Stephenson Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Freeport, Illinois.
- Location
- 2946 South Walnut Road, Freeport, Illinois 61032
- CMS Provider Number
- 145895
- Inspections on file
- 32
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Stephenson Nursing Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s dementia, gait unsteadiness, weakness, and documented memory problems, who required assisted ambulation with a gait belt, was being escorted to the toilet by a CNA. Staff and the resident’s spouse had previously observed that the resident tended to walk too far behind her rollator, allowing it to get away from her. During ambulation, the CNA noted the walker moving ahead, the resident’s buttocks protruding, and the resident appearing confused, but left the resident unsupported to retrieve a chair several steps away, without a gait belt in use. The resident fell in the common area and was later found with the left leg externally rotated and in significant pain, and was admitted to the hospital with a left hip fracture, in violation of the facility’s safe resident handling policy requiring continuous hands-on assistance and not leaving a resident unsupported when balance is compromised.
A resident with dementia, mobility issues, and incontinence was discharged to independent senior housing without a documented discharge plan or confirmation that home health and caregiver services were in place. Staff were unclear about the resident's discharge needs and the capabilities of the housing setting, resulting in the resident being found soiled and unable to get out of bed after discharge.
A resident with a history of falls and impaired mobility was assisted by a CNA after toileting without the use of a gait belt, despite care plan requirements. The resident became weak and fell, sustaining a left femur fracture that required surgical repair. Staff interviews and records confirmed the gait belt was not in use at the time, contrary to facility policy for high fall-risk residents.
A resident with dementia and a history of removing dressings had a fentanyl patch repeatedly applied to the chest instead of the back, contrary to physician orders. Nursing documentation showed the patch was missing on one occasion and later found in the resident's mouth, despite staff awareness of the resident's behaviors and the specific order to make the patch inaccessible.
A resident with chronic pain and multiple serious health conditions experienced unrelieved pain for several days due to delays in obtaining and administering prescribed morphine. Despite repeated requests from the resident and her family for stronger pain relief, staff were unable to provide adequate pain management in a timely manner, resulting in ongoing distress for the resident prior to her death.
Surveyors found that the kitchen was not maintained in a clean and sanitary manner, with dried food debris, grease, and dirty containers present throughout. The Dietary Manager handled kitchen utensils with bare hands without washing or wearing gloves, then placed them into food containers, contrary to facility policy requiring glove use and proper sanitation. The last deep cleaning of the kitchen had not occurred for over a month.
Agency CNAs did not receive annual training in abuse prevention and dementia care, as confirmed by facility records and interviews. The facility's policies require such training, and the lapse affected all residents, including those with Alzheimer's disease and dementia.
Several residents were found with bed bolsters, side rails, or tall barriers that restricted their ability to exit bed, with staff confirming these devices were used to prevent unsupervised bed exit or falls. These residents, many of whom were not cognitively intact and dependent on staff for mobility, did not have documented restraint assessments or appropriate orders as required by facility policy.
The facility failed to prevent the misappropriation of controlled substances for two residents. One resident's Norco tablets were found missing during a narcotic count, and an LPN reported the issue after an agency RN suggested unauthorized corrections. Surveillance footage showed the RN accessing the narcotic box without proper documentation. Another resident's fentanyl patch was missing, but the DON was unaware and no investigation was conducted. The facility's policies on controlled substances and abuse were not followed, leading to these deficiencies.
A facility failed to implement its abuse policy when a resident's fentanyl patch was found missing, and a new patch was applied early. The incident was not reported or investigated as potential misappropriation, despite the facility's policy requiring immediate notification to the DON. The resident had multiple diagnoses, including Alzheimer's and was under palliative care. The facility's policy aims to prevent abuse and misappropriation, but it was not followed in this instance.
A resident with multiple diagnoses, including Alzheimer's and anxiety disorder, was prescribed a fentanyl patch. A nurse discovered the patch missing and applied a new one early, but the incident was not reported or investigated for potential misappropriation. The DON was unaware of the missing patch, and the facility's policy requiring immediate reporting of such incidents was not followed.
