Accolade Healthcare Of Pontiac
Inspection history, citations, penalties and survey trends for this long-term care facility in Pontiac, Illinois.
- Location
- 300 West Lowell, Pontiac, Illinois 61764
- CMS Provider Number
- 146010
- Inspections on file
- 26
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Accolade Healthcare Of Pontiac during CMS and state inspections, most recent first.
A resident who was dependent for all transfers and cognitively intact reported hearing a pop and crack in the left knee during a total body mechanical lift transfer that was performed by a CNA without the required assistance of a second staff member, contrary to facility policy. The resident’s feet touched the floor, the left knee hit the side of the bed, and the resident immediately complained of pain. Initial ED evaluation and x‑ray identified a left knee sprain with no fracture, but the resident continued to report pain and later underwent a CT scan ordered by an NP and orthopedic provider, which revealed a left knee fracture. Facility leadership, including the DON and ADON, confirmed that two staff are required for all total body mechanical lift transfers and that this requirement was not followed in this case.
A resident who was dependent for all transfers and cognitively intact reported pain above the left knee and was sent to the hospital, where imaging initially showed a sprain of the medial collateral ligament and the resident received multiple pain medications. At a later orthopedic visit, a CT scan revealed a left knee fracture. The facility’s policy required completion of an Accident/Incident Report on the shift of the event and notification of the State Agency within 24 hours for any major injury, but the DON and Administrator acknowledged that the fracture was never reported to the State Agency, resulting in a failure to follow required reporting procedures.
A resident was returned to the hospital after the facility received a criminal background report indicating the resident was a registered sexual offender, but the facility did not complete or document the required transfer/discharge process. The facility’s policy required appropriate discharge procedures and a written or telephone physician order for transfer or discharge, yet the resident was dropped off at the ED with a stated social concern and later sent back again for nursing home placement without any discharge notice or discharge orders in the medical record. The resident’s POA was informed that the transfer was due to the background check results, and the SSD confirmed the CHIRP findings, while the Administrator verified that no required discharge documentation existed in the chart.
A resident with a C2 neck fracture returned from the hospital with orders for C-Collar care, including daily skin checks and adjustments while lying flat in bed. Staff placed the resident in a recliner that did not lay flat, did not perform daily skin checks, and delayed adjusting the C-Collar, resulting in the resident experiencing pain and discomfort. Facility leadership confirmed that admission orders were not followed.
Two residents with indwelling catheters and wounds did not receive proper Enhanced Barrier Precautions (EBP) as required. EBP signage and PPE were inconsistently provided, and staff failed to use gowns and gloves during high-contact care activities. Staff interviews confirmed that EBP was not routinely practiced, and required cleaning procedures were not followed after handling potentially infectious materials.
The facility did not provide required written bed hold and transfer notices to residents and their representatives during multiple hospitalizations, as confirmed by medical record review and staff interviews. Nursing staff did not distribute the bed hold policy at the time of transfer, and there was no documentation that admissions or social services followed up with the necessary paperwork.
Two dependent residents did not receive scheduled showers as required by facility policy, with no documentation of refusals or alternative hygiene care. Staff interviews confirmed that showers were missed and not properly recorded, and one resident reported rarely receiving assistance with bathing.
A resident with COPD and Atrial Fibrillation, who was receiving oxygen therapy and an anticoagulant, did not have these treatments or their monitoring included in the comprehensive care plan. Despite physician orders and observations confirming the use of oxygen and Apixaban, the care plan was not updated to reflect these needs, as confirmed by the facility administrator.
A resident with a history of urinary tract infections and cord compression did not receive complete incontinence care, as a CNA failed to clean the groin and buttocks areas during perineal care, contrary to facility policy requiring thorough cleansing of all soiled skin areas.
Two residents with end stage renal disease and dependence on dialysis did not have current physician orders for their dialysis treatments, despite receiving dialysis regularly. Staff interviews and facility records confirmed the absence of required orders, even though the facility is responsible for coordinating and documenting dialysis care as part of each resident's plan of care.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents with indwelling medical devices, as required by facility policy and physician orders. On multiple occasions, a CNA and an RN emptied urine collection bags without wearing gowns, despite posted instructions and care plans specifying the need for gowns and gloves during high-contact care. The DON confirmed that staff are expected to use these precautions.
