Abbington Vlge Nrsg & Rhb Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Roselle, Illinois.
- Location
- 31 West Central, Roselle, Illinois 60172
- CMS Provider Number
- 146065
- Inspections on file
- 19
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Abbington Vlge Nrsg & Rhb Ctr during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe cognitive impairment, malnutrition, immobility, incontinence, and existing heel pressure ulcers was identified as needing frequent repositioning and pressure injury prevention, but the care plan lacked a turning/repositioning program, heel off-loading, positioning devices, and specific nutrition strategies for poor intake. Skin check documentation was incomplete, with bruises and a rash noted without locations or follow-up, and several skin check forms left blank. Later, new sacral pressure ulcers were observed and treated by nursing staff, yet there was no subsequent assessment of these wounds by the wound NP or physician/physician extender, and the DON could not provide documentation of a repositioning schedule or plan to meet the resident’s identified needs.
The facility did not serve meals at the posted scheduled times, resulting in consistent delays of 20 to 60 minutes for all residents receiving oral diets. Multiple residents and staff confirmed the late meal service, which was attributed to reduced food service staffing and increased meal preparation demands. Resident council meeting minutes also documented ongoing concerns about late meal delivery.
Multiple residents, both cognitively intact and impaired, reported that their meals were frequently served late and cold. Resident Council Meeting minutes documented ongoing complaints about cold breakfast meals and delays in meal tray delivery by CNAs. The administrator confirmed the absence of a policy on food palatability or temperature expectations at the point of service.
Three residents with significant medical conditions who were fully dependent on staff for toileting and hygiene experienced prolonged waits for incontinence care, with some waiting over an hour or until the next shift for assistance. Staff did not consistently check or change incontinence briefs every two hours as required by facility policy, and communication lapses between shifts contributed to delays, resulting in residents remaining in soiled briefs for extended periods.
Multiple residents were found without accessible or functioning call lights, including individuals with limited mobility and cognitive impairments. Some had to yell or leave their rooms to seek help, while others had non-working call lights or shared a single device between beds. Facility policy requires call lights to be within reach and promptly repaired, but these procedures were not followed.
The facility did not consistently label or safeguard residents' clothing, leading to multiple reports of missing personal items after switching to an outside laundry service. Staff and resident interviews, as well as documentation, confirmed that laundry bags and clothing were often unlabeled, making it difficult to return items to the correct individuals and resulting in unresolved complaints.
The facility failed to maintain sanitary practices in the kitchen, affecting 57 residents. A dietary aide did not wash hands before handling clean dishes, and the hand sink lacked soap and towels. A sanitizer bucket had a low quaternary ammonia concentration, and food items in the cooler and freezer were improperly stored and labeled. Facility policies from 2017 were not adhered to.
The facility failed to follow its water management plan for Legionella, affecting all 57 residents. There was no documentation of required activities such as chlorine testing, ice machine maintenance, and water temperature checks. Additionally, the facility did not conduct Legionella testing during a prolonged closure of a resident unit, as confirmed by the DON.
The facility failed to maintain a homelike environment, as evidenced by cold rooms, water leakage, and damaged infrastructure affecting multiple residents. Despite reports from residents and visitors, issues such as drafts, peeling paint, and unsecured cords remained unresolved. The maintenance director acknowledged the need for repairs but did not provide immediate solutions.
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 13 residents. During a facility tour, it was observed that seven rooms were below ground level. The administrator acknowledged the noncompliance and mentioned a waiver application, but no waiver was provided, and a letter from the Illinois Department of Public Health indicated no waiver had been awarded.
A facility failed to maintain privacy for a resident during wound care. The ADON/Wound Care Nurse left the resident exposed from the waist down while retrieving additional items, contrary to the facility's policy on dignity and privacy. The resident, who was alert and oriented, later expressed that she should have been covered. The staff member acknowledged the importance of ensuring privacy during care.
