Sunset Rehabilitation And Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Illinois.
- Location
- 129 South 1st Avenue, Canton, Illinois 61520
- CMS Provider Number
- 146016
- Inspections on file
- 40
- Latest survey
- December 6, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Sunset Rehabilitation And Health Care during CMS and state inspections, most recent first.
A resident's primary care physician was changed to the facility's Medical Director without notifying the resident or their representative, despite facility policy requiring resident choice and notification. Interviews and record review confirmed that neither verbal nor written notice was provided regarding the change.
A resident with impaired cognition and poor safety awareness, dependent on a wheelchair, was given an open cup of hot coffee without a lid and without adequate supervision. While self-propelling in the hallway, the resident spilled the coffee onto his lap, resulting in a second-degree burn. Staff interviews confirmed awareness of the resident's safety risks, and the facility lacked a policy for hot beverage supervision at the time of the incident.
Two residents experienced falls without proper post-fall assessments, injury identification, or thorough investigation by nursing staff. In both cases, required neurological checks, documentation, and notifications to physicians and family were not completed per policy. Care plans were not promptly updated with new interventions, and staff were not informed of changes, resulting in inadequate supervision and failure to prevent further incidents.
A resident reported to a RN that two CNAs had hurt her with washcloths. The RN documented the allegation and informed the DON hours later, but the DON did not report the incident to the Administrator. Both the Administrator and Interim Administrator confirmed they were not notified of the allegation, resulting in a failure to follow the facility's abuse reporting policy.
A resident with intact cognition reported that a CNA placed a sock in her mouth, but the facility's investigation was incomplete. The Administrator only interviewed the resident and two CNAs involved, did not obtain formal statements, failed to assess the resident for injury, and did not involve Social Services, contrary to facility policy.
A facility failed to perform ongoing clinical assessments for a resident with multiple acute medical conditions, including COPD and a recent cerebrovascular infarction. Despite the facility's policy requiring documentation every shift for new admissions, no assessments were recorded for two days. The resident was eventually transferred back to the hospital due to decreased oxygen levels and altered mental status.
A resident with dysphasia was admitted to a facility with a physician-ordered pureed diet and nectar thick liquids. Despite this, the resident was served a meal with whole bread, diced meat, and regular consistency fluids, leading to choking. The resident's granddaughter, who is also their POA, reported the incident to an LPN, who confirmed the dietary error.
The facility's kitchen was found to be unsanitary, with significant buildup of dust, grease, and food debris. Food items were improperly labeled and dated, leading to confusion about their freshness and safety. Additionally, the facility failed to adhere to proper food cooling and thawing procedures, with inconsistencies in the Food Cooling Log and issues with leaking substances in the walk-in freezer and refrigerator.
A facility failed to align a resident's Physician Orders with their POLST form regarding CPR code status. The Physician Orders listed the resident as 'Full Code,' while the POLST indicated 'DNR' with selective treatment. The Assistant Director of Nursing admitted to missing this inconsistency.
The facility failed to implement dietary recommendations and physician orders for two residents, leading to significant weight loss and inadequate nutritional monitoring. One resident experienced a 15.03% weight loss over six months without receiving prescribed supplements, while another resident's weekly weights were not recorded as ordered. These deficiencies indicate lapses in communication and adherence to policies.
The facility failed to date oxygen tubing, place oxygen signs on doors, and change nebulizer equipment weekly for residents receiving oxygen therapy. A resident with heart failure had undated tubing and no sign on the door, while another with obesity and hypertension had similar issues. A third resident's nebulizer mask was not changed for over a month. The DON confirmed the policy requires weekly changes and proper dating.
A facility failed to attempt a Gradual Dose Reduction (GDR) of Olanzapine for a resident with Bipolar Disorder, despite the resident showing no episodes of paranoid thoughts/behaviors over nine months. The facility's policy requires GDRs to be attempted at least twice a year unless clinically contraindicated. The Assistant Director of Nursing confirmed no GDR was attempted in the past year, and it was unclear why the new psychiatric service did not attempt a reduction.
The facility failed to follow infection control protocols during incontinence care and wound management for two residents. A resident received incontinent care without staff changing gloves or performing hand hygiene. Another resident with multiple wounds was not placed under Enhanced Barrier Precautions, and staff did not wear gowns during wound care, contrary to facility policy.