A resident experienced a severe weight loss of 10.8% in 12 days due to the facility's failure to implement an ordered nutritional supplement and notify the resident's representative. The resident, who had a recent surgery and dementia, was observed without the prescribed supplements during meals. The Registered Dietitian's recommendation was not transcribed into the medical records due to an error, and the facility's policy on providing supplements was not followed.
The facility's kitchen was found in unsanitary conditions, with a can opener covered in grease and rust, and range hood filters with grease and dust build-up. The food preparation table and sink area also had significant contamination risks. The Dietary Manager confirmed these issues, indicating a failure to maintain cleanliness as per the facility's policy.
The facility failed to trend monthly resident infections, potentially affecting all 76 residents. There was no Infection Control Surveillance and Monitoring Policy or documentation of infection patterns and interventions. The Infection Preventionist admitted to not completing the trending.
A facility failed to properly store medications, including Schedule II controlled substances, as a medication cart was found unlocked and unattended multiple times by an LPN. The cart contained controlled substances like Norco and Methylphenidate. The facility's policy requires all medications to be securely stored, with controlled substances in a separately locked drawer.
A facility failed to respect a resident's right to have a service dog present during meals and did not ensure another resident's dignity by leaving their abdomen exposed in the dining room. The facility lacked a policy for service dogs, and a resident with cognitive impairment was not properly covered by an LPN, despite acknowledging the dignity issue.
A resident with a fractured shoulder did not have a physician's order for an arm sling, despite recommendations from the occupational therapist. The resident was observed multiple times without the sling, which was necessary to prevent subluxation. The facility failed to follow the hospital's emergency room orders for continuous sling use.
A resident with chronic pain conditions, including Lumbar Degenerative Disc Disease and Fibromyalgia, reported severe pain levels and inadequate pain relief from prescribed medications. Despite repeated complaints, the facility staff failed to effectively communicate these issues to the Nurse Practitioner in a timely manner, resulting in continued unmanaged pain for the resident.
A facility failed to dispose of discontinued medications for a resident. During an observation, a medication bottle without a label was found in a medication cart, containing vials of Haldol with the resident's name. The DON confirmed the medication was a one-time order and should have been destroyed or returned. The resident's physician order indicated the medication was for intramuscular use as needed for agitation and aggression. The facility's policy requires discontinued medications to be destroyed promptly.
A resident with quadriplegia and multiple sclerosis was unable to reach their call light, which was secured to the wall behind the bed. The resident needed an incontinence brief change but could not call for assistance. Staff confirmed the call light was out of reach and attributed it to a CNA's oversight. Facility policy mandates call lights be within easy reach.
A facility failed to prevent cross-contamination during incontinence care for a resident. A CNA and an RN changed a resident's saturated brief without removing contaminated gloves or performing hand hygiene, despite the facility's hand washing policy requiring such actions after contact with body fluids and after removing gloves.
Improper Mechanical Lift Transfer Causing Resident Knee Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hydraulic (Hoyer) lift policy requiring two staff members for total body mechanical lift transfers, resulting in an injury to a dependent resident. The facility’s policy, revised on 1/26, states that all nursing staff will be trained on proper use of hydraulic lifts and that staff must obtain assistance from a second staff member. The resident’s MDS documents that the resident is dependent for all transfers and cognitively intact. Nursing progress notes show that in the early morning hours of 11/29, the resident complained of pain above the left knee and was sent to the hospital, where an x‑ray initially showed a sprain of the medial collateral ligament of the left knee and no fracture. The ED nurse later reported that the resident stated hearing a pop when being transferred with a total body mechanical lift, and the resident received multiple pain medications, including Norco, Tylenol, fentanyl, and ketorolac, for pain management. From 11/29 through 12/3, the resident continued to complain of left knee pain and was treated with hydrocodone‑acetaminophen. On 12/3, the NP documented that the resident reported a CNA had hurt her during a prior transfer and insisted that something was wrong with her knee despite a negative x‑ray, requesting further diagnostic testing. The NP noted that an orthopedic referral would be made, and on 12/11 a CT scan of the left knee showed a fracture. On 2/9, the resident reported that a CNA had performed a total body mechanical lift transfer alone, without a second CNA, during which the CNA pushed on her, she heard a pop and a crack, her feet touched the floor, and her left knee hit the side of the bed; the CNA told her to look because she was standing, even though she had not stood in years. That same day, the CNA confirmed performing the mechanical lift transfer without assistance, and the DON and ADON both acknowledged that two staff members are required for all total body mechanical lift transfers, confirming that the transfer was not performed according to facility policy.
