Sunny Acres Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Petersburg, Illinois.
- Location
- 19130 Sunny Acres Road, Petersburg, Illinois 62675
- CMS Provider Number
- 146068
- Inspections on file
- 38
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Sunny Acres Nursing Home during CMS and state inspections, most recent first.
The facility failed to follow its controlled drug disposal policy, which requires two licensed staff to destroy CII–CV medications and complete destruction records. Review of controlled drug records for several residents receiving morphine, lorazepam, oxycodone/APAP, and hydrocodone/APAP showed multiple entries where pills were documented as dropped or wasted by an RN or another nurse without evidence of proper destruction or complete documentation, including one instance where a pill was taken with no date, time, or nurse signature. The Administrator later acknowledged that nursing staff were not discarding controlled substances correctly after an internal audit revealed that these issues were not isolated.
The facility failed to maintain an accurate count and reconciliation of a controlled substance for a resident receiving Lorazepam concentrate. Policy required between-shift counts, accurate documentation on controlled drug records, and immediate reporting of any shortages or overages to the DON and pharmacist. Despite the controlled drug record indicating only a small remaining volume, observation confirmed that the Lorazepam bottle contained a substantially larger amount. An RN acknowledged continuing to deduct doses based solely on the record even though the bottle clearly held more medication, and the Administrator confirmed that staff continued to sign off on the inaccurate controlled drug record while the actual volume in the bottle remained significantly higher than documented.
The deficiency involves a failure to provide adequate supervision to prevent verbal and physical abuse between two residents sharing a bathroom. One resident with dementia, agitation, and a documented history of behavioral symptoms, including recent physical behaviors, repeatedly sang an embarrassing phrase, provoking a verbal exchange with another cognitively intact, wheelchair-propelled resident. The situation escalated into a physical assault in which the aggressive resident punched the other in the face and struck both shins multiple times with a walker, as witnessed by a CNA who responded to calls for help and separated them. The assaulted resident sustained a facial laceration and large bilateral shin hematomas requiring ED evaluation and pain medication, and later continued to have an open shin wound and painful hematomas, while photos also showed bruising to the aggressor’s hand. These events occurred despite an abuse prohibition policy intended to protect residents from verbal and physical abuse.
Staff did not follow fall management protocols when a resident with a recent femur fracture was manually lifted from the floor to a wheelchair by a nurse and CNA after a fall, instead of using a mechanical lift as required by facility policy. Both staff members acknowledged not using the lift, and the DON confirmed this was against protocol.
Two residents with wounds and indwelling medical devices did not receive wound care in accordance with Enhanced Barrier Precautions. An LPN failed to sanitize scissors used during wound care and did not initially apply gauze as ordered, while another LPN placed wound care supplies on an unsanitized surface and returned partially used supplies to a communal cart for use on other residents. The interim DON confirmed that standard precautions and infection control measures were not followed.
A resident with severe cognitive impairment and multiple health conditions was left unsupervised in the dining room and not assessed for hot liquid risk as required by facility policy. The resident spilled hot chocolate on her thigh, resulting in second-degree burns. Staff were not present at the time of the incident, and the required hot liquid risk assessment and interventions were not in place.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
Two residents experienced mental and verbal abuse from a CNA, including rude and discourteous behavior during care and yelling in response to requests for assistance. One resident, with a history of childhood abuse, reported feeling belittled and verbally abused after the CNA questioned her need for help and refused to assist with personal hygiene.
A resident reported being verbally abused and belittled by a CNA when requesting assistance, but the facility did not suspend the CNA or conduct an investigation as required by its abuse policy. The CNA continued to work and have contact with all residents, affecting the safety of all 78 residents.
Multiple residents experienced unsanitary and uncomfortable living conditions due to unclean and poorly maintained rooms and restrooms, including non-functioning sinks and toilets, stained floors and walls, missing toilet tank lids, unlined waste receptacles, and improper disposal of soiled items. Staff and resident interviews confirmed these issues had persisted for extended periods, and facility records documented ongoing complaints about housekeeping and maintenance.
A resident reported to an SLP that a CNA was mean, yelled, and refused restroom assistance. The SLP documented the allegation and gave it to the DON, but neither reported it to the Administrator or the State Agency as required. The Administrator and DON were unaware of the incident until much later, and the allegation was never reported to the State Agency.
A resident with severe cognitive impairment suffered finger bruising when a CNA failed to ensure the resident's hand was inside the wheelchair during a transfer, resulting in the hand being pinched between the wheelchair and table. The facility did not investigate the incident, complete required occurrence documentation, or update the care plan with interventions to prevent future injuries.
A resident, assessed as cognitively intact, reported discomfort with a male CNA's actions during care to both the Activity Director and Activity Aide, but neither staff member reported the allegation to the Administrator/Abuse Coordinator as required by facility policy.
A resident with a history of arthritis and neuropathy did not receive her prescribed Fentanyl Transdermal Patch for over a week, leading to severe pain. The facility failed to perform adequate pain assessments, notify the physician for a refill, or address the resident's complaints. Staff interviews revealed a lack of communication and follow-up, resulting in the resident experiencing significant distress and uncontrolled pain.
