Symphony Maple Crest
Inspection history, citations, penalties and survey trends for this long-term care facility in Belvidere, Illinois.
- Location
- 4452 Squaw Prairie Road, Belvidere, Illinois 61008
- CMS Provider Number
- 145990
- Inspections on file
- 36
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Symphony Maple Crest during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow infection control practices for handling soiled linens and washcloths. In one room, a friend reported stool on a resident’s bedding, and the soiled bedding was later observed placed directly on the floor, where it remained for an extended period and was stepped on by a CNA who had removed it without having a bag available. The roommate reported that staff typically put dirty linens on the floor before bagging them. In another room, soiled washcloths were observed on the floor next to a trash can with no staff present. These practices did not comply with the facility’s policy requiring soiled linens and briefs to be treated as potentially infectious and placed in plastic bags or appropriate containers for transport.
A resident with multiple comorbidities and a history of pressure ulcers developed two new pressure injuries on the buttocks that were not identified by staff until they became unstageable. Despite orders for regular skin checks, the wounds progressed to advanced stages, with one requiring debridement and being classified as a stage 4 pressure injury. Staff interviews indicated that the resident's preference to remain seated and refusal of showers limited opportunities for thorough skin assessments.
A newly admitted resident with multiple diagnoses did not receive their prescribed medications for a scheduled dose. The facility's staff failed to administer medications as ordered, despite having a convenience box and a policy for safe medication administration. The resident's daughter brought medications, but the facility had already ordered them from their pharmacy.
The facility failed to provide adequate staffing, resulting in delayed care and unmet needs for residents. Residents experienced long waits for incontinence care, and staff were distracted by personal cell phones. Several residents were found with saturated briefs, and one developed a pressure injury due to inadequate wound care. The facility also had a high medication error rate and failed to provide snacks consistently, as indicated by a one-star staffing rating.
The facility failed to label opened insulin bottles and pens with expiration dates for four residents, as required by their medication storage policy. An LPN confirmed that insulin should be dated when opened, typically expiring 28 days later. The facility's policy mandates labeling opened medications with a date opened sticker and a new expiration date, which was not followed in this case.
The facility failed to follow infection control protocols, with staff not wearing PPE in contact isolation and enhanced barrier precaution situations, and not changing gloves during incontinence care, risking cross-contamination. A CNA entered a contact isolation room without PPE, and two CNAs did not wear gowns while caring for a resident with a pressure injury. Additionally, CNAs did not change gloves after providing incontinence care, contrary to facility policies.
A resident's privacy and dignity were compromised when a CNA provided peri-care with the room door open, exposing the resident to the hallway. The resident was later seen in a shower chair with their pants down, being pushed down the hallway, leaving fecal matter on the floor. This violated the facility's policy requiring privacy during incontinence care.
Three residents requiring extensive assistance with incontinence care were left in saturated briefs for extended periods, leading to wet clothing and skin irritation. Despite the facility's policy to check and change residents every two hours, this was not followed, resulting in inadequate care.
The facility failed to conduct weekly wound assessments and ensure proper pressure ulcer care for two residents. One resident developed a new unstageable pressure injury that was not consistently dressed, and another resident with a Stage 3 heel ulcer was not provided with the recommended heel boots to off-load pressure. Staffing issues contributed to these deficiencies.
A resident with dementia and dysphagia experienced significant weight loss, dropping from 126.4 lbs to 117.2 lbs in one month. The facility failed to conduct weekly weight monitoring as recommended by the RD and did not provide the prescribed supercereal at breakfast. The facility's policy required re-weighing and notifying the physician and RD for significant weight changes, but these steps were not followed.
The facility failed to properly administer and manage oxygen therapy for two residents. A resident was switched to a portable oxygen tank by non-nursing staff without a physician's order, and another resident's oxygen tubing was not changed weekly as required. These actions were against the facility's protocols and physician orders.
