point of service to promote palatability. The broccoli on the test tray was observed to be mushy and light green in color. Resident Council meeting minutes from two separate months documented ongoing concerns about cold food and food being too spicy. The DON stated an expectation that the facility adhere to its policy regarding food temperature and palatability, and the facility’s undated policy documented that food temperatures would be monitored daily to ensure foods are served at palatable temperatures.
Failure to Post Daily Nurse Staffing Information in Accessible Locations
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent place that was readily accessible to residents and visitors, affecting all 99 residents. On 1/8/26 at 8:32 AM, the receptionist stated that nursing assignments were posted only by the employee time clock, and there was no visible staffing information in the front lobby. Subsequent observations on the same date at multiple times showed no nurse staffing postings on Units 1-South, 1-North, 2-North, 2-South, 3-South, or 3-North. The ADON confirmed that daily nurse staffing assignments were not posted where residents and visitors could see them, and a nurse manager stated that staffing was not posted for visitors, explaining that if a visitor wanted to know who was caring for a resident, the nurse would check paperwork instead. An LPN reported that she kept nursing assignments on paper but did not post them for residents or visitors. The DON acknowledged that the facility had not been posting staffing information and did not have a policy regarding nurse posting, stating they would just follow the regulations. The CMS Form 802 dated 1/6/26 documented that 99 residents were living in the facility.
Inadequate Catheter Care Competency Leads to Resident Harm
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to demonstrate appropriate competency in the care of a resident with an indwelling urinary catheter. The resident, who had paraplegia and neuromuscular dysfunction of the bladder, required an indwelling catheter and was dependent on staff for transfers and partial assistance with mobility. According to documentation and interviews, the CNA pulled on the resident's catheter while attempting to empty the catheter bag, resulting in the catheter leaking urine and causing the resident pain. The resident reported that the CNA was rough and did not follow the correct procedure, which led to a hospital visit for catheter displacement. The resident also expressed a preference not to have that CNA provide care in the future. Further investigation revealed that the CNA attempted to lift the mattress to remove the catheter bag, which is not in accordance with facility procedures. The leg strap securing the catheter tubing was not properly positioned, and the CNA acknowledged that it should have been placed higher on the leg or not used at all, as the resident typically did not wear it. The facility's policy requires that catheter tubing be secured with a leg strap to prevent movement and trauma. Staff interviews confirmed that the CNA did not follow established procedures for catheter care, resulting in the incident.
Failure to Serve Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to provide appetizing food at palatable and safe temperatures for three out of five residents reviewed for food and nutrition services. Residents with complex medical conditions, including end stage renal disease, pressure ulcers, and muscle wasting, reported that the food was consistently cold, unappetizing, and sometimes arrived late. One resident with a pureed diet and mechanical soft preferences, as ordered by a Speech Language Pathologist, also expressed ongoing dissatisfaction with food quality. Grievances and resident council meeting minutes documented repeated concerns about cold food. Direct observation during meal service revealed that hot food items, such as gravy, were not maintained at appropriate temperatures, with a measured temperature of 105°F, below the facility's policy preference of 120°F or greater for palatability. The gravy was left on the counter without a method to keep it warm, and staff acknowledged this lapse. Facility policy and staff interviews confirmed the expectation that food should be served at acceptable temperatures, but this standard was not met during the survey period.
Failure to Provide Consistently Available Alternative Menu Options
Penalty
Summary
The facility failed to ensure that always available alternative food options were provided to residents as required. One resident with a renal diet and multiple complex medical conditions, including a stage 3 sacral pressure ulcer, extensive burns, and dependence on dialysis, reported that although an alternative menu existed, the items requested were consistently unavailable. This resident was cognitively intact and able to communicate these concerns directly. Another resident, with a pureed diet and double portions per SLP orders, also reported that the facility was frequently out of food items and did not request alternatives because he believed they would not be provided. This resident was moderately cognitively impaired. Interviews with facility staff confirmed that alternative menu items such as chicken strips and French fries were sometimes unavailable. The Regional Director of Operations/Interim Administrator acknowledged that while the alternative menu should be available from 7:00 AM to 7:00 PM, there were instances when certain foods were not in stock. Additionally, when the facility's policy regarding alternative menus was requested, no policy was provided. The facility's documented alternative menu included a variety of choices, but these were not consistently accessible to residents.