A resident was found unresponsive in a facility without documented Advanced Directives, resulting in staff failing to perform CPR. Despite the resident's expressed wish to be resuscitated, the absence of documentation led to inaction. The facility's policies on Advanced Directives were not followed, and staff were unclear about their responsibilities, leading to an Immediate Jeopardy situation.
A resident at high risk for pressure ulcers did not receive necessary interventions, such as repositioning and heel protection, leading to the deterioration of heel ulcers. The facility failed to conduct required assessments and treatments, resulting in the progression of the ulcers to more severe stages. Staff were unaware of the resident's condition, and no care plan was developed, highlighting significant lapses in care and communication.
A facility failed to provide adequate urinary catheter care for a resident, as required by their policy. The resident's records showed that catheter care was missed on 80 shifts, and observations revealed a crusty substance at the catheter site. Staff interviews confirmed the site often appeared dirty, indicating a lack of adherence to care protocols.
A resident with a UTI did not receive scheduled doses of Primaxin 500 mg IV due to a failure in obtaining the medication from the pharmacy. The facility's administrator confirmed that the pharmacy did not deliver the antibiotics because of an internal issue, leading to missed doses.
A resident with a UTI did not receive scheduled doses of the prescribed IV antibiotic Primaxin 500 mg on three occasions. The facility's Medication Error Policy mandates reporting and documentation of such errors, but the resident missed doses, which was later confirmed by the resident and the facility administrator.
A resident with a history of sexual aggression was inadequately supervised, resulting in multiple incidents of sexual and physical abuse against other residents. Despite the care plan requiring one-on-one supervision, the resident was left unsupervised, leading to inappropriate contact with several residents, some of whom were severely cognitively impaired. Staff were unaware of the supervision requirements, and no behavior tracking or intervention plan was in place.
A facility failed to implement its abuse prevention policies, resulting in unreported resident-to-resident abuse. A cognitively impaired resident engaged in non-consensual sexual activities with others, but staff did not report these incidents to authorities. The Administrator did not ensure compliance with reporting procedures, leading to ongoing abuse and regulatory non-compliance.
A facility failed to implement its abuse policies, resulting in a resident with a history of sexual aggression having unsupervised access to other residents, leading to multiple incidents of abuse. Despite documented needs for one-on-one supervision, the facility did not provide adequate monitoring or interventions. Staff did not thoroughly investigate or document the allegations, nor did they submit a final report to the State Agency within the required timeframe, allowing the abuse to continue.
The facility failed to protect resident privacy by not addressing the wandering behaviors of two residents, leading to frequent intrusions into other residents' rooms. Despite R8's care plan lacking strategies for his wandering and R38's plan only including general goals, both residents repeatedly entered others' rooms, causing distress. A CNA confirmed these behaviors, indicating a lack of effective interventions to uphold residents' rights to privacy.
Two residents experienced discomfort due to non-functional above-bed lighting and increased room humidity. The lights lacked pull strings, preventing them from being turned off, and a window was left partially open, causing humidity issues. Staff interviews revealed that maintenance was not informed due to a lack of work order submission.
Failure to Notify Resident and Representative of Physician Change
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician by changing the resident's primary care physician without notifying the resident or their representative. According to the facility's Resident Rights Policy, residents are entitled to autonomy and choice regarding their care, including the selection of their physician. The resident was admitted with a specific primary care physician, but the facility switched the resident's physician to the facility's newly hired Medical Director in May 2025. This change was documented in the electronic health record, which showed that the new physician continued to provide care in the following months. Interviews with the resident's family member and representative confirmed that neither was notified, verbally or in writing, about the change in physician. The Assistant Director of Nursing and the Administrator both verified that there was no documentation of notification to the resident or their representative regarding the physician change. The Administrator also stated that the decision to switch all residents to the new Medical Director was made by the facility after the Medical Director was hired.
