F0677

D

Failure to Reposition Dependent Residents as Required for ADL Care

Mascoutah, Illinois Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in providing positioning assistance to dependent residents who were unable to reposition themselves. One resident with multiple diagnoses including intracerebral hemorrhage, pulmonary hypertension, age-related debility, urinary retention, protein calorie malnutrition, HTN, COPD, anorexia, and pain was documented on the MDS as dependent with ADLs and care planned for an ADL self-care performance deficit requiring staff assistance. This resident was observed from the morning meal period until early afternoon in a reclining wheelchair, with observations made every 15–30 minutes showing no repositioning during that time. The resident was only observed being assisted to bed at 1:30 PM. A CNA later stated that the resident had been laid down and repositioned after breakfast with incontinence care, but could not provide an exact time and confirmed the resident was not laid down or repositioned again until 1:30 PM.

Another dependent resident was observed in a reclining wheelchair in the dining room from the morning through early afternoon, also checked in 15–30-minute increments without any observed repositioning. This resident was observed being assisted to bed in the early afternoon. A CNA stated that this resident had been laid down after breakfast for incontinence care and then returned to the reclining wheelchair, but was unsure of the time. The Administrator stated that residents unable to reposition themselves should be assisted by staff every two hours. The facility’s Activities of Daily Living Policy states that residents who are unable to carry out ADLs independently will be provided appropriate care and services, including support and assistance with mobility, in accordance with their plan of care.