Sunrise Skilled Nur & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Virden, Illinois.
- Location
- 333 South Wrightsman Street, Virden, Illinois 62690
- CMS Provider Number
- 145783
- Inspections on file
- 36
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Sunrise Skilled Nur & Rehab during CMS and state inspections, most recent first.
A resident with a history of psychiatric diagnoses reported a new allegation of sexual abuse to hospital staff, which was communicated to the facility. Despite facility policy requiring all abuse allegations to be reported and investigated, facility staff did not report or investigate this new allegation, citing its similarity to a previous incident that had already been addressed.
A resident with a history of psychiatric diagnoses and cognitive intactness reported sexual abuse to hospital staff, prompting the hospital case manager to notify facility leadership. Despite this new allegation, the Administrator and DON did not report it, citing a previous similar report, which was not in accordance with the facility's abuse reporting policy.
A resident with a history of paranoid schizophrenia and delusional disorder reported a new allegation of sexual abuse during a hospital stay, stating the incident occurred at the facility several weeks prior. Despite being notified by hospital staff, facility personnel did not investigate the new allegation, citing a previous similar report, and did not follow their abuse policy requiring investigation of all allegations.
A resident with severe cognitive impairment and high fall risk, who required two-person assistance and a mechanical lift for transfers, was transferred by a single CNA, resulting in a fall. The resident sustained injuries that were not initially detected but were later found to include a right hip fracture, leading to deep vein thrombosis and pulmonary embolism, which contributed to her death. The deficiency was due to failure to follow the resident's care plan for safe transfers.
A deficiency was cited when an area of the facility was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment presented risks that were not mitigated, and supervision was not sufficient to ensure resident safety.
A resident receiving Warfarin for pulmonary embolism did not have required PT/INR lab monitoring performed as ordered by the physician. The lapse in monitoring led to the resident being hospitalized with a critically high INR, acute blood loss anemia, and GI bleeding, requiring reversal of anticoagulation and multiple transfusions. Facility staff and records confirmed the ordered lab tests were not completed.
A resident with severe cognitive impairment and a history of dementia and Alzheimer's disease was found on the floor after a fall. Although a fall alarm was present, it was not properly connected following care provided by hospice staff, resulting in the alarm not functioning as intended and failing to alert staff to the resident's attempt to stand.
The facility failed to store medications at the correct temperature and did not dispose of expired medications, affecting all residents. The medication refrigerator was found to be above the recommended temperature range, and the temperature log was incomplete. Various medications, including insulin pens and IV bags, were stored improperly. An open vial of TB solution and an expired bottle of thiamin tablets were also found. The facility's policy requires proper storage and timely disposal of medications, which was not followed.
The facility failed to provide adequate incontinence care and maintain proper hygiene practices for several residents. A CNA was observed using the same soiled gloves multiple times, contaminating clean water during peri-care. Another resident on contact precautions did not receive proper glove changes or hand hygiene between wipes. Additionally, a resident with hemiparesis was left waiting for assistance, resulting in skin irritation and improper peri-care. These actions violated the facility's incontinence care policy.
The facility failed to follow infection control protocols, with staff not using appropriate PPE and neglecting hand hygiene. A CNA entered a resident's isolation room without PPE, and another used soiled gloves during peri-care, contaminating clean water. An RN did not perform hand hygiene before and after administering medications, and a CNA and COTA did not wash hands before or after transferring a resident. These actions violated the facility's policies on infection prevention.
A facility failed to prevent pressure ulcers in a cognitively impaired resident with incontinence issues. Despite a care plan indicating the need for assistance with repositioning, the resident was left sitting in a soiled state for extended periods, leading to skin redness and potential ulcer development. CNAs were unaware of the resident's skin condition, and there was a lack of consistent skin assessments and preventative measures.
The facility failed to implement safety interventions for residents, leading to deficiencies in care. A resident at high risk for falls did not have prescribed fall prevention measures in place, while another resident with a history of unsafe smoking was found unsupervised. Additionally, a resident with severe cognitive impairment was found on the floor without necessary fall prevention measures activated.