A resident who was fully dependent on staff for ADLs did not receive timely incontinence care after being transferred to bed by a CNA and an RN. Staff failed to check or change the resident's incontinence brief, resulting in the resident remaining in a saturated brief with visible wetness and skin redness for over an hour, contrary to the care plan and facility policy.
A resident with fragile skin and a history of skin tears was not consistently provided with protective arm sleeves as ordered in their care plan. Despite documented incidents of skin tears and staff acknowledgment of the need for protective measures, the resident was observed multiple times without arm sleeves or long sleeves while out of bed, resulting in a failure to follow the care plan and protect the resident from further injury.
Surveyors found that two residents did not receive appropriate pressure ulcer prevention and care. One resident's air mattress was unplugged and set at the wrong weight despite orders and care plan instructions, while another resident with a stage 3 pressure ulcer did not receive recommended dietary protein supplements due to a lack of communication between staff.
A resident with an indwelling urinary catheter and a history of UTIs was found lying in bed with a urinary drainage leg bag attached, despite facility policy and posted instructions stating leg bags should only be used when out of bed. The DON confirmed this practice was not appropriate and posed a risk for urine backflow and infection.
Three residents on pureed diets did not receive a pureed roll or bread item with their lunch as required by the posted menu. Instead, they were served only pureed ham, spinach, sweet potatoes, and cake. The dietary manager was unaware of the omission, despite facility policy requiring all menu items to be prepared and served as listed.
A resident with Alzheimer's and other conditions had a bruise on her forehead that was not reported to the abuse coordinator as required by the facility's policy. Despite the CNA reporting the bruise to an LPN, who documented it and informed the DON, the DON and Administrator were unaware, and no investigation was conducted.
A resident with fragile skin and a history of easy bruising was found with multiple bruises after being repositioned improperly by a CNA. The CNA used the resident's arms to reposition him instead of using an incontinence pad, which likely caused the bruising. The resident was observed with bruises on his wrists, and staff confirmed the resident's tendency to bruise easily.
The facility failed to submit final investigation reports to IDPH within the required 5-day period for three residents reviewed for abuse. The Administrator experienced technical difficulties with the online submission system and did not notify IDPH or verify fax submissions. The facility's policy mandates a complete written report within 5 working days, which was not followed.
The facility failed to thoroughly investigate alleged abuse and did not maintain proper records, affecting three residents. The interim Administrator admitted to not conducting a thorough investigation and failing to ensure residents felt safe. The facility's policy mandates a comprehensive investigation process, which was not followed.
Failure to Safely Supervise High-Risk Resident During Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and safely assist a resident with known fall risk and ambulation difficulties, resulting in a left hip fracture. The resident had diagnoses including Alzheimer’s dementia, unsteadiness of feet, weakness, and rheumatoid arthritis. A recent MDS indicated she was unable to complete the Brief Interview for Mental Status and had both short- and long-term memory problems. A restorative note documented that staff on the locked memory care unit and the resident’s husband had observed that when she was tired or not walking well, she tended to walk too far behind her rollator, and that the rollator sometimes "gets away from her." Staff interviews, including with the DON and nursing staff, confirmed that the resident required assistance with ambulation and the use of a gait belt for safety. On the day of the incident, a CNA was taking the resident to the toilet shortly after lunch while the other CNA on the unit was in a room providing care and the nurse assigned to the memory care unit was off the unit performing wound care on other units. The CNA observed that the resident’s walker was getting away from her, with the resident’s buttocks sticking out and her arms stretched out toward the walker. The CNA reported that the resident appeared confused and did not understand coaching to move toward the walker. Believing the resident would not make it safely to the bathroom, the CNA decided to step away a few steps to get a chair, during which time the resident fell. The CNA acknowledged that a gait belt was not in use and that she left the resident’s side despite recognizing the resident’s compromised positioning and confusion. Following the fall, the nurse responded and observed the resident lying on her back in the common area with the left lower extremity bent at the knee and externally rotated, and the area was immobilized. The nurse noted that the resident, who typically did not have pain, was experiencing significant pain, especially when the left leg was touched, and she believed the leg was broken based on the pain and rotation. The resident was subsequently admitted to the hospital with a left hip fracture. The facility’s Safe Resident Handling/Transfers policy required proper hands-on assistance during ambulation and specified that residents should never be left unsupported when balance is compromised or when the resident stops walking. Staff interviews, including with the DON and other CNAs and RNs, consistently indicated that the resident required assistance with ambulation and a gait belt, and that the CNA should not have left the resident unsupported but should have called for assistance and, if needed, used a gait belt to lower her to the floor.
