The Haven Of Bement.
Inspection history, citations, penalties and survey trends for this long-term care facility in Bement, Illinois.
- Location
- 601 North Morgan, Bement, Illinois 61813
- CMS Provider Number
- 145948
- Inspections on file
- 27
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at The Haven Of Bement. during CMS and state inspections, most recent first.
Two residents were not protected from abuse by their roommates. A non-verbal, quadriplegic resident who was totally dependent for ADLs reported through yes/no responses that an ambulatory roommate with multiple psychiatric and substance use diagnoses punched him in the stomach on three occasions when upset, causing pain and fear. In a separate situation, a resident with moderate cognitive impairment and depression reported being yelled at, cursed at, and called derogatory names by a cognitively intact roommate with dementia and other psychiatric conditions; staff had previously heard a loud verbal altercation between the two and noted that the victimized resident was very upset. Although the facility’s abuse policy defines and prohibits physical and verbal abuse, the Administrator initially treated the reported verbal aggression as a grievance rather than potential abuse, and the facility failed to prevent or adequately recognize these abusive interactions between residents.
The facility failed to timely investigate and report multiple allegations of resident-to-resident verbal abuse to the state agency. A cognitively impaired resident reported being yelled and cursed at by a roommate and expressed fear of this resident. A CNA and a psychotherapist/LCSW separately reported verbal altercations between the two residents to the Administrator and other staff, but no investigation was initiated, no staff interviews were conducted, and the required notification to the Department of Public Health was not made at the time of the initial reports. These actions were inconsistent with the facility’s abuse prevention policy, which requires immediate reporting and accurate, timely investigative reports for all abuse allegations.
The facility failed to investigate and respond appropriately to repeated allegations of verbal abuse between two roommates, one with moderate cognitive impairment and one cognitively intact. A resident reported being yelled at, cursed at, and called derogatory names by her roommate and expressed fear of further incidents. Staff, including a CNA and a psychotherapist/LCSW, had previously reported verbal altercations to the Administrator/Abuse Prevention Coordinator, but the Administrator treated the matter as a grievance, did not document it, did not initiate an abuse investigation, did not interview involved staff or residents, and did not promptly separate the residents. These actions were inconsistent with the facility’s Abuse Prevention Policy, which requires documentation, investigation, and protective measures, including separation of residents when abuse is alleged.
The facility failed to maintain complete and accurate medical records when staff did not document multiple incidents and allegations of verbal abuse between two roommates. One resident reported being yelled at and called offensive names by her roommate and expressed fear of further retaliation, while a CNA and a psychotherapist/LCSW both observed or learned of loud, upsetting verbal altercations and reported them to the Administrator/Abuse Prevention Coordinator and nursing staff. Despite these reports and the separation of the roommates, there was no timely documentation of the abuse allegations, staff notifications, or resident monitoring in either resident’s chart, and only late backdated social service notes were entered, contrary to facility policies requiring documentation of all incidents, allegations of abuse, and changes in condition.
A resident was involuntarily discharged for being a threat to another resident’s personal safety, but the EMR lacked a physician note documenting the basis for the discharge, the specific needs that could not be met in the facility, the attempts made by the facility to meet those needs, and the services available at the receiving facility. The Administrator and DON/Regional Consultant confirmed that no such physician documentation existed in the record, and the Administrator acknowledged not being aware of all requirements for an involuntary discharge.
A resident with multiple psychiatric and substance use diagnoses received an emergency involuntary discharge notice that lacked required information about appeal rights and advocacy agencies. The notice did not include the mailing and email address of the entity to receive an appeal, nor instructions on obtaining, completing, and submitting an appeal form. It also omitted the name, mailing address, email address, and phone number of the State LTC Ombudsman and the agency responsible for protection and advocacy of individuals with mental illness. The Administrator and DON later confirmed that these required elements were missing and that the Administrator was unaware of all requirements for an involuntary discharge notice.
A resident reported that personal ear buds went missing after the room was deep cleaned and, using a phone tracking function, identified their location at an address associated with two CNAs. The resident reported the suspected theft to the Administrator, expressed a desire to press charges, and stated that no police officer spoke with the resident and that the Administrator later said no charges would be pressed. The resident had to purchase replacement ear buds with personal funds while waiting for the facility to replace them and requested reimbursement. The resident reported feeling upset and angry about the theft and the delay in replacement, and surveyors determined the facility failed to protect the resident from misappropriation of property and to replace the misappropriated item in a reasonable time frame, resulting in psychosocial harm.
A resident experienced an 8% weight loss over a short stay, with documented rapid early weight loss and frequent meal intake of less than 50%, yet staff did not recognize or act on this as significant. Despite policies requiring monitoring of nutrition, identification of weight loss, and notification of the physician, RD, and family, the LPN, NP, RD, and primary care physician all confirmed they were not informed of the resident’s weight loss or poor intake, and the family was also not notified. A therapist reported the resident’s decline in ability to eat and need for assistance, but no further assessment or interventions were initiated. Concurrently, the resident’s potassium levels trended downward while in the facility, and the resident was later hospitalized with hypokalemia attributed by the hospitalist to severe malnutrition and dehydration due to lack of adequate food and fluids.
The facility lacked an effective process to verify the identity and CNA certification of agency staff, allowing an uncertified individual to work an entire CNA shift under another person’s name obtained through a staffing agency. The individual used the other CNA’s identity to access the EMR and provide direct care, while the administrator relied solely on the agency profile and did not independently confirm credentials on the state registry. Subsequent review showed the worker was not listed as a CNA on the Health Care Workers Registry and was only eligible for non‑CNA roles, affecting all 39 residents in the facility.
An uncertified individual worked an entire CNA shift under another CNA’s identity after being supplied through an agency, using the other CNA’s profile to access the EMR and provide resident care. The administrator acknowledged relying on the agency profile, did not verify the individual’s CNA status on the HCWR, and did not report the false identity and uncertified caregiving to the state agency. The scheduled CNA later confirmed not having accepted the shift, while another CNA reported that the uncertified worker was on duty for most of the day and engaged in a yelling altercation in front of residents in common and resident areas, affecting all 39 residents in the facility.
Two residents experienced significant unplanned weight loss and poor meal intake without required notification to their physician, RD, or family, in violation of facility policy. One resident with diabetes and coordination issues lost 8% of body weight over a short stay, with many meals documented as less than 50% consumed and some intake undocumented; an LPN acknowledged not notifying the physician or family, and the NP, RD, physician, and family all confirmed they were not informed. Another resident with multiple acute conditions, including fractures, acute anemia, AKI on CKD, and A-fib, lost 19% of body weight over several weeks, yet the NP, physician, and family member each reported they had not been notified of this weight loss. The DON confirmed both residents had significant weight loss and that required notifications to the physician, RD, and family were not made.