A facility failed to implement a person-centered care plan for a resident with PTSD, despite the resident's history of trauma and multiple diagnoses. The social services staff was unaware of the PTSD diagnosis, and the facility lacked a policy on Trauma-Informed Care, resulting in no care plan to address the resident's needs.
The facility failed to provide adequate hygiene and grooming care for residents requiring assistance with ADLs. One resident was observed with unmet grooming needs over several days, while another expressed a desire for grooming that was not addressed. Additionally, a resident was found wearing double incontinence briefs, with the inner brief soiled, contrary to facility policy. The Assistant Director of Nursing confirmed that these practices were not in line with the facility's standards.
A resident with overgrown toenails was not seen by a podiatrist despite having signed a consent for podiatry services upon admission. The CNA reported the issue to the nurse, but the toenails remained unclipped. The resident expressed a desire for his toenails to be clipped, stating they had not been cut since admission. The resident's MDS indicated he was alert and required assistance for grooming.
Two residents did not receive their prescribed Lidocaine patches for pain management due to a shortage and miscommunication within the facility. Despite being aware of the issue, nursing staff did not notify the physician or provide alternative pain relief, resulting in high pain scores for the residents.
A facility failed to provide trauma-informed care for a resident with PTSD, as critical information about triggers and interventions was missing from the care plan. The resident had a history of sexual abuse and other traumas, but the facility's documentation was incomplete, and staff were unaware of the resident's PTSD diagnosis. The facility also lacked a policy on trauma-informed care for residents with PTSD.
The facility failed to provide proper pureed diets to two residents, serving them granular and lumpy pureed rice and turkey instead of the required smooth consistency. The cook used ground turkey due to a supply issue, and the consultant dietitian confirmed the meals were not safe to serve.
The facility failed to serve planned menu items to all 27 residents due to budget cuts, resulting in inadequate meal substitutions. Essential food items were missing, and the dietitian was not consulted for substitutions, violating facility policy. Residents expressed dissatisfaction with the meals, noting frequent shortages and substitutions that did not meet nutritional needs.
Failure to Plan, Document, and Obtain Physician Assessment for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for a resident admitted with bilateral heel pressure wounds and multiple risk factors, including Alzheimer’s disease, moderate protein-calorie malnutrition, immobility, incontinence, and severe cognitive impairment. On admission, the resident required total assistance with all ADLs and was identified through a tissue tolerance assessment as needing repositioning more often than every two hours. A skin condition assessment documented a right heel pressure ulcer and listed ongoing interventions such as a pressure relief device in the chair, turning and repositioning program, nutrition and hydration interventions, and dressing changes, and directed staff to initiate a care plan. Despite these identified needs and risk factors, the care plan initiated later in December did not include pressure ulcer prevention measures such as a turning and repositioning program, use of positioning devices (e.g., wedges or pillows), a repositioning schedule, or off-loading of the heels while in bed. The nutrition care plan did not outline strategies for feeding the resident or actions to take when the resident refused to eat, even though staff reported the resident often refused to open his mouth at meals. CNAs reported the resident was tall, thin, underweight, did not get out of bed, and required two-person assistance for repositioning due to yelling and swinging at staff, yet there was no documented repositioning schedule or plan to address these needs. Skin monitoring and wound management were also deficient. Daily shower skin check sheets on multiple dates were incomplete or lacked documentation of whether the skin was intact, and when bruises and a rash were noted, no locations or follow-up interventions were documented. On one date in late December, an RN documented new sacral pressure ulcers with reddened skin and two open circular areas on both sides of the sacrum, cleansed the wounds, and applied ointment and foam dressing. However, after these new sacral wounds were identified, there was no documentation that the wound NP or physician/physician extender assessed the sacral wounds from that date through discharge. The DON acknowledged that residents with pressure wounds or at risk should have care plans for prevention and healing and be repositioned every two hours, but was unable to provide documentation that this resident was repositioned as expected or that a plan was in place to meet the resident’s repositioning needs prior to the development of the sacral pressure ulcers.