Three Springs Sr Living & Rhab
Inspection history, citations, penalties and survey trends for this long-term care facility in Chester, Illinois.
- Location
- 161 Three Springs Road, Chester, Illinois 62233
- CMS Provider Number
- 145497
- Inspections on file
- 23
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Three Springs Sr Living & Rhab during CMS and state inspections, most recent first.
A resident with a recent ankle fracture and non-weight bearing status was discharged home without a physician order or proper discharge planning. The care plan did not address discharge, and staff provided conflicting information to the resident and her family. Despite therapy recommendations against discharge and the primary physician's refusal to authorize it, a new RN and the Social Service Director facilitated the discharge, relying on home health services and a friend's assistance at home.
A resident with a history of stroke, hemiplegia, cognitive impairment, and high fall risk was left unsupervised outside in a wheelchair after being taken out for a cigarette. The resident, unable to communicate effectively and requiring total assistance for transfers, was observed rocking and moaning before slipping from the wheelchair and sustaining significant injuries, including a head hematoma and abrasions. Staff interviews revealed confusion about supervision requirements, and facility policies for direct supervision during smoking were not followed.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to ensure a licensed nurse was in charge on each shift, as required.
A resident with a history of falls and cognitive impairment was not provided with care planned fall prevention interventions, including non-skid socks and a non-skid mat for the wheelchair. The resident was observed without these interventions in place and experienced two falls in the dining room. The facility administrator confirmed that the required interventions were not implemented as specified in the care plan.
The facility failed to ensure staff encouraged COVID-19 positive residents to wear masks and that staff donned proper PPE. A resident with severe cognitive impairment was observed without a mask in common areas, and two CNAs provided care to another COVID-19 positive resident without appropriate PPE. The facility's DON confirmed the expectation for full PPE use during the ongoing COVID-19 outbreak.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. Staffing schedules showed no RN coverage on five days, and the administrator acknowledged a misunderstanding of coverage requirements. The Director of Nursing confirmed only two RNs are employed, with efforts to hire more. This deficiency potentially affects all 66 residents.
The facility failed to conduct proper infection control surveillance for residents with vomiting and diarrhea, affecting all 66 residents. The infection control specialist, who was uncertified, did not implement contact isolation or notify the health department. Despite testing for flu and COVID, no surveillance or tracking of affected rooms and staff was conducted. The medical director and hospital infection control specialist were not informed of the outbreak, and the facility's infection control policy was not followed.
The facility failed to provide scheduled showers to several residents, as confirmed by interviews and record reviews. A resident reported not receiving showers twice a week as per their care plan, and the DON confirmed the inconsistency. Another resident's family expressed dissatisfaction with the care, noting the resident often appeared unkempt. The facility's policy requires documentation of showers, but this was lacking, and the DON acknowledged the issue.
The Facility did not have an RN on duty for at least eight consecutive hours a day, seven days a week, as required. This was confirmed through interviews and record reviews, with the Administrator and DON citing staffing challenges and recruitment difficulties in a rural setting. The absence of an RN on specific dates affected all 70 residents.
A resident with a DNR order was mistakenly resuscitated due to conflicting code status documentation. Despite having a POLST form indicating DNR, the resident's records listed them as Full Code, leading an LPN to perform CPR when the resident was found unresponsive. The error occurred after the resident's orders were incorrectly reinstated following a brief discharge and return to the facility.
The Facility failed to adhere to proper food storage and labeling practices, potentially affecting all 66 residents. Observations revealed unlabeled and undated food items in various refrigerators and freezers, sticky oven handles, and improperly stored sanitizer. These actions violated the Facility's policies, which require all food items to be labeled and dated, and discarded after a certain period.
A facility failed to attempt Gradual Dose Reductions (GDR) on psychotropic medications for a resident with Alzheimer's and other conditions, despite policy requirements. The resident was cognitively intact and showed no behavioral symptoms, yet was on multiple psychotropic medications. No behavior monitoring or GDR attempts were documented, and pharmacy consults resulted in no new orders.
The facility failed to provide the required 80 square feet of floor space per resident bed for 50 residents. Rooms in various halls, all Medicaid certified, only provide 75 to 77 square feet per bed. This was confirmed by the Maintenance Director, and no resident complaints were noted. The VP of Operations stated no changes have been made to room measurements or certifications.