The facility failed to maintain proper food safety and hygiene standards, as observed during a survey. The Dietary Manager did not properly cleanse a food thermometer between uses and wore a hairnet incorrectly. Food items in the kitchen were not labeled or dated, and freezers lacked proper temperature monitoring. The dishwashing process did not verify the required temperature, and juice and coffee dispensers were found unclean. These issues could potentially affect all 85 residents.
The facility failed to follow proper hand hygiene and Enhanced Barrier Precautions during medication administration and resident care. An LPN did not sanitize hands between residents, and a CNA provided care without necessary precautions for residents with specific medical needs. Staff were unaware of the required precautions, despite existing protocols.
A facility failed to evaluate and prevent the improper use of physical restraints for a resident with severe cognitive impairment. The resident's care plan included a body pillow tucked under the fitted sheet to prevent falls, but this was used as a restraint without proper assessment or documentation. Staff confirmed the use of the body pillow as a restraint, and the administrator acknowledged the misuse, indicating non-compliance with the facility's restraint policy.
The facility failed to request a PASRR for a resident admitted with Vascular Dementia and other diagnoses. Despite the resident being cognitively intact and having no behavioral issues, the facility did not obtain a PASRR Level I prior to admission, as confirmed by the administrator.
A facility failed to refer a resident for a Level II PASRR evaluation after being diagnosed with Delusional Disorder. The resident, who was already diagnosed with Major Depressive Disorder and Anxiety Disorder, was prescribed Quetiapine for the new diagnosis. The facility's administrator confirmed that a Level II PASRR was not requested.
A facility failed to develop a comprehensive care plan for a resident's oxygen use, despite the resident having a physician's order for oxygen to maintain saturation levels. The resident, diagnosed with Parkinson's Disease and Dementia, did not have an oxygen care plan included in their care plan, as confirmed by a Restorative RN.
The facility failed to provide adequate nail care for a resident with Multiple Sclerosis, resulting in long, jagged nails with brown matter. Additionally, another resident with multiple health conditions did not receive a shower or bath for over two weeks, despite needing assistance with bathing twice a week. The resident expressed dissatisfaction with the inconsistency of bathing schedules.
A facility failed to follow a physician-ordered wound care regimen for a resident with multiple chronic conditions. The resident's treatment, which included daily dressing changes, was not documented as completed on several occasions, as confirmed by the resident and facility staff.
The facility failed to develop and implement services to maintain or improve range of motion (ROM) for two residents with documented limitations. Both residents lacked care plans addressing their ROM needs, and staff confirmed the absence of ROM exercises. Observations showed one resident unable to move her legs independently and another with a foot pointed inward, indicating a lack of necessary restorative care.
A resident with severe cognitive impairment experienced multiple falls despite interventions like a perimeter mattress and bed alarms. The room arrangement and use of a body pillow obstructed staff visibility, hindering effective supervision.
The facility failed to provide proper catheter care for two residents, leading to deficiencies in hygiene and infection control. A CNA did not follow proper procedures during catheter care, failing to use multiple washcloths, change gloves, or perform hand hygiene. Additionally, another resident's catheter bag was repeatedly observed resting on the floor, contrary to facility policy. The Infection Preventionist confirmed the improper positioning of the catheter bag.
A facility failed to label oxygen tubing and a humidifier bottle with the date and initials as required by their policy. A resident receiving oxygen therapy had equipment that was not tagged, despite a physician's order for oxygen to maintain saturation levels. This was confirmed by a registered nurse.
A facility failed to properly monitor and document urinary output for residents with indwelling catheters, leading to significant health issues for two residents. One resident was hospitalized with a UTI and encephalopathy due to lack of physician notification and follow-up on abnormal urinalysis results. Another resident experienced inadequate documentation of urine output without physician notification. These deficiencies resulted in an Immediate Jeopardy situation.
A resident experienced a significant decline in health due to the facility's failure to notify the physician of decreased urinary output and delayed urinalysis collection. The resident, suffering from a UTI, was hospitalized twice, receiving IV fluids and antibiotics. The facility did not follow its guidelines for notifying physicians of significant changes in condition, leading to a lack of timely medical intervention.
A facility failed to ensure a physician was available for emergency calls when a resident experienced significant health changes, including a rash, discharge, and lack of urination. Despite attempts to contact the physician, no response was received, and the resident was eventually sent to the emergency room after the family was informed. The facility's administrator acknowledged issues with reaching a physician while the medical director was on vacation.
A facility failed to timely obtain a physician-ordered urinalysis for a resident, leading to a delay in diagnosis and treatment. The urinalysis was ordered due to decreased urinary output and foul-smelling urine but was not collected until several days later. The resident was eventually hospitalized with a urinary tract infection and encephalopathy. The delay was not communicated to the physician, contrary to facility policy.