Failure to Ensure Discharge Services for Resident with ADL Needs
Penalty
Summary
The facility failed to ensure that appropriate discharge services were in place prior to discharging a resident with significant care needs to an independent senior housing apartment. The resident, an elderly female with diagnoses including osteoarthritis, gait and mobility abnormalities, type 2 diabetes, unspecified dementia, and cognitive communication deficits, required staff assistance with ambulation, was incontinent, and needed help with activities of daily living (ADLs). Despite these needs, the resident was discharged without a documented discharge plan addressing her required services, and there was no confirmation that home health or caregiver services were arranged prior to her return to independent living. Multiple staff interviews revealed a lack of clear communication and coordination regarding the resident's discharge needs. The Social Service Director (SSD) admitted to not knowing the type of setting the resident was being discharged to and did not ensure that caregiver services or home health were set up before discharge. The Restorative Nurse and Director of Therapy both expressed concerns about the resident's safety and appropriateness for independent living, noting her need for supervision, incontinence, and lack of safety awareness. The senior housing staff repeatedly informed the facility that they did not provide any care or assistance with ADLs, and that all necessary services should be arranged prior to discharge. However, these services were not confirmed to be in place, and the resident was left without adequate support. As a result of these failures, the resident was found in her apartment soiled in urine and feces, unable to get out of bed, and appeared to have been in bed since the previous day. Documentation showed that while referrals for home health and therapy were made, there was no follow-up to ensure these services were initiated, and critical information such as the resident's phone number was not communicated to service providers. The facility's own discharge policy requires the interdisciplinary team to review and develop a discharge plan based on the resident's needs, but this was not completed in this case.
Failure to Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
Staff failed to apply a gait belt while assisting a high fall-risk resident during ambulation after toileting. The resident, an alert and oriented female with a history of multiple falls, impaired mobility, and balance problems, was being assisted by a CNA when she became weak and fell while attempting to move from the bathroom to her recliner. The resident was not wearing a gait belt at the time of the fall, as confirmed by multiple staff interviews and direct observation after the incident. The resident sustained a left femur fracture requiring surgical repair as a result of the fall. The resident's care plan and fall risk assessment indicated she required one-person assistance, a gait belt, and a walker for transfers and ambulation due to her unsteady gait and high risk for falls. Staff interviews confirmed that the use of a gait belt was standard practice for this resident, but it was not in use at the time of the incident. The facility's fall program policy required evaluation and implementation of interventions for residents at risk for falls, but these interventions were not followed during the incident, directly leading to the resident's injury.
Failure to Apply Narcotic Patch in Inaccessible Location for Resident with History of Removal
Penalty
Summary
The facility failed to ensure that a narcotic pain patch was applied in an inaccessible location for a resident with a known history of removing such patches. The resident, who had diagnoses including scoliosis and dementia, was dependent on staff for most functional abilities and had both short- and long-term memory problems. Despite a physician's order to apply the fentanyl patch to the resident's back and cover it with a transparent film dressing, nursing documentation showed that the patch was repeatedly applied to the resident's chest. This occurred even after the order change intended to prevent the resident from accessing and removing the patch. Nursing notes and medication administration records indicated that the patch was missing on one occasion and later found in the resident's mouth on another, despite staff being aware of the resident's history of picking at dressings and patches. The facility's own policy required following special directions for medication administration, but staff failed to adhere to the specific order for patch placement. Interviews with nursing staff and the Director of Nursing confirmed that the patch was not applied as ordered, resulting in the resident being able to access and remove the narcotic patch.