Failure to Timely Report Resident Fracture to State Agency
Penalty
Summary
The facility failed to report a resident’s fracture to the State Agency within the required timeframe, contrary to its Accidents and Incidents policy. The policy, revised on 1/26, requires that accidents and incidents, including injuries of unknown origin, be reported to the department supervisor with an Accident/Incident Report completed on the shift of occurrence, and that the DON or designee report any accident or incident involving a major injury to the State Agency within 24 hours. Nursing progress notes show that on 11/29 at 3:04 AM, a resident who is dependent for all transfers and cognitively intact complained of pain above the left knee and was sent to the hospital, where pain medications were administered and an X-ray resulted in a diagnosis of a left medial collateral ligament sprain before the resident returned at 6:00 AM. On 12/11, after an orthopedic visit and CT scan of the left knee, the resident was diagnosed with a left knee fracture. Despite this fracture diagnosis, the DON confirmed on 2/9 that no reportable incident was sent to the State Agency, and the Administrator confirmed that the fracture identified on 12/11 was not reported, resulting in noncompliance with required reporting procedures. The deficiency centers on the facility’s inaction in failing to recognize and report the fracture as a reportable major injury once it was identified by CT scan, despite clear policy requirements and the resident’s dependence for transfers. Surveyor interviews with the DON and Administrator confirmed that the incident was not reported to the State Agency as required.
Failure to Document Required Transfer/Discharge for a Resident Returned to Hospital
Penalty
Summary
The facility failed to follow its required transfer/discharge process and documentation requirements for one resident who was discharged without a proper discharge notice or required elements in the medical record. The facility’s Discharge/Transfer Policy, revised 1/25, requires guidelines for appropriate discharge and transfer procedures and specifies that a written or telephone order from the attending physician is needed for a resident’s transfer or discharge. The resident was admitted to the facility on an unspecified date, and later, hospital notes dated 2/23/26 show the resident was dropped off at the Emergency Department (ED) from the facility with complaints of social concern. The facility reported that during a background check it was discovered the resident had a sexual offense and could not be admitted, and the facility attempted to find alternative placement but was unable to do so, then returned the resident to the ED for nursing home placement after receiving a CHIRP (Criminal History Information Response Process) result dated 2/23/26 indicating the resident was listed as a sexual offender. The resident’s Power of Attorney reported being told by the facility that the resident was being sent back to the hospital due to the background check results, and the Social Service Director confirmed the CHIRP findings and the decision to send the resident back to the hospital. The Administrator confirmed that no discharge documentation or discharge orders were found in the resident’s chart, indicating the required transfer/discharge process was not completed or documented.
Failure to Follow Admission Orders for C-Collar Care
Penalty
Summary
The facility failed to follow admission orders for a resident who returned from the hospital with a C2 neck fracture and an Aspen C-Collar. Upon readmission, the resident had orders for C-Collar care, including daily skin checks and the requirement to be laid flat in a bed for collar adjustments. However, staff placed the resident in a recliner instead of a bed, as the bed had been removed from the room. The recliner did not lay flat, and staff attempted to adjust the C-Collar while the resident was in the recliner, resulting in the resident experiencing pain and discomfort. No daily skin checks were performed as ordered, and the first adjustment of the C-Collar did not occur until several days after readmission. Staff interviews confirmed that the admission orders were not followed, and the facility's policy required review and implementation of all physician orders upon admission or readmission. The failure to follow these orders was acknowledged by facility leadership.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices and Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two of three residents reviewed for infection control. According to the facility's policy and CDC guidance, EBP requires the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices or chronic wounds. Observations revealed that while an EBP sign was posted on one resident's door, it was missing from another resident's door who had an indwelling catheter. Additionally, required equipment such as gowns and gloves was not consistently available outside resident rooms, particularly for newly admitted residents over the weekend. Staff interviews and record reviews indicated that EBP was not consistently practiced. A CNA was observed emptying a resident's catheter without using the required PPE and did not clean the shared toilet after disposing of urine. The CNA admitted that staff do not routinely use EBP. Physician orders and medical records confirmed that both residents required EBP due to conditions such as urinary catheters, urinary tract infection with E-Coli, and chronic wounds. The lack of signage and equipment was attributed to the resident's recent admission and oversight by the admitting nurse.