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve resident meals at the scheduled times as posted in the main dining room, affecting all 60 residents receiving oral diets. Observations showed that lunch trays began to be delivered 20 minutes after the scheduled time and were not fully served until 30 minutes past the scheduled time. Multiple residents reported that meals were consistently late, with some stating delays of 20 to 60 minutes. Staff interviews confirmed that meal service was often delayed, particularly after a reduction in food service aide staffing, which slowed down the tray delivery process. The facility's posted meal schedule and policy required meals to be served at specific times, but these times were not consistently met. Resident council meeting minutes from previous months documented ongoing concerns from residents about the timeliness of meal service, with repeated complaints that lunch was being served later and later. Staff, including a cook and food service workers, acknowledged the delays and attributed them to staffing shortages and the complexity of meal preparation. The facility census indicated that nearly all residents were affected, except for one who did not receive oral diets. The deficiency was identified through observation, resident and staff interviews, and review of facility records and policies.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide palatable food at appropriate temperatures, as evidenced by multiple cognitively intact and impaired residents reporting that their meals were often served late and the hot food was cold. Interviews with four out of five residents reviewed indicated consistent dissatisfaction with food temperature and timeliness. Resident Council Meeting minutes from two separate months documented ongoing complaints about breakfast meals being cold and delays in meal tray delivery by CNAs. Additionally, the facility administrator confirmed that there was no policy in place regarding food palatability or temperature expectations at the point of service to residents.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADL), specifically incontinence care, to residents who were dependent on staff. Three residents with significant medical conditions, including multiple sclerosis, obesity, congestive heart failure, neuromuscular dysfunction of the bladder, hemiplegia, hemiparesis, and dementia, were identified as being completely dependent on staff for toileting and personal hygiene. These residents were always incontinent of bowel and bladder and required the use of mechanical lifts for transfers. Observations and interviews revealed that residents waited extended periods for incontinence care. One resident reported waiting from late morning until the next shift for toileting assistance, with staff confirming that the resident's incontinence brief was extremely soiled with urine and bowel movement by the time care was provided. Another resident stated that it took over an hour for staff to arrive to change a soiled brief, and that the same brief had been worn since early morning. A third resident reported routinely waiting about an hour for CNAs to respond to requests for incontinence care on both first and second shifts. Record reviews and staff interviews indicated that staff were expected to check and change incontinence briefs every two hours, regardless of whether residents could verbalize their needs. However, staff did not consistently offer or provide incontinence care at the required frequency, and communication lapses between shifts contributed to delays. Facility policies required residents to be kept dry, comfortable, and odor-free, with incontinence care provided every two hours or more frequently as needed, but these standards were not met for the residents reviewed.
Failure to Provide Accessible and Functioning Call Lights to Residents
Penalty
Summary
The facility failed to ensure that residents had functioning call lights within their reach, as observed in six out of nine residents reviewed for accommodation of needs. In one shared room, only one call light was present and it was positioned closer to one bed, leaving the other resident without access. One resident reported having to pull the call light closer to his bed, while his roommate had no call light and had to yell or leave the room to seek assistance. The Director of Nursing confirmed the absence of a call light for one resident and was unsure why only one was available in the room. Another resident was found asleep in her wheelchair with her call light on the floor behind her bed, out of reach, and the Assistant Director of Nursing acknowledged it should have been clipped to her wheelchair. Additional residents reported non-functioning call lights or a complete lack of access, with one resident stating her call light had not worked since admission and that she had informed multiple staff members without any follow-up. Further observations revealed that some residents' call lights were several feet away and inaccessible, despite their limited mobility and medical conditions such as multiple sclerosis, stroke-related paralysis, dementia, and Alzheimer's disease. The facility's policy requires that call lights be within easy reach of residents in bed or confined to a chair, and that defective call lights be promptly reported to maintenance. However, these procedures were not followed, resulting in multiple residents being unable to summon assistance as needed.
