Alden Estates Of Naperville
Inspection history, citations, penalties and survey trends for this long-term care facility in Naperville, Illinois.
- Location
- 1525 South Oxford Lane, Naperville, Illinois 60565
- CMS Provider Number
- 145582
- Inspections on file
- 42
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Alden Estates Of Naperville during CMS and state inspections, most recent first.
A resident with GERD and a physician order for a GI consult was not transported to the specialist in a timely manner. The resident reported being told about the GI appointment but never getting to see the doctor. The appointment and transportation scheduler described repeated problems with the contracted transportation company, including late arrival that led to a canceled visit and a subsequent missed visit when the driver went to the wrong facility, with no backup transportation options in place. A new appointment was scheduled for a later date, and the NP, who was unaware of the missed visits, stated the consult was for abdominal pain and acid reflux and still expected timely transport.
A resident with stroke-related right-sided weakness, apraxia, aphasia, seizures, and severe dry skin was allowed to shave using a personal electric razor that family later observed to have a damaged head with a gouge in the metal and raised edges. Staff routinely handed the razor to the resident for self-shaving and then put it away, but did not identify or report the damage before use. A family member reported that the razor had been dropped and cracked, that the resident’s face was cut and scratched from shaving with it, and that staff did not initially assess the resident’s face, only stating the razor would be replaced. Nursing documentation noted scratches to the resident’s chin and neck from shaving, and the DON acknowledged staff should check razors for damage before use, but neither staff nor management could explain how the razor became broken, and no razor safety policy was produced when requested.
A resident with multiple stage 2 pressure injuries was not provided with a low air loss mattress as ordered by the wound physician and outlined in the care plan. Despite facility policy and active orders, the resident was found on a regular mattress after a room change, and wound deterioration was observed by the wound care nurse.
The facility did not ensure that the QAPI committee met quarterly with all required members present. Attendance records for meetings were incomplete, missing signatures from key members such as the Infection Preventionist, Medical Director, and Director of Nursing. The Administrator confirmed the absence of the Medical Director from meetings since the previous year and noted the lack of Pharmacy and Laboratory representatives, only receiving quarterly reports.
The facility failed to provide properly prepared pureed and mechanically altered meals for residents requiring specific dietary consistencies. Pureed meals contained lumps unsuitable for residents, and mechanical soft diets included whole meatballs and raw vegetables, contrary to dietary guidelines. Staff acknowledged the discrepancies, confirming the meals did not meet the required standards.
A resident's personal refrigerator contained unlabeled and undated food items stored over spills and debris, without a thermometer, violating the facility's food safety policy. The resident, with multiple health conditions, orders food from outside due to dissatisfaction with the facility's meals. An LPN confirmed the lack of compliance with labeling and temperature monitoring requirements.
A resident with severe cognitive impairment was found exposed in a hallway due to a lack of necessary incontinence supplies, which were not provided by the family. Staff did not address the situation until prompted by a surveyor, highlighting a failure to maintain the resident's dignity and privacy.
A resident with multiple health conditions reported missing personal items, but the facility failed to follow its grievance policy. The grievance was not documented or communicated to the Administrator, and the resident was not informed of any investigation results. Staff members did not adhere to the facility's procedures, leading to unresolved concerns.
The facility failed to assess and provide appropriate splints and therapy services for three residents with range of motion limitations. One resident with arthritis had contractures in the right hand without a splint, another with hemiplegia was unable to move the right upper extremity, and a third with polyarthritis had deformed fingers without any device. Occupational therapy evaluations recommended specific splints and therapy services for each resident to prevent further deformities and maintain motion.
A facility failed to follow proper procedures for g-tube medication administration for a resident with dysphagia. The LPN did not check g-tube placement by aspirating for gastric content and administered medications by pushing them through the tube instead of using the gravity method. The facility's policy required a 30 ml water flush before and after each medication, which was not followed.
A facility failed to follow proper infection control practices for a resident in contact isolation due to C-diff. An LPN was observed in the resident's room without a gown and did not wash hands with soap and water after exiting, contrary to the facility's policy. The Regional Nurse Consultant confirmed the necessity of these precautions to protect residents and staff.
The facility failed to administer insulin as ordered, resulting in elevated blood sugars for two residents. One resident reported missing doses due to the facility running out of insulin, and there was no documentation showing that the physician was notified. Another resident also experienced missed doses, with no physician notification. The nurse practitioner confirmed that missing doses significantly impacted the residents' blood sugar levels.