Failure to Provide Bed Hold and Transfer Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required written notifications to residents and their representatives regarding hospital transfers and bed hold policies for five residents who were hospitalized. Nursing notes documented multiple instances where residents were transferred to the emergency room or hospitalized, but there was no documentation in the medical records that a bed hold notice or written notice of transfer was provided to the residents or their representatives at the time of each transfer. The facility's own Bed Reserve Policy states that this information should be given at admission and each time a resident is transferred from the facility, but records and interviews confirmed this was not done. Interviews with facility staff, including the Social Service Director and an LPN, revealed that while the bed reserve policy is signed at admission, nursing staff do not provide the bed hold policy form when residents are transferred out. Instead, follow-up is reportedly handled by admissions or social services, but there was no evidence that this occurred for the residents in question. One resident confirmed not receiving any bed hold policy or paperwork during multiple hospitalizations. The lack of documentation and direct statements from staff and residents indicate that the facility did not meet regulatory requirements for notification during resident transfers.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two dependent residents who required assistance with activities of daily living (ADLs). According to the facility's Bath/Shower Policy, all residents are to receive a bath or shower at least weekly, with nursing assistants responsible for providing the care and charge nurses responsible for ensuring the schedule is followed. Record review showed that one resident with severe cognitive impairment and significant physical limitations missed multiple scheduled showers over a two-month period, with no documentation of refusals or alternative hygiene measures such as bed baths. Another resident, who was cognitively intact but dependent on staff for ADLs, also missed several scheduled showers, and similarly, there was no documentation of refusals or alternative care provided. Interviews with staff confirmed that showers should be provided and documented according to the schedule, and that refusals or alternative care should also be recorded. However, both the charge nurse and nursing supervisor acknowledged that the affected residents did not receive all scheduled showers and that there was no documentation of refusals or bed baths in the residents' charts. One resident reported rarely receiving scheduled showers and stated that staff often provided excuses for not assisting with bathing.
Failure to Include Oxygen and Anticoagulant Therapy in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for one resident, as required by its own Care Planning Policy. Despite the resident being observed with a nasal cannula in place on multiple occasions and having documented diagnoses of Chronic Obstructive Pulmonary Disease and Atrial Fibrillation, the resident's care plan did not include interventions or monitoring related to oxygen therapy or anticoagulant medication use. The resident's physician orders specified oxygen therapy to maintain O2 saturation above 90% and the use of Apixaban as a blood thinner, both of which were also reflected in the Minimum Data Set. However, a review of the current care plan revealed that it lacked any mention of the resident's oxygen use, monitoring requirements, or anticoagulant therapy and associated monitoring. The facility administrator confirmed that care plans are expected to be updated with any change in condition and acknowledged that the resident's care plan did not include these critical elements.
Incomplete Incontinence Care Provided to Resident
Penalty
Summary
Facility staff failed to provide complete incontinence care for a resident with a primary diagnosis of unspecified cord compression, who had a history of urinary tract infections and was receiving antibiotics for this condition. During observed incontinence care, a CNA cleansed, rinsed, and dried the resident's inner and outer labia but did not clean the groin or buttocks area, which was acknowledged as incomplete by the CNA when questioned. The resident reported feeling strange and had started a new antibiotic for another urinary tract infection on the same day. The facility's policy requires all soiled skin areas, especially between skin folds, to be washed and dried thoroughly during incontinence care.
Failure to Maintain Physician Orders for Dialysis Treatments
Penalty
Summary
The facility failed to maintain current physician orders for dialysis treatments for two residents who were dependent on renal dialysis and diagnosed with end stage renal disease. For one resident, the medical diagnosis sheet listed dependence on renal dialysis and end stage renal disease, but the physician's order sheet did not include any dialysis treatment orders. Staff interviews confirmed that the resident was receiving dialysis five times a week, yet the necessary orders were missing from the documentation. The regional quality assurance staff acknowledged that the dialysis order had likely been omitted from the physician's order sheet. Similarly, another resident with diagnoses of end stage renal disease, stage 4 chronic kidney disease, and dependence on renal dialysis did not have dialysis treatment orders documented from the time of readmission until a later date. This resident also confirmed receiving dialysis treatments in the facility, and a licensed practical nurse verified the absence of dialysis treatment orders. The facility's own records and agreements indicated that the LTC facility is responsible for the development and implementation of each dialysis resident's overall plan of care, including coordination of dialysis access orders, but failed to ensure that current orders were in place for these residents.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who were identified as requiring these precautions due to the presence of indwelling medical devices. According to the facility's EBP policy, staff are required to wear gowns and gloves during high-contact care activities for residents at high risk of Multidrug Resistant Organism (MDRO) acquisition, such as those with wounds or indwelling devices. Both residents had care plans and physician orders specifying the need for EBP during high-contact care, including activities involving their indwelling urinary catheters. Despite clear signage and documented orders, staff did not consistently follow EBP protocols. On separate occasions, a CNA and an RN emptied the urine collection bags of the two residents without wearing gowns, as required by policy. Both staff members acknowledged that gowns should have been worn during these activities. The Director of Nursing confirmed that all staff are expected to use gowns and gloves during high-contact care for residents on EBP.