Failure to Report and Investigate New Allegation of Abuse
Penalty
Summary
The facility failed to follow its abuse policy by not reporting and investigating a resident's allegation of sexual abuse. The resident, who had diagnoses including paranoid schizophrenia and delusional disorder and was cognitively intact and dependent for transfers, expressed concerns of sexual abuse while hospitalized and requested a transfer to another facility. The hospital social worker and case manager both reported the resident's allegation, which was said to have occurred two to three weeks prior to hospitalization, to the facility. However, facility staff, including the Administrator and DON, did not report or investigate the new allegation, stating it was similar to a previous allegation made by the resident months earlier that had already been investigated. The facility's abuse policy requires immediate and thorough investigation of all abuse allegations and timely reporting to the appropriate authorities. Despite this, the facility did not initiate a new investigation or report the recent allegation, as required by their policy, because they considered it a repeat of a previously addressed concern. This failure was confirmed through interviews with facility staff and review of the facility's documentation and policies.
Failure to Report New Allegation of Abuse
Penalty
Summary
The facility failed to report a new allegation of abuse for one resident who was admitted with diagnoses including paranoid schizophrenia and delusional disorder, and who was cognitively intact and dependent for transfers. The resident reported to hospital staff that she had been sexually abused while at the facility and requested a transfer upon discharge. The hospital case manager notified the facility of this new allegation, which reportedly occurred two to three weeks prior to the resident's hospitalization, and the resident was unable to identify the perpetrator. Despite being informed of the new allegation, facility leadership, including the Administrator and DON, did not report it to authorities, stating that a similar allegation had been reported by the resident several months earlier. The facility's abuse policy requires all allegations of abuse to be reported in a timely manner according to state and federal guidelines, but this policy was not followed in this instance.
Failure to Investigate New Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate a new allegation of sexual abuse made by a resident with diagnoses of paranoid schizophrenia and delusional disorder. The resident, who was cognitively intact and dependent for transfers, reported during a hospital stay that she had been sexually abused at the facility two to three weeks prior to her hospitalization. The hospital's case manager and social worker both communicated this new allegation to facility staff, noting that the resident did not know the identity of the perpetrator. Despite being notified of the new allegation, facility staff, including the administrator and other personnel, did not initiate an investigation. They stated that a similar allegation had been investigated in the past and therefore did not pursue the current report. The facility's abuse policy requires immediate and thorough investigation of all abuse allegations, but this policy was not followed in this instance.
Failure to Follow Transfer Protocols Resulting in Resident Fall and Fatal Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple comorbidities, including dementia, osteoporosis, and a history of fractures, was not transferred according to her care plan requirements. The resident's care plan specified that she required two-person physical assistance and the use of a full body mechanical lift device for all transfers and bed mobility due to her high fall risk and extensive assistance needs. Despite these documented interventions, a CNA attempted to transfer the resident alone, during which the resident's knees buckled, and she was lowered to the floor, resulting in a fall. Following the fall, the resident sustained a skin tear to her right elbow and began to complain of pain in her left leg the next day. Initial x-rays did not reveal any fractures, but the resident continued to experience pain and decreased mobility. The resident was under hospice care, and pain management was provided as the primary intervention. The resident's condition deteriorated, and she passed away several days after the fall. An autopsy later revealed a right femoral neck fracture, deep vein thrombosis, and pulmonary thromboembolism, which were determined to be consequences of the fall and contributed to the resident's death. Interviews with facility staff confirmed that the resident should not have been transferred by a single staff member, as her care plan required two-person assistance and mechanical lift use. The failure to follow the established care plan and provide adequate supervision and assistance during transfers directly led to the resident's fall and subsequent fatal injury.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment posed risks that were not addressed, and supervision was insufficient to prevent potential incidents. No further details about the specific hazards, the nature of the supervision, or the residents involved are provided in the report.
Failure to Monitor Anticoagulant Therapy Leads to Hospitalization
Penalty
Summary
The facility failed to obtain physician-ordered laboratory testing for a resident who was receiving Warfarin for a diagnosis of pulmonary embolism. Despite having a physician order dated 4/23/25 to check PT/INR levels weekly, the resident's PT/INR was not monitored as required. The last PT/INR test was completed on 3/26/25, and no further tests were performed after that date, even though the resident continued to receive Warfarin. This lapse in monitoring was identified when the resident was admitted to the hospital with a supratherapeutic INR greater than 10, well above the target therapeutic range of 2-3. Hospital records documented that the resident suffered from acute blood loss anemia, probable gastrointestinal bleed, and required reversal of Warfarin with Kcentra, as well as multiple blood transfusions. The resident's family member expressed concern that the required INR checks were not being performed, and the attending physician confirmed that the weekly monitoring order had been given but not followed. Facility staff interviews and record reviews confirmed that the PT/INR tests were not conducted as ordered, and the Director of Nursing acknowledged that the tests should have been performed but were not. The facility's own anticoagulant policy required regular monitoring of PT/INR for residents on Warfarin, but this was not adhered to in this case, resulting in the resident experiencing significant medical complications.
