Failure to Assess Change in Condition and Perform Safe Hoyer Transfer Resulting in Severe Injuries
Summary
The deficiency involves the facility’s failure to ensure a resident received timely assessment and care in accordance with professional standards of practice and the resident’s care plan after a reported change in condition. The resident was an elderly female with Alzheimer’s disease, dementia, prior cerebral infarction, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers, requiring a two-person Hoyer lift transfer at all times. Her care plan and Kardex both identified her as non–weight bearing and requiring Hoyer lift with two staff. On the afternoon of the day before the incident, documentation by an LVN indicated no edema or injuries, and a late-night note by another LVN documented edema but did not specify location, grade, or associated pain. During the night shift, a CNA transferred the resident from wheelchair to bed using a Hoyer lift alone, despite knowing the resident required a two-person Hoyer transfer and acknowledging awareness that Hoyer lifts required two staff. The CNA reported not being trained on the Hoyer lift at the facility and not checking the Kardex due to lack of access to the electronic system. After the transfer, while providing incontinence care, the CNA noticed bruising on the resident’s left leg and skin tears on her arms near the wrists. The CNA stated she informed a CNA supervisor, who allegedly said the leg had always been like that and did not check it, and that she also informed the night-shift LVN that the resident appeared to be in pain and asked the LVN to look at the leg. The LVN reportedly responded that the resident would be screaming if she was in pain and later, when shown the resident’s left foot with edema around 5:10–5:15 a.m., told the CNA to elevate the leg and then continued providing care to other residents without immediately assessing the resident. The LVN who had worked the prior day shift and returned for the morning shift stated that the resident had no bruises, edema, or skin tears when she left the previous evening. After receiving morning report, this LVN was asked by the night LVN to assess the resident at approximately 6:40 a.m. Upon pulling back the covers, she observed extensive new findings: discoloration and bruising to both arms and the right thigh, left lower extremity swelling and discoloration, multiple skin tears with missing top skin and no flaps, a knot on the right forearm, a scratch on the forehead, a large bruise on the back, fresh blood on the gown and blankets, and significant pain responses (grimacing, moaning, and frowning) when the resident was touched or moved. The resident was unable to articulate what had happened and denied falling or being harmed when questioned. Hospital evaluation documented a forehead abrasion, obvious deformity of the left lower extremity, severe hematoma of the right upper extremity, bilateral upper extremity contusions with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling, with concern for elder abuse noted. The facility’s investigation found no reported falls or incidents that could explain the injuries, confirmed that the night LVN had been notified of leg changes but did not promptly assess the resident, and classified the situation as an Immediate Jeopardy related to failure to assess and respond to a change in condition and to follow safe transfer requirements.
Removal Plan
- Suspended CNA A and LVN C immediately pending investigation
- Terminated LVN C for failure to assess and document a resident after being notified of a change in condition
- Completed facility-wide skin assessments with no new or abnormal findings
- Conducted environmental and safety rounds with no hazards or abnormal findings identified
- Conducted resident safe surveys with residents reporting they feel safe in the facility environment
- Provided staff education on abuse, neglect, and exploitation policies
- Completed mechanical lift (Hoyer) competencies with nursing staff
- Conducted targeted staff interviews with employees who had direct contact with the resident within the previous 72 hours regarding observed abnormalities and reporting
- Re-educated staff regarding the role of the Facility Abuse Coordinator, incident and accident reporting, documentation requirements, and charting expectations
- Reviewed electronic records of residents for assessment issues; no issues identified
- Held an AD HOC QAPI meeting with the interdisciplinary team to review the incident and identify system improvements
- Implemented staff training and competency testing/demonstration on abuse/neglect/reporting, documentation, transfers, resident assessment, and pain assessment
- Conducted in-services for all direct care staff; staff not present were not permitted to work their assignment until in-serviced
- In-serviced all new hires during facility orientation
- In-serviced all agency staff prior to working their floor assignment
- Completed in-service training on falls, documentation, Stop and Watch alert tool in PCC, and reporting abuse/neglect immediately to the Abuse Coordinator; 100% of staff trained
- Completed nursing staff training and competencies on skin assessments and pain assessments; 100% of nursing staff trained
- Conducted impromptu observations and skills/knowledge checks of Hoyer lift transfers and resident assessments
- Conducted daily reviews of resident records for assessments via daily 24-hour report review
- Monitored staff daily and conducted impromptu knowledge checks
- Reviewed 24-hour reports daily and reviewed resident charts for required charting
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Care Plan for Protective Sleeve: A resident with severe cognitive impairment, Alzheimer’s disease, dementia, and PVD had a care plan directing staff to keep protective sleeves on the left elbow at all times due to skin tear risk. During repeated dining room observations, the resident was not wearing the sleeve. A NA said she did not apply it because the resident would remove it and chew on it, and an RN said he was unaware the sleeve was not being worn.