The facility failed to ensure timely medication procurement, causing three residents to miss critical doses of insulin, Vitamin D, and pain relief patches. The EMR documented multiple instances of medications being 'on order,' and the facility did not consistently follow its policy to reorder medications when a two-day supply remained.
The facility failed to ensure nebulizer treatments were completed and documented for two residents with COPD. One resident's family member found the breathing treatment mask on the floor, and another resident reported not always receiving his treatments. The MARs for both residents showed missing documentation for the prescribed treatments.
A resident missed three doses of her seizure medication, Vimpat, due to the facility's failure to reorder it, resulting in a grand mal seizure and hospitalization. Staff interviews and records confirmed the medication was out of stock and not reordered in time, leading to the resident's severe health event.
The facility failed to reorder medications timely, causing residents to miss doses of prescribed medications. Additionally, the facility did not follow proper procedures for handling controlled substances, as only one signature was present for wasted medications and shift-to-shift controlled substance sheets were not signed off by two licensed professionals.
The facility failed to follow infection control measures during incontinence care and COVID-19 isolation. Staff did not change gloves or perform hand hygiene during incontinence care and entered rooms of residents under COVID-19 isolation without proper PPE. The residents involved had severe cognitive impairment and various chronic conditions.
A resident with severe cognitive impairment and multiple medical conditions was not provided adequate assistance for ADLs, resulting in prolonged exposure to moisture and significant skin excoriation. The resident's care plan and facility policies were not followed, leading to the deficiency.
Failure to Ensure Timely Transportation for GI Specialist Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely transportation to a scheduled GI (gastroenterology) consultation as ordered. The resident had a diagnosis of GERD (Gastroesophageal Reflux Disease) and a physician order entered on 10/27/25 for a GI consult. On 1/20/26, the resident reported that he had been told he was supposed to go to an appointment with a GI doctor but had not yet been able to see one. The Nurse Practitioner stated the resident was to see the GI specialist for previous abdominal pain and acid reflux and was not aware that the resident had missed his GI appointments, while also stating that even though the appointments were considered non-urgent, she would still expect the resident to be transported on time. The Appointment and Transportation Scheduler reported ongoing issues with the transportation company used by the facility, including problems getting residents to appointments on time and the lack of any backup transportation options. She confirmed that she had been trying to get the resident to the GI appointment and described two missed appointments: on 12/23/25, the transportation company called to report they would be late, and the physician’s office could not accommodate a late arrival, resulting in rescheduling; on 1/12/25, the transportation company went to the wrong facility, causing the resident to miss the appointment again. The scheduler stated that a new GI appointment was made for 3/18/26. The facility’s Transportation policy dated 9/2020 states that the facility will assist residents in obtaining transportation to their appointments as needed, but the resident was not successfully transported to the ordered GI consult in a timely manner.
Failure to Prevent Resident Injury From Use of Damaged Electric Razor
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to a resident’s use of a personal electric razor. The resident had a history of stroke with right-sided weakness, apraxia, aphasia, epileptic seizures, and severe dry skin, and required staff to hand him his razor because he could not use his right arm. According to the resident’s POA and a family member, the razor was in good condition several days before the incident, but when the family visited, they observed the resident’s face scratched with scabbed blood and noted that the razor head was damaged with a large gouge in the metal part. The POA reported that the damaged area of the razor had metal edges sticking up that would scratch skin if touched lightly, and stated that staff should not have given the resident a broken razor. On the date of the incident, a family member completed a concern form stating that the resident’s razor had been dropped, the head of the blades was cracked, and the razor was not working the same, resulting in the resident’s face being cut. The family member reported that staff did not look at the resident’s face and only told him they would replace the razor. Nursing documentation from that day described dry spot scratches to the resident’s left chin and neck due to shaving, and indicated that the nurse practitioner was notified and treatment orders were obtained. The family also reported finding another razor in the resident’s room that did not belong to him and believed the facility was trying to cover up that the resident’s razor had been damaged. Staff interviews showed that CNAs and the RN regularly assigned to the resident stated that the resident shaved himself and staff would set him up by handing him the razor and putting it away afterward. The CNA recalled the family member being very upset and yelling about the broken razor and the resident’s face being cut, but did not recall the appearance of the resident’s face that day. The RN confirmed there was a day when the resident was cut by the razor and that she documented a progress note, but she did not know how the razor became broken. The DON stated that staff were expected to check the razor for damage before handing it to the resident and acknowledged that a damaged razor head would increase the risk of cutting the resident’s face, but she did not personally examine the razor. The facility’s investigation was unable to determine how the razor was broken, and a requested policy related to razor safety was not provided.
