Alden Of Waterford
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Illinois.
- Location
- 2021 Randi Drive, Aurora, Illinois 60505
- CMS Provider Number
- 146008
- Inspections on file
- 28
- Latest survey
- January 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Alden Of Waterford during CMS and state inspections, most recent first.
Two residents with venous ulcers and significant lower extremity edema did not receive care and treatment consistent with physician orders and the care plan. For one resident, surveyors observed a right leg venous ulcer without a dressing in place after showering, despite orders for specific wound dressings and ace wraps; the wound nurse confirmed she was unaware the dressing had been removed and that it should have been re-applied. Another resident with bilateral venous ulcers, cellulitis, CHF, and kidney disease was repeatedly observed in a wheelchair with legs dependent and reported not having a reclining chair or wheelchair to elevate his legs, while the DON and nursing staff acknowledged that leg elevation was needed but that no effective elevation interventions were in place, even though the care plan and wound physician documentation called for leg elevation and compression therapy.
A resident with COPD, heart disease, PVD, chronic venous ulcers, diabetes, and a history of falls was care planned and assessed for a restorative walking "walk to dine" program using a rolling walker with wheelchair follow, requiring assistance with ambulation. The resident reported that therapy had been stopped due to insurance and that staff did not offer to walk with him, so he sometimes walked alone. Nursing and restorative staff acknowledged the resident should be on a restorative walking program but were unclear who was responsible for providing the services, and a CNA stated floor CNAs do not perform restorative care. Documentation showed that on most days in the review period the resident did not receive restorative walking services, and the care plan lacked documentation of refusals, despite the facility policy requiring individualized restorative programs to be reflected on the care plan and consistently implemented.
A resident with a fever had an IV Imipenem-Cilastatin 500 mg dose ordered to start the next morning, but when the nurse attempted to administer it, the only dose available in the automated medication dispensing machine was expired and documented as not available on the eMAR. The DON stated that pharmacy is responsible for monthly inventory and outdating of the automated system and that staff cannot see expiration dates until a medication is pulled, and also acknowledged that pharmacy was not contacted about the expired antibiotic. Because the expired medication could not be used and a replacement dose would not arrive until later, the resident did not receive the ordered morning dose and was subsequently sent to the ER at the request of the resident’s NP daughter.
Two residents who were dependent on staff for bathing did not receive scheduled showers as required, with both missing multiple showers and experiencing extended periods without a shower. Facility records and interviews confirmed that although showers were scheduled twice weekly, the residents often received only bed baths due to staffing issues.
A resident with multiple chronic conditions and intact cognition reported being physically abused by a CNA. The Administrator suspended the CNA and notified the physician and family, but failed to report the allegation to law enforcement as required by facility policy. Police became involved only after the family contacted them, and the Administrator later admitted she should have notified law enforcement immediately.
A resident with multiple chronic conditions, including respiratory failure and dependence on supplemental oxygen, experienced a decline marked by excessive sweating and low oxygen saturation. Nursing staff increased oxygen support without notifying the physician, contrary to facility policy, and the provider on call was not informed before the resident was transferred to the hospital.
A resident with complex medical needs was not promptly assessed by nursing staff after a CNA reported lethargy and refusal to eat. Despite facility protocol requiring immediate evaluation and documentation, the LPN and agency LPN delayed assessment until shift change, and no change of condition assessment form was completed before the resident was transferred to the hospital.
The facility failed to submit accurate licensed nurse working hours for PBJ submissions in July, August, and September 2024, affecting all 75 residents. The CASPER report indicated no RN hours and lack of 24-hour licensed nurse coverage. The administrator acknowledged the inaccuracy, and documentation showed communication about CNA hours but not licensed nurse hours.
The facility failed to accurately account for controlled medications for seven residents, with discrepancies observed in the medication cart's controlled drug compartment. Nurses did not sign out medications on the controlled drug receipt, leading to mismatches between actual and recorded counts. The facility's policy requires proof-of-use forms and shift counts, but these procedures were not followed, resulting in the discrepancies.