Failure to Safeguard and Label Resident Clothing Results in Loss of Personal Items
Penalty
Summary
The facility failed to ensure that residents' clothing items were properly labeled and safeguarded from loss, as required by their own policies and procedures. Multiple residents reported missing clothing items, with one resident stating that several pairs of pants had been missing since their laundry was first sent out, and another resident reporting that their clothes did not return from the laundry. A third resident indicated that clothing items went missing upon admission. Observations revealed that laundry bags and clothing were often not labeled, making it difficult for staff to identify ownership. Staff interviews confirmed that complaints about missing clothing had been received, and that there was no consistent process for labeling clothing or laundry bags. The facility had recently switched to an outside laundry service due to broken washing machines, which coincided with an increase in complaints and grievances about missing clothing. Documentation, including resident council concern forms, meeting reports, grievance forms, and email communication between the administrator and the laundry vendor, further substantiated ongoing issues with missing clothing and unreturned laundry bags. The facility's Personal Effects Policy required prompt investigation and resolution of missing property, but the lack of labeling and tracking contributed to the loss of residents' personal items. Staff interviews indicated that while there was an expectation for clothing and bags to be labeled, this was not consistently done, resulting in unidentifiable clothing and unresolved resident complaints.
Sanitary Practices Not Followed in Facility Kitchen
Penalty
Summary
The facility failed to adhere to sanitary practices in the kitchen, affecting 57 residents who received food prepared there. During an inspection, a dietary aide was observed washing dishes on the soiled side of the dish machine and then putting on new gloves without washing her hands before handling clean dishes. Additionally, the hand sink near the dish machine lacked soap and paper towels, and the dietary aide confirmed that housekeeping did not have any supplies available. Furthermore, a red sanitizer bucket in the kitchen was tested and found to have a quaternary ammonia concentration of 0-150 ppm, which is below the recommended range of 150-400 ppm. In the walk-in cooler, a tub of cottage cheese with a broken lid was found, exposing its contents, and the use-by date had already passed. In the walk-in freezer, opened bags of sliced strawberries and blueberries were found exposed to air. The dietary aide mentioned that these were used for a specific resident. The facility's policies from the 2017 manual were not followed, which included proper handwashing procedures, correct sanitizer concentration, and appropriate storage and labeling of food items.
Failure to Implement Water Management Plan for Legionella
Penalty
Summary
The facility failed to adhere to its water management plan for Legionella, impacting all 57 residents. The plan outlined specific measures to manage the risk of Legionella exposure, including quarterly testing of free chlorine levels, monthly maintenance of ice machines, weekly water temperature checks, and monthly monitoring of water heaters. However, the facility lacked documentation to confirm these activities were conducted. Interviews with the Administrator and Maintenance Director revealed that water temperature logs were not maintained, and there was no evidence of ice machine maintenance or free chlorine testing. Additionally, the facility did not implement control measures during the prolonged closure of a resident unit on the second floor, which was closed for several months and reopened without documented Legionella testing. The Director of Nursing confirmed the closure and reopening dates but acknowledged the absence of documentation for control measures or testing during this period. This oversight in maintaining and documenting the water management plan's activities and addressing the prolonged unit closure contributed to the deficiency.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for several residents, as evidenced by multiple deficiencies observed during the survey. One resident, R9, experienced a cold room due to a lack of window coverings and a draft from the window. Despite reporting the issue to staff, the curtain and rod remained unfixed for several days, and a towel was used unsuccessfully to block the draft. Additionally, there was peeling paint and water leakage from the ceiling, which had not been addressed despite being reported by the resident and a visitor. Another resident, R24, faced similar issues with water leakage from the ceiling, which had been ongoing since January. The resident's bed had to be moved due to water dripping onto it, yet the problem persisted in the new location. The maintenance request logs did not reflect the original dates of the requests, and the issues remained unresolved. The maintenance director acknowledged the draft in R9's room but did not provide a resolution. Further deficiencies were noted in other residents' rooms. In R43's room, a television cord was improperly secured, sagging from the ceiling, and there was crumbling drywall. In R45's room, the metal radiator was damaged, with rust and flaking. The maintenance director admitted that there was significant work needed in the building, but no immediate actions were taken to address these concerns.