The facility experienced a 31.25% medication error rate due to late administration of medications to three residents. An LPN administered medications late to a resident due to being behind schedule, while another LPN was delayed by attending to a deceased resident. The facility's medication pass schedule was not followed, leading to errors.
Two residents in an LTC facility suffered injuries due to inadequate supervision and failure to follow safety protocols. One resident, with a history of falls, attempted to self-transfer without a gait belt, resulting in a femur fracture. Another resident, with Parkinson's and a fractured arm, fell from a wheelchair lacking foot pedals during transport, requiring 21 sutures. Both incidents highlight the facility's failure to adhere to safety policies and provide adequate staff support.
A resident with cognitive impairments and decreased safety awareness sustained severe burns after spilling hot coffee on her thighs. The facility failed to monitor and log the temperatures of hot beverages before serving them, with the hot water machine set at a high temperature. Staff interviews revealed a lack of awareness and training regarding safe hot beverage handling, contributing to the deficiency.
A resident who requires assistance with ADLs did not receive scheduled showers, leading to discomfort and an itchy scalp. The resident, who has no cognitive impairment, reported missing showers on her designated days. The DON confirmed the oversight and acknowledged the importance of adhering to the shower schedule for hygiene purposes.
A resident with bladder incontinence and a history of UTIs was not provided thorough incontinence care, as a CNA only cleaned the frontal area and neglected the buttocks and thighs. This was against the facility's policy and care plan, which aimed to prevent skin breakdown and infection. An LPN confirmed the need for comprehensive cleaning to avoid skin irritations.
A resident with dementia and other health issues experienced verbal abuse from a CNA, who yelled at him and pushed him into his room, violating the facility's abuse prevention policy. The incident was witnessed by staff, leading to the CNA's termination.
The facility failed to ensure newly-hired nursing staff received dementia care training before caring for residents. Several CNAs and an LPN worked multiple shifts without the required training, as confirmed by interviews and record reviews. The HR and DON acknowledged the lapse, citing immediate staffing needs and recent changes in leadership.
The facility failed to supervise a dementia resident, leading to the resident wandering into other residents' rooms. Despite a care plan indicating the need for close monitoring, staff did not adequately supervise the resident, resulting in multiple incidents and distress to other residents. Staff also reported not receiving dementia training, contributing to the inadequate supervision.
Improper Handling of Soiled Linens and Washcloths
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to the handling of soiled linens and washcloths for multiple residents. On one occasion, a friend of a resident reported stool on the resident’s bedding to the Laundry and Housekeeping Manager, who stated she would inform staff that the bedding needed to be changed. Shortly thereafter, surveyors observed the soiled bedding from that resident’s bed placed directly on the floor with nothing underneath it. The resident’s roommate reported that staff usually put dirty linen on the floor and then bag it when they are done. A CNA acknowledged placing the bedding on the floor because she realized there was no bag available after removing the soiled linens and left to get one. Later the same day, the soiled bedding remained on the floor, and the same CNA stepped on it while walking past to retrieve an item. Another staff member, identified as a CNA/Ward Clerk, stated that soiled linens should be either in a bag or in the linen room, and the CNA reiterated that she had removed the bedding before realizing she did not have a bag. In a separate observation that afternoon, another surveyor found soiled washcloths on the floor next to a trash can in another resident’s room, with no staff present. The facility’s written Laundry and Linen Handling & Storage policy specified that linen, clean or soiled, should not touch clothing or uniforms, that all soiled linen should be handled as potentially infectious, and that soiled linens and briefs should be placed in plastic bags or appropriate containers for transport, which was not followed in these instances.