Resident Discharged Without Physician Order or Safe Discharge Planning
Penalty
Summary
A deficiency occurred when a resident was discharged home without a physician's knowledge, order, or consent. The resident had a recent history of right ankle trimalleolar fracture with open reduction internal fixation (ORIF), was non-weight bearing, and required partial to moderate assistance with ambulation and transfers. The care plan identified risks for falls and orthopedic complications but did not address discharge planning or the resident's preferences regarding discharge. There was no documentation in the care plan or progress notes indicating that the resident had expressed a desire to leave the facility or that discharge planning had been discussed with her. On the day of discharge, conflicting information was provided to the resident and her family regarding whether she could be released, with staff initially stating she could go home, then later retracting this due to the absence of a physician's order, and finally stating she could be discharged. The resident was ultimately discharged with the assistance of a friend, who provided care at home, including help with mobility, wound care, and daily activities. Occupational therapy had recommended continued stay in the facility due to environmental barriers at home and the need for physical assistance with stairs, and the primary physician had explicitly stated that discharge was not safe due to ongoing therapy needs and uncertainty about the resident's support system at home. Interviews with facility staff revealed that a new RN was instructed to obtain a discharge order but did not actually secure one from the physician. The Social Service Director believed an order had been obtained, and home health services were arranged, but the discharge proceeded without proper physician authorization. The primary physician later confirmed that he had denied the discharge request due to safety concerns, and the Medical Director stated he would not have approved discharge against therapy recommendations or the primary physician's wishes. The facility's discharge policy requires physician authorization and appropriate planning, which was not followed in this case.
Failure to Supervise Resident with Impaired Mobility and Cognition Resulting in Fall
Penalty
Summary
A deficiency occurred when a moderately cognitively impaired resident with a history of stroke, hemiplegia, hemiparesis, muscle weakness, and impaired mobility was left unsupervised outside the facility in her wheelchair. The resident required total assistance for transfers and had documented risks for falls, as well as impaired visual function and cognitive deficits. Despite these needs, the resident was left unattended after being taken outside for a cigarette, with no staff present to supervise her, even though her care plan and facility policies indicated the need for supervision. While outside, the resident was observed by a surveyor rocking back and forth in her wheelchair, moaning, and slumped in the chair, with no staff monitoring her or other residents in the area. The resident was unable to communicate her needs effectively and was not alert when approached. She subsequently leaned forward, slipped out of her wheelchair, and fell onto the concrete, sustaining abrasions to her knees, a large swelling on her forehead, and a black eye. The surveyor had to alert staff to the incident, and the resident was sent to the hospital for evaluation and treatment. Interviews with staff revealed a lack of clarity regarding the supervision requirements for the resident while outside, despite her documented need for assistance and supervision, especially during smoking. The staff member who took the resident outside did not remain with her and was unsure if supervision was necessary beyond smoking. Facility policies required direct supervision for residents with restricted privileges, such as supervised smoking, but these were not followed, resulting in the resident being left unsupervised and subsequently experiencing a fall with injury.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for one resident with a history of falls and multiple medical diagnoses, including metabolic encephalopathy, orthostatic hypotension, chronic atrial fibrillation, and cognitive impairment. The resident was assessed as moderately cognitively impaired and required supervision or assistance with transfers. Despite being care planned for non-skid socks and a non-skid mat on and below the wheelchair pad, the resident was observed wearing socks without non-skid material and without the required non-skid mat in place during multiple observations. The absence of these interventions was confirmed by the facility administrator. The resident experienced two falls in the dining room, one of which was witnessed and triggered an alarm, and another where the resident was found sitting on the floor in front of her wheelchair. The facility's policy requires staff to implement individualized fall prevention interventions based on resident risk, and the administrator acknowledged that the interventions specified in the care plan were not in place at the time of the observations.
