Villa Health Care East
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman, Illinois.
- Location
- 100 Marian Parkway, Sherman, Illinois 62684
- CMS Provider Number
- 145721
- Inspections on file
- 18
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Villa Health Care East during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, aphasia, and other comorbidities, who was ordered a pureed diet with moderately thick (honey) liquids, was observed receiving diced pears instead of fully pureed fruit. A CNA stated the pears were pureed and continued to serve them despite visible chunks, and the resident was seen removing a piece of pear from their mouth. The Food Services Supervisor confirmed that pureed items should be baby-food consistency with no chunks, and facility policy requires use of guest tickets at each meal to ensure diet accuracy.
Two residents with cognitive impairment and high fall risk were not adequately supervised, despite care plan interventions requiring staff presence during transfers and toileting. Both residents attempted to ambulate or perform personal hygiene independently, resulting in one sustaining a left hip fracture and the other a head laceration, with both requiring hospitalization. Staff interviews and documentation revealed that alarms and call lights were not effectively used or accessible, and staffing levels were insufficient to provide the necessary supervision.
The facility did not provide enough nursing staff on certain shifts, resulting in residents not receiving timely assistance and supervision, including a resident who fell in the bathroom while unattended despite care plan instructions. Multiple residents and staff reported inadequate staffing, especially at night, and facility records confirmed minimal nurse and CNA coverage during these times.
The facility did not consistently update or revise care plans for several residents after they experienced falls, despite documented histories of cognitive impairment, physical limitations, and repeated incidents. In some cases, required interventions such as alarms and supervision were not implemented or followed, and care plans were not adjusted to address new risk factors or incidents, contrary to facility policy.
Staff did not ensure privacy for a resident during incontinence care, leaving the door, curtain, and blinds open while a person was present outside the window. Additionally, several staff members, including CNAs, an RN, and the DON, were observed standing while feeding residents with severe cognitive impairment or dementia, rather than sitting with them as expected for dignified dining assistance.
A resident with significant fall risk factors was left unsupervised on the side of her bed by a CNA, resulting in a fall and femur fracture requiring surgery. The care plan required dependent staff assistance with transfers and did not document all necessary fall interventions, such as gripper socks, despite facility policy and the resident's high-risk status.
A resident with dementia and high fall risk was left unattended on the toilet, resulting in a fall and hip fracture. Despite care plans and visual reminders, staff failed to provide necessary supervision. The facility's policy emphasized monitoring high-risk residents, but the deficiency in supervision led to the incident.
The facility failed to securely store and properly label medications, with open bottles of eye drops and ointments lacking open dates, and expired Pantoprazole found in storage. An unlocked medication cart was also observed. Additionally, expired blood glucose control liquids were used for diabetic residents, with staff unclear on responsibility for checking expiration dates.
The facility failed to implement proper infection control practices, with staff not adhering to PPE protocols and inadequate disinfection of equipment. An LPN did not sanitize hands before donning gloves and inadequately disinfected a glucometer used on a COVID-19 positive resident. A resident with symptoms was not tested timely, leading to a positive result after hospital admission. Staff, including a CNA and an LPN, were observed not wearing required PPE when entering COVID-19 positive rooms, breaching infection control protocols.
A resident with enterocolitis due to C. difficile did not receive prescribed vancomycin doses because the medication was unavailable from the pharmacy. The LPN and DON confirmed the missed doses, which violated the facility's medication administration policy.
The facility failed to educate and document the COVID-19 vaccination status for three residents. The Infection Preventionist LPN admitted the absence of educational materials and declination refusals for the COVID-19 vaccine. The facility's policy requires education on the vaccine, but it lacks guidance on documenting acceptance or refusal. The EMRs for these residents do not show evidence of education or vaccine offers, indicating a deficiency in policy adherence and documentation.