The facility did not follow the menu extension sheet for serving portion sizes for pureed and mechanical soft diets, affecting six residents. Incorrect scoop sizes were used during meal service, leading to inadequate dietary intake. The dietary manager was informed, and the dietitian emphasized the importance of correct portion sizes for nutritional adequacy.
The facility failed to provide meals in the correct consistency for residents on specialized diets. A resident on a pureed diet received improperly pureed mashed potatoes, while three residents on mechanical soft diets were served potato wedges with skin, contrary to facility policy. The issues were attributed to errors in meal preparation and menu documentation.
The facility failed to ensure privacy during care and record handling. A nurse left a medication cart unattended with a resident's information visible, and conducted a blood glucose check and insulin administration in a public area. Another resident received personal care without privacy curtains drawn, exposing them to their roommate. The facility's policy on privacy was not followed.
The facility failed to manage urinary catheters properly for two residents, leading to potential infection risks. One resident's catheter bag was lifted above the bladder during care, causing urine backflow, while another resident's catheter bag was observed touching the floor. Both residents had medical histories that included urinary issues, and the facility's Director of Nursing acknowledged the importance of proper catheter positioning to prevent infections.
A resident received an incorrect dose of Insulin Novolog due to a staff member's decision to administer only 4 units instead of the prescribed 17 units, based on a sliding scale order. Additionally, a scheduled dose of Nystatin-Triamcinolone ointment was not administered, although it was signed off as given. These actions resulted in a medication error rate of 6.9%, exceeding the acceptable threshold.
The facility failed to follow infection control practices during incontinence care and in an isolation room. Two CNAs did not change gloves or perform hand hygiene between tasks while providing incontinence care to a resident. Additionally, a physical therapist did not wear the required PPE while providing care to a resident on contact isolation for C-diff, despite signage indicating the need for gloves and a gown.
The facility failed to adhere to its narcotics administration and disposal policies, leading to two RNs using a discharged resident's Hydrocodone/APAP tablets for another resident in pain. The nurses bypassed protocol by not obtaining a new order or accessing the emergency supply, resulting in a discrepancy in the controlled drug count.
A facility failed to follow a physician's treatment order for a resident with a stage 3 pressure injury and did not inform the physician of a new pressure injury. The wound care nurse used an ABD dressing instead of the prescribed foam dressing and did not notify the wound physician of a new deep tissue injury. The physician expected immediate notification of skin alterations and adherence to treatment orders.
A resident with a history of falls and mobility issues was not provided with a gait belt during a transfer to the bathroom, resulting in a fall. Despite the resident's care plan indicating a need for assistance, the CNA did not use the required gait belt, as confirmed by the Restorative Nurse and Therapy Director. The facility's policy mandates gait belt use for residents needing hands-on assistance.
Failure to Maintain Wound Dressings and Implement Leg Elevation for Residents With Venous Ulcers
Penalty
Summary
The facility failed to provide necessary care and treatment for residents with vascular ulcers as ordered and care-planned. For one resident with a right calf venous ulcer, surveyors observed that the right lower extremity had no dressing in place, with the leg discolored, reddened, and with two open areas. The wound nurse cleansed the skin and applied xeroform, gauze, and an elastic bandage at the time of observation, and stated she had not known the dressing had been removed and that if a dressing is removed it should be re-applied. The resident reported that the dressing had been removed during a shower the previous day and not replaced. The wound physician’s progress note and physician orders showed specific treatment orders for the right calf venous ulcer, including cleansing with normal saline and application of xeroform, gauze, absorbent pad, kerlix, and elastic bandage, and ace wraps to both lower extremities that may be removed for ADL care, indicating the dressing should have been in place after shower care. Another resident with bilateral venous ulcers and cellulitis of the lower limbs had significant lower extremity edema, pain, and burning sensations, and was observed sitting in a wheelchair with feet on the floor, wearing shoes without laces to accommodate swelling, and later in the activity room with gauze wraps and elastic bandages in place and visible swelling. The resident stated he did not have a chair to recline in to elevate his legs and expressed a desire for a reclining wheelchair to elevate them, explaining that when in bed he rests his feet on the bed in the lowest position. Nursing staff, including the RN, wound nurse, and DON, acknowledged the resident’s chronic pain and swelling, co-morbidities (including CHF and kidney disease), and the need for leg elevation, and the DON stated the resident did not have interventions in place to elevate his legs. The wound physician’s progress note documented venous ulcers on both legs with edema, warmth, erythema, drainage, and cellulitis, and the plan of care included leg elevation. The current care plan listed interventions such as compression therapy and leg elevation, but staff statements and observations showed that effective leg elevation interventions were not in place or implemented.