Failure to Provide Timely and Adequate Pain Management
Penalty
Summary
A resident with multiple complex medical conditions, including nonrheumatic aortic valve stenosis, congestive heart failure, gastrointestinal stromal tumor, osteoporosis, scoliosis, and chronic back pain, was admitted to the facility and had a history of chronic pain. The resident's care plan indicated that pain should be routinely evaluated and managed according to physician orders, with effectiveness documented and reported as needed. Despite these plans, the resident experienced ongoing, inadequately controlled pain, as evidenced by frequent requests for ibuprofen, reports of high pain levels, and repeated requests for stronger pain medication by both the resident and her daughter. The resident's pain management regimen initially consisted of ibuprofen, which was not effective in controlling her pain, as she continued to report pain levels of 8-9 out of 10 even after administration. The resident's daughter repeatedly requested stronger pain medication since admission, and staff recognized the need for additional comfort measures as the resident's condition declined. Although a physician order for morphine was eventually obtained, there was a significant delay in the medication being delivered and administered. The resident waited several days for the morphine, during which time she continued to experience unrelieved pain, as documented by staff and reported by the resident herself. Communication breakdowns occurred between nursing staff, the physician, and the pharmacy, resulting in the morphine prescription not being promptly processed and delivered. Staff were unable to access morphine from the emergency box due to pharmacy instructions, and the resident did not receive the ordered morphine until several days after the initial request. During this period, the resident's pain remained inadequately managed, and she was observed to be in significant distress prior to her death.
Failure to Maintain Kitchen Sanitation and Prevent Cross Contamination
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen during two separate tours. Dried grease and food debris were found on the stove, ovens, steamers, and the bottom shelf of the food prep table. Several plastic containers holding dried cereal had visibly dirty and sticky lids, with a brown, sticky substance on one container. A plastic milk crate was covered with grease and food debris, and the commercial food processor was noted to have a greasy residue. The shelf under the plate warmer rack was cluttered with opened salt packets and napkins, and the steam table had dried liquid and food debris on its surfaces. A dirty oven mitt was also found on the floor under the steam table. During food service, the Dietary Manager handled multiple kitchen utensils and scoops with bare hands, without washing hands or wearing gloves, and placed these utensils directly into various food containers. The Dietary Manager later confirmed that staff are required to wear gloves when handling utensils or dishes to prevent cross contamination and stated that the last deep cleaning of the kitchen was likely over a month ago. The facility's policy requires proper hand washing, glove use, and cleaning and sanitizing of all utensils and food contact surfaces after every use.
Failure to Provide Required Abuse and Dementia Training to Agency CNAs
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs), specifically agency staff, received required annual training in abuse prevention and dementia care. Record review and interviews confirmed that three agency CNAs had not completed any abuse or dementia training in the past year, and neither the facility nor the agency provided this education. The facility's own assessment and policy documents indicated that staff are expected to receive training in these areas upon orientation and throughout the year. At the time of the deficiency, the facility had a census of 46 residents, including individuals with Alzheimer's disease and dementia, who were potentially affected by this lapse.