Staff failed to report a verbal altercation and threats between CNAs that occurred in resident care areas and in front of multiple residents, including in a resident’s room and the cafeteria. One CNA yelled, made racially derogatory comments, and threatened coworkers following a dispute over which staff member was responsible for a resident who had not been cared for since early morning. Law enforcement was called, and during the investigation the administrator learned that the CNA involved in the altercations was not listed as a CNA on the registry, despite having worked a full shift in that role. The administrator knew of the incident but did not report either the staff altercation or the use of an unqualified individual as a CNA to proper authorities.
A resident discovered personal ear buds missing after a deep cleaning of their room and, using a phone tracking function, identified the device at an address shared by two CNAs. The resident reported the suspected theft to staff, and the facility documented that local police were notified; however, the resident later stated they never spoke with law enforcement and still wished to press charges. The Administrator reported having called the local police, but the local sheriff’s office had no record of any call, dispatch, or report from the facility. This sequence of events shows the facility failed to timely and effectively report the misappropriation of the resident’s property to law enforcement, contrary to its abuse prevention policy.
Two residents experienced harm due to the facility's failure to maintain transport equipment, properly secure a resident during van transport, and implement individualized fall interventions. One resident suffered significant injuries after falling from a wheelchair in a van with a faulty seatbelt, while another experienced multiple unwitnessed falls without root cause analysis or appropriate care plan updates. Staff did not consistently follow protocols for safe transfers or use required equipment.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day, resulting in missed RN coverage on two days and limiting the ability to provide services such as IV medication administration for all residents.
A resident with a urinary catheter experienced a catheter-associated urinary tract infection (CAUTI) due to the facility's failure to monitor and report changes in urine characteristics. Despite symptoms such as hematuria and mucus in the urine, the facility delayed notifying the physician and implementing Enhanced Barrier Precautions (EBP). The resident's urine culture results, indicating resistance to the prescribed antibiotic, were not reported promptly, leading to delayed treatment and hospitalization.
The facility failed to provide adequate CNA staffing, resulting in delayed response to call lights and missed showers for residents. Observations and staff interviews confirmed that only two CNAs were working during certain shifts, despite the need for more staff due to resident acuity. The administrator acknowledged the staffing issues, which were confirmed by the facility's schedules.
The facility failed to staff a full-time DON, potentially affecting all 32 residents. Observations over three days showed no DON present, and the nurse schedule lacked documentation of a full-time DON. The administrator confirmed the absence of a full-time DON since December 2023.
The facility did not document registry verifications of nurse aide competency for five newly hired nurse aides before they began working, potentially affecting all 32 residents. The checks were delayed until after the aides had started, despite being hired in October and November. The administrator confirmed the lack of documentation proving checks were done before employment.
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, with the Dietary Manager lacking necessary qualifications and the dietician working only one day per month. This led to unsanitary food storage and unplanned resident diets, potentially affecting all 32 residents.
The facility failed to maintain sanitary conditions in the kitchen's walk-in cooler, affecting all 32 residents. Surveyors observed the cooler's flooring soiled with decomposed food debris and spilled liquids. The Dietary Manager could not identify the source of the liquids, and the condition remained unchanged over several days. The food in the cooler is available for all residents, indicating a potential widespread impact.
The facility failed to effectively monitor resident infections and develop a comprehensive water management plan to mitigate Legionella risk. Infection logs showed multiple UTIs and E. Coli infections without documented corrective actions beyond hand hygiene training. The Maintenance Director was unaware of the Legionella plan and had not completed a required risk assessment, leaving potential risk areas unaddressed.
The facility failed to implement its antibiotic stewardship policy, as evidenced by incomplete documentation and lack of evaluation of clinical data for appropriate antibiotic use. A resident was treated with an antibiotic for pneumonitis, which is not an infection, without documented symptoms. The Infection Preventionist was unfamiliar with the stewardship program and had not used assessment tools to determine infection criteria, potentially affecting all 32 residents.
The facility failed to document and follow up on grievances regarding missing personal items for several residents. Despite the facility's Grievance Policy requiring investigation and reporting of findings, there was no documented follow-up or resolution for grievances reported during resident council meetings. Staff members were informed, but the facility did not maintain proper records or adhere to its grievance policy, leading to the deficiency.
The facility failed to serve pureed diets as planned, affecting three residents who did not receive pureed bread and sugar cookies with their meals. Observations showed the absence of these items, and the Dietary Manager confirmed that pudding was served instead due to staff not preparing the cookies.
The facility failed to provide scheduled showers and personal hygiene care for three residents who depend on staff assistance. One resident did not receive a shower for 13 days, another went 12 days without a shower due to staffing issues, and a third was observed with unremoved facial hair despite scheduled grooming. These deficiencies indicate non-compliance with the facility's policies and residents' care plans.
A facility failed to safely perform a mechanical lift transfer for a resident. The CNA did not use the leg strap on the sit-to-stand lift, contrary to the facility's policy. The resident, who has impaired range of motion and requires assistance for transfers, was not documented to use a mechanical lift or leg strap in their care plan. The Director of Rehab stated that the leg strap should be used for all residents during transfers.
The facility failed to provide adequate respiratory care for two residents. One resident with a tracheostomy did not have their oxygen mask replaced weekly, and a replacement tracheostomy was not kept at the bedside. Another resident with COPD received oxygen at a higher rate than prescribed. These actions indicate non-compliance with facility policies and physician orders.
Two residents experienced significant medication errors due to the facility's failure to ensure medications were available and administered as ordered. One resident missed doses of Losartan due to unavailability, with no physician notification. Another resident missed insulin doses, with no documentation of physician notification, and Novolog was unavailable on one occasion.
The facility failed to offer and document pneumococcal vaccinations for three residents, leading to a deficiency in immunization practices. Despite guidelines and facility policy, a resident with chronic conditions was not documented as being offered the vaccine, and two other residents had outdated vaccination records without further offers or documentation. The Infection Preventionist/MDS Coordinator admitted to not managing the vaccinations due to uncertainty about the schedule.
A resident's medications were found crushed in the garbage, and an LPN reported the incident to the administrator, who failed to respond or initiate an investigation as required by facility policy. No report was made to the Department of Public Health regarding the suspected misappropriation.
A resident's crushed medications were found discarded in the garbage by an LPN, who promptly reported the incident to the administrator. The administrator failed to follow up, conduct interviews, or initiate any investigation or documentation, in violation of the facility's abuse prevention policy.
A resident with epilepsy did not receive scheduled seizure medications when an agency nurse was unable to administer them due to a missing PEG tube adapter, resulting in the medications being found discarded. The incident was reported verbally to the administrator and during shift change, but no follow-up, documentation, or required reporting was completed by the administrator or staff, contrary to facility policy.
A resident with multiple diagnoses experienced a significant increase in Risperdal dosage, leading to lethargy and inability to eat. Despite facility policy, the RN did not notify medical providers of the change in condition. The CNA reported concerns, but no action was taken until the NP was informed two days later, resulting in a medication adjustment and hospital evaluation.
A resident with a history of aggression physically abused another resident who is unable to defend themselves due to severe disabilities. The incident occurred in the dining room, where the aggressive resident slapped the vulnerable resident multiple times, despite the facility's abuse prevention policy and the aggressive resident's care plan aimed at preventing harm.