Failure to Enforce PPE and Mask Protocols for COVID-19 Positive Residents
Penalty
Summary
The facility failed to ensure that staff were encouraging COVID-19 positive residents to wear masks and that staff donned proper personal protective equipment (PPE) to prevent the spread of COVID-19. This deficiency was observed in the case of two residents, both of whom were COVID-19 positive. One resident, identified as R6, was noted to be severely impaired for cognition and had a history of wandering due to dementia. Despite being on isolation precautions, R6 was observed multiple times without a mask while ambulating in the hallway and sitting near the dining room, with no staff intervention to encourage mask-wearing. Another resident, R8, who also tested positive for COVID-19, was observed in her room with staff providing care without wearing the appropriate PPE. Two certified nursing assistants (CNAs) were seen transferring R8 using a mechanical lift while only wearing surgical masks, without N95 masks, eye protection, or gowns, as required by the facility's COVID-19 guidance. The CNAs admitted to not noticing the PPE requirements posted on the door and not being aware of R8's COVID-19 status. The facility's Director of Nursing (DON) confirmed that staff should have been wearing full PPE when providing care to COVID-19 positive residents. The facility was experiencing a COVID-19 outbreak, with several residents testing positive. The facility's COVID-19 guidance and CDC guidelines require healthcare personnel to use proper PPE, including N95 respirators, gowns, gloves, and eye protection, when exposed to residents with suspected or confirmed COVID-19.
RN Coverage Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through a review of staffing schedules for the past 14 days, which revealed that there was no RN coverage on five specific days: Wednesday 10/30/2024, Thursday 10/31/2024, Saturday 11/2/2024, Sunday 11/3/2024, and Monday 11/4/2024. The facility's administrator acknowledged the issue, noting a misunderstanding regarding the RN coverage requirements, particularly concerning the Director of Nursing's role. The Director of Nursing confirmed that the facility currently employs only two RNs, including herself, and that efforts are underway to hire more RNs. The facility's staffing policy, dated 10/2017, states that sufficient numbers of staff with the necessary skills and competencies are to be provided to meet the needs of all residents. However, the staffing schedules did not reflect compliance with this policy, as evidenced by the lack of RN coverage on the specified days. This deficiency has the potential to impact all 66 residents living in the facility.
Inadequate Infection Control Surveillance
Penalty
Summary
The facility failed to ensure proper infection control surveillance for residents experiencing vomiting and diarrhea, potentially affecting all 66 residents. The administrator acknowledged that a few residents had these symptoms a few weeks prior, but claimed they were now resolved. The infection control specialist, who started working at the facility on October 25, 2024, had not yet completed the necessary certification course. They reported that 11 residents experienced symptoms, with three being hospitalized. Despite testing all residents for flu and COVID, which returned negative results, no contact isolation was implemented, nor was the health department notified. Surveillance and tracking of affected rooms and staff were not conducted, even though staff members also experienced similar symptoms. The facility's infection control policy, revised in September 2017, requires ongoing surveillance for healthcare-associated infections and other significant infections. However, the infection control specialist did not perform any surveillance or tracking, and the medical director and infection control specialist for the hospital were not informed of the outbreak. The facility provided an undated floor plan that did not identify residents or document interventions, except for COVID and flu vaccinations. The lack of proper surveillance and communication with relevant health authorities contributed to the deficiency in infection control practices.
Deficiency in Providing Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents received their scheduled showers, which is a part of their activities of daily living care. This deficiency was identified for four out of five residents reviewed in a sample of thirteen. Resident 2, who is cognitively intact and uses a wheelchair, reported not receiving the scheduled showers twice a week as per their care plan. The Director of Nursing confirmed that Resident 2 was supposed to receive showers on Wednesdays and Saturdays, but this was not consistently happening. Similarly, Resident 6, who is also cognitively intact, reported only receiving one shower per week over the past 14 days, despite being scheduled for two showers per week. Resident 3's family expressed dissatisfaction with the inconsistent care, noting that Resident 3 often appeared unkempt and had not received the scheduled showers. The Director of Nursing was unable to provide documentation to confirm that Resident 3 received the showers as scheduled. Resident 12 also reported issues with not receiving showers, which was a topic of discussion in the resident council meetings. The facility's policy requires documentation of showers, including any refusals and the condition of the resident's skin, but this documentation was lacking. The Director of Nursing acknowledged the complaints and stated efforts were being made to address the issue.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The Facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by federal regulations. This deficiency was identified through interviews and record reviews, which revealed that the Facility's Nurse's Schedule did not document an RN being scheduled for the required hours on specific dates. The Administrator confirmed the absence of an RN for the required hours on these dates, citing staffing challenges due to call-offs and recruitment difficulties in a rural setting. The Director of Nursing also acknowledged the staffing issues and the ongoing efforts to recruit staff. The Facility does not have a specific policy on RN staffing and follows federal regulations, impacting all 70 residents living in the Facility.