Failure to Provide Ordered Pressure Redistribution Mattress for Resident with Pressure Injuries
Penalty
Summary
The facility failed to implement ordered wound care interventions for a resident with multiple pressure injuries. Upon observation, the resident was found in bed on a regular mattress, despite an active physician order and care plan intervention for a low air loss mattress to aid in pressure redistribution. The wound care nurse and technician confirmed that the resident had stage 2 pressure injuries on both buttocks, which were present on admission and required daily dressing changes. The nurse expressed concern about wound deterioration, noting an increase in wound size and peri-wound irritation with minor bleeding. The nurse also stated uncertainty regarding why the resident was not provided with the specialized mattress after a recent room change. Record review showed that the resident's wounds had been measured and documented by the wound physician, with a consistent order for a low air loss mattress since admission. The care plan identified the resident as being at risk for further skin breakdown and included interventions for pressure redistribution. Facility policy required implementation of individualized care plans and provision of low air loss mattresses for residents assessed as needing them. Despite these orders and policies, the resident was not provided with the required mattress, and wound deterioration was observed.
QAPI Committee Meeting Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met quarterly and included the required members. The facility's records showed attendance for meetings on December 7, 2023, March 14, 2024, and an undated meeting, but these records were incomplete. Specifically, the Infection Preventionist and the Medical Director did not sign the attendance records for the December and March meetings. Additionally, the undated record lacked signatures from the Director of Nursing, the Medical Director, and the Infection Preventionist. The facility's Administrator acknowledged that the Medical Director had not attended a QAPI meeting since the previous year and that there were no representatives from the Pharmacy and Laboratory present, only quarterly reports submitted for review. This indicates that the facility did not comply with the requirement for quarterly QAPI meetings with all necessary members present.
Inadequate Preparation of Pureed and Mechanical Soft Diets
Penalty
Summary
The facility failed to provide appropriately prepared pureed and mechanically altered meals for residents requiring specific dietary consistencies. During an observation, a cook was seen preparing pureed ground meat with spaghetti sauce, which contained small lumps of fat and meat particles that were not suitable for residents on a pureed diet. The dietary supervisor confirmed that the food needed further processing to meet the required consistency. The facility's policy specifies that pureed foods should have a pudding-like consistency, excluding any foods that require chewing. The facility's diet type report indicated that several residents were on pureed diets, yet the food provided did not meet these standards. Additionally, the facility did not adhere to the mechanical soft diet requirements for residents who have difficulty chewing. During a lunch meal service, residents on a mechanical soft diet were served whole meatballs instead of ground meat as specified in the menu spreadsheet. One resident also received a regular consistency salad and mixed vegetables, including corn, which they were unable to chew. The dietary supervisor acknowledged that the resident should have received shredded lettuce or mechanically altered coleslaw instead. The facility's policy for mechanical soft diets states that hard-to-chew foods should be replaced with easily swallowable alternatives, and raw vegetables should be avoided. The diet type report confirmed that several residents were on mechanical soft diets, yet the meals served did not comply with these guidelines.
Improper Storage of Resident's Food in Personal Refrigerator
Penalty
Summary
The facility failed to store a resident's food in a safe and sanitary manner, as observed in the personal refrigerator of a resident diagnosed with malignant neoplasm of the head of the pancreas, type 2 diabetes mellitus without complications, alcohol dependence with unspecified alcohol-induced disorder, and adult failure to thrive. The resident, who is cognitively intact, reported ordering Indian food from outside the facility due to dissatisfaction with the facility's food. Upon inspection, the refrigerator contained five clear plastic containers of cooked food and another item wrapped in silver foil, all placed over excessive spills, food debris, and miscellaneous brownish-black particles. These food items were not labeled or dated, and there was no thermometer found in the refrigerator, although a temperature monitoring log was present. A Licensed Practical Nurse (LPN) confirmed that the resident orders food from an outside source and that the food items should be labeled and dated, with a thermometer present in the refrigerator. The LPN also mentioned that the night shift nursing staff is responsible for checking the refrigerator and logging the temperatures. The facility's policy requires food to be stored at 41 degrees Fahrenheit or below and mandates that resident food be in a tight container labeled with the name, food item, and date it was prepared. The failure to adhere to these policies resulted in the deficiency noted during the survey.