Improper Disposal and Documentation of Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of controlled substances in accordance with its own Controlled Drug Handling, Reconciling, Count Discrepancy, & Disposal Policy and Procedure dated 5/30/2017. The policy requires that CII–CV controlled drugs be destroyed by two licensed staff and that records of destruction include the medication name, strength, quantity destroyed, patient name, prescription number, and both signatures and dates destroyed. Review of controlled drug receipt/ disposition records showed multiple instances where controlled medications were documented as dropped or wasted without evidence of proper destruction or complete documentation. For one resident with an order for Morphine Sulphate IR 30 mg every six hours, the record showed entries on two dates by an agency RN indicating “dropped/wasted.” Another resident with an order for Lorazepam 0.5 mg twice daily had an entry documented as “dropped” by the same agency RN. Additional controlled drug records showed similar issues for three more residents. One resident with an order for Oxycodone/APAP 5/325 every eight hours had two separate entries documented as “dropped/wasted” by the same agency RN. Another resident with an order for Hydrocodone/APAP 5-325 mg every six hours as needed had an entry documented as “dropped” by an unidentified nurse. A fifth resident with an order for Hydrocodone/APAP 7.5/325 mg five times daily had a record showing one pill taken with no date, no time, and no nurse signature. In an interview, the Administrator stated she became aware of multiple controlled drug record issues after an agency RN contacted her about medications being packed incorrectly and, upon conducting a house audit, she realized that improper discarding of controlled substances was not an isolated incident. She confirmed that nursing staff were not discarding controlled substances correctly.
Failure to Maintain Accurate Controlled Substance Count for Lorazepam
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate reconciliation and accounting of a controlled substance for one resident receiving Lorazepam concentrate. The facility’s written policy dated 5/30/2017 requires that controlled medications be counted between shifts or whenever there is a change in nurses, that each controlled medication received from the pharmacy be counted and a count sheet initiated by a nurse, and that all shortages or overages be reported immediately to the DON and pharmacist on call. For this resident, the Controlled Drug Receipt Record/Disposition Form dated 1/2/2026 documented an order for Lorazepam concentrate 2 mg/mL, 0.5 cc (1 mg) PO every 2 hours as needed, and showed that only 2 mL remained as of 3/26/2026. However, on 3/25/2026 at 1:10 PM, observation and confirmation by an RN showed that the Lorazepam bottle actually contained 12 mL, which was significantly more than the 2 mL documented on the controlled drug record. The RN stated that she continued to deduct doses from the bottle based on the sheet, despite the visible discrepancy between the recorded amount and the actual volume in the bottle. On 3/26/2026 at 2 PM, the Administrator confirmed that the Lorazepam concentrate for this resident was over by far too much and that nursing staff continued to sign off on the controlled drug record even though the amount in the bottle was far greater than what was being recorded, demonstrating a failure to ensure the narcotic count was correct in accordance with facility policy.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent verbal and physical resident-to-resident abuse, resulting in one resident physically assaulting another. The facility’s Abuse Prohibition Policy, dated 1/29/2026, states that all residents have the right to be free from verbal, sexual, physical, and mental abuse, as well as neglect and exploitation, and defines physical and verbal abuse. One resident (R1) was an older adult with Alzheimer’s disease, dementia with agitation, major depressive disorder, and anxiety disorder, with an MDS indicating moderate cognitive impairment and behaviors occurring every one to three days. R1’s care plan documented behaviors including yelling out, being demanding, making inappropriate sexual comments, touching staff, and, most recently, physical behavioral symptoms. Another resident (R2) was an older adult with osteoarthritis, cardiomyopathy, aortic aneurysm, hypertensive heart disease with heart failure, and idiopathic peripheral autonomic neuropathy, and was cognitively intact and self-propelled in a wheelchair. On the evening of 2/7/26, R1 and R2, who shared a common bathroom, became involved in a verbal altercation in that bathroom. According to the final abuse report, police report, and interviews, R1 and R2 argued, and R1 then struck R2 in the face with closed fists and hit R2’s legs multiple times with R1’s walker. A CNA (V3) reported hearing someone yell for help, entering R2’s room, and observing R1 in the bathroom punching R2 in the chin with closed fists while holding onto R2’s wheelchair, requiring the CNA to physically separate them. R2 reported that R1 had been in the bathroom repeatedly singing a phrase that R2 found embarrassing and aggravating, leading R2 to yell at R1 and call him a derogatory name, after which R1 slammed the walker into R2’s legs repeatedly and punched R2 in the face. Emergency department documentation noted an abrasion to the left side of R2’s face and bilateral hematomas to the shins from being hit multiple times with the walker, with R2 receiving tramadol for pain. Police photographs showed a laceration to R2’s left upper cheek and a softball-sized dark purple hematoma to the right lower leg, and discoloration to R1’s right hand. On later observation, R2 still had an open area on the left shin with a dressing and a large dark red hematoma on the right shin, and R2 stated that the shins remained swollen and painful every day. These events occurred despite the facility’s abuse prohibition policy and R1’s known history of behavioral symptoms, demonstrating a failure to adequately supervise and prevent resident-to-resident abuse.