Failure to Provide Diets as Ordered and Follow Pre-Planned Menus
Penalty
Summary
The facility failed to provide diets as ordered and did not follow pre-planned menus for two of four sampled residents. One resident, who is cognitively intact and on a consistent carbohydrate diet, reported not always receiving the food items ordered from the menu due to the facility running out of food or not having the listed items available. Another resident, who is mildly cognitively impaired and requires supervision or assistance with eating, stated she is on a mechanical soft diet but often receives only two items on her tray instead of the three or four items listed on the menu. Multiple grievances documented issues such as not offering different drink choices, serving incomplete meals, not providing breakfast to early dialysis patients, lack of protein in meals, poor food quality, repeated menu items, and food being cold or missing from trays. Interviews with staff, including the interim Certified Dietary Manager, LPNs, Activities Assistant, and CNA, confirmed that residents on special diets such as mechanical soft or pureed were not consistently receiving the full menu as ordered, often receiving only two items instead of the required three or four. Staff acknowledged that not all menu items were prepared for residents with special diets, particularly on weekends. The facility's policy requires that the nutritional needs of residents be met according to recommended dietary allowances and that menus be prepared and presented as planned, which was not consistently followed.
Inadequate Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, leading to significant health issues. One resident, who was admitted with acute on chronic congestive heart failure, lymphedema, and chronic obstructive pulmonary disease (COPD), did not receive the ordered nebulizer treatments. This resident experienced chest pain, tightness, shortness of breath, and decreased oxygen saturation levels. Despite having orders for breathing treatments, the resident reported not receiving them, and the staff failed to administer the treatments as scheduled. The resident's oxygen levels were inconsistently monitored, and there was a lack of communication among staff regarding the resident's treatment needs. Another resident, with diagnoses including congestive heart failure and COPD, was observed without a nasal cannula attached, despite orders for continuous oxygen therapy. The resident's oxygen saturation levels were critically low, yet the staff failed to respond appropriately. The resident was left alone with low oxygen levels, and the staff did not communicate the resident's condition to the nursing team. This lack of attention and communication resulted in the resident being taken to physical therapy without proper oxygen support. Additional residents also experienced issues with their oxygen therapy. One resident was found with an empty oxygen tank, and another was receiving oxygen at an incorrect flow rate. The facility's policies on oxygen administration and medication were not followed, leading to inaccurate documentation and failure to administer necessary treatments. The staff's inability to adhere to the facility's policies and communicate effectively contributed to the deficiencies in respiratory care for these residents.
Failure to Maintain Resident Dignity and Adequate Staffing
Penalty
Summary
The facility failed to maintain the dignity and pride of three residents, leading to feelings of embarrassment and frustration. One resident, who is cognitively intact and dependent on staff for activities of daily living, was left lying in her own feces for over 30 minutes after notifying a CNA of her condition. The CNA prioritized delivering breakfast trays over providing incontinence care, resulting in the resident feeling messy, stinky, and embarrassed. Another resident, who has moderate cognitive impairment and is dependent on staff for toileting, was left waiting for assistance for over an hour after activating her call light. The CNA on duty, who was the only one working the floor, instructed the resident to soil herself in bed, promising to clean her up later. This instruction was given due to a lack of available staff to assist with the resident's transfer to the toilet, causing the resident to feel humiliated and stripped of her dignity. A third resident, who is cognitively intact and serves as the President of the Resident Council, expressed concerns about the facility's staffing levels and the treatment of residents. The resident reported feeling belittled and treated like a child by some staff members, who displayed a lack of respect and professionalism. These incidents highlight the facility's failure to uphold its Resident Rights Policy, which guarantees residents a dignified existence and self-determination.