Failure to Timely Identify and Assess Pressure Injuries
Penalty
Summary
The facility failed to identify two areas of pressure injury on a resident until the wounds became unstageable. The resident, who had diagnoses including Type 2 Diabetes Mellitus, peripheral vascular disease, and existing stage three and stage four pressure ulcers, was cognitively intact and required moderate assistance with personal hygiene. Despite physician orders for skin checks to be completed twice weekly, new pressure areas on the resident's left and right buttocks were not detected until they had progressed to unstageable wounds, as documented in wound assessment reports. One of these wounds required debridement and was subsequently classified as a stage four pressure injury, while the other was identified as a stage three pressure injury. Interviews with facility staff revealed that the resident preferred to remain seated in a wheelchair throughout the day, often using a bedpan in the chair and refusing showers, which limited opportunities for staff to observe the skin on the buttocks. The Assistant Director of Nursing acknowledged that the new pressure ulcers should have been identified before reaching advanced stages. The DON confirmed that staff responsible for the resident's care were also responsible for conducting skin checks. The wound care physician noted that the resident's constant sitting and reluctance to move contributed to the development of the pressure ulcers, and that the wounds were already advanced when first assessed.
Failure to Administer Medications as Ordered for Newly Admitted Resident
Penalty
Summary
The facility failed to administer medications as ordered to a newly admitted resident, identified as R1, who was part of a sample of six residents reviewed for medication administration. R1 was admitted with multiple diagnoses, including Diabetes Mellitus, Malnutrition, Hodgkin's Lymphoma, Chronic Gout, Benign Prostatic Hyperplasia, and Weakness. The Medication Administration Record for February indicated that R1 had several prescribed medications, including Allopurinol, Atorvastatin, Flomax, Lantus, Eliquis, Famotidine, Magnesium Oxide, Metformin, and Senna Plus. However, none of these medications were administered for the 7:00 PM dose on February 19, 2025. Interviews with facility staff revealed that the resident's daughter brought in medications on February 20, 2025, which were handed over to a registered nurse, V3. The nurse mentioned that the facility had already ordered the medications from their pharmacy. The Director of Nursing, V2, confirmed the existence of a convenience box for medication access and stated that staff should contact the doctor for substitute orders if medications are unavailable. The facility's policy on medication administration emphasizes the provision of safe and accurate medication administration to residents, which was not adhered to in this instance.
Inadequate Staffing and Care Deficiencies
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in significant delays in care and unmet needs. Residents reported waiting for extended periods for assistance with incontinence care, with one resident waiting up to 2.5 hours. This delay in care was particularly problematic during the afternoon and weekend shifts. Additionally, residents expressed concerns about staff being distracted by personal cell phones, which contributed to the lack of timely assistance. The facility's policy prohibits cell phone use on the floor, yet this rule was not enforced, leading to further neglect of resident needs. The facility also failed to provide adequate care for residents dependent on staff for activities of daily living (ADLs), such as toileting. Several residents were found with saturated incontinence briefs, indicating infrequent changes and inadequate care. One resident developed a pressure injury that was not properly assessed or treated due to the absence of a wound nurse and the departure of the Director of Nursing. The facility's failure to maintain proper wound care protocols resulted in the resident's pressure injury being left uncovered and untreated. Furthermore, the facility exhibited a high medication administration error rate of 31.25 percent, with medications not being provided on time due to staff attending to other residents. The facility's staffing data report indicated a one-star staffing rating, highlighting the insufficient staffing levels. Residents also reported not receiving snacks as per the facility's policy, with the responsibility of distribution falling on the nursing staff, who failed to provide them consistently.
Failure to Label Insulin with Expiration Dates
Penalty
Summary
The facility failed to ensure that opened, multi-dose insulin bottles and insulin pens were labeled with expiration dates for four residents. The residents involved were receiving various types of insulin, including Lantus, Aspart, and Lispro, as per their physician orders. During an inspection of the medication cart on the 100 wing, it was observed that insulin pens and bottles for these residents were opened but not labeled with expiration dates. This oversight was confirmed by a Licensed Practical Nurse (LPN), who acknowledged that insulin should be dated when opened to track its expiration, typically 28 days after opening. The facility's policy on medication storage, dated November 2021, mandates that medications and biologicals be stored safely and properly, following manufacturer or supplier recommendations. The policy specifically requires that once certain medications, such as insulins, are opened, they must be labeled with a date opened sticker and a new expiration date. The failure to adhere to this policy resulted in the deficiency noted during the survey, as the insulin medications for the residents were not labeled with the necessary expiration information.