Failure to Use Mechanical Lift After Resident Fall
Penalty
Summary
Staff failed to follow established fall management safety protocols when a resident with multiple medical conditions, including a recent non-displaced fracture of the left femur, experienced an unwitnessed fall in their room. After the fall, the nurse and a CNA manually lifted the resident from the floor and transferred them to a wheelchair without using a mechanical lift, as required by facility policy. The resident was assessed by the nurse and denied pain at the time of the incident. Facility records, including progress notes, incident logs, and staff disciplinary forms, confirm that the mechanical lift was not used during the transfer. Both staff members involved acknowledged not following the protocol, and the DON verified that the facility's fall management policy mandates the use of a mechanical lift for resident transfers after a fall. The deficiency was identified through record review and staff interviews.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow infection control standards for Enhanced Barrier Precautions during wound care for two residents with wounds and indwelling medical devices. For one resident with a neck wound and an enteral feeding device, an LPN performed wound care without sanitizing the bandage scissors before or after use, and initially failed to cover the wound with gauze as ordered. The LPN also placed the used scissors in her pocket without cleaning them, and there was no wound care policy outlining standard precautions available at the facility. For another resident with a left thigh wound and an enteral feeding device, an LPN placed wound care supplies directly onto the overbed table without sanitizing the surface or using a clean barrier. The LPN also placed an opened roll of gauze and absorbent dressings directly on the table, then returned the partially used supplies to a communal wound cart for use on other residents. The interim Director of Nursing confirmed that standard precautions and infection control measures were not followed during these wound care procedures.
Failure to Supervise and Assess Hot Liquid Risk Leads to Resident Burn
Penalty
Summary
The facility failed to follow its own hot liquids policy, did not identify potential hazards related to hot liquids, and did not provide adequate staff supervision to prevent an accident involving hot liquids. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including dementia, hallucinations, and repeated falls, was not assessed for hot liquid risk as required by facility policy. The resident was left unsupervised in the dining room during meal service, despite being at risk for injury from hot liquids. No hot liquid burn interventions were in place for this resident prior to the incident. As a result, the resident spilled hot chocolate on her left thigh during lunch, sustaining second-degree burns with three blisters. The incident was unwitnessed by staff, and the resident reported that no staff were present in the dining room at the time. Documentation confirmed that the required Hot Beverage Use Assessment had not been completed for the resident, and the Director of Nursing acknowledged that the facility had not been following its hot liquids policy prior to the incident.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Prevent Staff-to-Resident Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect residents from staff-to-resident mental and verbal abuse, as evidenced by two separate incidents involving a Certified Nursing Assistant (CNA). In one case, a resident reported that the CNA was repeatedly rude and discourteous during care, which was confirmed by a complaint form and resulted in a verbal warning for the CNA. The resident described the CNA as appearing frustrated while providing care, which made the resident feel uncomfortable and disrespected. In another incident, a cognitively intact resident with a documented history of childhood abuse reported that the same CNA responded to a call light with a loud and mean tone, questioned the resident's need for assistance, and verbally stated she would not help with personal hygiene. The resident felt belittled, verbally abused, and treated like a child. These actions were corroborated by both the resident and a speech language pathologist who received the complaint and documented the resident's distress.
Failure to Investigate and Protect Residents After Abuse Allegation
Penalty
Summary
The facility failed to implement its Abuse Prohibition Policy after an allegation of staff-to-resident verbal abuse was reported. According to the facility's policy, any employee accused of abuse must be immediately suspended from resident contact pending investigation, and a thorough investigation must be conducted. However, after a resident reported that a CNA yelled at and belittled her when she requested assistance to the restroom, the facility did not suspend the CNA or initiate an investigation. The administrator-in-training confirmed awareness of the allegation but took no action to remove the CNA from resident care or to investigate the incident. The resident involved was cognitively intact and reported feeling verbally abused and belittled by the CNA's actions and words. Documentation showed that the CNA continued to work regular shifts and had contact with all residents during the period following the allegation. The facility's failure to follow its own abuse policy and to protect residents from the alleged perpetrator affected all 78 residents in the facility.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple observations of unclean and poorly maintained resident rooms and restrooms. Surveyors found that several shared restrooms had non-functioning sinks and toilets, with one restroom containing a sink full of standing water and a toilet that would not flush, both of which had been in disrepair for over a year according to staff and residents. Floors around toilets were stained with dark or orange-brown substances, and walls had missing drywall and paint. Additionally, some toilets were missing tank lids, and used washcloths were left on sinks. Waste receptacles were found unlined and contained trash, and there was a strong odor of urine in some restrooms. Interviews with residents and staff confirmed the ongoing nature of these issues, with residents stating that their restrooms had not been properly cleaned or repaired for extended periods. Resident council meeting minutes also documented complaints about agency staff improperly disposing of soiled briefs and housekeeping failing to remove trash on weekends. The facility's own job descriptions for maintenance and housekeeping staff outlined responsibilities for cleaning, repairs, and refuse disposal, but these duties were not being fulfilled as required, resulting in unsanitary and uncomfortable living conditions for multiple residents.