Failure to Supervise Resident Handling Hot Beverage Resulting in Burn
Penalty
Summary
The facility failed to provide adequate supervision to a resident with moderately impaired cognition and poor safety awareness while handling a hot beverage. The resident, who has a history of chronic medical conditions including COPD, seizures, TIA, cerebral infarction, and unspecified dementia, was given coffee by kitchen staff in an open cup without a lid. The resident, who is dependent on a wheelchair for mobility and requires assistance with transfers and mobility, attempted to self-propel his wheelchair while holding the cup. This resulted in the resident spilling the hot coffee onto his lap, causing burns to his right thigh and knee. Staff interviews confirmed that the resident was frequently seen with coffee and that staff were aware of his impaired safety awareness and cognition. Prior to the incident, the facility did not have a policy regarding the use and supervision of hot beverages. The care plan for the resident did not include interventions such as providing a cup with a lid or staff assistance when handling hot beverages. Multiple staff members, including the CNA, LPN, and DON, expressed concerns about the resident's ability to safely handle hot beverages, noting that he often tilted his cup in his lap while moving in his wheelchair. The lack of a hot beverage policy and failure to implement appropriate supervision or safety measures directly contributed to the resident sustaining a second-degree burn.
Failure to Conduct Post-Fall Assessments and Implement Interventions
Penalty
Summary
The facility failed to follow its own policies and procedures regarding post-fall assessments, injury identification, incident investigation, and implementation of interventions for two residents who experienced falls. In one case, a resident with severe cognitive impairment and multiple medical conditions was found on the floor after an unwitnessed fall. The nursing staff did not conduct a full body assessment prior to moving the resident, and neurological checks were not performed as required by policy. Documentation was incomplete, with missing records of pain assessments, medication administration, and timely notification of the resident's power of attorney and physician. The care plan was not updated promptly to reflect new interventions for skin integrity or fall prevention, and pain management orders from the hospital were not reconciled in the medical record. In another instance, a resident with a history of behavioral issues and recent hospitalization for sepsis experienced a change of plane, interpreted by staff as intentional behavior rather than a fall. As a result, no post-fall assessment, risk management incident report, or follow-up assessments were conducted. The physician and family were not notified, and the event was not documented in the resident's record. Staff interviews revealed a lack of awareness and understanding of the need to document and investigate such incidents, regardless of perceived intent. The facility's investigation into these incidents was limited to direct care staff interviews and did not include a thorough root cause analysis. Staff were not informed of new interventions implemented after the falls, and there was a lack of communication regarding changes to care plans. The deficiencies identified include failure to provide adequate supervision, failure to assess and document post-fall injuries, failure to notify responsible parties, and failure to update care plans and implement interventions to prevent further incidents.
Failure to Report Alleged Abuse to Administrator
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the Administrator as required by its own abuse prevention policy. According to the facility's policy, any employee or agent who becomes aware of abuse or neglect must immediately report the matter to the Administrator or their designee. In this case, a resident reported to a Registered Nurse that two CNAs had hurt her with washcloths. The nurse documented the allegation and reported it to the Director of Nursing (DON) hours later. However, the DON did not report the incident to the Administrator, and both the Administrator and Interim Administrator confirmed they were not informed of the allegation. The failure to report the incident to the appropriate authority resulted in noncompliance with the facility's abuse reporting policy.
Failure to Thoroughly Investigate Alleged Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with diagnoses including cerebral palsy, hypothyroidism, and cerebrovascular disease, who was cognitively intact at the time of the incident. The resident reported to a case manager that a staff member had placed a sock in her mouth. Upon being notified, the Administrator spoke with the resident, who initially denied that the staff member physically placed the sock in her mouth, but later changed her account to confirm the physical act. Despite the facility's policy requiring a comprehensive investigation, including interviews with all relevant staff and residents, formal written statements, assessment for injury by nursing, and a trauma-informed care assessment by Social Services, these steps were not completed. The Administrator only spoke with the resident and the two staff members involved, without obtaining formal statements or conducting broader interviews. No assessment for injury or trauma was performed, and Social Services was not involved in the investigation process. The Administrator acknowledged that the investigation was lacking and did not follow the facility's established procedures for abuse allegations. The failure to conduct a thorough investigation and to document appropriate actions as outlined in the facility's policy resulted in a deficiency related to the facility's response to an alleged violation of resident rights.