Failure to follow wound care orders and dressing documentation requirements was cited for multiple residents. A resident had a skin tear dressed without a physician order, another resident had a knee dressing with no date or initials, and a third resident had a dated dressing and pain patch that did not reflect the ordered treatment schedule. The DON and wound care RN acknowledged that dressings and treatments should be completed as ordered and that dressings are expected to be dated and initialed.
Failure to Follow Ordered Treatments and Weight Monitoring: The facility did not ensure ordered care was carried out for several residents. One resident with Parkinson’s disease and anxiety sustained a skin tear to the hand during an agitated episode, but there was no physician order for the wound treatment that was provided. Two residents had ordered weekly weights that were not obtained as scheduled, and the records did not explain why. Another resident with HTN, depression, and DM had body blisters, but the wound company’s recommendation for skin prep was not entered as an order, and there was no documented evidence that the practitioner was contacted about the missed recommendation.
Failure to Follow Insulin Orders: Two residents with diabetes received insulin contrary to physician orders. One resident was given insulin aspart at times when blood glucose was below the ordered hold parameter, and a second resident received scheduled insulin without documented meal intake despite orders to hold if blood sugar was low or if less than 50% of the meal was eaten. The DON confirmed the medication administration did not follow the orders.
Failure to follow bowel management protocol: three residents had extended periods without a BM and no documented nursing interventions despite the facility’s protocol requiring specific measures after 2, 3, 4, and 5 days without a BM. The residents had significant diagnoses including schizophrenia, Parkinson’s disease, stroke, TBI, and Alzheimer’s disease, and the RNC confirmed the missing BM-related interventions in the chart.
A resident with dementia, severe cognitive impairment, limited ROM in both LEs, and dependence on staff for wheelchair locomotion was observed sitting in her wheelchair with her feet hovering above the footrests. CNAs confirmed her feet did not reach the footrests, and an administrative nurse stated the footrest needed to be adjusted to better fit and support her feet.
Failure to Follow Care Plan for Protective Sleeve
Penalty
Summary
The facility failed to ensure a sleeve protector was provided in accordance with the comprehensive care plan for a resident with severe cognitive impairment, Alzheimer’s disease, dementia, and peripheral vascular disease. The resident’s admission MDS identified the resident as needing partial/moderate assistance with upper body dressing and footwear and as being at risk for pressure ulcer/injury without existing pressure ulcers. The Pressure Ulcer/Injury CAA identified the resident as at risk for pressure ulcers and in need of a pressure relieving device for the bed and chair. The resident’s care plan, revised 7/28/26, identified a skin tear/potential for skin tear of the left anterior shin and left posterior calf related to falling and hitting self on the wheelchair, and directed staff to keep protective sleeves on the left elbow at all times. During multiple observations in the dining room, the resident was seated in a tilt-in-space wheelchair and was not wearing the protective sleeve to the left elbow. A NA stated she had been assigned to the resident all week and did not put the sleeve on because the resident would take it off and chew on it. An RN stated he was unaware the resident was not wearing the sleeve but said the resident should wear it if it was care planned. The DON stated the sleeve protector should be assessed and removed from the care plan if inappropriate, but staff were expected to follow the care plan to ensure the resident received the needed care.
Failure to Follow Wound Care Orders and Dressing Documentation
Penalty
Summary
The facility failed to ensure physician orders and facility policy were followed for wound care for 3 of 10 residents reviewed for wounds. Resident #28 was observed with a gauze dressing to the right wrist dated 08/06/2026, and the nursing note documented that a CNA noticed a new skin tear to the right wrist that was bleeding, was assessed by the nurse, cleaned, and dressed. However, review of the physician orders showed no wound care order for the right wrist. The wound care RN stated the resident did not have any wounds to her knowledge and explained that when a resident gets a skin tear, the nurse should cleanse it, recover the skin, dress it, notify the physician and family, and enter new orders. The DON stated the resident did not have orders for wound care to the right wrist and that the LPN should have notified the provider and obtained orders. Resident #21 was observed with an island dressing on the right knee that had no date or initials. The DON stated dressings are expected to be dated, and the wound care RN stated it is her practice to date and initial every dressing change, with weekend and PRN dressing changes done by the nurse on the cart. The TAR directed daily cleansing and application of a long island dressing to the right knee surgical site, and the facility policy for clean/dry dressings required tape/labels with date and initials. Resident #113 was observed with a dressing dated 8/6 and a white pain patch on the left arm dated 8/6/2026. The physician order required cleansing the left arm skin tear and applying xeroform, honey gel, and border gauze every day shift, and another order directed Aspercreme Lidocaine Patch 4% to the left shoulder in the morning and night and to the left hip with removal at bedtime. The wound care RN stated she was not familiar with the resident's skin tear dressing orders and that wound care should be done as ordered, while the DON stated dressings and treatments should be done as ordered and a check mark in the treatment record means completed.