Failure to Provide Ordered Restorative Walking Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered restorative walking services to a resident with multiple chronic conditions, including COPD, hypertensive heart disease, type 2 diabetes, chronic venous ulcers to both lower extremities, PVD, a history of falls, and heart disease. The resident was observed seated in a wheelchair with a rolling walker present in his room and later in the activity room. He reported that his therapy had been discontinued due to insurance coverage and that, although he has a walker, he only walks sometimes by himself because staff do not offer to walk with him. Nursing staff, including an RN, stated that the resident is alert, oriented, compliant with care, and has a walker, but they had not seen him walk often and were unsure when or how often restorative staff work with residents. The Restorative Nurse reported that residents are assessed on admission and quarterly for restorative services, and that when therapy is discontinued, recommendations and goals are to be continued in a restorative program carried out by unit managers and floor CNAs. She stated that the resident should be on a walk-to-dine program but was unaware he was not receiving those services and was not aware of any pattern of refusals, despite noting there were many refusals documented. A CNA reported not knowing who performs restorative services and stated that floor CNAs do not do them. The resident’s restorative nursing assessment documented that he was on a restorative walking program and should walk to and from the dining room with a rolling walker and wheelchair follow, and his care plan indicated he requires assistance with ambulation. However, the Nursing Rehab Walking report showed that on 11 of 14 days reviewed he did not receive restorative walking services, and the care plan did not document refusals prior to the survey date, contrary to the facility’s Restorative Nursing Program policy that individualized programs be reflected on the care plan and consistently carried out by staff.
Expired IV Antibiotic in Automated Dispensing Machine Prevents Timely Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications stored in its automated medication dispensing machine were not expired, resulting in an ordered IV antibiotic dose being unavailable for administration. A resident developed an elevated temperature of approximately 100.2–100.4°F, and the resident’s daughter, who is also a nurse practitioner, requested that an IV antibiotic (Imipenem-Cilastatin 500 mg) be started immediately. A physician order was entered for Imipenem-Cilastatin IV 500 mg once daily for febrile illness, with the first dose scheduled for administration at 6:00 AM. The Medication Administration Record documented the scheduled dose with a notation to see progress notes, and subsequent progress notes and eMAR entries indicated that the medication was “not available” at the time it was due. The DON reported that the dose of Imipenem-Cilastatin available in the facility’s medication dispensing machine was expired and therefore could not be administered when ordered. The DON stated that the pharmacy is responsible for maintaining the automated medication storage system, including tracking medication expiration dates and performing monthly inventory and outdating, as outlined in the facility’s Automated Medication Storage System policy. The DON also stated that facility staff do not have the ability to check expiration dates until a nurse pulls the medication from the machine, and that she did not contact the pharmacy regarding why an expired antibiotic remained in the machine. Because the ordered antibiotic was expired and not immediately usable, the resident could not receive the scheduled morning dose from the dispensing machine and was later sent to the emergency room at the request of the resident’s daughter.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers to two residents who were dependent on staff for bathing. One resident, admitted with multiple diagnoses including chronic heart failure, paraplegia, and severe obesity, was cognitively intact and required assistance for showers. According to the electronic medical record and shower intervention task reports, this resident missed several scheduled showers over a period of weeks, including a stretch of nine consecutive days without a shower. The resident reported receiving bed baths instead and attributed the missed showers to insufficient staffing, as communicated by CNAs. Another resident, with diagnoses such as hemiplegia, chronic respiratory failure, and altered mental status, was also dependent on staff for bathing. This resident missed multiple scheduled showers, with two separate periods of nine consecutive days without a shower. The resident’s spouse, who shared the room, confirmed that the resident received bed baths but not the scheduled showers. Facility documentation and staff interviews confirmed that showers were scheduled twice weekly, but the residents did not consistently receive them as planned.