Infection Control Deficiencies in PPE Use and Glove Changes
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple instances of staff not wearing appropriate Personal Protective Equipment (PPE) in contact isolation and enhanced barrier precaution situations. In one instance, a Certified Nursing Assistant (CNA) entered a contact isolation room without donning PPE and assisted a resident with incontinence care, despite the resident being on contact isolation for a multi-drug resistant organism (ESBL) in the urine. Additionally, two CNAs failed to wear protective gowns while providing incontinence care to a resident with a sacral pressure injury, despite the resident's care plan requiring enhanced barrier precautions. Further deficiencies were observed in the failure to change gloves during incontinence care, leading to potential cross-contamination. In one case, a CNA did not change gloves after cleaning a resident's groin and perineal area, and then proceeded to reposition the resident and handle clean items. Similarly, another CNA did not change gloves after providing incontinence care to a resident, subsequently touching the resident, their bedding, and bed with contaminated gloves. These actions were contrary to the facility's infection control policies, which require glove changes when they become dirty and before touching clean items.
Violation of Resident Privacy and Dignity During ADL Care
Penalty
Summary
The facility failed to ensure that a resident's right to dignity and privacy was maintained during the provision of Activities of Daily Living (ADL) care. On November 19, 2024, a resident was observed in a compromising situation where their buttocks and posterior thighs were visible from the hallway while a Certified Nursing Assistant (CNA) provided peri-care with the room door open. Later, the same resident was seen sitting in a shower chair with their pants around their knees, being pushed down the hallway by the CNA, with fecal matter dropping onto the floor every few feet. This incident was contrary to the facility's Incontinence Care policy, which mandates providing privacy for residents during such care. On November 20, 2024, another CNA stated that the standard procedure before providing peri-care includes washing hands, donning appropriate Personal Protective Equipment (PPE), and closing the resident's room door to ensure privacy. The failure to adhere to these procedures resulted in a breach of the resident's rights to dignity and privacy.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for three residents who required staff support for incontinence care and toileting. Resident 21, who needed extensive assistance for toileting, transferring, and repositioning, was found in a wet incontinence brief and wheelchair pad, indicating a lack of timely care. Despite expressing the need to urinate, Resident 21 was not attended to until much later, resulting in a saturated brief and wet clothing. Similarly, Resident 1, who was completely dependent on staff for repositioning and toileting, was found with a saturated incontinence brief and red buttocks, suggesting prolonged exposure to urine. The brief had not been changed since early morning, despite a noticeable urine odor in the room. Resident 40, also requiring extensive assistance, was left in a saturated brief for several hours, leading to bright red skin in the groin and buttocks area. The facility's administrator confirmed that residents should be checked and changed every two hours, which was not adhered to in these cases.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to complete weekly wound assessments and ensure proper pressure ulcer care for two residents. One resident, who was at risk for impaired skin integrity due to decreased mobility, incontinence, and dementia, developed a new unstageable pressure injury on the sacral area. Despite physician orders for specific wound care, the resident's wound was not consistently dressed, and weekly assessments were not conducted. The facility's administrator acknowledged the lapse in care, attributing it to staffing issues, including the departure of the wound nurse and the Director of Nursing. Another resident with a Stage 3 pressure wound on the right heel was observed without the recommended heel boots, which were intended to off-load pressure and aid in healing. The wound nurse confirmed that the resident's heels should be offloaded with heel boots or pillows to prevent contact with the mattress. The facility's Skin Management Program policy emphasized the need for ongoing monitoring and evaluation to ensure optimal outcomes, which was not adhered to in these cases.