A facility failed to document a resident-to-resident physical abuse incident in a victim's medical record. Two residents were involved in an altercation where one slapped the other multiple times. The incident was not recorded in the victim's medical record, only in the aggressor's, as reported by a Registered Nurse.
Failure to Protect Residents From Physical and Verbal Abuse by Roommates
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and physical abuse by another resident. One resident with cerebral vascular accident, quadriplegia, contractures, anxiety, and total dependence for all ADLs, who is non-verbal but cognitively intact and communicates by yes/no head movements, reported being punched in the stomach by his ambulatory roommate on three separate occasions. Nursing progress notes document that this dependent resident had decreased appetite and an upset stomach in the days preceding disclosure. On one occasion, a CNA brought the resident to a nurse because the resident was afraid to return to his room due to his roommate, and during further evaluation the resident accused the roommate of assaulting him. The medical record documents that the non-verbal resident indicated his roommate hit him in the stomach with a closed fist on three occasions when the roommate was upset about facility issues such as smoking or leaving the building. The resident reported that the punches hurt and made him feel bad, and that he was afraid of his roommate. The facility’s investigative report and a police incident report confirm that the resident communicated fear of reprisal if the roommate remained in the facility and that the roommate had a prior history of leaving the facility and threatening violence toward staff if they tried to stop him. The roommate’s diagnoses included personality disorder, bipolar disorder, schizoaffective disorder, major recurrent depression, anxiety, stimulant abuse, and cannabis use, and he was ambulatory and made attempts to leave the building without notifying staff. These circumstances show that the facility did not prevent repeated physical abuse of a highly dependent, non-verbal resident by another resident. The deficiency also includes the facility’s failure to recognize and respond to verbal abuse between roommates as potential abuse. One resident with moderate cognitive impairment and major depressive disorder in remission reported feeling fearful of her former roommate, who was cognitively intact and diagnosed with dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The fearful resident stated that her roommate yelled, cursed, and repeatedly used an expletive toward her about a week prior and that this behavior scared her. A CNA reported that about a week before a later reported incident, staff heard the cognitively intact roommate loudly yelling at the other resident, that the fearful resident was very upset, and that both residents were verbally arguing back and forth before the CNA intervened to de-escalate the situation and then reported it to the Administrator and nurse. A psychotherapist/LCSW later reported hearing the same verbally aggressive resident call her roommate a derogatory name, after which the residents were separated. The Administrator/Abuse Prevention Coordinator stated that when this verbal altercation was reported, it was viewed as more of a grievance and was not entered on the grievance log, and acknowledged it should have been handled as a potential abuse issue. The facility’s own Abuse Prevention Policy affirms residents’ rights to be free from abuse and defines verbal abuse as the use of disparaging and derogatory language, including saying things to frighten a resident. Despite this policy, the facility did not initially treat the reported verbal aggression and the fearful resident’s statements as potential abuse, contributing to the failure to protect residents from verbal abuse by another resident.
Failure to Timely Report and Investigate Resident-to-Resident Verbal Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s repeated failure to timely report allegations of resident-to-resident verbal abuse to the Illinois Department of Public Health (IDPH) as required by its abuse prevention policy. One resident (R18) had a BIMS score of 12/15, indicating moderate cognitive impairment, and another resident (R15) had a BIMS score of 15/15, indicating no cognitive impairment. R18 reported that approximately one week prior to the survey, R15 yelled, cussed, and repeatedly used the f*** expletive toward her, causing R18 to feel afraid and fearful of retaliation. R18 stated she had been R15’s roommate and was moved to a separate room after this incident, and she described R15 as regularly using offensive language and a confrontational tone. Staff interviews revealed that facility leadership was aware of at least one verbal altercation between these two residents before the surveyor’s notification, but no investigation or required external reporting was initiated at that time. The Social Service Director (V10) stated that on the day before the survey, the psychotherapist/LCSW (V7) reported that R15 and R18 had a verbal altercation, and V10 directed V7 to report this to the Administrator/Abuse Prevention Coordinator (V1). V1 later confirmed that V7 had reported that R15 called R18 a derogatory name (“d*****s”) on that date, but V1 did not initiate an investigation, did not interview residents or staff, and did not notify IDPH at that time, despite acknowledging that the allegation should have been investigated and reported. Further, a CNA (V9) reported that about a week prior to the LCSW’s report, there had been another incident in which R15 yelled at R18, with both residents eventually arguing back and forth. V9 stated that R18 was initially very upset and that V9 intervened to de-escalate the situation, then immediately reported the incident to the Administrator and that another CNA reported it to a nurse. V9 stated that no one interviewed her about the incident and that the residents were not moved to separate rooms until several days later. The facility’s undated Abuse Prevention Policy requires accurate and timely investigative reports and mandates that when an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation is made, the Administrator or designee must immediately notify the Department of Public Health’s regional office. Despite these policy requirements and multiple staff reports of verbal altercations, the facility did not timely investigate or report the allegations of verbal abuse involving R15 and R18 to IDPH until after the surveyor brought the issue to the Administrator’s attention.
Failure to Investigate and Timely Separate Residents After Verbal Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond appropriately to repeated allegations of resident-to-resident verbal abuse, and to timely separate the alleged perpetrator from the alleged victim. Two cognitively assessed residents shared a room for over two months; one resident had a BIMS score of 12/15 indicating moderate cognitive impairment, and the other had a BIMS score of 15/15 indicating no cognitive impairment. The resident with moderate cognitive impairment reported that her roommate repeatedly yelled, cursed, and used explicit language toward her, stated she was afraid of her roommate, and declined to provide the roommate’s name out of fear of retaliation. She reported that the roommate regularly used offensive language and a confrontational tone and that she was scared of further verbal abuse. Multiple staff members were aware of verbal altercations between the two residents prior to the surveyor’s interview, but the facility did not initiate or document an abuse investigation as required by its Abuse Prevention Policy. The Administrator/Abuse Prevention Coordinator acknowledged that a psychotherapist/LCSW had reported a verbal altercation in which one resident called the other a derogatory name, but the Administrator considered it a grievance rather than potential abuse, did not log it as a grievance, and did not document anything in either resident’s chart. The Social Service Director stated that she directed the psychotherapist/LCSW to report the incident to the Administrator, which occurred, but no internal investigation steps were taken at that time. Additionally, a CNA reported that about a week before the psychotherapist’s report, she and other agency staff heard one resident yelling at the other, observed the alleged victim to be upset, and immediately reported the incident to the Administrator after calming the situation. Despite this earlier report, the Administrator did not interview the CNA or other staff, did not interview the residents regarding the incident, did not initiate an internal investigation, and did not report the allegation to the state survey agency. The facility’s own Abuse Prevention Policy requires that all incidents and allegations involving abuse be documented, investigated, and that residents who allegedly abuse others be immediately evaluated and separated as necessary to ensure safety. These steps were not taken in a timely or documented manner in response to the repeated verbal abuse allegations between these two residents.