Failure to Timely Report Alleged Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to implement its Abuse Policy by not immediately reporting an allegation of abuse involving a resident to the Administrator and the State Agency. According to the facility's policy, any employee who becomes aware of alleged abuse or neglect must immediately report it to the Administrator, who is then responsible for notifying the resident's representative and the Illinois Department of Public Health (IDPH) both by telephone and in writing. In this case, a resident reported to a Speech Language Pathologist (SLP) that a Certified Nursing Assistant (CNA) was mean, yelled at her, and refused to assist her to the restroom. The SLP documented the allegation and provided it to the Director of Nursing (DON), but neither the SLP nor the DON reported the incident to the Administrator as required by policy. Further review of the facility's records and interviews with staff revealed that the allegation was not reported to the State Agency, and key administrative staff, including the Administrator and DON, were unaware of the incident until much later. Even after the Administrator became aware of the allegation, the facility did not report it to the State Agency, with the Administrator stating that since the report was already late, it did not matter if it was reported at that point. This sequence of actions and inactions resulted in the facility's failure to follow its own abuse reporting procedures and regulatory requirements.
Failure to Investigate and Prevent Resident Injury During Wheelchair Transfer
Penalty
Summary
A resident with severe cognitive impairment sustained bruising to the left third and fourth fingers after a certified nursing assistant (CNA) failed to ensure the resident's hand was inside the wheelchair during a transfer from the dining room table. The CNA admitted to pinching the resident's fingers between the table and the wheelchair, resulting in dime-sized purple bruises. The incident was observed and reported by therapy staff, and the resident was noted to have no pain or issues with finger movement at the time of assessment. Despite the injury, the facility did not complete a Risk Watch Occurrence Form, conduct an investigation into the cause of the injury, or update the resident's care plan with interventions to prevent future injuries. The facility's policy requires immediate care, monitoring, notification of physician and family, completion of an occurrence report, and documentation of the facts and witness statements for any incident or accident affecting a resident. These steps were not followed in this case, as confirmed by the facility administrator.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the Administrator/Abuse Coordinator as required by its Abuse Prohibition Policy. A resident, who was cognitively intact according to her most recent MDS assessment, reported that a male CNA patted her bottom while assisting her at bedtime. She expressed her discomfort to the CNA and requested that he leave, after which the female CNA completed her care. The resident later shared her concerns with both the Activity Director and the Activity Aide, mentioning her discomfort with the male caregiver and specifying that she did not want men providing her care. Despite these disclosures, neither the Activity Director nor the Activity Aide reported the resident's statements to the Administrator/Abuse Coordinator. The Activity Director acknowledged that she did not recognize the statement as a potential abuse allegation at the time, attributing it to confusion with other care-related complaints discussed during a resident council meeting. The Activity Aide also admitted to not reporting the conversation, only realizing in hindsight that it should have been communicated. The Administrator confirmed that both staff members were required by policy to immediately report such concerns.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to administer a prescribed opioid medication, specifically a Fentanyl Transdermal Patch, to a resident, resulting in uncontrolled pain. The resident, who was cognitively intact and had a history of arthritis, neuropathy, and GERD, did not receive her scheduled pain medication from February 17 to February 24. This lapse in medication administration led to the resident experiencing severe pain, rated as high as seven out of ten, which significantly impacted her daily activities and caused distress. The facility's pain management policy emphasizes the importance of promptly assessing and managing pain, involving physicians in the process, and ensuring residents' comfort and dignity. However, during the period in question, the facility did not perform adequate pain assessments or notify the physician about the resident's need for a medication refill and her increased pain levels. The resident repeatedly expressed her discomfort and frustration to staff, but no action was taken to address her pain or secure the necessary medication. Interviews with facility staff, including the administrator and pharmacist, revealed a lack of communication and follow-up regarding the resident's medication needs. The pharmacist confirmed that a refill request for the Fentanyl patch was not received until February 24, and the physician's office was not notified of the need for a refill until the same day. The administrator acknowledged that the staff should have contacted the physician or management to resolve the issue, but this did not occur, leaving the resident in excruciating pain for over a week.