Failure to Implement Nutritional Supplement Leads to Severe Weight Loss
Penalty
Summary
The facility failed to implement an ordered nutritional supplement and did not notify a resident's representative of significant weight loss, resulting in a severe weight loss of 10.8% over 12 days for a resident. The resident, who was admitted to the facility after surgery and diagnosed with dementia, was observed without the prescribed nutritional supplements during meals. The family member present was unaware of any nutritional supplements being ordered or the resident's weight loss. The Registered Dietitian recommended nutritional supplements, which were accepted by the Nurse Practitioner, but the order was not transcribed into the resident's medical records. The Registered Nurse confirmed the absence of the order in the Electronic Medical Record, and the Registered Dietitian acknowledged the error of sending the signed recommendation to an invalid email address. The facility's policy requires that residents unable to meet nutritional needs through regular meals be provided with supplements, but this was not followed in this case.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen food service areas and equipment in a clean and sanitary condition, which could potentially lead to cross-contamination and food-borne illness affecting all 76 residents. During an initial tour of the kitchen, a commercial table-mounted can opener was found with a build-up of a grease-like substance, metal fragments, and rust. The blade of the can opener was missing silver laminate, exposing bare metal and rust. The Dietary Manager confirmed these observations and acknowledged the need for cleaning before further use. Additionally, the range hood filters above the cooking surfaces were covered in a dark and light brown grease-like substance with dust-like strands hanging over the cooking areas. The Dietary Manager admitted that the cleaning service, which cleans the filters every three months, would need to increase the frequency of cleaning. Further inspection revealed that the 15-foot-long metal food preparation table had caulking at the wall junction embedded with brown and black sticky, food-like substances. The caulking had crusted food particles, which the Dietary Manager confirmed could contaminate food preparation areas. The three-well sink area had a windowsill with a significant build-up of dust and grease, and the window frame above had rust and chipped paint. The ceiling above the clean dish racks also had chipped paint and cobwebs. The facility's policy stated that stove hoods and filters should be cleaned monthly, but the current condition indicated a failure to adhere to this schedule, as confirmed by the Dietary Manager.
Failure to Trend Monthly Resident Infections
Penalty
Summary
The facility failed to trend the monthly resident infections, which has the potential to affect all 76 residents residing in the facility. During an interview and record review, it was found that the facility did not provide an Infection Control Surveillance and Monitoring Policy, nor were there any documents showing how the facility trends monthly infections to prevent further infection. Additionally, there was no documentation for identified infection patterns or trends and interventions. On August 21, 2024, the Infection Preventionist admitted to not completing the trending for the facility's infections.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications, including Schedule II controlled substances, were stored appropriately and within the visual control of the nurse. During an observation, the medication cart in the [NAME] Wing was found unlocked and not secured to the wall, with no staff present. An opened stock bottle of Melatonin was sitting on top of the medication cart. The LPN responsible for the cart left it unattended and unlocked multiple times while attending to residents in their rooms. The Director of Nursing confirmed that the medication cart should have been locked when not in sight of the staff. The unlocked cart contained several controlled substances, including Norco and Methylphenidate, which are classified as Schedule II narcotics. The facility's policy, dated 10/2023, requires all medications to be stored safely and properly at all times, with mobile medication carts locked when not under visual control. The policy also mandates that Schedule II controlled substances be stored in a separately keyed and locked drawer within the medication cart.
Failure to Respect Resident Rights and Dignity
Penalty
Summary
The facility failed to respect a resident's right to have a visitor with a service support animal present during meal service. During an observation, a family member of a resident was asked to remove a certified service dog from the dining room despite the resident's request to keep the dog present. The facility's administrator later acknowledged that there was no policy in place for service dogs and that the dietary consulting company had recommended not having the service dog in the dining room during meals. The facility provided documentation indicating that healthcare facilities must permit the use of service animals by persons with disabilities, but this was not adhered to in this instance. Additionally, the facility failed to ensure a resident's right to dignity by not covering a resident's exposed abdomen in the dining room. The resident, who had moderate cognitive impairment and required assistance with dressing due to a stroke, was observed with a bare abdomen while seated in a wheelchair. A Licensed Practical Nurse (LPN) moved the resident's wheelchair without addressing the exposed abdomen, despite acknowledging that it was a dignity issue. This incident occurred in the presence of other residents and visitors, further compromising the resident's dignity.