Failure to Prevent Use of Physical Restraints Without Proper Assessment
Penalty
Summary
The facility failed to ensure that four residents were free from the use of physical restraints unless required for medical treatment. Observations revealed that several residents had devices such as side rails and bolsters attached to their beds, which restricted their ability to exit the bed independently. For example, one resident was observed with half side rails and bolsters secured with straps, and staff confirmed these were in place specifically to prevent the resident from getting out of bed. Documentation showed that the resident was not able to use the side rails for positioning, and there was no restraint or side rail assessment available for this resident. Another resident was found with bolsters attached to both sides of the bed, and staff stated these were used because the resident was at risk of falling and would otherwise attempt to get out of bed unsafely. The care plan for this resident indicated a history of restlessness and fall risk, with instructions to ensure bolsters were properly attached. However, the facility's own policy required evaluation and documentation for restraint use, which was not completed for this or other residents observed with similar devices. Additional residents were observed with tall barriers or bolsters on both sides of their beds, with staff confirming these were used to prevent the residents from getting out of bed or falling. In these cases, the residents were not cognitively intact and were dependent on staff for mobility. Despite the use of these restrictive devices, there were no documented restraint assessments or appropriate orders as required by facility policy and regulations.
Misappropriation of Controlled Substances in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for two residents, R41 and R11. For R41, the issue arose when five Norco tablets were found missing during a narcotic count. The discrepancy was discovered by an LPN who noted that the count was off by five tablets. The LPN reported the issue to the Director of Nursing (DON) after an agency RN suggested correcting the count without proper authorization. The DON's investigation included reviewing surveillance footage, which showed the agency RN accessing the narcotic box at times that did not align with medication administration records. The missing tablets were not accounted for, and the police were involved in the investigation. For R11, the deficiency involved a missing fentanyl patch. The resident's progress notes indicated that a new patch had to be applied earlier than scheduled because the existing patch was not found on the resident's body. The DON was unaware of this incident and had not conducted an investigation into the missing patch. The facility's policy requires staff to report missing controlled substances immediately, but this protocol was not followed in R11's case. The RN who documented the missing patch no longer worked at the facility, and there was no follow-up on the incident. The facility's policies on controlled substances and abuse affirm the residents' rights to be free from misappropriation of property. However, the failure to adhere to these policies resulted in the misappropriation of controlled substances for both residents. The lack of proper narcotic counts and failure to report missing medications contributed to the deficiencies identified in the report.
Failure to Implement Abuse Policy for Missing Fentanyl Patch
Penalty
Summary
The facility failed to implement its abuse policy for a resident who was admitted with multiple diagnoses, including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and was receiving palliative care. The resident had a physician's order for a fentanyl patch to be administered every 72 hours. On December 21, 2024, a registered nurse noted that the fentanyl patch was missing from the resident's body and applied a new patch earlier than scheduled. This incident was not reported or investigated as a potential misappropriation of a controlled substance, which is a requirement under the facility's abuse policy. The Director of Nursing (DON) admitted that no investigation into potential misappropriation had been conducted in the last three months, despite the missing fentanyl patch. The facility's policy mandates that staff notify the DON immediately if a fentanyl patch is missing, as it could indicate theft. An LPN confirmed that the protocol is to inform the DON and the administrator if such an incident occurs. The facility's abuse policy, effective since April 2020, aims to prevent abuse, neglect, exploitation, and misappropriation of property by training employees to recognize and report such occurrences. However, in this case, the policy was not followed, leading to a deficiency in the facility's compliance with its own procedures.
Failure to Report Missing Controlled Substance
Penalty
Summary
The facility failed to report a missing controlled substance, specifically a fentanyl patch, for a resident diagnosed with anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and receiving palliative care. The resident was prescribed a fentanyl patch to be administered every 72 hours. On December 21, 2024, a registered nurse (RN) noted that the current patch was missing and applied a new one early. Despite this, the incident was not reported to the Director of Nursing (DON) or investigated for potential misappropriation. The DON was unaware of the missing fentanyl patch and stated that no investigation had been conducted regarding any potential misappropriation in the past three months. The facility's policy requires staff to report any suspicion of misappropriation immediately to the administrator or a compliance officer. However, this protocol was not followed, as the missing patch was not reported or investigated, leading to a deficiency in the facility's handling of controlled substances and potential abuse reporting.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for activities of daily living, including incontinence care, was not provided timely assistance. After being transferred to bed by a CNA and an RN using a mechanical lift, the staff did not check or change the resident's incontinence brief. Over an hour later, the resident was found with a saturated incontinence brief, visible wet spots on their clothing, redness in the perineal and buttocks areas, and a small amount of stool present. The resident's care plan required staff to render perineal care after every incontinent episode and to keep the resident clean and dry. Facility policy, as stated by the DON, was to check residents for incontinence every two hours and as needed, especially when putting a resident to bed.