Food Safety and Hygiene Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene protocols, as observed during a survey. The Dietary Manager, identified as V7, did not properly cleanse a food thermometer before use and between checking different food items on the steam table. Instead of using a food-safe sanitizing wipe or alcohol wipe, V7 rinsed the thermometer under tap water and wiped it with a paper towel. Additionally, V7 did not wear a hairnet correctly, leaving a portion of her ponytail uncovered, which is against the facility's policy on personal hygiene. Further deficiencies were noted in the labeling and dating of food items. The kitchen's reach-in refrigerator contained a large tub of lettuce that was not labeled or dated, and the dry food storage room had several opened and undated food items, including bags of pasta, dried milk, breadcrumbs, and cereal. The walk-in refrigerator contained a mislabeled container of ham salad and another container with sandwiches that were not labeled or dated. The facility's freezers also lacked proper temperature monitoring, with one thermometer broken and another missing entirely. The facility's dishwashing procedures were inadequate, as the Dietary Aide, V8, did not use temperature testing strips to ensure the dishwasher reached the required temperature during the rinse cycle. Instead, V8 relied on the digital reading of the machine, which did not verify the surface temperature of the dishes. Additionally, the juice and coffee dispensers in the main dining room were found to be unclean, with visible slime and debris, and there was no documentation to confirm regular cleaning. These failures have the potential to affect all 85 residents residing in the facility.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper hand hygiene and Enhanced Barrier Precautions during medication administration and resident care. A Licensed Practical Nurse (LPN) did not perform hand hygiene between administering medications to different residents, despite handling items such as a television remote and medication cups. The LPN admitted to typically using hand sanitizer, which was missing from the medication cart on the day of observation. This lapse in protocol was observed during the administration of medications to multiple residents, including one who had experienced emesis earlier that day. Additionally, the facility did not implement Enhanced Barrier Precautions for residents with specific medical needs, such as a gastrostomy tube and an indwelling catheter. A resident with a gastrostomy tube did not have the required Enhanced Barrier Precaution sign outside their room, and a Registered Nurse was unaware of the need for such precautions. Similarly, a Certified Nursing Assistant (CNA) provided incontinence care to a resident with an indwelling catheter without sanitizing hands or wearing a gown, as required by the facility's protocol. The CNA was also unaware of the resident's need for Enhanced Barrier Precautions, despite the administrator having a list of residents requiring such measures.
Failure to Evaluate and Prevent Improper Use of Physical Restraints
Penalty
Summary
The facility failed to evaluate and prevent the use of physical restraints for a resident who was at risk of falls. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia with agitation, was found to have a body pillow tucked under the fitted sheet on the left side of the bed. This setup was intended to prevent the resident from getting out of bed or rolling out of bed. The resident's care plan included interventions such as a low bed, concave mattress, body pillow, alarm to bed, and a mat to maintain a safe environment. However, the use of the body pillow as a restraint was not properly assessed or documented as required by the facility's policies. Observations and interviews with staff revealed that the body pillow was used to prevent the resident from self-transferring out of bed, which was not in compliance with the facility's restraint policy. The staff, including CNAs and a restorative registered nurse, confirmed the use of the body pillow as a restraint without a proper assessment. The facility's administrator acknowledged that the staff should not have been using the body pillow in this manner, indicating a lack of adherence to the facility's policies on restraint use and documentation.
Failure to Obtain PASRR for Resident
Penalty
Summary
The facility failed to request a Pre-Admission Screening and Resident Review (PASRR) for a resident, identified as R10, who was part of a sample of 35 residents reviewed for PASRR compliance. R10 was admitted to the facility with diagnoses including Vascular Dementia, Major Depressive Disorder, and Anxiety Disorder. Despite R10's cognitive intactness and lack of behavioral issues as documented in the Minimum Data Set (MDS) Assessment, the facility did not obtain a PASRR Level I prior to R10's admission. This oversight was confirmed during an interview with the facility's administrator, who acknowledged that the PASRR Level I had not been obtained for R10.
Failure to Obtain Level II PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to refer a resident to the PASRR State Agency for a Level II PASRR evaluation after the resident was diagnosed with a mental illness. The resident, identified as R10, was admitted with diagnoses including Major Depressive Disorder and Anxiety Disorder. On November 24, 2023, R10 was diagnosed with Delusional Disorder, a serious mental illness, and was prescribed Quetiapine, an antipsychotic medication, to be taken at bedtime. Despite this diagnosis, the facility did not obtain a Level II PASRR for R10, as confirmed by the facility's administrator, who stated that the request was never made.
Failure to Develop Oxygen Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident's oxygen use, which was identified during a survey. The facility's Resident Care policy requires a comprehensive, person-centered care plan to be developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. This care plan should include goals, measurable objectives, and interventions, and must be completed by day 21 of the resident's stay. The resident in question, who was admitted on 9/28/23, has diagnoses including Parkinson's Disease with Dyskinesia and Dementia, and has a physician's order for oxygen at two liters as needed to maintain oxygen saturation above 91 percent. However, the resident's care plan, printed on 3/5/25, did not include an oxygen care plan, which was confirmed by a Restorative Registered Nurse on 3/4/25.
Deficiencies in Nail Care and Bathing Frequency
Penalty
Summary
The facility failed to maintain proper nail care for a resident diagnosed with Multiple Sclerosis, Osteoporosis, and Hypertension, who was at risk for an ADL self-care deficit. Observations on two separate occasions revealed that the resident's fingernails were long, jagged, and had brown matter underneath. The resident could not recall the last time their nails were clipped and cleaned, and a CNA acknowledged that the nails needed attention, stating they should be trimmed with every bed bath. Additionally, the facility did not ensure that another resident, with a range of medical conditions including Acute and Chronic Diastolic Congestive Heart Failure and Chronic Obstructive Pulmonary Disease, received a shower or bath at least once a week. Despite the resident's care plan indicating the need for assistance with bathing twice a week, records showed a period of over two weeks without a shower or bath. The resident expressed dissatisfaction with the inconsistency of bathing schedules, noting a lack of hygiene maintenance during a bout of influenza.