Failure to Implement Weight Loss Interventions for a Resident
Penalty
Summary
The facility failed to ensure that a resident with a history of significant weight loss received the necessary interventions as ordered by the dietitian. The resident, who was at risk for malnutrition due to dementia and dysphagia, experienced a weight drop from 126.4 pounds to 117.2 pounds within a month, indicating a 7.28% weight loss. Despite the dietitian's recommendation for weekly weight monitoring over four weeks, the facility did not document any weekly weights for the resident during the specified period. Additionally, the resident was not provided with the prescribed supercereal at breakfast, which was intended to address the weight loss by adding calories and protein to the diet. The dietary manager confirmed that the resident did not receive supercereal with breakfast, as indicated on the meal ticket. The dietitian acknowledged that the recommended weekly weigh-ins were not conducted, and the resident did not receive the prescribed dietary intervention. The facility's policy on communication of weight concerns required re-weighing and notifying the physician and dietitian in the event of significant weight changes, followed by appropriate interventions and care plan updates. However, these procedures were not followed, contributing to the deficiency in care for the resident.
Deficiencies in Oxygen Administration and Management
Penalty
Summary
The facility failed to ensure proper administration and management of oxygen therapy for two residents. In the first instance, a certified nursing assistant and a restorative aid were observed assisting a resident, R116, with a nasal cannula connected to an oxygen concentrator set at 2 liters. They attempted to switch the resident to a portable oxygen tank without the involvement of a nurse, which is against the facility's protocol. The Director of Nursing confirmed that only nurses should administer oxygen and set the dial according to the physician's order. Furthermore, it was revealed that there was no physician order for R116's oxygen therapy at the time of the observation, although an order was later documented specifying 2 liters of oxygen via nasal cannula for COPD management. In the second instance, another resident, R31, was found using oxygen tubing that had not been changed since 11/4/24, despite the facility's policy requiring weekly changes. The Assistant Director of Nursing confirmed that the tubing should be changed weekly and as needed. R31's physician orders also indicated that the oxygen tubing should be changed weekly. The facility's procedure for oxygen administration, dated August 2024, mandates that the oxygen delivery device and tubing be changed weekly or as needed, with the tubing dated to track changes. These oversights in oxygen management and adherence to physician orders and facility protocols contributed to the deficiencies identified during the survey.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 31.25%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed during a medication pass involving three residents. For Resident 60, medications including Carvedilol, Calcium/Vitamin D, PreserVision, Tramadol, and Tylenol were administered late at 9:46 AM instead of the prescribed 8 AM. The LPN responsible for the medication pass admitted to running late and still learning the residents, which contributed to the delay. The facility's policy considers medication administration late if it occurs one hour or more after the prescribed time. Additionally, two other residents, R117 and R11, received their medications late, with their EMAR tabs indicating a delay. The LPN administering these medications explained that the delay was due to attending to a resident who had passed away earlier that morning. The medications for these residents included aspirin, bupropion, losartan, multivitamins, and other prescribed drugs. The facility's medication pass schedule was provided, showing specific times for medication administration, which were not adhered to in these instances.
Failure to Ensure Safe Transfers and Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents, resulting in significant injuries. The first resident, an elderly male with a history of frequent falls and cognitive impairment, attempted to self-transfer from the bed to a wheelchair without assistance. During this attempt, his legs crossed, causing him to fall and sustain a right femur fracture. Staff members present did not use a gait belt, which was required by the facility's policy for safe transfers. The resident was known to be impulsive and required frequent cueing, yet the staff did not adequately supervise or assist him during the transfer, leading to his injury. The second incident involved a female resident with Parkinson's disease and a fractured left arm, who fell from her wheelchair while being transported to a doctor's appointment. The resident was being pushed by her husband and a facility activity aid, who was not a CNA, on a windy day. The wheelchair lacked foot pedals, and the resident was unable to stabilize herself due to her arm brace. The sidewalk's slope contributed to the resident leaning forward and falling out of the wheelchair, resulting in a laceration that required 21 sutures. The facility's failure to ensure the wheelchair was equipped with foot pedals and to provide adequate staff assistance during transport contributed to the accident. Both incidents highlight the facility's failure to adhere to its own safety policies and adequately supervise residents at high risk for falls. The lack of proper equipment and insufficient staff support during critical moments of resident care led to preventable injuries. These deficiencies underscore the need for strict adherence to safety protocols and comprehensive staff training to prevent similar occurrences in the future.