Failure to Document Ongoing Clinical Assessments
Penalty
Summary
The facility failed to perform ongoing clinical assessments for a resident experiencing an acute medical condition. The resident, who was admitted to the facility with a history of COPD, asthma, diabetes mellitus, chronic kidney disease, and a recent cerebrovascular infarction, was not assessed or documented on for two days following their admission. The facility's policy requires documentation every shift for new admissions, but no nursing assessments or progress notes were recorded for the resident on 2/6/2025 and 2/7/2025. The resident was admitted to the facility from the hospital with symptoms including decreased appetite, shortness of breath, and wheezing, and was placed on a pureed diet with nectar thick consistency due to speech difficulties. Despite these conditions, the facility did not document any skilled care assessments during the critical period leading up to the resident's transfer back to the hospital due to decreased oxygen levels, altered mental status, and elevated temperature. The Director of Nurses confirmed the lack of documentation and acknowledged that the nurses were not performing necessary assessments.
Failure to Provide Correct Textured Diet to Resident with Dysphasia
Penalty
Summary
The facility failed to provide the correct textured diet to a resident with a documented diagnosis of dysphasia. The resident, who had a history of cerebral infarction, dysphasia, aphasia, diabetes mellitus, chronic kidney disease, and influenza A, was admitted to the facility following a hospital stay where they were placed on a pureed diet with nectar thick consistency liquids. Upon admission to the facility, the resident's physician order sheet and diet order form both specified a pureed diet with nectar thick liquids. However, shortly after the resident's admission, their granddaughter, who is also their power of attorney, observed that the resident was served a meal tray that did not comply with the prescribed diet. The tray contained whole white bread with diced meat and shredded cheese, along with regular consistency cranberry juice and water. The resident began consuming the incorrect meal and subsequently choked. The granddaughter reported the incident to a Licensed Practical Nurse, who confirmed that the resident had been given the wrong diet and fluids, acknowledging the error upon reviewing the resident's medical records.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by observations of significant buildup of dust, grease, and food debris in various areas of the kitchen. The pass-through window over the steam table wells, the microwave, and storage bins containing flour, sugar, brown sugar, and oats were all found to be dirty and unlabeled. Food carts and kitchen equipment such as burners, ovens, and convection ovens were also observed to have old food splatters and grease buildup. The Dietary Manager acknowledged the need for extensive cleaning. Additionally, the facility did not properly label and date food items in storage, leading to confusion about the freshness and safety of the food. The walk-in refrigerator contained several food items with unclear labeling, including pans of barbeque pork, Swiss steak, and puddings, as well as various dairy products and condiments without open dates. Some items were found to be past their expiration dates, and others were covered in mold. The Dietary Manager admitted that the labeling system was not being followed correctly. The facility also failed to adhere to proper food cooling and thawing procedures. The Food Cooling Log showed inconsistencies and inaccuracies, with identical start times and temperatures recorded for different food items, suggesting a lack of proper monitoring. A case of supplements was found thawing in the refrigerator without a thaw date, indicating a lack of awareness of the required procedures. Furthermore, the walk-in freezer and refrigerator had issues with leaking substances, which were not adequately addressed, posing a risk of contamination to stored food items.
Discrepancy in CPR Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's Physician Orders matched their Practitioner Order for Life-Sustaining Treatment (POLST) regarding Cardio-Pulmonary Resuscitation (CPR) code status. Specifically, for one resident reviewed for Advanced Directives, the Physician Orders indicated a 'Full Code' status, while the POLST form, signed by the resident's Power of Attorney, Medical Director, and Care Plan Coordinator, documented a 'Do Not Resuscitate' (DNR) status with selective treatment only. The Assistant Director of Nursing acknowledged the discrepancy, stating responsibility for ensuring the Physician Orders align with the POLST form, and admitted to missing the inconsistency in the resident's November Physician Orders.
Failure to Implement Dietary Recommendations and Monitor Nutritional Status
Penalty
Summary
The facility failed to adhere to a dietician's recommendations and physician orders regarding nutritional supplements for two residents, leading to deficiencies in their care. Resident R66 experienced a significant weight loss of 15.03% over six months, from 153 pounds in May 2024 to 130 pounds in November 2024. Despite the dietician's recommendations for Med Pass supplements to address this weight loss, these orders were not processed by the nursing staff. The dietary recommendations were delayed in being sent to the physician due to the dietary manager's absence, and once signed by the physician, they were not implemented by the nursing staff. Additionally, Resident R43, who was admitted with a gastric tube and diagnoses of dehydration, severe protein-calorie malnutrition, and hypernatremia, did not have their weekly weights recorded as ordered by the physician. The facility's records show only one weight recorded for October 2024, despite the requirement for weekly weight monitoring. The Director of Nursing and Assistant Director of Nursing confirmed the lack of documentation for R43's weekly weights, indicating a failure to monitor the resident's nutritional status adequately. These deficiencies highlight a breakdown in communication and process within the facility, where dietary recommendations and physician orders were not effectively communicated or implemented. The absence of a care plan for R66's unplanned weight loss and the failure to conduct weekly weight assessments for R43 demonstrate lapses in the facility's adherence to its own policies and procedures for monitoring and addressing residents' nutritional needs.