Noncompliance with Room Location Requirements
Penalty
Summary
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 13 residents. During an initial tour of the facility, it was observed that seven rooms (101, 102, 103, 104, 105, 106, and 107) were situated below ground level. The facility's Resident Roster confirmed that the affected residents were residing in these below-ground-level rooms. The facility's administrator acknowledged awareness of this noncompliance and mentioned that an application for a waiver had been submitted. However, no waiver was provided, and a letter from the Illinois Department of Public Health indicated that no waiver had been awarded for these rooms.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain resident privacy during wound care for one resident. On February 19, 2025, the Assistant Director of Nursing (ADON) and Wound Care Nurse, identified as V3, provided wound care to a resident with a pressure ulcer on her left buttock. During the dressing change, V3 left the resident's bedroom to retrieve additional items without covering the resident with a blanket or sheet, leaving her exposed from the waist down. The resident, who was alert and oriented according to her Minimum Data Sheet dated January 19, 2025, expressed on February 20, 2025, that the staff should have covered her before leaving. V3 acknowledged that staff must ensure privacy for dignity, aligning with the facility's policy that emphasizes promoting and protecting resident privacy during personal care and treatment procedures.
Failure to Implement PTSD Care Plan
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident diagnosed with PTSD. The resident, who was admitted with multiple diagnoses including PTSD, major depressive disorder, and anxiety disorder, did not have a care plan addressing her PTSD. The resident's electronic medical record and Minimum Data Set confirmed the PTSD diagnosis, and a progress note highlighted a history of sexual abuse. However, there was no care plan in place to address the resident's PTSD, identify her triggers, or provide interventions for her medical, physical, or mental needs. During an interview, the social services staff member, who had been at the facility for two weeks, was unaware of the resident's PTSD diagnosis. Upon reviewing the resident's electronic medical record, the staff member discovered the resident's history of trauma, including financial abuse, sexual assault, physical assault, and mental abuse, but found no identified triggers. The facility administrator confirmed that there was no policy on Trauma-Informed Care for residents with PTSD, indicating a lack of structured guidance for addressing such cases.
Deficiency in Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide adequate hygiene and grooming care for residents who require assistance with activities of daily living (ADL). Three residents were observed with unmet grooming needs. One resident was noted to have overgrown facial and nasal hair, jagged and discolored fingernails, and uncombed hair over several days, despite being totally dependent on staff for hygiene care. Another resident, who requires substantial assistance for grooming, expressed a desire for her facial hair to be shaved and her fingernails to be clipped, but these needs were not addressed. The Assistant Director of Nursing stated that nail care and shaving should be done during shower days and as needed, while hair care should be done daily. Additionally, a resident requiring substantial assistance for toileting hygiene was found wearing double incontinence briefs, with the inner brief soiled. The staff failed to change the soiled brief immediately, contrary to the facility's policy to keep residents clean, dry, and comfortable. The Assistant Director of Nursing confirmed that it is not the facility's practice to use double incontinence briefs due to the risk of urinary tract infections. The resident's care plan indicated the need for incontinence care as soon as incontinence was noted, which was not adhered to in this instance.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who required foot care was seen by a podiatrist. During an observation on February 19, 2025, a Certified Nursing Assistant (CNA) noticed that the resident had overgrown toenails that curled over the top of each toe. The CNA reported this issue to the nurse, but the toenails had not been clipped. The resident expressed a desire for his toenails to be clipped, stating that they had not been cut since his admission to the facility. The nurse confirmed that during admission, a head-to-toe assessment is conducted, and any issues requiring a physician's attention are referred. The resident had signed a consent for podiatry services upon admission, indicating that he should have been seen by a podiatrist. The resident's Minimum Data Set (MDS) indicated that he was alert and oriented and required substantial assistance for grooming and hygiene.