Failure to Monitor Hot Beverage Temperatures Leads to Resident Burns
Penalty
Summary
The facility failed to monitor the temperatures of hot beverages before serving them to residents, leading to a resident sustaining severe burns. The incident involved a resident with a history of spinal stenosis, dementia, Parkinson's disease with dyskinesia, and neuropathy of the lower limbs, who had severe cognitive impairment and decreased safety awareness. On the day of the incident, the resident spilled hot coffee on her thighs, resulting in second and third-degree burns. Observations revealed that the facility's dietary staff did not check or log the temperatures of hot beverages before serving them to residents. The hot water machine was set at a high temperature, and there was no established procedure for ensuring the safety of hot beverages. The Dietary Manager admitted to not checking the temperature of the coffee since starting at the facility and was unaware of the appropriate serving temperature for hot liquids. Interviews with staff indicated a lack of awareness and training regarding the safe handling of hot beverages. The Dietary Manager and Dietary Aid both confirmed that there was no temperature log for hot beverages, and the coffee temperature was not checked before serving. The Administrator was informed of the incident but did not implement immediate measures to monitor hot beverage temperatures, contributing to the deficiency.
Removal Plan
- Procedure developed and implemented to ensure safety with hot beverages, including checking and logging temperatures prior to the beverages leaving the kitchen and beverages not being served if they do not meet the appropriate temperature range of 120 F to 135 F.
- Preferred temperature for consuming coffee/tea is 135 F +/- 15 F. Procedure includes acceptable temperature range.
- 100% of kitchen staff in-serviced on procedure to check hot beverage temperatures. Hot beverages are only prepared by kitchen staff.
- 100% of kitchen staff in-serviced on safe temperature range for consuming hot beverages.
- Appropriate thermometer present in kitchen with ability to be calibrated. Temperature range 0 F to 220 F.
- Four additional thermometers were ordered with the ability to be calibrated with a temperature range 0 F to 220 F.
- The fifty residents currently residing in the facility that were identified to prefer hot beverages had screening completed to assess for safe handling of hot beverages.
- The remaining twenty five residents in the facility that were not identified to prefer hot beverages will have screening completed to assess for safe handling of hot beverages in case of preference change.
- All residents will be screened by therapy/nursing using the Interdisciplinary therapy screening tool to determine safe handling of hot beverages. Diet order, diet tray card and individualized care plan will be updated accordingly.
- Staff training to be 100% completed.
- Screening for safe handling of hot beverages audit tool to be completed by DON/designee and results reviewed at QAPI with Interdisciplinary Team (IDT) and Medical Director.
- Hot beverage temperature audit tool to be completed by Dietary Manager/Administrator and results reviewed at QAPI with Interdisciplinary Team (IDT) and Medical Director.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to provide showers to a resident who requires assistance with activities of daily living (ADL). The resident, identified as R3, has no cognitive impairment and relies on staff for bathing and personal hygiene. According to R3's care plan, she is scheduled to receive showers on Mondays and Thursdays. However, R3 reported that she had not received a shower or had her hair washed since July 1st, despite her scheduled shower days. On July 10th, R3 expressed discomfort due to an itchy scalp and mentioned that she had only been able to wash up in her sink. The Director of Nursing confirmed the resident's shower schedule and acknowledged that all residents should receive showers as per their schedule for hygiene purposes.