Failure to Honor Resident's DNR Wishes
Penalty
Summary
The facility failed to respect the end-of-life wishes of a resident who had chosen Do Not Resuscitate (DNR) as their advanced directive. The resident, who had multiple diagnoses including diabetes mellitus type 2, chronic kidney disease stage 3, liver cirrhosis, heart failure, and chronic venous hypertension, had a POLST form completed and signed by their physician indicating no CPR should be attempted. Despite this, the resident's physician orders contained conflicting instructions for both Full Code and DNR. When the resident was found unresponsive, a Licensed Practical Nurse (LPN) checked the admission records and face sheet, which incorrectly listed the resident as Full Code, and initiated CPR. This action was taken without knowledge of the resident's POLST form indicating DNR status. The facility's administrator acknowledged the error, noting that the resident's code status was initially Full Code upon admission but was later clarified to DNR. However, after a brief discharge and return to the facility, the orders were reinstated incorrectly, leading to the confusion and subsequent failure to honor the resident's end-of-life wishes.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The Facility failed to store foods in a manner that prevents foodborne illness, potentially affecting all 66 residents. During observations, surveyors noted several deficiencies in food storage and labeling practices. Crumbs were found on the bottom shelf of the serving counter and food preparation area, and oven handles were sticky. In the standing refrigerator, a plastic bag with julienned zucchini and various colored cups of liquids were not labeled or dated. Opened containers of whipped cream were not re-wrapped or dated, and a container of unlabeled fruit was dated 6/2/24. The deep freezer contained an opened package of chicken breasts that were not resealed or labeled. Additionally, two Styrofoam containers of salad in the dry storage room refrigerator were not labeled or dated. Further issues were identified in the break room refrigerator, where three plastic bags labeled with a resident's identifier were found, with only one labeled as toffee and none dated. The freezer had brown smears on the bottom shelf, and the refrigerator had red spills. A large container of sanitizer was placed directly on the floor of the dry storage room, in close proximity to food items. The Facility's policies from 2016 require all food items to be labeled and dated, with specific guidelines for discarding food past expiration or after a certain period. However, these policies were not adhered to, as evidenced by the unlabeled and undated food items found during the survey.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to attempt Gradual Dose Reductions (GDR) on psychotropic medications for one resident, identified as R23, out of a sample of ten. R23 was admitted with multiple diagnoses, including Alzheimer's Disease, unspecified dementia with psychotic disturbance, and major depressive disorder. Despite being cognitively intact with a BIMS score of 13 and no behavioral symptoms reported, R23 was prescribed several psychotropic medications, including Ativan, Risperidone, and Zoloft, among others. The care plan indicated the need for quarterly consultations with the pharmacy and physician to consider dosage reductions, but no new orders were made following pharmacy consults on various medications from January to June 2024. The facility's policy requires that antipsychotic medications be prescribed at the lowest possible dosage for the shortest period and be subject to gradual dose reduction and re-review. However, there was no documentation of behavior monitoring or attempts at GDR for R23, as noted in the Medication Administration Record (MAR) for the months of January through June. The Director of Nurses acknowledged the lack of behavior monitoring and documentation and mentioned plans to start a committee to address these issues, but at the time of the survey, these actions had not been implemented.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident bed for 50 residents in a sample of 63. Observations and interviews revealed that rooms in A Hall, B Hall, C Hall, and D Hall, which are all Medicaid certified, only provide 75 to 77 square feet per bed. This deficiency was confirmed by the Maintenance Director, who measured the rooms and verified the inadequate space. Despite the deficiency, no concerns or complaints were vocalized by residents regarding the room size during the survey period. The Vice President of Operations confirmed that there have been no changes to the historical measurements and accuracy of the facility's waivered resident room numbers and certifications.
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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