Failure to Provide Necessary Supplies for Resident Dignity
Penalty
Summary
The facility failed to provide necessary supplies to preserve a resident's dignity and privacy, as observed in the case of a resident with multiple diagnoses including chronic diastolic heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, and unspecified dementia. The resident, who was severely cognitively impaired and required assistance with activities of daily living, was found sitting in the hallway without pants, exposing his genitals. This incident occurred while staff were present nearby, but they did not respond until the issue was pointed out by a surveyor. Further investigation revealed that the resident did not have access to the incontinence products he required, specifically pull-up briefs, because the family had not provided more supplies. A CNA confirmed the absence of these products in the resident's room and subsequently retrieved them from the facility's supply room. Another observation noted the resident sitting in his room without pants, with the door open, and putting on a brief himself, with minimal assistance from a CNA. The facility's policy on resident dignity, as provided by the administrator, emphasizes the importance of maintaining residents' privacy and satisfaction.
Failure to Follow Grievance Policy for Missing Items
Penalty
Summary
The facility failed to adhere to its grievance policy by not informing the Administrator or designee upon receipt of a grievance and not informing the resident of the investigation results. This deficiency was identified in the case of a resident with multiple diagnoses, including end-stage renal disease, diabetes mellitus type 2, and vascular dementia, who reported a missing wallet and pants. Despite the resident's moderate cognitive impairment and need for assistance with activities of daily living, the facility did not document or address the grievance in a timely manner. The resident reported the missing items to a staff member, but there was no record of the grievance being filed or investigated. The Administrator was unaware of the grievance until several days later, and the staff members involved did not follow the facility's policy for handling grievances. The facility's grievance forms for the month did not include the resident's complaint, and the staff failed to communicate the issue to the appropriate personnel, resulting in a lack of resolution and communication with the resident.
Failure to Provide Appropriate ROM Care and Splints
Penalty
Summary
The facility failed to assess and provide appropriate splints and therapy services to maintain or prevent further progression of deformities or reduction in range of motion for three residents. One resident with multiple diagnoses, including rheumatoid arthritis and osteoarthritis, was observed with contractures in the right hand without a splinting device. The resident expressed willingness to be evaluated for therapy, and an occupational therapist later recommended specific splints and occupational therapy to address the deformities and improve hand function. Another resident, who had hemiplegia and hemiparesis following a cerebral infarction, was found to have right-sided paralysis and was unable to move the right upper extremity. Despite being alert, the resident communicated nonverbally and demonstrated weakness in the right arm and hand. An occupational therapist evaluated the resident and recommended a resting hand splint to prevent contracture, along with occupational therapy services. The third resident, diagnosed with hemiplegia and polyarthritis, was observed with deformed and hyperextended fingers on both hands without any splint or device. The resident was confused but verbally responsive. An occupational therapist assessed the resident and recommended specific splints for both hands to prevent further deformity and maintain current motion. The therapist also suggested occupational therapy services to support the resident's condition.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed for the administration of medications and flushes through a gastric tube (g-tube) for a resident, identified as R147. The resident, who was admitted with multiple diagnoses including dysphagia and pneumonitis due to inhalation of food/vomit, required tube feeding and stoma site care. The care plan for R147 specified that the placement and patency of the feeding tube should be checked prior to administering medications, feedings, and flushes. However, during an observation, it was noted that the Licensed Practical Nurse (LPN) did not check the g-tube placement by aspirating for gastric content before administering medications. Instead, the LPN palpated the abdomen and asked the resident about pain, which was not in accordance with the facility's policy. Additionally, the LPN administered the medications and flushes by pushing them through the tube rather than using the gravity method as recommended by the facility's policy. The policy required a 30 ml water flush before and after each medication administration, but the LPN used only 15 ml of water for each medication and did not follow the proper technique. The Regional Nurse Consultant confirmed that the correct procedure was not followed, highlighting the facility's failure to adhere to its own medication pass guidelines.