Inadequate Incontinence Care Leads to Deficiency
Penalty
Summary
The facility failed to provide adequate incontinence care to a resident, identified as R2, who is incontinent of bladder function and has a history of urinary tract infections. On the morning of July 10, 2024, R2 was observed sitting in a wheelchair with a strong urine odor. A Certified Nursing Assistant (CNA) removed a urine-soiled incontinent brief and only wiped R2's frontal area, neglecting to cleanse the buttocks or thigh area before applying a new brief. This incomplete care was contrary to the facility's policy and R2's care plan, which emphasized thorough cleaning to prevent skin breakdown and infection. A Licensed Practical Nurse (LPN) later confirmed that thorough incontinence care should include the back area, buttocks, and thighs to prevent skin irritations and redness, which R2 was already experiencing.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a male resident. The resident, who is alert and oriented with occasional forgetfulness and confusion, has a medical history that includes diabetes, atrial fibrillation, dementia with psychotic disturbance, depression, chronic kidney disease, and congestive heart failure. On the day of the incident, a Registered Nurse (RN) reported that the CNA was observed yelling at the resident, telling him to shut up and go to his room, and subsequently slamming the door. The RN intervened, reminding the CNA that the resident was a fall risk and should not be left alone with the door shut. Interviews with staff and the resident confirmed the occurrence of verbal abuse. The resident did not recall the incident when interviewed later, but staff members provided consistent accounts of the CNA's inappropriate behavior. The CNA was reported to have pushed the resident in his wheelchair into his room and slammed the door after telling him to be quiet. The facility's abuse prevention policy, which prohibits all forms of abuse and has a no-tolerance philosophy, was violated in this instance. The CNA involved was terminated following a substantiated investigation into the abuse allegation.
Failure to Provide Dementia Training to Newly-Hired Staff
Penalty
Summary
The facility failed to ensure that newly-hired nursing staff received dementia care training and education prior to caring for residents. This deficiency was identified through interviews and record reviews, which revealed that several CNAs and an LPN had not received the required dementia training upon hire. Specifically, V3 CNA, V4 CNA, V7 CNA, and V8 LPN were all found to have worked multiple shifts without having completed the necessary dementia training. The facility's General Orientation Checklist indicated that dementia care education should be provided during orientation, but this was not adhered to in these cases. V9 HR admitted that the newly hired staff had not gone through orientation due to the immediate need to have them on the floor. V2 DON, who had only been in her role for three weeks, acknowledged that staff should receive dementia training upon hire and annually thereafter. However, she could not account for the training status of staff hired before her tenure. This lapse in training has the potential to affect all 73 residents in the facility, as proper dementia care and monitoring are critical for resident well-being.
Failure to Supervise Dementia Resident
Penalty
Summary
The facility failed to supervise a resident diagnosed with dementia, leading to the resident wandering into other residents' rooms. The care plan for the resident, who was cognitively impaired due to dementia, indicated behaviors such as wandering, rummaging through others' belongings, confusion, poor judgment, impulsivity, and delusions. Despite these documented behaviors, the staff did not adequately monitor the resident, resulting in multiple incidents where the resident attempted to enter another resident's room, causing distress to the other resident. On one occasion, a cognitively intact resident threw water on the dementia resident to prevent her from entering his room after she had repeatedly tried to do so. The cognitively intact resident expressed frustration that staff were not intervening despite being aware of the situation. Interviews with staff members revealed that the dementia resident frequently wandered into other residents' rooms and that staff found it challenging to keep track of her movements. Some staff members also reported not receiving dementia training, which may have contributed to the inadequate supervision. The facility's policies on dementia care and wandering indicated that residents with such behaviors should be closely monitored and have individualized care plans. However, the staff did not consistently implement these policies, as evidenced by the lack of frequent checks and the failure to redirect the resident effectively. The administrator acknowledged that staff should have been checking on the resident's whereabouts every 15-30 minutes to prevent such incidents, but this was not done, leading to the deficiency in care.
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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