Removal Plan
- Audit of all resident laboratory orders was completed by Director of Nursing.
- Audit of all residents that have physician orders for Warfarin were identified and have active lab orders for PT/INRs to monitor for therapeutic effectiveness was completed by Director of Nursing.
- Facility licensed nursing staff were educated by phone or in person in the following categories: Obtaining laboratory testing as ordered by the physician, with special consideration for those residents on Warfarin by Director of Nursing.
- Audit of all scheduled labs was completed, including PT/INRs by Director of Nursing.
- Audit of all residents with Warfarin medication orders were ensured to have scheduled laboratory testing of PT/INRs to monitor for therapeutic effectiveness by Director of Nursing.
- Director of Nursing initiated a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary.
- Licensed agency staff will not work at the facility until they are educated by the Director of Nursing/Designee on the importance of ensuring PT/INR levels are ordered with Warfarin to monitor for therapeutic effectiveness.
- The facility will educate all Agency and Facility licensed nursing staff on a quarterly basis and during orientation on the order process for labs, with emphasis on the need for therapeutic monitoring for effectiveness for residents with medication orders for Warfarin, by the Director of Nursing or Designee.
- The Director of Nursing or designee has put into place a Warfarin tracking system that consists of reviewing the Electronic Medical Record to ensure that any resident with new orders for Warfarin have orders in place for monitoring therapeutic effectiveness with a PT/INR laboratory testing and results are obtained and the resident's physician are notified of those results with new orders obtained as necessary.
- The Director of Nursing or designee will complete random audits of scheduled laboratory testing as ordered by the physician, with special consideration for those residents on warfarin until compliance is achieved.
- Results of the above reviews will be discussed at a weekly quality assurance meeting that the Administrator is the head of/holds and will provide additional education as needed and implement interventions for improvement until resolution.
Failure to Ensure Proper Functioning of Fall Alarm
Penalty
Summary
A resident with diagnoses of dementia and Alzheimer's disease, who was severely cognitively impaired and required partial to moderate assistance for transfers, experienced a fall in their room. The resident was found lying on the floor by staff, and it was noted that although an alarm was present on the resident's recliner, it was not properly attached to the alarm box. Earlier in the day, hospice staff had provided a bath for the resident but did not reconnect the alarm correctly afterward. The facility's documentation indicated that the root cause of the incident was the alarm box malfunction, specifically that the alarm was not properly connected. The facility's policy requires that all accidents and incidents be investigated and reported, with the interdisciplinary team responsible for determining the root cause and implementing interventions. The failure to ensure the fall alarm was functioning as intended directly contributed to the resident's fall.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to store medications at the appropriate temperature and did not dispose of expired multi-dose or stock medications, potentially affecting all 83 residents. During an inspection of the South-East medication room, it was observed that the medication refrigerator contained two thermometers reading 50 degrees Fahrenheit, which is above the recommended range of 36 to 46 degrees Fahrenheit. The temperature log for the refrigerator was incomplete, with several dates missing, and recorded a temperature of 48 degrees Fahrenheit on one occasion. The refrigerator contained various medications, including insulin pens, liquid vancomycin, and IV bags of daptomycin, which were stored at an incorrect temperature. Additionally, an open vial of TB solution with an open date was found in the refrigerator, and it was noted that such a vial is considered expired after 30 days. The South medication cart contained an expired bottle of thiamin vitamin B-1 tablets. The facility's policy on medication storage requires that medications be stored safely and securely, following the manufacturer's recommendations, and that opened vials be dated and used within 30 days unless otherwise specified. The failure to adhere to these policies was confirmed through interviews with the LPN and the Administrator, who acknowledged the issues with the refrigerator and the expired medications.