Failure to Provide Ordered Pureed Diet Consistency
Penalty
Summary
The deficiency involves the facility’s failure to provide food in the prescribed texture and consistency according to a physician’s diet order for one resident. The resident had multiple diagnoses, including Alzheimer’s disease, atrial fibrillation, GERD, hypertension, spinal stenosis, aphasia following cerebral infarction, and glaucoma, and was documented on the MDS as moderately cognitively impaired and requiring setup assistance with meals. The physician’s order specified a pureed texture diet with moderately thick (honey) liquids. During a lunch meal observation, the resident was served pureed meat, peas, and carrots, but the pears with whipped topping appeared diced rather than pureed. A CNA was observed sitting next to the resident and cutting the pears with a butter knife, and when asked if the pears were pureed, the CNA stated they were. At the surveyor’s request, the CNA placed a scoop of pears on a spoon, which showed visible chunks of pear that the CNA continued to leave for the resident. The resident was then observed reaching into her mouth and placing a piece of pear onto her plate. The Food Services Supervisor later stated that a pureed diet should be the consistency of baby food and that there should not have been any chunks in the pears. The facility’s Menus and Meal Service policy documented that guest tickets should be printed for each resident at every meal to ensure diet accuracy and that a system needs to be established to ensure each resident receives their food at every meal.
Failure to Supervise High Fall Risk Residents Resulting in Serious Injuries
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for two residents, resulting in significant injuries and hospitalizations. One resident, with diagnoses including Alzheimer's disease and a history of falls, was found sitting unsupervised on the side of her bed with the bed not in the lowest position, the bed alarm not sounding, and her call light out of reach. This resident later fell in the bathroom while attempting to ambulate independently, despite care plan interventions requiring staff supervision during transfers and toileting. Staff interviews confirmed that the resident was known not to use her call light and required supervision, but she was left unattended, leading to a left hip fracture. Another resident, also with a history of repeated falls, cognitive impairment, and hemiplegia, experienced multiple falls over a period of time, including a significant incident where she fell off the toilet while attempting to clean herself, resulting in a right frontal laceration that required hospitalization and sutures. The resident's care plan specified that staff should remain with her in the bathroom and not leave her unattended, but documentation and staff interviews revealed that she was left alone or given privacy, contrary to these interventions. The resident's fall risk assessments consistently rated her as high risk, and her medical records documented frequent reminders and interventions that were not consistently followed. Staff interviews indicated that both residents rarely used their call lights and often attempted to perform tasks independently despite their high fall risk and care plan requirements for supervision. Staffing levels were noted to be low, with only one CNA for a hallway of 23 residents during certain shifts, making it difficult to provide the required supervision. The facility's own falls policy required individualized care planning and consistent implementation of fall prevention interventions, which were not adhered to in these cases, directly contributing to the residents' injuries.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents and staff/resident interviews. One resident, who was moderately cognitively impaired and required supervision for activities of daily living, experienced a fall in the bathroom after becoming dizzy and was found on the floor by a CNA. The resident's care plan specifically required that she not be left unattended in the bathroom or while sitting on the side of the bed, and that her call light be kept within reach with prompt response to requests for assistance. On the night of the fall, there was only one nurse and one CNA assigned to the hallway where this resident and others resided. Other residents and staff reported that there was not enough help on the night shift, with only one nurse and one CNA typically assigned to certain halls, making it difficult to provide timely care and supervision. Residents who were dependent on staff for transfers and mobility, and those at risk for falls, expressed concerns about insufficient staffing, particularly during evening and night shifts. Staff assignment sheets confirmed that on several reviewed dates, only one nurse and one CNA were assigned to the relevant hallways during overnight hours. Additional documentation, including grievance forms and resident council meeting minutes, indicated ongoing concerns about call lights not being answered promptly and the need for CNAs to check on residents every two hours. The facility's staffing plan referenced CMS minimum staffing guidelines and described a methodology for determining staffing needs, but interviews with the scheduler and administrator revealed that staffing decisions were based on these minimums and the facility assessment, without a specific policy for nursing staff levels.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to update and revise care plans for multiple residents after they experienced falls, as required by both facility policy and regulatory standards. For example, one resident with a history of repeated falls, cognitive impairment, and physical limitations experienced several falls on specific dates, but her fall risk care plan was not updated after at least two of these incidents. Another resident, who was severely cognitively impaired and required assistance for transfers, also experienced multiple falls, yet his care plan was not revised following at least two of these events. In one instance, it was documented that the resident was wearing inappropriate footwear at the time of a fall, and a family grievance noted that required alarms were not consistently in place, despite being care planned interventions. A third resident, who was cognitively intact but required supervision for transfers and used a wheelchair, reported that staff did not provide assistance to prevent falls and that she often had to manage on her own. The care plan for this resident included interventions to prevent her from being left unattended, but these were not consistently followed. Additionally, a fourth resident with a history of hip fracture and Alzheimer's disease fell after losing balance while leaving the bathroom, and although recommendations were made for reeducation on call light use, the care plan was not updated with new interventions following the fall. Facility policies require that care plans be reviewed and revised by the interdisciplinary team after each assessment and after any fall, with input from caregivers and consideration of environmental hazards. Despite these requirements, the care plans for these residents were not consistently updated or revised after falls, and interventions were not always implemented or adjusted in response to incidents, as documented in interviews, observations, and record reviews.