Failure to Document Resident-to-Resident Verbal Abuse Incidents in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to allegations of resident-to-resident verbal abuse. One resident (R18) reported that her former roommate (R15) yelled, cursed, and repeatedly used offensive language toward her about a week prior, causing her to feel afraid and reluctant to identify the roommate for fear of retaliation. A CNA (V9) corroborated that sometime the previous week, R15 was loudly yelling at R18, that R18 was visibly upset, and that the two residents were arguing back and forth. The CNA stated that an agency staff member notified an unidentified nurse, and that the CNA notified the Administrator/Abuse Prevention Coordinator (V1) the same day after calming the residents. Despite these reports, there was no contemporaneous documentation of the verbal abuse allegations or related monitoring in either R15’s or R18’s medical records. The facility’s initial report to the Illinois Department of Public Health (IDPH), dated 3/10/26 and written by V1, shows that V9 had reported an incident from approximately one week earlier and that a psychotherapist/LCSW (V7) reported on 3/9/26 hearing R15 call R18 a derogatory name, after which the residents were moved to separate rooms. The IDPH report also records that R18 described feeling fearful of R15, citing the earlier name-calling incident that she had been too afraid to report at the time, and that R18 stated R15 regularly used offensive language and a confrontational tone. V1 acknowledged that when V7 reported hearing R15 call R18 a derogatory name, V1 viewed it more as a grievance, did not enter it on the grievance log, did not treat it as a potential abuse issue, and did not document anything in either resident’s chart. Review of the electronic medical records for R15 and R18 confirmed that neither social services (V10, Social Service Director; V7, LCSW/Psychotherapist) nor nursing staff documented the abuse allegations or any monitoring on the dates the incidents were reported by staff or surveyors. Late social service notes for both residents were created on 3/12/26, backdated to 3/9/26, indicating that the Administrator and an NP were notified that one resident called the other a name and to monitor for further behaviors or anxiety, but these notes did not capture the earlier incident reported by the CNA or the subsequent allegations reported on 3/9/26 and 3/10/26. These omissions occurred despite facility policies requiring that all incidents, allegations, or suspicions of abuse, and all incidents, accidents, or changes in condition, be documented in the resident’s medical record.
Lack of Required Physician Documentation for Involuntary Discharge
Penalty
Summary
The facility failed to ensure that a physician documented the required elements in the medical record to support an involuntary discharge of a resident. For one resident (R44) reviewed for discharge, the comprehensive electronic medical record did not contain a physician note documenting the basis for the discharge, the specific needs the resident had that could not be met in the facility, the attempts the facility made to meet those needs, and the services available at the receiving facility to meet those needs. An involuntary discharge notice dated 1/30/26 stated that the resident was being discharged due to being a threat to the personal safety of another resident (R23), but this notice was not supported by the required physician documentation in the medical record. During an interview on 3/12/26, the Administrator, with the DON/Regional Consultant present, confirmed that there was no physician note in the resident’s record addressing the basis for the discharge or the other required elements, and confirmed that the resident had been discharged and would not be returning. As of 3/13/26, the Administrator had not provided any evidence of such a physician note and stated that this was her first involuntary discharge and she was not aware of all of the requirements.
Incomplete Involuntary Discharge Notice Lacking Advocacy and Appeal Information
Penalty
Summary
The facility failed to include required information regarding advocacy agencies and appeal rights in an emergency involuntary discharge notice for one resident. The resident was admitted with multiple psychiatric and substance use diagnoses, including Personality Disorder, Bipolar Disorder, Schizoaffective Disorder, Major Recurrent Depression, Anxiety, Stimulant Abuse, and Cannabis Use. Review of the resident’s emergency involuntary discharge notice dated 1/30/26 showed it did not contain the mailing and email address of the entity that would receive an appeal of the discharge, nor information on how to obtain, complete, and submit an appeal form. The notice also omitted the name, mailing address, email address, and phone number of the State LTC Ombudsman, as well as the mailing address, email address, and phone number of an agency responsible for protection and advocacy of individuals with mental illness. During an interview, the Administrator, with the DON/Regional Consultant present, confirmed that the required information was not included in the involuntary discharge notice and acknowledged that this was the Administrator’s first involuntary discharge and that she was not aware of all the requirements. The resident had already been discharged and was not expected to return.
Failure to Timely Address Resident’s Reported Theft and Property Loss
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal property and did not replace the misappropriated item in a reasonable time frame, resulting in psychosocial harm. The resident reported that a pair of ear buds, which were kept in a specific place in the resident’s room, went missing after the room was deep cleaned, during which a CNA assisted in placing the resident’s belongings on the bedside table. Later that evening, when the resident attempted to use the ear buds, they were no longer there. The resident used the tracking function on a cellular phone and identified the location of the missing ear buds at an address approximately 30 miles away, which the resident associated with a mother and daughter who were both CNAs employed at the facility. The facility’s abuse prevention policy affirms residents’ rights to be free from misappropriation of property and to be kept informed of investigation conclusions. The resident reported the theft to the Administrator and expressed a desire to press charges. The resident stated that no police officer spoke with the resident that night and that the Administrator later told the resident that no charges were being pressed. The resident also reported having to purchase replacement ear buds with personal funds while waiting for the facility to replace them, and later requested reimbursement. The resident stated feeling upset and angry that someone could steal from the resident and other residents in what the resident considers home, and reiterated the desire to press charges more than two months after the incident. The survey findings concluded that the facility failed to replace the misappropriated goods in a reasonable time frame and failed to report the incident to the police as the resident requested, resulting in psychosocial harm to the resident.
Failure to Identify and Address Significant Weight Loss and Poor Intake
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and respond to a resident’s significant weight loss and declining nutritional status. The facility had policies requiring monitoring of weight and nutritional status, identification of recent or rapid weight loss, and notification of the physician, dietitian, and family of significant changes, including possible fluid and electrolyte imbalances. Despite these policies, the resident’s weights from admission to discharge showed a total loss of 14.1 pounds (8%) over 22 days, with early rapid losses documented, but no evidence that this weight loss was identified as significant or that appropriate assessments were completed. During the resident’s stay, meal intake records showed that out of 61 meals served, six had no documented intake percentage, and of the 55 documented meals, 29 reflected less than 50% consumption and 15 reflected less than 25% consumption. A speech therapist observed a sharp decline in the resident’s abilities, including talking less and not feeding herself, and reported this to an LPN, who documented that the therapist had to assist the resident with eating and that the resident seemed to be declining. However, the LPN later stated they did not recall notifying the physician or family of the resident’s decline or weight loss. The registered dietitian confirmed not being informed of the weight loss and did not see the resident in the facility, instead making diet recommendations based only on prior speech therapy notes. Laboratory results showed a downward trend in the resident’s potassium levels while at the facility, from 3.5 mEq/L on one date to 2.6 mEq/L on the day of discharge, compared to a prior hospital potassium level of 4.0 mmol/L. The nurse practitioner and primary care physician both confirmed they were not notified of the resident’s weight loss or poor intake, and both acknowledged that limited meal consumption could lead to weight loss and electrolyte imbalance. The resident’s family also reported not being informed of the weight loss or lack of food consumption. The resident was ultimately sent to the hospital for altered mental status and possible stroke, and the hospitalist documented that the resident was admitted with hypokalemia secondary to severe malnutrition and dehydration, stating that the lack of food and drink at the facility was the cause of the hypokalemia.