Deficiencies in Incontinence Care and Hygiene Practices
Penalty
Summary
The facility failed to provide timely and complete incontinence care for several residents, leading to deficiencies in care. For instance, a Certified Nursing Assistant (CNA) was observed providing peri-care to a resident with severe cognitive impairment and multiple health conditions, including dementia and chronic kidney disease. During the care, the CNA used the same soiled gloves multiple times, contaminating the clean water used for cleaning the resident, which is against proper hygiene protocols. Another incident involved a resident on contact precautions for Extended-Spectrum Beta-Lactamase (ESBL) of urine. The CNA failed to change gloves or perform hand hygiene between wipes while providing peri-care, which is a breach of infection control practices. This resident was also found without a brief and lying on a slightly saturated bed pad, indicating a lack of timely incontinence care. Additionally, a resident with a history of cerebral vascular accident and hemiparesis was left waiting for assistance to use the toilet for an extended period, resulting in a urine-saturated brief and subsequent skin irritation. The CNA did not perform proper peri-care, as evidenced by the resident's pain and the presence of stool and skin tears. The facility's incontinence care policy requires changing gloves and performing hand hygiene to prevent cross-contamination, which was not adhered to in these cases.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple instances of staff not using appropriate Personal Protective Equipment (PPE) and neglecting hand hygiene. A Certified Nursing Assistant (CNA) entered a resident's room, who was on contact isolation for C. difficile, without wearing the required gown and gloves. The CNA admitted to forgetting to don the PPE and was observed using hand sanitizer instead of washing hands with soap and water, which is necessary after contact with a resident with infectious diarrhea. Another incident involved two CNAs providing peri-care to a resident without changing soiled gloves, contaminating clean water used for washing the resident. This action violated the facility's policy on incontinence care, which requires changing gloves and performing hand hygiene to prevent cross-contamination. Additionally, a Registered Nurse (RN) failed to perform hand hygiene before and after administering medications to a resident, even after touching potentially contaminated surfaces, such as the resident's lap and the floor. Further deficiencies were noted when a CNA and a Certified Occupational Therapy Assistant (COTA) did not perform hand hygiene before or after transferring a resident using a mechanical lift. The facility's hand hygiene policy emphasizes the importance of handwashing to prevent the spread of infections, yet staff failed to comply with these procedures. The Assistant Director of Nursing and the facility's Administrator both expressed expectations for staff to follow proper hand hygiene and PPE protocols, which were not met in these instances.
Failure to Prevent Pressure Ulcers in Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and did not implement adequate preventative measures for a resident with severe cognitive impairment and incontinence issues. The resident, diagnosed with dementia and disturbances of skin sensation, was found to have an unstageable pressure ulcer acquired in-house, which began on April 25, 2024. Despite the care plan indicating the resident was at risk for impaired skin integrity and required assistance with turning and repositioning, observations revealed that the resident was left sitting in a soiled state for extended periods, contributing to skin redness and potential ulcer development. On multiple occasions, the resident was observed in a wheelchair for prolonged periods without being repositioned or checked for incontinence, contrary to the facility's pressure ulcer prevention policy. Certified Nursing Assistants (CNAs) were unaware of the resident's skin condition, and there was a lack of consistent skin assessments and preventative measures, such as floating the heels while in bed. The facility's failure to adhere to its own guidelines for pressure ulcer prevention and treatment contributed to the resident's compromised skin integrity.
Failure to Implement Safety Interventions for Residents
Penalty
Summary
The facility failed to ensure that care plan interventions were followed for several residents, leading to safety and supervision deficiencies. Resident R17, who was at high risk for falls due to severe cognitive impairment and multiple health conditions, did not have the prescribed fall prevention measures in place. Observations revealed that R17's wheelchair lacked dycem, and a pressure alarm was not activated while the resident was in bed, contrary to the care plan. Staff interviews confirmed the absence of these interventions, indicating a lack of communication and adherence to the care plan. Resident R46, who was cognitively intact but had a history of unsafe smoking practices, was found smoking unsupervised without a smoke apron, despite a recent incident where she singed her hair. The facility's smoking policy required assessments and supervision for residents who smoke, but R46's smoking assessments were incomplete, and the necessary supervision was not provided. This oversight allowed R46 to engage in potentially hazardous behavior without the required safety measures in place. Resident R64, with severe cognitive impairment and a high risk for falls, was found on the floor with fall prevention measures not implemented. The fall mat was folded against the wall, the call light was out of reach, and the bed alarm was not activated. Despite previous falls and a high fall risk assessment, the facility did not ensure that interventions were in place to prevent further incidents. Staff interviews highlighted a reliance on visual monitoring rather than ensuring the physical safety measures were in place, contributing to the resident's fall.
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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