Failure to Provide Privacy During Care and Dignity During Dining Assistance
Penalty
Summary
Staff failed to provide privacy and dignity during care for several residents. In one instance, a CNA provided incontinence care to a cognitively intact resident with the door, curtain, and blinds left open, exposing the resident to potential view from outside, where a person was present in the courtyard. The resident expressed embarrassment about the possibility of being seen naked through the window. The facility's Resident Rights booklet states that medical and personal care are private, and both the CNA and Administrator acknowledged that privacy should have been maintained by closing the door, curtain, and blinds during care. Additionally, multiple staff members, including CNAs, an RN, and the DON, were observed standing while feeding residents who were dependent on staff for eating due to severe cognitive impairment or dementia. These actions occurred in the dining room and involved residents with diagnoses such as Alzheimer's disease and severe dementia. The Administrator confirmed that there was no facility policy on feeding residents but stated that staff should sit with residents rather than stand over them during feeding.
Failure to Provide Adequate Supervision and Fall Precautions
Penalty
Summary
A deficiency occurred when a resident with multiple high-risk factors for falls, including muscle weakness, impaired gait, dependence on a wheelchair, and a history of falls, was left unsupervised sitting on the side of her bed by a CNA. The CNA left the resident momentarily to retrieve a sit-to-stand lift, during which time the resident slid off the bed and sustained a distal femoral shaft fracture, later requiring surgical repair. The resident's care plan indicated a need for dependent staff assistance with transfers using a mechanical lift and substantial/maximal assistance for bed mobility, but these interventions were not followed at the time of the incident. Additionally, the care plan failed to document the use of gripper socks as an intervention, despite this being identified in the fall investigation. Interviews with facility leadership confirmed that the resident was considered a high fall risk and should not have been left sitting on the bedside unsupervised. The facility's fall policy required individualized care planning and implementation of interventions for high-risk residents, which was not adequately executed in this case.