Failure to Follow Ordered Treatments and Weight Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with orders and professional standards for four residents. Facility policy stated that weights were to be obtained routinely to monitor nutritional health, including weekly for the first four weeks after admission or readmission and more often if risk was identified or as ordered. For one resident with diagnoses including high blood pressure, Parkinson’s disease, and anxiety, a nursing note documented that the resident sustained a skin tear to the right hand during an episode of agitation and attempted physical aggression toward staff while being assisted out of bed. The wound nurse confirmed there was no physician order for treatment of the right hand skin tear, although steri-strips had been applied and the wound nurse stated steri-strips are the preferred treatment for skin tears. For two residents, physician orders required weekly weights, but the clinical record did not show that the ordered weights were obtained as directed. One resident had weights not obtained on two scheduled dates, and the record lacked additional documentation explaining why the weights could not be obtained. Another resident had one missed weekly weight, and the record also lacked additional documentation explaining why the weight was not obtained. The DON confirmed that the facility failed to make certain these residents were provided appropriate treatment and care. For another resident with diagnoses including hypertension, depression, and diabetes, the record showed the resident was admitted with marks and blisters on the body and no treatment was ordered. A contracted wound company later recommended skin prep to the blisters, but physician orders did not include skin prep. A wound nurse stated there was no order for skin prep and confirmed the facility did not follow the wound company’s recommendations. An RN stated the recommendations were not followed, but the facility had no documented evidence of speaking with the practitioner about treatment for the blisters or the reason the recommendations were not followed.
Failure to Follow Insulin Orders
Penalty
Summary
The facility failed to follow physician orders for two residents receiving insulin. One resident was cognitively intact, required maximum assistance with daily care needs, had diabetes, and was ordered to receive 6 units of insulin aspart at 8:00 a.m. with instructions to hold the medication if blood sugar was less than 110 mg/dL. Review of the MAR showed the resident received the insulin on multiple occasions when blood sugar readings were below that threshold, including readings of 92, 106, 105, 104, 94, and 75 mg/dL. The DON confirmed that the insulin had been administered on those dates and should have been held per the physician's order. A second resident was cognitively impaired, dependent on staff for daily care needs, and had insulin-dependent diabetes. The physician ordered 6 units/mL of insulin aspart twice daily with lunch and supper, with instructions to hold the dose if blood sugar was less than 150 mg/dL or if the resident ate less than 50 percent of the meal. The MAR showed no documented meal intake for several lunch and dinner meals on specified dates, yet the insulin was still administered. The DON confirmed that staff should have obtained the resident's meal intake before giving the insulin on those occasions.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to follow its Bowel Management - Clinical Protocol for residents who did not have a bowel movement within the required time frame. The protocol dated April 2026 directed staff to assess, monitor, and manage bowel and bladder function according to individualized needs and physician/provider orders, with specific interventions beginning on Day 2, Day 3, Day 4, and Day 5 without a BM. For Resident #31, the record documented no BM from 7/27/26 at 2146 to 7/31/26 at 2130, with no documented nursing interventions during that period. Resident #31 had diagnoses including schizophrenia and alcohol abuse. Resident #4’s record documented no BM from 7/9/26 to 7/12/26 with no documented nursing interventions related to the lack of BM during that time. Resident #4 had diagnoses including Parkinson’s Disease and major depressive disorder. Resident #56’s record documented no BM from 7/21/26 to 7/28/26 and again from 7/29/26 to 8/2/26, with no documented nursing interventions during those periods. Resident #56 had diagnoses including stroke, traumatic brain injury, and Alzheimer’s disease. On 8/5/26, the RNC stated that Residents #4, #31, and #56 had no documented BM-related interventions for July and the first part of August 2026 and should have.
Wheelchair Footrest Not Adjusted for Resident With Limited LE ROM
Penalty
Summary
The facility failed to ensure appropriate wheelchair positioning for R11. R11 had a diagnosis of dementia, severe cognitive impairment on MDS assessments, limited ROM in both lower extremities, and was dependent on staff for locomotion in her wheelchair. Her care plan, revised 07/02/2026, instructed staff that she was dependent on staff for locomotion in her wheelchair. During observations on 08/03/2026 and 08/04/2026, R11 was seen sitting in her wheelchair at the dining room table with her feet hovering several inches above the wheelchair footrest. CNA M confirmed on 08/04/2026 that R11's feet did not reach the footrests, and CNA N stated the footrest needed to be adjusted to fit R11 better. On 08/05/2026, Administrative Nurse D also stated the footrest needed to be adjusted to better fit the resident and support her feet. The facility policy for Use of Assistive Devices stated that assistive device use would be based on the resident's needs, as indicated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.