Failure to Obtain Order and Apply Arm Sling for Resident
Penalty
Summary
The facility failed to obtain a physician's order for an arm sling recommended by the occupational therapist for a resident with a fractured right shoulder. The resident, who had a history of a mechanical fall resulting in a comminuted transverse fracture of the right humeral neck, was observed multiple times without the prescribed arm sling. Despite the occupational therapist's recommendation for the sling to prevent subluxation, the facility did not secure the necessary order, and the resident was seen without the sling during various observations. The resident's family member and the resident themselves indicated the need for the sling, yet it was not consistently applied. The orthopedic physician assistant's nurse confirmed that the hospital's emergency room orders included wearing the sling continuously with specific movement restrictions. However, the facility did not follow through with these orders, as evidenced by the lack of a documented order and the resident's repeated appearances without the sling.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R29, who was reviewed for pain management. R29, who is cognitively intact, has a history of Lumbar Degenerative Disc Disease and Fibromyalgia, and is prescribed Acetaminophen and Ibuprofen for chronic pain. Despite these medications, R29 reported severe pain levels of 10/10 on multiple occasions and expressed that the current pain management regimen was ineffective. R29 communicated to staff that stronger medication was needed, but felt that her concerns were not adequately addressed, as she was told that stronger medications would not be provided due to concerns about addiction. The facility's Pain Management Policy emphasizes the importance of addressing resident pain through effective communication with physicians. However, the Nurse Practitioner, V11, was not informed of R29's significant pain complaints until several days after they were reported. V11 confirmed that R29 has multiple medical conditions contributing to her chronic pain and expressed reluctance to prescribe narcotic pain medication. The Director of Nurses acknowledged that R29's complaints of uncontrolled pain needed to be addressed, indicating a lapse in the facility's adherence to its pain management policy and communication protocols.
Failure to Dispose of Discontinued Medications
Penalty
Summary
The facility failed to properly dispose of discontinued medications for one resident, identified as R9, among the 22 residents reviewed for physician orders. During an observation on August 21, 2024, at 4:30 PM, it was found that the bottom drawer of the [NAME] Wing Medication Cart contained a medication bottle without a label. Inside this bottle were three new vials of Haldol, an antipsychotic medication, with a sticker bearing R9's name. The Director of Nursing, identified as V2, acknowledged that the Haldol was a one-time order and should have been destroyed or returned to the pharmacy. R9's Physician Order Sheet from July 2024 documented an order received on July 15, 2024, for Haloperidol Lactate Injection Solution 5mg/5ml, to be administered intramuscularly every 8 hours as needed for agitation and aggression, for 14 days. The facility's policy on destroying medication, dated September 2023, states that all discontinued medications or medications of discharged residents should be destroyed as soon as possible.
Call Light Out of Reach for Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a resident reviewed for call lights. The resident, who has diagnoses including quadriplegia, multiple sclerosis, anxiety disorder, and neuromuscular dysfunction of the bladder, was found sitting in a motorized wheelchair and unable to reach the call light, which was secured to the wall behind the bed. The resident expressed the need for an incontinence brief change but was unable to call for assistance due to the call light's placement. Staff confirmed that the call light was out of reach and explained that it had been misplaced by a CNA who made the bed earlier that morning. The facility's policy requires that call lights be within easy reach of residents when they are in bed or confined to a chair.
Failure to Prevent Cross-Contamination During Incontinence Care
Penalty
Summary
The facility failed to prevent possible cross-contamination during incontinence care for a resident. During an observation, a CNA and an RN were changing a resident's incontinence brief, which was saturated with urine and stool. The CNA donned gloves and used disposable wipes for incontinence care but then grabbed a clean brief without removing the potentially contaminated gloves or performing hand hygiene. The resident urinated again onto the new brief, prompting the CNA to change gloves but still not perform hand hygiene. The CNA continued to provide care, cleaning another bowel movement, and again placed a clean brief under the resident without changing gloves or performing hand hygiene. The facility's hand washing policy requires hand hygiene after contact with body fluids and after removing gloves, which was not followed in this instance.
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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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