Failure to Follow Physician-Ordered Wound Care
Penalty
Summary
The facility failed to adhere to a physician-ordered treatment plan for a resident with skin alterations. The resident, a female with a history of multiple chronic conditions including congestive heart failure, respiratory failure, and chronic kidney disease, was admitted with a wound on the umbilical area of her abdomen. The physician's order required daily cleansing, packing with collagen, and application of calcium alginate with silver, covered with a gauze island dressing. However, the Treatment Administration Record (TAR) indicated that the treatment was not performed on several specified dates. The deficiency was confirmed through interviews and record reviews. The resident herself reported that the dressing changes were not conducted as ordered. This was further verified by the facility's administrator and a registered nurse, who acknowledged that the treatment was not documented as completed on the specified dates. This lapse in following the prescribed treatment regimen constitutes a failure to provide appropriate care according to the physician's orders and the resident's needs.
Failure to Implement ROM Services for Residents
Penalty
Summary
The facility failed to develop and implement services to maintain and/or improve range of motion (ROM) for two residents, R3 and R36, who were identified with limitations in ROM. R3's Minimum Data Set (MDS) assessments indicated functional limitations in both lower extremities and a high risk of developing contractures, yet there was no care plan in place to address these limitations. Observations revealed that R3 was unable to move her legs independently and confirmed that staff did not perform ROM exercises with her. Similarly, R36's MDS assessments documented limitations in one side of the upper and lower extremities, with a moderate risk of contractures, but also lacked a care plan for ROM. Observations showed R36's right foot pointed inward, and the resident confirmed the absence of ROM exercises. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Restorative Nurse, corroborated the lack of ROM exercises for both residents. The CNA stated that neither resident received ROM exercises or restorative care, while the Restorative Nurse acknowledged the absence of care plans addressing the residents' ROM limitations. This deficiency highlights the facility's failure to provide necessary restorative programs to prevent further decline in the residents' physical conditions.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident who was severely cognitively impaired. The resident experienced six falls out of bed over a period of several months, with three of these falls resulting in bruising or skin tears. Despite the implementation of various interventions such as a perimeter defining mattress, a body pillow, a concave mattress, a low bed, a fall mat with an alarm, and a bed alarm, the resident continued to fall. The resident's bed was positioned against the wall, and a body pillow was tucked under the fitted sheet, which obstructed visibility from the doorway, making it difficult for staff to supervise the resident effectively. The Restorative Registered Nurse acknowledged that the resident's falls were primarily due to self-transferring or rolling out of bed. The facility's administrator noted that the room arrangement, including the placement of the resident's roommate's recliner, further hindered the ability to supervise the resident from the hallway. The body pillow also contributed to the lack of visibility. The facility's Fall Assessment and Management Policy required assessments on admission, quarterly, and after each fall, but the interventions in place were insufficient to prevent the resident from falling.
Deficiencies in Catheter Care and Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to deficiencies in maintaining hygiene and infection control. For one resident, a Certified Nursing Assistant (CNA) did not follow proper procedures during catheter care. The CNA used a single washcloth to clean the resident's meatus without folding it to use clean parts, did not use a separate washcloth to rinse, and failed to wash the catheter tubing. Additionally, the CNA did not change gloves or perform hand hygiene between handling soiled and clean items, which was acknowledged by the CNA during an interview. Another resident's urinary catheter bag was observed on multiple occasions to be improperly positioned, with half of the bag resting on the floor. This was noted over two consecutive days, despite the facility's policy that the catheter bag should not touch the floor. The resident had a history of chronic kidney disease and benign prostatic hyperplasia with lower urinary tract symptoms, and the improper positioning of the catheter bag was confirmed as inappropriate by the facility's Infection Preventionist.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to adhere to its Oxygen Administration policy by not labeling the oxygen tubing and humidifier bottle with the date and initials for a resident who was receiving oxygen therapy. The policy, dated 1/28/25, requires that nasal cannulas, oxygen tubing, humidifiers, and reservoirs be tagged with the date and initials of the person who changed them, with guidelines specifying that oxygen tubing and humidifier bottles should be changed weekly. On 3/3/25, it was observed that the resident's oxygen tubing and humidifier bottle were not labeled as required. This was confirmed by a registered nurse, who verified the absence of labeling on the equipment. The resident had a physician's order for oxygen at two liters as needed to maintain oxygen saturation above 91 percent, with the order dated 2/3/25.