Staffing Deficiencies Lead to Resident Care Issues
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, as evidenced by the experiences of four residents. One resident, who requires two staff members for transfers and assistance with toileting, reported that staff response to call lights could take 15-30 minutes, and on one occasion, a CNA had to perform tasks alone due to being the only staff member on the floor. This resident was left in a soiled state for over 30 minutes, causing distress and embarrassment. Another resident, who also requires assistance for ADLs, experienced a delay in staff response to a call light, resulting in a non-functioning oxygen concentrator going unchecked. The resident's daughter confirmed that call lights often went unanswered, and the facility was understaffed, particularly at night. A third resident, dependent on staff for toileting, was told by a CNA to soil herself in bed due to the lack of available staff to assist her. The resident's daughter, a licensed practical nurse, had to assist with care due to the staffing shortage. The facility's staffing records confirmed that only one CNA was working on a particular unit, contrary to the usual staffing of three CNAs. The Assistant Director of Nursing acknowledged the staffing issue and the difficulty in securing additional staff from an agency. The Director of Nursing was unavailable to assist during the staffing crisis, and the facility lacked a formal staffing policy, relying instead on state guidelines.
Unsafe Transfer of Resident Using Mechanical Lift
Penalty
Summary
The facility failed to provide a safe transfer for a resident, identified as R1, who was dependent on staff for activities of daily living and required the use of a full body mechanical lift device for transfers. R1, who had multiple medical conditions including COPD, respiratory failure, and morbid obesity, was transferred by a CNA without assistance, contrary to the facility's policy and the lift device's user manual, which recommend two assistants for safe operation. On a particular day, due to staffing shortages, a CNA was the only staff member available to assist R1, leading to the CNA performing the transfer alone. During the transfer, the CNA did not lock the wheelchair, and R1 was left free-swinging in the air without anyone holding onto them, which is against the recommended procedure. The facility's policy emphasizes resident safety, dignity, and comfort during transfers, but these were compromised in this instance. The user manual for the lift device also specifies that the wheelchair should be locked to prevent movement during the transfer, which was not adhered to, creating a potential hazard for R1.
Inadequate Incontinent Care and Resident Dignity Issues
Penalty
Summary
The facility failed to provide timely and complete incontinent care for two residents, R1 and R3, leading to deficiencies in maintaining their dignity and hygiene. R1, who has multiple medical conditions including COPD, respiratory failure, and bladder incontinence, was left in a soiled state for over 30 minutes after notifying a CNA of a bowel movement. The CNA, V13, failed to perform proper peri-care, did not change gloves when visibly soiled, and did not use a cleaning solution, leaving R1 feeling frustrated and embarrassed. R3, who suffers from conditions such as hypoglycemia, end-stage renal disease, and bladder incontinence, experienced a similar lack of timely care. R3's daughter reported that her mother was left waiting for over an hour after requesting assistance to use the restroom. The CNA, V9, instructed R3 to soil herself in bed due to a lack of available staff to assist with her transfer to the toilet, which was not handled appropriately and affected R3's dignity. The facility's failure to adhere to proper incontinent care procedures, as outlined in their Peri-Care Skills Checklist and Infection Prevention and Control Policy, contributed to these deficiencies. The staff did not follow the expected standards of practice for peri-care, including changing gloves and performing hand hygiene, which compromised the residents' dignity and hygiene.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy as ordered for a resident (R2) who is oxygen-dependent due to chronic obstructive pulmonary disease (COPD) and acute respiratory failure. R2's care plan specified the need for continuous oxygen at 3 liters per minute via nasal cannula, yet observations revealed that the oxygen concentrator was off and beeping, indicating a malfunction. Despite the beeping, the certified nursing assistant (CNA) only turned the machine on to 2 liters per minute and informed the nurse, who did not check on the resident. The resident's oxygen was not consistently maintained at the prescribed level, as evidenced by the resident's daughter finding the oxygen set at only 1 liter per minute on a separate occasion. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's oxygen needs. A CNA assumed the oxygen was on after a breathing treatment, and a registered nurse (RN) was unaware of the oxygen being off, despite the resident requiring continuous oxygen. The assistant director of nursing (ADON) confirmed the malfunctioning concentrator and replaced it, but the issue of incorrect oxygen settings persisted, as noted by the resident's daughter. The facility's oxygen administration policy requires verification of physician orders and proper setup and monitoring of oxygen equipment, which was not adhered to in this case. The nurse practitioner emphasized the critical nature of continuous oxygen for the resident's health, highlighting the potential risk to the resident's well-being due to the facility's failure to ensure proper oxygen administration as ordered by the physician.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a manner that prevents potential contamination, affecting all 103 residents. During observations, multiple instances of improperly stored food were noted across various kitchen units and resident refrigerators. These included uncovered cheese slices, unlabeled and undated containers of rice, eggs, and other food items, as well as expired yogurt. The lack of proper labeling and dating was evident despite a laminated sign in the Resident Refrigerator instructing that all items should be clearly labeled with a name and date. Interviews and record reviews further confirmed the deficiency. The Dietary Manager acknowledged that all items placed in refrigerators and freezers should be labeled with a name and date. The facility's policy on labeling and dating foods was not adhered to, as evidenced by the numerous unlabeled and undated food items found during the survey. This oversight in food storage practices poses a risk of contamination and potential harm to the residents.
Failure to Submit PBJ Data for 4th Quarter 2024
Penalty
Summary
The facility failed to submit the required Payroll-Based Journal (PBJ) data for the 4th quarter of 2024, which has the potential to affect all 103 residents. The PBJ report for this period documented low weekend staffing, RN coverage for 8 consecutive hours per day, and licensed nurse coverage for 24 hours per day, resulting in a one-star staffing rating. The facility did not submit the PBJ data to CMS, as confirmed by the Administrator on January 14, 2025, who provided a notice from the State Agency documenting this failure. On January 17, 2025, the Administrator explained that the data was submitted to the corporate office in a timely manner but was not forwarded to CMS due to a new employee at the corporate office. Additionally, the facility lacked a policy regarding PBJ data submission.
Failure to Notify Family of Resident's Pneumonia Diagnosis
Penalty
Summary
The facility failed to notify a family representative of a significant illness and test results for a resident with moderate cognitive impairment. The resident's daughter, who is the family representative, filed a grievance expressing concern about not being informed of her mother's x-ray results, which indicated pneumonia. Despite the daughter's efforts to communicate with the Social Service Director about her mother's symptoms, she was not informed of the pneumonia diagnosis until she visited the facility and expressed her dissatisfaction. The nurse's progress notes confirmed that the daughter was unaware of the x-ray and its results, and the nurse informed her of the new orders related to the pneumonia diagnosis. The grievance filed by the daughter was founded, and the responsible LPN received a write-up and re-education on the importance of notifying families about significant changes in a resident's condition. The facility's policy on significant condition change and notification was not adhered to, leading to the deficiency.
Inappropriate Staff Cell Phone Use Violates Resident Rights
Penalty
Summary
The facility failed to protect the rights and dignity of two residents, as evidenced by the inappropriate use of personal cell phones by staff during care. One resident, who is cognitively intact and requires assistance due to various medical conditions including overactive bladder and diabetes, reported that CNAs frequently use earbuds and talk on their phones while providing care. This behavior led to confusion and irritation for the resident, as they often mistook the staff's phone conversations for communication directed at them. Another resident, also cognitively intact and dependent on staff for activities due to conditions such as myocardial infarction and hemiplegia, described similar issues with staff cell phone usage. The resident noted that a nurse would complete tasks and then watch her phone for extended periods, while CNAs with earbuds would inadvertently ignore the resident's questions. The issue of cell phone use was repeatedly raised in Resident Council Meetings and documented in grievance logs, yet the facility lacked a policy addressing cell phone use, despite having a policy on resident rights emphasizing respect and dignity.