Failure to Supervise High Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as R2, who was at high risk for falls due to her medical conditions, including dementia and Lewy Body Dementia. R2's care plan emphasized the need for anticipating and meeting her needs, ensuring her call light was within reach, and responding promptly to her requests for assistance. Despite these precautions, R2 attempted to walk back to her bed from the toilet without assistance, resulting in a fall that led to a left hip fracture. The incident was unwitnessed, and the root cause was identified as R2 being new to the facility and attempting to move without calling for help. Interviews with facility staff revealed that R2 was known to be a high fall risk, and there were visual reminders such as a whiteboard and a 'call don't fall' sign in her room. However, it was noted that R2 might not have understood how to use the call light due to her cognitive impairment. Staff members, including LPNs and CNAs, acknowledged that R2 should not have been left unattended on the toilet, given her fall risk and cognitive limitations. The CNA who assisted R2 on the day of the fall did not return a call for further clarification on the incident. The Director of Nurses confirmed that R2 should not have been left alone on the toilet and that interventions such as bed and chair alarms and clear communication during shift changes were standard for high fall risk residents. The facility's policy on fall assessment and management emphasized the need for an interdisciplinary approach to care planning and monitoring. R2's physician indicated that the injury could have been prevented if staff had stayed with her, highlighting the deficiency in supervision and adherence to care protocols.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications, as well as the use of non-expired medical supplies. During an observation, a medication cart was found with several open bottles of eye drops and ointments that were not labeled with the date they were opened, including Timolol eye drops and Durezol for specific residents. Additionally, an open tube of Systane eye lubricant was found unlabeled, and an expired bottle of Pantoprazole Oral Suspension was discovered in the medication storage room. Furthermore, a medication cart was left unlocked and unattended, which was confirmed by the staff present. The facility also failed to ensure the use of non-expired blood glucose control liquids, which were found to be expired for several diabetic residents. The staff, including an LPN and the Infection Preventionist, indicated that checking the expiration dates of these control liquids was not their responsibility, and the facility's policy did not adequately address the quality control measures for blood glucose monitoring. The Director of Nursing acknowledged the expectations for medication labeling and disposal of expired medications, but the facility's policy did not cover these aspects comprehensively.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by multiple instances of staff not adhering to PPE protocols and inadequate disinfection of multi-use equipment. A Licensed Practical Nurse (LPN) was observed not sanitizing hands before donning gloves and inadequately disinfecting a blood glucose glucometer after use on a COVID-19 positive resident. The facility's policy required dedicated medical equipment for COVID-19 positive residents, which was not followed, as the glucometer was not dedicated and was inadequately disinfected. The facility also failed to conduct timely COVID-19 testing for residents showing symptoms. One resident, who was admitted with congestive heart failure and hypertension, exhibited symptoms consistent with COVID-19 but was not tested between specific dates, leading to a positive test result only after being taken to the hospital by a family member. This indicates a lapse in the facility's testing protocol, which required symptomatic residents to be tested immediately. Additionally, staff members, including an agency CNA and an LPN, were observed not wearing the required PPE when entering rooms of COVID-19 positive residents. The CNA did not perform hand hygiene consistently and failed to wear eye protection or a gown while delivering meal trays to COVID-19 positive residents. Similarly, the LPN entered a COVID-19 positive resident's room with only a mask, disregarding the requirement for full PPE. These actions demonstrate a significant breach in infection control protocols, contributing to the spread of infection within the facility.
Medication Administration Failure
Penalty
Summary
The facility failed to administer medications as prescribed to a resident diagnosed with enterocolitis due to Clostridium difficile. The resident was on contact/droplet isolation precautions and had a physician's order for vancomycin oral suspension, to be administered four times a day. However, the Medication Administration Record (MAR) indicated that the vancomycin doses were not administered on specific dates and times. An LPN confirmed that the doses were missed because the medication did not arrive from the pharmacy, and the convenience box did not contain any vancomycin. The Director of Nursing corroborated this explanation, noting that the medication was unavailable from the pharmacy on the specified dates. The facility's policy on medication administration requires accurate administration per doctor's orders, which was not adhered to in this instance.
Failure to Educate and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide education or document refusal for the COVID-19 vaccine for three residents, identified as R44, R51, and R231, out of a sample of 55 residents reviewed for immunizations. On August 5, 2024, the Infection Preventionist LPN, identified as V2, acknowledged that the facility lacked educational materials and declination refusals for the COVID-19 immunization. V2 confirmed that R44, R51, and R231 were the only residents in the building who had not been vaccinated for COVID-19. The facility's COVID-19 Vaccination Policy for Residents, dated February 1, 2022, mandates that education be provided to all residents or their responsible parties regarding the COVID-19 vaccination. However, the policy does not specify how acceptance or refusal of the vaccine should be documented. The admission records for R51, R44, and R231, printed on August 12, 2024, indicate that these residents were admitted on unspecified dates. Their electronic medical records (EMRs) lack documentation showing that they were educated about and offered the COVID-19 vaccine. This omission highlights a deficiency in the facility's adherence to its vaccination policy and documentation procedures.
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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