Infection Control Breach in C-diff Isolation
Penalty
Summary
The facility failed to adhere to proper infection control practices for a resident in contact isolation due to Clostridium Difficile (C-diff). The resident, who was cognitively intact, was admitted with multiple diagnoses including C-diff. The care plan indicated that the resident was in a single room under contact isolation, and staff were to be educated on isolation precautions. However, an LPN was observed in the resident's room without wearing a gown, despite the presence of a contact isolation sign and a PPE cart outside the room. The LPN exited the room wearing the same gloves, disposed of them at the nurses' station, and did not wash hands with soap and water as required. The facility's policy, dated 2020, mandates the use of contact precautions for residents with C-diff, including wearing appropriate PPE and washing hands with soap and water, as alcohol-based hand sanitizers are ineffective against C-diff spores. The Regional Nurse Consultant confirmed that these precautions are necessary to protect both residents and staff. The failure to follow these procedures was observed and confirmed through interviews, highlighting a deficiency in the facility's infection prevention and control program.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer insulin as ordered by the physician, resulting in elevated blood sugars and lab values for two residents. One resident reported missing their morning dose of insulin on a specific date due to the facility running out of the medication. This resident's EMR showed multiple instances where insulin was not administered as ordered, and there was no documentation indicating that the physician was notified of the missed doses. The resident's blood sugar levels were significantly elevated on these occasions, and their HBA1C levels indicated poor glycemic control over several months. Another resident also experienced missed doses of insulin, as documented in their EMR. The facility's policy on medication administration requires that medications be administered as prescribed and that the physician be notified if an order cannot be followed. However, the facility did not adhere to this policy, as there was no documentation showing that the physician was informed of the missed doses for either resident. The nurse practitioner confirmed that the first resident is a brittle diabetic and that missing even one dose of insulin significantly impacts their blood sugar levels. The facility's failure to ensure the availability of insulin and to notify the physician of missed doses directly contributed to the residents' elevated blood sugar levels and poor diabetes management.
Failure to Obtain Medications in a Timely Manner
Penalty
Summary
The facility failed to ensure medications were obtained from the pharmacy in a timely manner, resulting in residents missing medication doses as ordered by their physicians. This deficiency affected three residents who experienced delays in receiving critical medications, including insulin, Vitamin D, and depression medication. For instance, one resident reported missing a morning dose of insulin and experiencing inconsistent blood sugar levels due to the facility running out of the medication. The resident also missed doses of Vitamin D and depression medication. The EMR documented multiple instances where medications were marked as 'on order,' indicating they were not available when needed. Another resident, who was cognitively intact and required supervision with ADLs, also experienced delays in receiving insulin and pain relief patches. The EMR showed several instances where these medications were documented as 'on order,' leading to lapses in therapy. The pharmacy confirmed that the facility requested refills but did not follow the proper process to ensure timely delivery. The facility's policy requires nursing staff to reorder medications when a two-day supply remains, but this procedure was not consistently followed. A third resident, with multiple diagnoses including end-stage renal disease and diabetes, also faced delays in receiving pain relief patches. The pharmacy records indicated that the facility requested refills but did not adhere to the policy of reordering medications in advance. Interviews with the pharmacy staff and the DON revealed that the facility staff did not consistently request medication refills in a timely manner, leading to lapses in therapy for the residents. The facility's policy on reordering medications was not effectively implemented, contributing to the deficiency.
Failure to Administer and Document Nebulizer Treatments
Penalty
Summary
The facility failed to ensure nebulizer treatments were completed and documented on the medication administration record (MAR) for two residents diagnosed with chronic obstructive pulmonary disease (COPD). On 4/8/24, a family member of one resident (R1) reported finding the resident's breathing treatment mask on the floor and the nebulizer machine turned off. The MAR for March 2024 indicated that R1 was supposed to receive a treatment of Ipratropium-Albuterol via nebulizer on 3/28/24 at 6:00 AM, but there were no recorded nurse initials to confirm the medication was administered. Another resident (R10) reported on 4/9/24 that staff did not always ensure he received his prescribed nebulizer treatments twice per day. The MAR for March 2024 showed that R10 was also supposed to receive a treatment of Ipratropium-Albuterol via nebulizer on 3/28/24 at 6:00 AM, but again, there were no recorded nurse initials to indicate the medication was provided. The Director of Nursing confirmed that both residents should have received their treatments as ordered and that the administration should have been documented on the MAR.