Inadequate Incontinence Care and Infection Control Practices
Penalty
Summary
The facility failed to provide complete and timely incontinent care using proper techniques, which resulted in a urinary tract infection (UTI) for one of the residents. The report highlights that the facility did not perform hand hygiene and glove changes appropriately for three residents reviewed for incontinence care. Specifically, a certified nursing assistant (CNA) was observed performing peri-care on a resident without changing gloves or performing hand hygiene between different stages of the care process. This included using the same gloves to handle soiled linens and clean areas, which is against standard infection control practices. The report details the medical history and condition of the residents involved. One resident, who was cognitively intact and dependent on staff for toileting, was frequently incontinent of both bowel and bladder. This resident developed a UTI and was placed on antibiotic therapy. Another resident, also cognitively intact and totally dependent on staff for toileting, reported having to sit in soiled conditions for extended periods before being cleaned. The third resident, who was severely cognitively impaired, was observed receiving improper incontinence care, with the CNA using the same towel and gloves for different areas, leading to visible redness and irritation in the peri region. Interviews with staff and residents revealed that the facility's staff did not consistently follow proper hand hygiene and glove use protocols. Some staff members acknowledged the need for more training on these procedures, and the Resident Council President noted that staff did not check on residents every two hours as required. The facility's administrator confirmed the expectation for staff to perform timely and complete incontinence care, including proper hand hygiene and glove changes, but admitted that there was no specific policy on incontinent care, only a checklist.
Infection Control Deficiency in Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control practices and policies, specifically in the area of glove changing and hand hygiene during resident care. This deficiency was observed in the care of three residents, who were part of a sample of ten reviewed for infection control. The staff did not perform hand hygiene between glove changes, which is a critical step in preventing the transmission of infections. For Resident 7, a Certified Nursing Assistant (CNA) was observed performing peri-care without changing gloves or performing hand hygiene between tasks. The CNA used the same gloves to handle clean and soiled items, which is against the facility's infection control policy. Resident 7 has multiple health conditions, including urinary tract infection, and is dependent on staff for toileting and other activities of daily living. Similarly, Resident 6 and Resident 8 were also subjected to improper infection control practices. The CNAs involved did not change gloves or perform hand hygiene between different care tasks, such as cleaning soiled areas and handling clean linens. These actions were contrary to the facility's infection control and hand hygiene policies, which emphasize the importance of glove changes and hand hygiene to prevent the spread of infections.
Improper Transfer Techniques Result in Resident Injury and Fatality
Penalty
Summary
The report details a critical incident where a resident (R2) in a nursing home sustained bilateral femur fractures leading to her death due to improper transfer techniques by a Certified Nurse's Aide (V8). R2 had a history of Alzheimer's Disease, chronic pain syndrome, and vascular dementia with agitation, requiring substantial/maximal assistance for various activities including transfers. Despite the care plan indicating a 2-person assist for transfers, V8 attempted to transfer R2 alone, resulting in the fall and subsequent fractures. The incident occurred late in the evening, and despite efforts to assess and assist R2 promptly, the severity of the injuries was significant. The facility's documentation highlighted the lack of adherence to the care plan and proper transfer protocols, as V8 admitted to regularly transferring R2 alone despite her known limitations. The Licensed Practical Nurse (V9) also noted the absence of proper equipment like a gait belt or sit-to-stand device during the transfer. The report indicates that the facility's Fall Prevention Policy emphasized safety, assessment, fall prevention, and education for staff and residents, yet the failure to follow established protocols led to the tragic outcome for R2. The incident raised concerns about staff training, supervision, and adherence to care plans in ensuring resident safety during transfers. Medical professionals involved, including the ER Physician and Medical Director, noted the severity of R2's condition, with osteopenia complicating her ability to withstand surgical intervention for the fractures. The Medical Director attributed R2's death to the bilateral femur fractures.
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.