Unverified Agency CNA Identity and Certification Leading to Unqualified Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nurses and nurse aides had appropriate competencies and valid certification, specifically by not having a policy or process to verify the identity and credentials of agency staff working as CNAs. The facility’s CNA job description required a current CNA certification in accordance with Illinois law. However, on one occasion, an individual (V28) worked an entire scheduled CNA shift under another person’s identity (V20) obtained through a contracted staffing agency. The administrator (V1) reported to law enforcement (V29) that V28 was operating under the false name V20 while working as a CNA and that the only documentation V1 had seen was the staffing agency profile for V20. V1 later checked the registry under V28’s real name and discovered that V28 was not listed as a CNA. During the incident, V28 arrived for a scheduled shift that was assigned to V20 and used V20’s name to gain access to the EMR and work as a CNA from 6:00 a.m. until an altercation occurred around 5:00 p.m. Another staff member (V19) reported that V28 had been working that full shift, and V20 later stated that they had not picked up any shifts at the facility. An email from the Health Care Workers Registry confirmed that V28 did not have CNA certification and was not eligible to be employed as a CNA, though eligible to work in a non‑CNA capacity. The facility census at the time was 39 residents, and the lack of a policy to verify agency staff identity and certification resulted in an uncertified individual providing CNA-level care to residents under another person’s credentials.
Uncertified Individual Worked as CNA Under False Identity Without Registry Verification
Penalty
Summary
The deficiency involves the facility’s failure to verify nurse aide certification and ensure that only properly certified CNAs provided resident care. On a specific date, an individual identified as V28 presented to the facility and worked an entire shift as a CNA by using the identity and staffing profile of another CNA, V20, who was scheduled to work that day. The Administrator (V1) stated that the facility uses a contracted agency to supply certified staff and that the profile being used belonged to V20, a CNA. V28 provided V20’s name as their own in order to work, access the electronic medical record, and provide resident care. Subsequent verification with the Health Care Worker Registry (HCWR) confirmed that V28 did not hold CNA certification and therefore was not eligible to be employed as a CNA, although eligible to work in a non‑CNA capacity. The report further documents that V1 did not report the incident of false identity and uncertified personnel providing resident care to the state agency. Interview with V20 confirmed that V20 did not pick up any shifts at the facility, despite the nursing schedule listing V20 to work a 6:00 a.m. to 6:00 p.m. shift on the date in question. Interview with another CNA, V19, indicated that V28 worked from 6:00 a.m. until an altercation occurred around 5:00 p.m., during which V28 was yelling and screaming in front of residents in the cafeteria and in a resident’s room. The facility’s resident roster documented a census of 39 residents, all of whom were affected by the presence of an uncertified individual working as a CNA and providing care under a false identity.
Failure to Notify Physician and Family of Significant Weight Loss in Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians, the dietitian, and family members of significant weight loss and decreased nutritional intake for two residents, contrary to its own policies on change in condition and impaired nutrition/unplanned weight loss. The facility’s policy required staff to monitor and document residents’ weights in a way that allowed month-to-month comparison, identify recent or rapid weight loss, and notify the physician and family of significant weight changes or persistent declines in appetite or intake. The policy also required the physician and staff to review possible causes of weight loss and monitor nutritional status and response to interventions. For one resident (R1), admitted with diabetes mellitus due to underlying condition with diabetic neuropathy and other lack of coordination, weight records showed a decline from 175.2 lbs at admission to 161.1 lbs at discharge over 22 days, a total loss of 14.1 lbs or 8%. During the stay, the resident was served 61 meals; documentation of intake was missing for 6 meals, and of the 55 meals with documentation, 29 meals showed less than 50% consumption and 15 meals showed less than 25% consumption. The LPN who documented in the record stated they did not recall notifying the family or physician of the resident’s decline and confirmed they did not inform them of the weight loss. The NP, RD, and primary care physician each confirmed they had not been notified of the resident’s weight loss, and the family member confirmed they were not informed of the weight loss or lack of food consumption. The DON confirmed the resident had a significant weight loss and that the family, physician, and RD had not been notified. For another resident (R8), admitted with multiple acute conditions including mechanical fall with right lower extremity fractures, severe pain, acute hypotension/shock versus anemia, acute anemia, suspected GI bleed ruled out, acute kidney injury on chronic kidney disease, and atrial fibrillation, serial weights showed a decline from 201.8 lbs near admission to 161.1 lbs over 44 days, a total loss of 36.8 lbs or 19%. Despite this significant weight loss, the NP and the resident’s physician each confirmed they had not been informed of any weight loss. The resident’s family member reported noticing that the resident was losing weight but was unaware of the extent of the loss and stated they had not been notified by staff. The DON confirmed that this resident also had significant weight loss and that the family and physician had not been notified, demonstrating a failure to follow facility policy for physician and family notification of significant changes in condition related to weight and nutrition.
Failure to Report Staff Altercation and Use of Unqualified CNA
Penalty
Summary
The deficiency involves the facility’s failure to timely report to proper authorities an altercation between staff that occurred in the presence of residents, and the discovery that an unqualified individual was working as a CNA. A sheriff’s deputy was dispatched to the facility after receiving 911 calls from two CNAs regarding threats made by one CNA toward another. One CNA reported that the other CNA told her to meet by the time clock so she could beat her, which made her feel uncomfortable and unsafe. This conflict arose after a dispute over which CNA was responsible for a resident who had not been cared for since early that morning. The reporting CNA also described an earlier verbal altercation that same shift between the same aggressive CNA and a different CNA, during which threats were made and had to be de-escalated. The aggressive CNA was reported to have yelled, accused coworkers of disrespect, and made racially derogatory comments. The incident included yelling and screaming by the aggressive CNA in front of residents in the cafeteria and in a resident’s room, with at least one resident later confirming that two CNAs were yelling and having a disagreement in the resident’s room and that one CNA walked out. The administrator acknowledged knowing about the incident but did not report it. During the law enforcement contact, the administrator also stated that, upon checking the registry, it was discovered that the CNA who had been working from early morning until the time of the incident was not actually a CNA. Despite this, there is no indication in the report that the facility reported either the staff altercation in the presence of residents or the fact that an unqualified individual had been working as a CNA to the appropriate authorities.