Failure to Reorder Seizure Medication Leads to Resident Hospitalization
Penalty
Summary
The facility failed to reorder a resident's seizure medication, Vimpat, resulting in the resident missing three doses. This led to the resident experiencing a grand mal seizure and subsequent hospitalization. Interviews with various staff members, including LPNs and RNs, revealed that the medication was out of stock and not reordered in a timely manner. The resident's family member and neurology specialist confirmed that the missed doses likely caused the seizure. The facility's progress notes and Medication Administration Review (MAR) documented the missed doses and the out-of-stock status of the medication. The resident, who had a history of epilepsy and other medical conditions, required Vimpat twice daily to manage her seizures. The failure to administer the medication as prescribed resulted in the resident having multiple seizures, requiring emergency medical intervention and hospitalization. The facility's policy on medication administration was not followed, leading to a significant medication error that compromised the resident's health and safety.
Medication Reordering and Controlled Substance Handling Deficiencies
Penalty
Summary
The facility failed to reorder medications in a timely manner, resulting in residents missing doses of their prescribed medications. One resident missed three doses of Vimpat due to the medication being out of stock, as documented in the facility's progress notes. Another resident did not receive her scheduled morphine doses because the prescription had ended, and the staff failed to reorder it in time. Both residents had significant medical conditions that required consistent medication management, and the lapses in medication administration were noted in their Medication Administration Records (MAR) and Electronic Medical Records (EMR). Additionally, the facility did not adhere to proper procedures for handling controlled substances. The Controlled Drug Receipt/Record/Disposition Forms for two residents showed that only one signature was present for wasted medications, instead of the required two signatures. This was confirmed during a review of the medication cart and interviews with staff members. The facility's policy mandates that two licensed professionals must sign off on wasted controlled substances to prevent drug diversion and ensure safe disposal. The facility also failed to have two licensed professionals sign off on the shift-to-shift controlled substance sheet. Multiple days were identified where the controlled substances were not verified and signed off by two nurses, as required by the facility's policy. This lapse was confirmed by the Consultant Pharmacist and the Director of Nursing, who both acknowledged the necessity of having two signatures for verification and handoff of narcotics. The facility's policies on reordering medications and controlled drug documentation were not followed, leading to these deficiencies.
Infection Control Deficiencies During Incontinence Care and COVID-19 Isolation
Penalty
Summary
The facility failed to follow infection control measures for several residents during incontinence care and COVID-19 isolation. Specifically, a CNA provided incontinence care for a resident without changing gloves or performing hand hygiene after removing a dirty brief and before handling clean items and applying barrier cream. This resident had severe cognitive impairment and required total dependence on staff for toileting hygiene and other activities of daily living. Additionally, multiple staff members entered rooms of residents under COVID-19 isolation without wearing the required personal protective equipment (PPE). For instance, a CNA entered a resident's room with only a surgical mask, and an LPN entered another resident's room without a gown, glasses, or an N-95 mask. A social work intern also entered a room with two residents under COVID-19 isolation without wearing an N-95 mask and eye protection. The residents involved had various medical conditions, including severe cognitive impairment, hemiplegia, hemiparesis, metabolic encephalopathy, pressure ulcers, and other chronic conditions. The Director of Nursing acknowledged that staff should wear a gown, gloves, N-95 mask, and face shields before entering rooms under COVID-19 isolation precautions. However, the Director was unable to specify when gloves should be changed and hand hygiene performed during incontinence care. The facility's policies on Universal PPE for Staff and Perineal Care were not followed, leading to these deficiencies in infection control practices.
Failure to Provide Adequate Assistance for ADLs
Penalty
Summary
The facility failed to provide adequate assistance to a resident (R11) for activities of daily living (ADLs). On the morning of 12/21/23, a family member expressed concerns to an LPN about R11 not being checked on frequently enough and needing to be cleaned up. R11, who had severe cognitive impairment and multiple medical conditions including pneumonia and COVID-19, was found by a CNA to have urine and stool in his incontinence brief, with excoriated and red skin around his perineal area, buttocks, and sacrum. The resident was in visible pain during the cleaning process. Despite these observations, the CNA did not report the skin breakdown to the LPN. Later, a wound LPN and wound tech confirmed the skin damage was due to prolonged moisture exposure and noted that R11's lunch tray was untouched, indicating a lack of assistance with eating as well. The Director of Nursing (DON) confirmed that staff are required to check on residents every two hours and provide incontinence care as needed, and that excoriated skin can result from prolonged moisture. The DON also stated that staff should check meal trays within an hour to monitor residents' food intake. R11's care plan required turning and repositioning every two hours, pericare after every incontinent episode, and monitoring for skin excoriation. However, these care plan interventions were not followed, leading to the resident's condition. The facility's policies on feeding and perineal care were also not adhered to, contributing to the deficiency.
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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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