Failure to Monitor and Document Urinary Output Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure proper care and monitoring of residents with indwelling urinary catheters, leading to significant health issues for two residents. One resident, identified as R1, experienced a lack of documented urinary output for two days without physician notification or medical intervention. This resident was subsequently sent to the emergency room and hospitalized with a urinary tract infection (UTI) positive for ESBL and E. coli, as well as cystitis and hydronephrosis. The facility did not notify the physician of the abnormal urinalysis results or follow up with treatment orders, resulting in a repeated hospitalization for the resident due to a UTI and encephalopathy. The facility's failure to document and communicate changes in the resident's condition, such as decreased or absent urinary output, was evident in the case of R1. Despite the facility's policy requiring notification of significant changes in condition, there was no documentation of physician notification from 12/23/24 to 12/28/24. Additionally, the facility did not obtain a urinalysis as ordered by the physician, and the resident's medical chart lacked documentation of urinary output on multiple occasions. This lack of communication and documentation contributed to the resident's deteriorating health condition and subsequent hospitalizations. Another resident, R5, also experienced issues with urinary output documentation. The facility failed to document urine output on several shifts and did not notify the physician of absent or decreased urinary output. This pattern of inadequate monitoring and communication posed a risk to the health and safety of residents with indwelling urinary catheters, leading to the identification of an Immediate Jeopardy situation. The facility's deficiencies in monitoring, documenting, and communicating changes in residents' conditions were significant factors in the adverse health outcomes experienced by the residents.
Removal Plan
- Implement a new process for shift-to-shift communication and medical provider notification and follow-up to ensure physician orders and labs are obtained timely and the physician is notified of results. This includes a practice to exchange information related to urinary output on each shift verbally with a signature from the CNA and the nurse they are giving report to.
- In-service all clinical staff on monitoring outputs for residents with indwelling catheters, which includes completing, monitoring, reporting, and documenting.
- In-service all licensed staff on physician orders and labs being obtained timely and the notification of the physician timely.
- In-service all licensed staff on physician notification of change in urinary status or any change in condition.
- Educate new staff during onboarding and have an in-service sign-off sheet to show the education has been completed.
- Create a binder for agency staff with the educational documents of the same information all of the in-house staff was educated on, and they are to read and sign off on prior to starting their next shift.
- Monitor for compliance to ensure compliance of intervention by auditing.
Failure to Notify Physician of Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition, specifically decreased or absent urinary output, and did not follow up on abnormal urinalysis results. The resident, identified as R1, had a urinary tract infection (UTI) with no antibiotic medication orders, and the urinalysis lab work was collected four days after it was ordered. These failures led to R1 being transferred to the emergency room for evaluation and subsequent hospitalization, where she received intravenous fluids and antibiotics for a UTI. The resident was diagnosed with urinary retention, cystitis, and hydronephrosis, which could potentially be life-threatening. The facility's guidelines required nurses to notify the physician of significant changes in a resident's condition before the end of each shift. However, there was no documentation of the physician being notified about R1's condition from 12/23/24 to 12/28/24. The medical director and the on-call physician confirmed they did not receive any communication from the facility regarding R1's condition. Additionally, there was a delay in collecting a urinalysis ordered on 1/9/25, which was not collected until 1/13/25, leading to another hospitalization for R1 with a diagnosis of UTI and encephalopathy. The Director of Nursing confirmed the urinalysis should have been collected the same day it was ordered, and the medical director was not informed of the delay.
Failure to Ensure Physician Availability for Emergency Calls
Penalty
Summary
The facility failed to ensure a physician was available for emergency calls related to changes in condition for a resident. The facility's policy requires nurses to notify a physician of significant changes in a resident's condition before the end of their shift. If unable to contact the physician, the nurse may send the resident to the hospital for evaluation. On 12/28/24, a nurse documented that a resident had a rash, brown mucous and discharge from the vagina, and had not urinated in her catheter for two days. The resident's urine culture from 12/23/24 showed an antibiotic-resistant urinary tract infection. Despite these significant changes, there were no new treatment orders or documentation of a physician's response in the resident's medical chart. The facility's administrator acknowledged that nursing staff had issues reaching a physician while the medical director was on vacation. The administrator instructed staff to send residents to the emergency room if they could not reach a physician. The resident was eventually sent to the emergency room after the family member was informed of the situation and agreed to the transfer. The emergency room nurse confirmed that the facility reported being unable to reach the physician for three days. The nurse on duty on 12/28/24 confirmed multiple attempts to contact the physician without success, leading to the decision to involve the family member and send the resident to the emergency room.
Failure to Timely Obtain Urinalysis Leads to Hospitalization
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis result in a timely manner for one resident. On January 9, 2025, a Licensed Practical Nurse (LPN) received an order for a urinalysis due to the resident's decreased urinary output and foul-smelling urine. However, the LPN did not have time to collect the sample and passed the task to the oncoming nurse. The urinalysis was not collected until January 13, 2025, despite the resident's condition worsening, with urine described as dark yellow, containing sediment, and murky. The delay in obtaining the urinalysis was not communicated to the physician, as required by the facility's policy. The resident was eventually catheterized on January 13, 2025, to obtain a urine sample, which was green, thick, and foul-smelling. The resident was subsequently sent to the hospital, where they were diagnosed with a urinary tract infection and encephalopathy, requiring intravenous antibiotics. The Director of Nursing confirmed the lack of documentation for the urinalysis collection on January 9, 2025, and the Medical Director stated that lab tests should be completed the same day they are ordered unless otherwise notified.
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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