Failure to Timely Report Misappropriation of Resident Property to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to timely report to local law enforcement the misappropriation of a resident’s personal property. On the evening of 11/6/2025, a resident discovered that their ear buds, which were normally kept in a specific place in their room, were missing after the room had been deep cleaned and a CNA assisted with placing personal belongings on the bedside table. Around 9:00 PM, when the resident attempted to use the ear buds, they realized they were gone and used the tracking function on their cell phone, which showed the ear buds at an address approximately 30 miles away. The resident asked a CNA on shift for her address, and the CNA stated she lived with her mother, who was also a CNA at the facility, and confirmed that the address matched the location where the ear buds were pinged. The resident reported the theft to staff that night. The facility reported the misappropriation of goods to the state agency, and the facility’s incident report documented that the CNA was terminated, local police were notified, and the ear buds would be replaced. However, during a later interview, the resident stated they did not speak to a police officer that night and still wished to press charges, but reported being told by the Administrator that no charges were being pressed. The Administrator stated they called the local police department around 9:30 PM on 11/6/2025 but could not recall whom they spoke with. Subsequently, the local sheriff’s office reported there was no call log, dispatch, or report from the facility on or around that date. The facility’s Abuse Prevention Policy affirms residents’ rights to be free from misappropriation of property and states that residents will be kept informed of investigation conclusions, but the record and interviews show that the facility did not timely or effectively report the misappropriation to law enforcement as required.
Failure to Maintain Safe Transport and Fall Prevention Practices
Penalty
Summary
The facility failed to maintain transport equipment in working order and did not ensure the safe and proper securing of a resident during van transport. One resident, who was cognitively intact but physically dependent and classified as high fall risk, was transported in a facility van with a seatbelt that was not properly attached to the floor anchor. The staff member responsible for securing the resident did not verify the functionality of the seatbelt or the anchor, resulting in the resident falling from the wheelchair during transport. The fall led to significant injuries, including a forehead hematoma, multiple facial lacerations requiring sutures, and bilateral nasal bone fractures. The van's equipment was later found to have stiff, loose, and aged lap belts, with a faulty anchor that contributed to the incident. Additionally, the facility failed to implement and update fall interventions and did not conduct root cause analyses for multiple falls experienced by another resident. This resident, who had significant cognitive and physical impairments and was classified as high fall risk, experienced several unwitnessed falls while attempting self-transfers. Despite repeated incidents, the facility did not document root causes for these falls or update the care plan with appropriate interventions. Staff were observed transferring the resident without required assistance, mechanical lift, or gait belt, and the resident's wheelchair was not adjusted as specified in the care plan. Personal alarms and other interventions were also not in place as directed. The facility's own policy requires individualized interventions, hazard analysis, and root cause identification for all residents at fall risk. However, documentation and investigation of falls were insufficient, lacking necessary details to determine causes and prevent recurrence. The failure to maintain equipment, ensure proper supervision, and follow established protocols directly contributed to the injuries and repeated falls experienced by the residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for eight consecutive hours each day, seven days per week, as required. Staffing postings for a one-week period showed that there was no RN on duty on two separate days. On one of those days, an RN worked the overnight shift but was only present until approximately 7:40 AM, which did not meet the eight-hour requirement. The administrator confirmed these staffing gaps and stated that the absence of an RN prevented the facility from providing certain services, such as administering intravenous medications. At the time of the deficiency, 39 residents were residing in the facility.
Failure to Monitor and Report Urine Changes Leads to CAUTI and Hospitalization
Penalty
Summary
The facility failed to adequately monitor and report changes in urine characteristics for a resident with a urinary catheter, leading to a catheter-associated urinary tract infection (CAUTI) and subsequent hospitalization. The resident, who was cognitively intact and dependent on staff for toileting hygiene, experienced hematuria and mucus in the urine, which were not timely reported to the physician. The facility's policy required notification of the physician for symptoms of infection, but there was a lack of documentation and follow-up on the resident's urine characteristics between May and July 2024. The resident was admitted to the facility with a urinary catheter and later developed symptoms of a UTI, including lower abdominal pain and a blocked catheter. Despite the presence of blood and mucus in the urine, the facility did not implement Enhanced Barrier Precautions (EBP) until months later. The resident's urine culture results, which indicated resistance to the prescribed antibiotic Levaquin, were not reported to a practitioner until three days after they were received, delaying the change in antibiotic treatment. Interviews with facility staff, including the Infection Preventionist and a Nurse Practitioner, confirmed that the urine culture results should have been reported immediately and that routine monitoring of urine characteristics was necessary. The resident was hospitalized twice due to complications from the CAUTI, highlighting the facility's failure to adhere to infection control measures and timely communication with healthcare providers.
Inadequate CNA Staffing Leads to Delayed Care
Penalty
Summary
The facility failed to provide sufficient staffing of certified nursing assistants (CNAs) to meet the needs of its residents, affecting four residents directly and potentially impacting all 32 residents in the facility. During a resident council meeting, several residents reported waiting up to an hour for their call lights to be answered and not receiving scheduled showers. Observations revealed that only two CNAs were working during certain shifts, which was insufficient given the number of residents requiring full mechanical lifts for transfers. The facility's staffing records and interviews with staff confirmed that there were instances where only one or two CNAs were available during shifts, despite the facility's assessment indicating a need for more staff based on resident acuity and census. The facility's administrator acknowledged the staffing issues and confirmed the accuracy of the CNA schedules, which showed a pattern of understaffing. The facility's master shower schedule also indicated that residents were not consistently receiving their scheduled showers due to staffing shortages.
Absence of Full-Time Director of Nursing
Penalty
Summary
The facility failed to staff a full-time Director of Nursing (DON), which has the potential to affect all 32 residents in the facility. Observations conducted on three consecutive days between 9:15 AM and 4:00 PM revealed the absence of a DON working in the facility. The facility's assessment, reviewed on May 23, 2024, indicated that a full-time DON would be staffed, yet the nurse schedule from November 23, 2024, to December 15, 2024, did not document a full-time DON. The facility administrator confirmed that the facility has been without a full-time DON since December 2023. The facility's Long-Term Care Facility Application for Medicare and Medicaid, dated December 11, 2024, documented a resident census of 32.
Failure to Verify Nurse Aide Competency Before Employment
Penalty
Summary
The facility failed to document registry verifications of nurse aide competency for five newly hired nurse aides before they began employment. This oversight potentially affects all 32 residents residing in the facility. The employee files show that the facility did not check the nurse aide registry for competency verification for four nurse aides until December 11, 2024, and for one nurse aide until November 22, 2024, despite their hire dates being in October and November 2024. The facility administrator confirmed that while background checks were completed prior to hiring, there was no documentation to prove that these checks were done before the staff started working in the facility.
Failure to Employ Qualified Director of Food and Nutrition Services
Penalty
Summary
The facility failed to employ a clinically qualified Director of Food and Nutrition Services, which has the potential to affect all 32 residents. During the survey, it was observed that the Dietary Manager, V2, was actively supervising dietary operations without the necessary qualifications. V2 admitted to not being a certified dietary manager, dietician, or having the required educational background or experience to meet the State of Illinois standards for the position. Additionally, the facility's dietician was reported to work only one day per month, which is insufficient to meet the facility's needs as outlined in their Facility Assessment. Throughout the survey, the facility also failed to maintain sanitary food storage areas and did not serve resident diets as planned on facility menus. These deficiencies were observed from December 9 to December 12, 2024. The facility's Long-Term Care Facility Application for Medicare and Medicaid documented that 32 residents reside in the facility, all of whom could potentially be affected by these failures.