Failure to Notify Law Enforcement After Alleged Physical Abuse
Penalty
Summary
The facility failed to notify local law enforcement after an allegation of physical abuse was made by a resident. The resident, who was cognitively intact and had multiple diagnoses including congestive heart failure, chronic kidney disease, and pulmonary hypertension, reported to the Administrator that she believed she had been 'smacked in the face' by her CNA. The CNA was suspended pending investigation, a body check was completed with no new findings, and the physician, resident, and her daughter were notified of the investigation process. However, the Administrator did not contact the police after receiving the allegation, instead only informing the state agency and stating that she would only call the police if the resident requested it. The facility's policy and posted crime reporting requirements clearly state that any reasonable suspicion of a crime against a resident must be reported directly to both law enforcement and the state survey agency, with specific timeframes depending on the severity of the injury. Despite this, law enforcement was only involved after the resident's family contacted them, and the Administrator later acknowledged that she should have notified the police immediately after being informed of the allegation.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who was reviewed for this issue. On the evening in question, the resident experienced a decline, including excessive sweating and an oxygen saturation level of 89 percent. Despite these changes, the nurse increased the resident's oxygen from 2 liters to 4 liters via nasal cannula without first notifying the physician, as required by facility policy. The nurse on duty was not aware that the provider had not been notified, and the nurse practitioner on call did not receive any communication regarding the resident's change in condition or subsequent transfer to the hospital. The resident involved had a complex medical history, including acute and chronic respiratory failure, chronic obstructive pulmonary disease, multiple cardiac conditions, end-stage renal disease, anemia, hemiplegia, and dependence on supplemental oxygen. The facility's clinical guidelines specified that any change in condition, particularly oxygen saturation below 90 percent, should be reported immediately to the attending physician or provider on call. However, this protocol was not followed, and the provider was not informed prior to the resident's transfer to the hospital.
Failure to Timely Assess Resident After Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to immediately assess a resident after a reported change in condition. The resident, a male with multiple complex diagnoses including acute and chronic respiratory failure, chronic obstructive pulmonary disease, multiple cardiac diseases, end-stage renal disease, anemia, hemiplegia, and hemiparesis, was dependent on supplemental oxygen and staff for activities of daily living. On the evening in question, the resident was found to be lethargic and not eating his meals. The CNA reported this to the LPN, but the LPN and an agency LPN did not assess the resident until approximately 30 minutes later, during the shift turnover. Family members also raised concerns and contacted the Director of Nursing, who then instructed the LPN to check on the resident. Despite the facility's protocol requiring immediate attention and completion of a change of condition assessment form when such changes are reported, there was no documentation of an assessment or completion of the required form prior to the resident's transfer to the hospital. This lapse in timely assessment and documentation constituted a failure to provide appropriate treatment and care according to orders and the resident’s needs.
Inaccurate PBJ Submission for Licensed Nurse Hours
Penalty
Summary
The facility failed to submit accurate licensed nurse working hours for the Payroll Based Journal (PBJ) submission for the months of July, August, and September 2024. This deficiency affected all 75 residents residing in the facility. The CASPER report for Quarter 4, 2024, indicated that the facility had no recorded RN hours and failed to maintain licensed nurse coverage 24 hours a day from July 1, 2024, through September 30, 2024. The facility's administrator acknowledged that the hours for licensed nurse staffing were not accurately reported. Documentation provided by the administrator showed email communication between the corporate office and the Department of Healthcare and Family Services (HFS) regarding an error in PBJ data submission for CNA hours. However, there was no reference to the error in reporting licensed nurse hours for Quarter 4. The facility's PBJ Staffing Data Report for FY Quarter 2 2024 confirmed the absence of RN hours and the lack of 24-hour licensed nursing coverage. The facility's policy on staffing data submission required the electronic submission of complete and accurate direct care staffing information, including the category of work for each direct care staff member.