Failure to Comply with Oxygen and Nebulizer Equipment Management
Penalty
Summary
The facility failed to adhere to its Oxygen Administration Policy by not dating oxygen tubing, not placing oxygen signs on resident doors, and not changing nebulizer facemasks and tubing weekly for three residents receiving oxygen therapy. Resident R5, who has diagnoses including congestive heart failure and diabetes, was observed with undated oxygen tubing and no oxygen sign on the door. The tubing was last documented as changed over a week prior. Similarly, Resident R56, with conditions such as morbid obesity and hypertension, was found with undated oxygen tubing and no sign on the door, with no documentation of the last tubing change. Both residents were confirmed by an LPN to be on oxygen without the required signage. Resident R34, who has an order for Albuterol nebulizer treatment, was found using a nebulizer facemask dated over a month prior, contrary to the policy of weekly changes. The Director of Nursing confirmed that the equipment should be changed weekly and dated accordingly. These observations indicate a failure to comply with the facility's policy on oxygen and nebulizer equipment management, potentially impacting the quality of care provided to the residents.
Failure to Attempt Gradual Dose Reduction of Olanzapine
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) of Olanzapine for a resident diagnosed with Bipolar Disorder, who was being monitored for paranoid thoughts/behaviors. Despite the facility's policy requiring GDRs to be attempted at least twice a year unless clinically contraindicated, the resident had not experienced any episodes of paranoid thoughts/behaviors over a nine-month period, as documented in behavior tracking sheets. The resident's psychiatric note indicated that a GDR was clinically contraindicated at the time, yet the facility did not attempt a reduction in the past year. The Assistant Director of Nursing confirmed that the resident had not undergone a GDR of Olanzapine in the last twelve months. The facility had recently started with a new psychiatric service, but it was unclear why a reduction was not attempted in October. The facility's failure to attempt a GDR as per their policy led to the deficiency noted in the report.
Infection Control Deficiencies in Incontinence and Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during the provision of incontinent care and the implementation of Enhanced Barrier Precautions (EBP) for two residents. For one resident, identified as R5, the facility's staff did not change gloves or perform hand hygiene while providing incontinent care. This resident, who was admitted with conditions including morbid obesity and heart failure, was dependent on staff for toileting and occasionally incontinent of bowel and bladder. During an observation, a Certified Nursing Assistant (CNA) removed a soiled brief and cleaned the resident without changing gloves or sanitizing hands, contrary to the facility's incontinence care policy. Another resident, identified as R56, was not placed under Enhanced Barrier Precautions despite having multiple wounds, including a full-thickness abdominal wound and wounds on both ankles. The resident's care plan required daily dressing changes, yet staff did not wear gowns during wound care, and there was no PPE or signage indicating EBP outside the resident's room. The Wound Physician and Wound Nurse both failed to wear gowns while assessing and dressing the wounds, which is a requirement under the facility's EBP policy for residents with open wounds. The Assistant Director of Nursing confirmed that the staff did not follow the EBP protocol for R56, as they were unaware that all wounds required such precautions. This lack of adherence to infection control measures highlights a significant deficiency in the facility's implementation of its own policies, potentially increasing the risk of cross-contamination and infection spread among residents.