Unsanitary Conditions in Kitchen Walk-In Cooler
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen's walk-in cooler, which has the potential to affect all 32 residents residing in the facility. On multiple occasions, surveyors observed the cooler's flooring to be soiled with accumulations of dark-colored decomposed food debris and spilled liquids. The Dietary Manager, who was present during these observations, was unable to identify the source of the liquids. Despite the issue being noted on December 9, 2024, the condition of the cooler remained unchanged during subsequent observations on December 10 and December 12, 2024. The food stored in the cooler is available for all residents to consume, indicating a widespread potential impact on the facility's population.
Inadequate Infection Control and Legionella Management
Penalty
Summary
The facility failed to implement effective surveillance monitoring of resident infections and did not develop a comprehensive water management plan to mitigate the risk of Legionella and other pathogens. The Infection Control Surveillance and Monitoring policy required routine surveillance, monitoring, and analysis of infection data to identify trends and implement corrective measures. However, the facility's infection control logs from February to December 2024 showed multiple instances of urinary tract infections (UTIs) and wound infections with Escherichia Coli (E. Coli), but there was no documentation of tracking infections by resident room location or implementing corrective actions beyond hand hygiene training in March. The Infection Preventionist acknowledged the lack of training and documentation of follow-up education or audits on identified infection control trends. Additionally, the facility's Legionella Management Procedure required a risk assessment of the water system to identify and control potential sources of Legionella bacteria. The Maintenance Director was unaware of the facility's Legionella plan, risk areas, and control measures, and had not received training on Legionella. The Administrator confirmed that the Maintenance Director was responsible for completing the Legionella Risk Assessment, but it had not been done, leaving risk areas and control measures unidentified. The facility's application for Medicare and Medicaid documented a resident census of 32, indicating the potential impact of these deficiencies on all residents.
Failure to Implement Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy effectively, as evidenced by the lack of evaluation of clinical data to ensure infection criteria and appropriate use of antibiotics. The facility's Antibiotic Stewardship Program, dated November 1, 2017, was intended to improve antibiotic use and reduce resistance through core elements such as leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. However, the program included an incomplete checklist for these core elements. Additionally, the facility's policy on the assessment of infections and antimicrobial usage required monthly reviews to determine if criteria were met, including alignment with the Centers for Disease Control and Prevention's standard definitions for infection surveillance. Despite this, the facility's infection control logs from February to December 2024 did not document clinical signs and symptoms for each prescribed antibiotic, indicating a failure to adhere to the policy. A specific instance involved a resident who was treated with one dose of Levaquin, an antibiotic, for pneumonitis, which is not considered an infection. The infection control logs did not document the symptoms that justified this antibiotic use. During a review with the facility's Infection Preventionist, it was confirmed that no assessment tool, such as the McGeer Criteria, was used to determine infection criteria and appropriate antibiotic use. The Infection Preventionist admitted to a lack of familiarity with the facility's antibiotic stewardship program and had not received adequate training on it. This oversight has the potential to affect all 32 residents in the facility, as the program's implementation was not effectively monitored or executed.
Failure to Document and Follow Up on Resident Grievances
Penalty
Summary
The facility failed to document and follow up on grievances for five residents regarding missing personal items. The facility's Grievance Policy requires grievances to be investigated within five working days, with findings and corrective actions reported to the person who filed the grievance. However, the facility did not adhere to this policy. During a resident council meeting, several residents reported missing clothing and blankets, but there was no documented follow-up or resolution. The Resident Council Meeting Minutes repeatedly documented concerns about missing items, but the facility did not maintain proper records of grievances or follow-up actions. Staff members, including the Maintenance Director, Activity Director, and Social Services Director, were informed of the grievances, but there was no documented investigation or resolution. The facility's administrator stated that items are offered to be replaced on a case-by-case basis, as residents sign an admission contract stating the facility is not responsible for lost items. Despite this, the facility's grievance policy was not followed, and there was a lack of documentation and follow-up on the reported grievances, leading to the deficiency.
Failure to Serve Planned Pureed Diets
Penalty
Summary
The facility failed to serve pureed diets as planned on the menu, affecting three residents who were supposed to receive pureed bread and pureed sugar cookies with their meals. On December 9, 2024, observations revealed that no pureed bread was present among the prepared food items in the kitchen or with the meals of residents receiving pureed diets. A Certified Nurse Aide feeding one of the residents was unaware of the absence of pureed bread. On December 10, 2024, residents were observed eating pureed meals without the planned pureed sugar cookies. The Dietary Manager reported that pudding was served instead of pureed cookies because the staff did not prepare the cookies.
Failure to Provide Scheduled Showers and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for residents who are dependent on staff assistance for activities of daily living. Specifically, three residents, identified as R4, R8, and R22, did not receive showers as per their care plans and facility policy. R4, who requires partial/moderate assistance for bathing, did not receive a shower for 13 days, despite being scheduled for showers twice a week. R22, who requires substantial/maximum assistance, went 12 days without a shower due to staffing shortages, as confirmed by the resident. Both residents expressed dissatisfaction with the frequency of showers received. Additionally, R8, who requires assistance with personal hygiene, was observed with facial hair that should have been removed during scheduled shower days. The facility's policy mandates that residents be free of facial hair unless they request otherwise, which was not documented in R8's care plan. The facility's shower schedule and documentation revealed that R8 missed several scheduled showers, and staff confirmed the oversight in grooming. These deficiencies highlight a failure to adhere to the facility's policies and residents' care plans, impacting the residents' personal hygiene and care preferences.
Failure to Use Leg Strap During Mechanical Lift Transfer
Penalty
Summary
The facility failed to perform a mechanical lift transfer safely for a resident reviewed for transfers. The Stand-Up Lift policy requires the use of a leg strap to stabilize the feet during transfers. However, during an observation, a Certified Nursing Assistant transferred a resident to and from the toilet using a mechanical sit-to-stand lift without utilizing the leg strap. The resident has impaired range of motion in both legs and requires partial/moderate assistance for toilet transfers. The resident's care plan indicates transfers with one staff person and a gait belt but does not document the use of a mechanical sit-to-stand lift or the necessity of the leg strap. The Director of Rehab confirmed that the leg strap should be used for all residents during such transfers.
Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, R23 and R24, as observed during a survey. For R23, who has a tracheostomy due to a total laryngectomy, the facility did not replace the tracheostomy oxygen mask weekly as required, with the mask dated 9/15/24 still in use on 12/09/24. Additionally, R23's tracheostomy was not reinserted promptly after removal, and a replacement tracheostomy was not kept at the bedside as per the facility's policy. The tracheostomy was found lying in a container on the bedside table, and the replacement was locked in an office, contrary to the policy that it should be clearly visible at the head of the bed. For R24, who has a diagnosis of Chronic Obstructive Pulmonary Disease, the facility failed to administer oxygen according to the physician's order. R24 was receiving oxygen at five liters per nasal cannula, exceeding the prescribed range of two to four liters. This discrepancy was confirmed by a registered nurse who acknowledged that the oxygen should have been delivered at two liters per nasal cannula. These failures indicate a lack of adherence to the facility's respiratory care policies and physician orders, potentially compromising the residents' care.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure medications were available and administered as ordered, resulting in significant medication errors for two residents. For one resident, Losartan Potassium was not administered on three separate occasions due to unavailability, and there was no documentation that the physician was notified of these missed doses. The facility had a backup medication system that included Losartan, but it was not utilized, and the nursing notes lacked follow-up communication with the pharmacy or the physician. Another resident did not receive Insulin Glargine and Insulin Lispro as ordered, with several instances of missed doses and unrecorded blood glucose results. The nursing notes indicated that the resident refused to eat or have their blood glucose checked on some occasions, but there was no documentation of physician notification for the missed insulin doses. Additionally, there was an instance where Novolog insulin was unavailable, and the nurse did not report this to the administrator.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccinations and maintain proper documentation for three residents, leading to a deficiency in immunization practices. The Centers for Disease Control and Prevention guidelines specify that adults aged 19-64 with chronic health conditions should receive the PCV20 or PCV15 followed by PPSV23, and adults over 65 should receive PCV20 or PPSV23 based on their previous vaccination history. However, the facility's policy, which requires offering the vaccine within 30 days of admission and documenting it in the resident's records, was not followed. Resident 18, aged 63 with Type Two Diabetes Mellitus, Interstitial Pulmonary Disease, and nicotine use, did not have documentation of being offered the pneumococcal vaccine, despite the Minimum Data Set indicating a decline. Resident 19, aged 76 with Asthma and Obstructive Sleep Apnea, received Prevnar13 in 2018 but had no further vaccinations or offers documented. Resident 22, aged 73 with Atherosclerotic Heart Disease, received Pneumovax23 in 2021, with no additional offers or vaccinations documented. The Infection Preventionist/MDS Coordinator admitted to not managing pneumococcal vaccinations due to uncertainty about the schedule, resulting in a lack of documentation and adherence to guidelines.
Failure to Report and Investigate Suspected Misappropriation of Medication
Penalty
Summary
The facility failed to report an allegation of misappropriation of medication for one resident. A Licensed Practical Nurse (LPN) discovered crushed medications labeled for a resident in the garbage and was informed by an agency nurse that an adapter for the resident's gastrostomy tube was missing. The LPN notified the facility administrator via text message about the incident, as there was no Director of Nursing present at the time. The administrator did not respond to the text and did not initiate any investigation or reporting process regarding the incident. According to the facility's Abuse Prevention Program Policy, the administrator is required to appoint an investigator and report the results to the Department of Public Health within five working days of the incident. However, the administrator confirmed that no report or investigation was conducted following the LPN's notification. The failure to follow policy resulted in the lack of timely reporting and investigation of a potential misappropriation of resident medication.
Failure to Investigate Alleged Misappropriation of Medication
Penalty
Summary
The facility failed to investigate a reported incident of misappropriation of a resident's medication. An LPN discovered a resident's crushed medications in the garbage at the start of a night shift and immediately reported the finding to the administrator. However, the administrator did not follow up on the report, did not conduct any interviews, and did not initiate any investigation or documentation regarding the incident. This inaction was contrary to the facility's Abuse Prevention Program Policy, which requires a thorough investigation process for all allegations, including interviews and written reports.
Failure to Administer and Report Missed Seizure Medications
Penalty
Summary
A resident with a diagnosis of intractable focal epilepsy requiring scheduled administration of seizure medications and therapeutic drug monitoring did not receive prescribed doses of Levetiracetam and Carbamazepine. The medications, which were to be administered via PEG tube, were found crushed and discarded in the trash by an LPN at the start of the night shift. The LPN learned from an agency nurse that the PEG tube adapter was missing, which prevented medication administration, and subsequently found a new adapter in the medication cart. The discarded medications were identified by the resident's name on the medication cup, and the incident was verbally reported to the facility administrator and during shift report. Despite being informed of the incident, the administrator did not follow up, interview staff, or initiate any documentation or reporting as required by the facility's policy on medication discrepancies. The policy mandates immediate reporting to the physician, documentation in the medical record, completion of a Medication Discrepancy Report, and review by the medical director and Quality Assurance Committee. No such actions were taken, and the incident was not documented or investigated further, resulting in a failure to ensure the resident was free from significant medication errors.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's change in physical condition, which affected one of the three residents reviewed for nursing care. The facility's policy requires prompt notification of medical providers regarding changes in a resident's condition. The resident in question, diagnosed with Dementia, Covid-19, Heart Failure, Dissociative and Conversion Disorder, Major Depression, and Lewy Body Dementia, experienced a significant increase in Risperdal dosage due to uncontrollable behaviors. Following the dosage increase, the resident became lethargic, slept more than usual, and was unable to stay awake to eat, appearing sedated. Despite these changes, the Registered Nurse responsible for the resident's care over the weekend did not notify any medical providers about the resident's condition. The Certified Nurses Assistant also observed the resident's decline and reported it to the Registered Nurse, but no action was taken. The Nurse Practitioner was not informed of the resident's condition until two days later, at which point the medication was adjusted, and the resident was sent to the hospital for evaluation. This delay in notification and response contributed to the deficiency identified in the report.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by an incident involving two residents. Resident R1, who has a history of physical aggression, was documented to have slapped Resident R2 approximately ten times on the thigh while they were seated next to each other in the dining room. R2, who suffers from quadriplegia, epilepsy, cortical blindness, profound intellectual disabilities, cerebral palsy, and major depressive disorder, is completely dependent on staff for all activities of daily living and is unable to defend themselves due to upper extremity impairment. The incident was witnessed by a unit aide, V2, who reported hearing R2 scream in pain and observed R1 continuing to slap R2 even after the initial altercation began. The facility's abuse prevention policy affirms the right of residents to be free from abuse, yet the incident investigation revealed a failure to prevent R1's aggressive behavior towards R2. R1's care plan had previously documented their physical aggression, including behaviors such as grabbing, biting, and pinching, with a goal to prevent harm to themselves or others. Despite this, the incident occurred, indicating a lapse in the implementation of measures to protect residents from abuse, particularly those who are vulnerable and unable to defend themselves.
Failure to Document Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to document a resident-to-resident physical abuse incident and investigation in a resident's medical record. On June 16, 2024, two residents were involved in an altercation in the dining room where one resident began making noises that agitated the other, leading to the latter slapping the former on the thigh approximately ten times. Despite this incident, the victim's electronic medical record and nursing progress notes for June 2024 did not contain any documentation of the altercation or the fact that the resident was a victim of physical abuse. On June 27, 2024, it was reported that the Registered Nurse only documented the incident in the aggressor's medical record and not in the victim's medical record. This oversight was identified during an interview and record review, affecting one of the three residents reviewed for abuse in the sample.
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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