Failure to Apply Protective Arm Sleeves for Resident with Fragile Skin
Penalty
Summary
A resident with a history of fragile skin, skin tears, and anticoagulant use was not consistently provided with protective arm sleeves as ordered in their care plan. Nursing notes documented multiple incidents where the resident sustained skin tears to the right forearm after bumping it on a table during meals. Observations on several occasions showed the resident sitting at the dining room table without protective arm sleeves or long sleeves, despite the care plan specifying the use of these interventions to protect the resident's skin while out of bed. Staff interviews confirmed that protective arm sleeves were implemented following a previous skin tear and that the resident should be wearing them when out of bed to prevent further injury. The resident's care plan, updated after the most recent skin tear, reiterated the need for arm protectors while out of bed. However, the resident was repeatedly observed without these protective measures in place, leading to a failure to provide care according to the resident's assessed needs and care plan.
Failure to Implement Pressure Ulcer Prevention and Dietary Interventions
Penalty
Summary
Surveyors identified deficiencies in pressure ulcer prevention and care for two residents. For one resident with a history of pressure ulcers and dependent on staff for mobility, eating, and hygiene, the air mattress intended to relieve pressure was found unplugged and set at an incorrect weight for an extended period. The mattress was supposed to be set at 159 pounds according to physician orders and the care plan, but it was observed set at 80 pounds, despite the resident weighing 151 pounds. Staff interviews confirmed the mattress had been unplugged and incorrectly set for several hours, and the care plan specifically directed staff to ensure the mattress was set at the correct weight. For another resident with a stage 3 pressure ulcer on the coccyx, dietary recommendations to promote wound healing were not implemented. The dietitian had recommended high protein supplements three times daily and sandwiches twice daily to increase protein intake, but the recommendation for sandwiches was not communicated to the dietary department. As a result, the resident did not receive the additional sandwiches with meals as intended. Staff interviews revealed that the recommendation was discussed but not formally documented or relayed to the dietary manager, and the resident's meal tickets did not reflect the dietary changes.
Failure to Remove Urinary Leg Bag While Resident in Bed
Penalty
Summary
A deficiency was identified when a resident with a history of urinary retention and urinary tract infections was observed lying in bed with a urinary drainage leg bag attached. The resident's care plan indicated the need for an indwelling urinary catheter, and facility policy specified that leg bags should only be used when the resident is out of bed. During observation, the leg bag was not visible initially, but a CNA confirmed that the resident had a leg bag on while in bed. A sign above the bed also instructed not to leave the leg bag on when the resident is in bed, yet the leg bag was found attached and then detached by the CNA during the surveyor's visit. The Director of Nursing confirmed that the resident should not have a leg bag while in bed due to the risk of urinary tract infections and potential for urine backflow. The facility's policy on Foley catheter management emphasized that urinary drainage tubing should be kept below bladder level and that leg bags, if used, should only be in place when the resident is out of bed. The failure to follow these protocols resulted in the resident remaining in bed with a leg bag attached, contrary to both the care plan and facility policy.