Failure to Administer Prescribed Pain Patches
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, R19 and R203, who had physician orders for Lidocaine adhesive patches to manage their chronic pain. R19, who has diagnoses including radiculopathy, hemiplegia, and osteoarthritis, reported not receiving his prescribed pain patches for a week, resulting in a pain score of 8/10. Despite being aware of the shortage, the nursing staff did not notify the physician or provide an alternative pain management solution. R19's care plan required the application of Lidocaine patches to multiple sites, but these were not administered as ordered. Similarly, R203, with conditions such as spinal stenosis and arthritis, also did not receive the prescribed Lidocaine patch for several days, leading to a pain score of 7/10. The Director of Nursing confirmed that the patches were house stock and should have been reordered by the central supply staff. However, due to a miscommunication, the patches were not available, and no alternative pain management was provided. The central supply staff was unaware of the shortage until it was reported, highlighting a breakdown in communication and inventory management within the facility.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, as evidenced by the lack of identification of triggers and appropriate interventions in the resident's care plan. The resident, who had a history of sexual abuse and other traumas, was admitted with multiple mental health diagnoses, including PTSD. Despite this, the facility's documentation, such as the Admission Trauma-Informed Care Observation, was incomplete, with critical sections regarding triggers and responses left blank. Additionally, the care plan did not include specific behavior monitoring or interventions tailored to the resident's PTSD. Interviews with facility staff revealed a lack of awareness and understanding of the resident's PTSD diagnosis and needs. The social services staff member, who had only been at the facility for two weeks, was unaware of the resident's PTSD and had not reviewed the care plan to address it. Furthermore, the facility lacked a policy on trauma-informed care for residents with PTSD, indicating systemic issues in addressing the needs of residents with trauma histories. The psychiatric care provided focused solely on medication without addressing the resident's trauma-related needs.
Failure to Provide Proper Pureed Diets
Penalty
Summary
The facility failed to provide pureed consistency diets for two residents who had orders for such diets. On February 18, 2025, during a lunch meal, the facility served pureed rice and turkey that appeared granular and lumpy to two residents requiring pureed diets. The cook, V8, mentioned that ground beef did not arrive as ordered, and ground turkey was used instead. The pureed food was observed to be granular and required chewing, which is inconsistent with the facility's policy for pureed diets that should be smooth and pudding-like. The consultant dietitian, V5, confirmed that the consistency was not appropriate for a pureed diet, indicating that the meals were not safe to serve to the residents.
Failure to Serve Planned Menu Items Due to Budget Cuts
Penalty
Summary
The facility failed to serve food items to residents as shown on the facility's planned and approved menu, affecting all 27 residents. During a tour of the kitchen, it was observed that the walk-in cooler and freezer shelves were sparse, lacking essential food items such as eggs, mayonnaise, and ketchup. Residents reported receiving meals that did not match the planned menu, with substitutions made due to budget cuts and lack of ingredients. For instance, on Father's Day, residents were supposed to receive roast beef but were instead served hot dogs without bread or condiments. The Food Service Director (FSD) admitted to making substitutions due to budget constraints, which included replacing roast beef with hot dogs and substituting oatmeal pies for lemon cheese bars. The facility also ran out of bread, ketchup, and mayonnaise, limiting alternative meal options. The dietitian was not consulted regarding these substitutions, which did not meet the same nutritive value as the planned menu items. The facility's policy requires menu changes to be of similar nutritive value and approved by a dietitian, which was not followed. Residents expressed dissatisfaction with the meals, noting frequent shortages of items like yogurt, mustard, and fresh fruit. The FSD acknowledged the inability to serve planned menu items due to budget cuts, resulting in inadequate meal substitutions. The facility's administrator confirmed that the food budget was cut in half, leading to these deficiencies. The facility's policy on menu changes was not adhered to, as changes were not indicated on the posted menu, nor were they of similar nutritive value.
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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