Failure to Document Advanced Directives Leads to Critical Incident
Penalty
Summary
The facility failed to formulate and document Advanced Directives for five out of six residents reviewed, leading to a critical incident involving a resident who was found unresponsive. The resident, who had no documented Advanced Directives, was not provided CPR by the staff, despite the absence of a Do Not Resuscitate (DNR) order. The resident's family later confirmed that the resident had expressed a desire to be resuscitated, which was not honored due to the lack of documentation. The facility's policies require that upon admission, residents are informed of their rights to accept or refuse medical treatment and to formulate an advance directive. However, this process was not completed for several residents, including the one who passed away without receiving CPR. The staff involved were unaware of the resident's code status due to incomplete documentation, resulting in a failure to initiate life-saving measures. Interviews with staff revealed a lack of understanding and communication regarding the responsibility for documenting and acting upon Advanced Directives. The admitting nurse did not complete the necessary documentation, and the nurse who found the resident unresponsive did not perform CPR, citing the absence of Advanced Directives in the resident's chart. This oversight led to an Immediate Jeopardy situation, highlighting significant gaps in the facility's adherence to its own policies and procedures.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to adhere to its own policies regarding pressure ulcer prevention and care, resulting in the deterioration of a resident's heel pressure ulcers. The resident, identified as R7, was at high risk for pressure ulcers according to the Braden Scale assessments conducted in March 2024. Despite this, the facility did not implement necessary interventions such as providing a pressure-relieving cushion, turning and repositioning the resident every two hours, or using heel protectors. Furthermore, the facility did not conduct the required weekly Braden Scale assessments or daily skin checks, as evidenced by missing documentation in the resident's medical records. The facility's Treatment Administration Records (TARs) and Physician's Order Sheets (POSs) indicated that R7 did not receive daily skin checks on 24 occasions and weekly skin documentation was only completed once between March and July 2024. Additionally, the physician-ordered skin prep treatment for R7's heels was not administered 82 times during this period. The facility also failed to document the turning and repositioning of R7 every two hours as ordered by the physician. These lapses in care contributed to the progression of R7's heel pressure ulcers from stage one to an unstageable ulcer on the right heel and a stage three ulcer on the left heel. Observations and interviews further highlighted the facility's deficiencies. On multiple occasions, R7 was found lying in bed without heel protection or dressings on the pressure ulcers, and staff were unaware of the resident's treatment needs. The hospice nurse reported that R7 was not being turned or repositioned by facility staff, and the Assistant Director of Nursing and Care Plan Coordinator were unaware of R7's pressure ulcers. The lack of communication and documentation resulted in the absence of a pressure ulcer care plan and appropriate interventions for R7, ultimately leading to the deterioration of the resident's condition.
Failure to Provide Adequate Urinary Catheter Care
Penalty
Summary
The facility failed to maintain proper urinary catheter care for a resident, identified as R7, who was part of a sample of 13 residents reviewed for urinary catheter care. The facility's policy, dated 10-7-22, outlines the necessity of providing catheter care every shift to prevent catheter-associated urinary tract infections. However, R7's Treatment Administration Records (TARs) from 5-16-24 to 7-31-24 indicate that catheter care was not provided on 80 shifts during this period. This lack of care was confirmed by the facility administrator. Observations and interviews further highlighted the deficiency. On 7-27-24, R7 was observed with a crusty brown substance at the catheter insertion site, indicating inadequate cleaning. A hospice nurse and a certified nursing assistant both reported that R7's catheter site often appeared dirty and uncleaned, with dried yellowish drainage. These observations and statements corroborate the failure to adhere to the facility's catheter care policy, resulting in inadequate care for R7.
Failure to Administer Scheduled IV Antibiotics
Penalty
Summary
The facility failed to provide scheduled IV antibiotics to a resident diagnosed with a urinary tract infection. The physician's order required Primaxin 500 mg IV to be administered every six hours. However, the medication administration records show that the resident did not receive the scheduled doses on three occasions. The resident confirmed missing several doses and was informed by the staff that the antibiotics were not delivered from the pharmacy. The facility administrator acknowledged the issue, stating that the pharmacy failed to send the IV antibiotics due to an internal issue with their system, resulting in the missed doses.
Failure to Administer Prescribed IV Antibiotic
Penalty
Summary
The facility failed to administer a physician-ordered intravenous antibiotic to a resident diagnosed with a urinary tract infection. The resident, identified as R8, was prescribed Primaxin 500 mg IV every six hours to treat an infection caused by Extended B-Lactamase E. Coli. However, the medication administration records indicate that the scheduled doses on July 23, 2024, at 2:00 AM, 8:00 AM, and 2:00 PM were not administered. The facility's Medication Error Policy requires nursing personnel to report and document any medication errors, including notifying the attending physician and the resident's power of attorney. Despite this policy, the resident missed several doses of the prescribed antibiotic, as confirmed by the resident and the facility administrator. This oversight was identified during a review of the resident's medication administration records and was acknowledged by the facility administrator, who completed a medication error report.