Failure to Provide All Menu Items for Pureed Diets
Penalty
Summary
The facility failed to follow its posted menu for residents on pureed diets, as observed for three residents who were supposed to receive a pureed roll or bread item with their lunch. On the specified date, these residents were served pureed ham, spinach, sweet potatoes, and cake, but no pureed roll or bread was present on their trays. The dietary manager confirmed that residents on pureed diets should receive the same food items as those on regular diets and was unaware that the pureed roll had not been provided. The facility's policy requires that menu items be prepared according to the posted menu and standardized recipes, but this was not followed for the affected residents.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the abuse coordinator for a resident, identified as R2, who was admitted with diagnoses including Alzheimer's disease, dementia, anxiety disorder, rheumatoid arthritis, and age-related osteoporosis. R2's care plan required immediate reporting of any suspected abuse or neglect. On June 6, 2024, a CNA noticed a bruise on R2's forehead and reported it to an LPN, who documented the incident and informed the Director of Nursing (DON). However, the DON later stated that no staff had reported the bruise to her, and the Administrator confirmed that no abuse investigation was conducted for R2. The facility's policy mandates that suspicious bruises or injuries of unknown origin be reported and documented immediately. Despite this, the bruise on R2's forehead was not reported to the abuse coordinator, and no investigation was initiated. Observations on July 2, 2024, noted a fading yellow area on R2's forehead, indicating the bruise had not been addressed according to protocol. The lack of communication and failure to follow the facility's abuse policy resulted in the deficiency noted in the report.
Resident Bruising Due to Improper Repositioning
Penalty
Summary
The facility failed to ensure a resident was repositioned in bed safely, leading to multiple bruises on the resident. The resident, who was admitted with conditions such as congestive heart failure, dementia, and muscle contractures, was on anti-platelet medication and had a history of bruising easily due to fragile skin. On June 13, 2024, a CNA reported fresh bruises on the resident's arm and foot, which were assessed by an LPN and an RN. The resident, described as very frail and unable to move his legs independently, was found with bruises that appeared fresh and unexplained. Further investigation revealed that a CNA had repositioned the resident by pulling on his arms to help him grab the side rails, rather than using an incontinence pad as required for his sensitive skin. This method of repositioning likely caused the bruising. The resident was observed with a large dark bruise on his right wrist and a fading bruise on his left wrist. Staff interviews confirmed that the resident bruises easily and that the proper technique to prevent bruising was not followed during repositioning.
Failure to Submit Final Investigation Reports Timely
Penalty
Summary
The facility failed to submit final investigation reports to the Illinois Department of Public Health (IDPH) within the required 5-day period for three residents who were reviewed for abuse. Initial Incident Investigation Reports for these residents were submitted on different dates, but the final reports were not received by IDPH. The Administrator admitted to experiencing technical difficulties with the online submission system and did not notify IDPH of these issues. Additionally, attempts to fax the reports were made without verifying the correct fax number or confirming receipt by IDPH. The facility's policy mandates that a complete written report of the investigation's conclusion be sent to IDPH within 5 working days, which was not adhered to in these cases.
Failure to Investigate Alleged Abuse and Maintain Records
Penalty
Summary
The facility failed to perform a thorough investigation of alleged abuse and did not maintain proper records of the abuse investigation. This deficiency affected three residents. The Incident Investigation Report Final Summary for these residents showed that the facility did not interview the accused staff members, did not identify other residents at risk for abuse, did not interview residents to ensure they felt safe, and did not interview employees working on the same shift as the accused staff members. The surveyor requested the abuse investigation files and received them after a delay, only to find that the interim Administrator had merely jotted down notes in a notebook instead of maintaining proper records. The interim Administrator, who has been in the position since January 2024, admitted to not conducting a thorough investigation and failing to ensure the residents felt safe and that staff felt confident working with the accused staff members. The facility's policy on abuse, effective since March 2021, mandates a comprehensive investigation process, including interviewing the person who reported the incident, anyone likely to have direct knowledge of the incident, and the resident if interviewable. The policy also requires reviewing written statements and pertinent medical records, and interviewing other residents and employees who regularly interacted with the accused. These steps were not followed in the cases of the three residents involved.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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