Failure to Supervise Resident Leads to Multiple Abuse Incidents
Penalty
Summary
The facility failed to adequately supervise a resident with a history of sexual aggression, leading to multiple incidents of resident-to-resident sexual and physical abuse. The resident, who was diagnosed with sexual aggression, dementia with behavioral disturbances, anxiety, and major depression disorder, was not provided with the one-on-one supervision as outlined in their care plan. This lack of supervision allowed the resident to engage in inappropriate sexual contact with several other residents, some of whom were severely cognitively impaired and unable to consent or defend themselves. The incidents involved the aggressive resident sexually assaulting three residents on multiple occasions, groping another resident, and physically assaulting yet another. Despite the care plan specifying the need for constant supervision and behavioral interventions, these measures were not implemented or tracked effectively. Staff interviews revealed that the aggressive resident had been left unsupervised, and there was a lack of awareness among staff about the resident's history and care plan requirements. The facility's failure to implement and monitor the necessary interventions and supervision led to an Immediate Jeopardy situation. The staff, including the administrator, were unaware of the resident's need for one-on-one supervision, and there was no behavior tracking or intervention plan in place to address the resident's inappropriate behaviors. This oversight resulted in repeated incidents of abuse, highlighting significant lapses in the facility's abuse prevention and resident supervision protocols.
Removal Plan
- V1 is no longer employed by the facility.
- R1 was placed on one-on-one staff supervision at all times to prevent recurrence.
- An audit tool was developed and implemented to ensure all staff provide one-on-one staff supervision to R1 indefinitely and is being reviewed by V2 daily to ensure compliance.
- R1's care plan was reviewed and updated with behavioral interventions to address R1's sexually aggressive behaviors towards other residents.
- The IDT met to discuss discharge planning for R1 to a more appropriate setting.
- All staff were in-serviced on the facility's Abuse Policy and providing adequate supervision of residents to prevent further abuse by V7 (Corporate Manager).
- Department supervisors conducted an abuse assessment on all residents to screen all residents for potential abuse, concerns, or incidences.
- V20 (Administrator-In-Training) submitted initial abuse reports for R1, R2, R5, R6, R10, and R11 to the state agency.
- V13 (Social Service Director) completed assessments to address psychosocial needs of R1, R2, R5, R6, R10, and R11.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program policies and procedures, resulting in the failure to identify and report resident-to-resident suspected crimes and abuse immediately to the appropriate authorities. This deficiency involved six residents who were subjected to further criminal sexual and physical assault by another resident. The facility's policy required immediate reporting of any potential or alleged mistreatment, exploitation, neglect, and abuse to a supervisor and the Administrator, as well as contacting the police in cases of physical sexual contact. However, these protocols were not followed, leading to an Immediate Jeopardy situation. The incidents involved a resident who was severely cognitively impaired and engaged in non-consensual sexual activities with other residents. Staff members, including CNAs and LPNs, witnessed or were informed of these incidents but failed to report them to the police, the residents' families, or the state agency. The Administrator, who was responsible for ensuring compliance with the abuse policy, did not take appropriate action to investigate or report these incidents. As a result, the affected residents continued to be exposed to the perpetrator, who admitted to engaging in sexual activities with multiple residents. Interviews with staff and residents revealed a lack of awareness and confusion about the reporting process and the identity of the Abuse Coordinator. Several staff members did not know who to report the incidents to, and there was no documentation of investigations or notifications to the relevant authorities. The facility's failure to follow its abuse policy and ensure staff were informed and trained on reporting procedures contributed to the ongoing abuse and the facility's non-compliance with regulatory requirements.
Removal Plan
- V1 is no longer employed by the facility.
- A mandatory All-Staff meeting was held by V7 (Corporate Manager) to educate staff on the Abuse Program and to ensure all staff are informed of who the Abuse Coordinator is and the process for reporting allegations of abuse. Those staff, including agency staff, not in attendance at this training will be in-serviced by a department head prior to their next scheduled shift.
- V20 (Administrator-In-Training) submitted initial abuse reports for R1, R2, R5, R6, R10, and R11 to the State Agency.
- V20 notified R1, R2, R5, R6, R10, and R11's family representatives of all allegations of abuse.
- V20 notified the police of all allegations of abuse of R1, R2, R5, R6, R10, and R11.
Failure to Implement Abuse Policies Leads to Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policies and procedures effectively, resulting in multiple incidents of sexual and physical abuse by a resident with a history of sexual aggression and severe cognitive impairment. The resident, identified as R1, had unsupervised access to other residents, leading to repeated assaults on several residents, including R2, R5, R6, R10, and R11. Despite R1's documented history of sexual inappropriateness and the need for one-on-one supervision, the facility did not provide adequate monitoring or interventions to prevent further abuse. The facility's staff, including the administrator and director of nursing, did not thoroughly investigate the allegations of abuse or implement measures to ensure the safety and supervision of residents during the investigation. Reports of R1's inappropriate behavior were not properly documented or addressed, and the facility failed to submit a final report of the investigation to the State Agency within the required five working days. This lack of action allowed R1 to continue having unsupervised access to other residents, exacerbating the risk of further abuse. Interviews with staff and residents revealed a pattern of neglect in addressing R1's behavior. Staff members were aware of R1's actions but did not take appropriate steps to separate R1 from other residents or increase supervision. The facility's failure to act on these reports and implement effective interventions contributed to the ongoing risk and occurrence of abuse, resulting in an Immediate Jeopardy situation.
Removal Plan
- V1 is no longer employed by the facility.
- R1 was placed on one-on-one staff supervision at all times to prevent recurrence.
- An audit tool was developed and implemented to ensure all staff provide one-on-one staff supervision to R1 indefinitely and is being reviewed by V2 daily to ensure compliance.
- R1's care plan was reviewed and updated with behavioral interventions to address R1's sexually aggressive behaviors towards other residents.
- The IDT met to discuss discharge planning for R1 to a more appropriate setting.
- A mandatory All-Staff meeting was held by V7 (Corporate Manager) to educate staff on the Abuse Program and to ensure all staff are informed of who the Abuse Coordinator is and the process for thoroughly investigating all allegations of abuse, protecting residents from abuse while the investigation is underway, and reporting to IDPH with a five-day final report. Those staff, including agency staff, not in attendance at this training will be in-serviced by a department head prior to their next scheduled shift.
- V20 (Administrator-In-Training) submitted final abuse reports for R1, R2, R5, R6, R10, and R11 to the State Agency.
- Department supervisors conducted an abuse assessment on all residents to screen all residents for potential abuse, concerns, or incidences.
- V13 (Social Service Director) completed assessments to address psychosocial needs of R1, R2, R5, R6, R10, and R11.
Failure to Address Wandering Behaviors Infringes on Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by not adequately addressing the wandering behaviors of two residents, identified as R8 and R38. R8's care plan did not include any strategies to manage his wandering behavior, while R38's care plan acknowledged impaired cognition and wandering due to Lewy Body Dementia but only included general goals of supervision and redirection. This lack of specific interventions led to multiple incidents where these residents entered the rooms of other residents, infringing on their privacy. Several residents reported frequent and unwanted intrusions by R8 and R38. For instance, R3 experienced an intrusion by R8, who entered his room and bathroom, despite R3's protests. Similarly, R4, R46, and R47 expressed discomfort and frustration over R8 and R38 entering their rooms uninvited, with R46 noting that R8 entered his room about ten times a day. A CNA confirmed that both R8 and R38 were known to wander into other residents' rooms, and staff attempted to redirect them when possible. These incidents highlight the facility's failure to implement effective measures to protect residents' rights to privacy and a homelike environment as outlined in their Residents' Rights policy.
Failure to Maintain Comfortable and Homelike Environment
Penalty
Summary
The facility failed to ensure that the above-bed lighting was in working condition and that room temperatures were kept at comfortable levels for two residents. During an observation, it was noted that both residents' above-bed lights were missing pull strings, making it impossible for them to turn the lights on or off. One resident expressed difficulty sleeping due to the lights being on all night. Additionally, the window in their room was found to be unlocked and partially open, allowing outside air to enter and causing increased humidity and discomfort. Interviews with staff revealed that the maintenance director was unaware of the issue because a maintenance work order slip had not been filled out. The administrator-in-training acknowledged the problem and indicated that new switches were needed for the lights. A CNA confirmed that the lights had been on continuously, even during the night, due to the missing pull strings. The facility's failure to address these issues resulted in an environment that was not safe, clean, comfortable, or homelike, as required by their Residents' Rights policy.
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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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