Controlled Medication Discrepancies
Penalty
Summary
The facility failed to ensure accurate and timely accounting of controlled medications for seven residents. On March 26, 2025, discrepancies were observed in the medication cart's controlled drug compartment on both the first and second floors. For instance, R69 had one less Alprazolam tablet than recorded, and R234 had one less Modafinil tablet than documented. The Licensed Practical Nurse, V17, admitted to not signing out the medications on the controlled drug receipt due to being busy, which led to the discrepancies. Additionally, the controlled substance shift count documentation was not signed by the on-duty nurse, V17, although she claimed to have performed the count with the outgoing nurse. On the second floor, similar discrepancies were noted. R24 had one less Alprazolam tablet, R21 had one less Morphine Sulfate tablet, R18 had one less Clonazepam tablet, R48 had one less Hydrocodone/Apap tablet, and R2 had one less Phenobarbital tablet than recorded. The Registered Nurse, V18, also failed to sign the controlled drug receipt after administering the medications, citing a lack of opportunity to do so during the morning medication pass. The Director of Nursing, V2, confirmed that the controlled medications should be signed out immediately after being taken from the blister pack to ensure proper accounting. The facility's policy on controlled drug documentation, dated June 2022, mandates the use of proof-of-use forms to document each dose administered and requires controlled substances to be counted and verified every shift by authorized professionals. The policy also states that any discrepancies must be reported to the Resident Care/Nursing Director immediately. The failure to adhere to these procedures resulted in the observed discrepancies in the controlled medication counts.
Failure to Follow Menu Extension Sheet for Dietary Requirements
Penalty
Summary
The facility failed to adhere to the menu extension sheet guidelines for serving portion sizes for pureed and mechanical soft diets, which are necessary to meet the dietary requirements of the meal. This deficiency was observed on March 24, 2024, during the lunch meal tray line service on the 1st floor. The chef and dietary aide used incorrect scoop sizes to serve meals to six residents, including those on mechanical soft and pureed diets. Specifically, a #8 scoop was used for ground country fried steak and pureed country fried steak, and a #10 scoop was used for pureed green beans, contrary to the menu extension sheet instructions that specified a #6 scoop for the ground and pureed country fried steak and a #8 scoop for the pureed beans. The dietary manager was informed of the incorrect scoop sizes used during the meal service. The dietitian confirmed that the correct scoop sizes are essential to ensure residents receive the adequate amount of protein, carbohydrates, and calories as planned in their meals.
Inadequate Meal Preparation for Specialized Diets
Penalty
Summary
The facility failed to provide meals in the appropriate consistency for residents on specialized diets. On March 24, 2024, a resident on a pureed diet received mashed potatoes that were not properly pureed, containing granules that required chewing. The resident expressed dissatisfaction with the texture, and upon taste testing, the chef confirmed the presence of granules, attributing the issue to insufficient water and blending by a new cook. The facility's policy requires pureed foods to be homogenous and pudding-like, excluding any foods that require mastication. On March 25, 2025, three residents on mechanical soft diets were served Vesuvio potato wedges with skin, contrary to the facility's policy that such diets should avoid potato skins. The dietary manager initially believed the diet extension allowed for potato skins, but the dietitian later clarified that the menu was marked in error. The corporate dietitian, responsible for planning and signing the menus, only signed the first and last pages of the cycle menus, leading to the oversight. The facility's diet type report confirmed the dietary requirements of the affected residents.
Privacy Breach in Resident Care and Record Handling
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as well as during the provision of care. On March 24, 2025, a medication cart was left unattended in the 2nd floor C/D hallway with a computer displaying a resident's information, visible to passersby. A nurse, identified as V19, was observed leaving the cart unattended while attending to a resident in a nearby room. Additionally, the same nurse conducted a blood glucose level check and administered insulin to another resident in a public area, with the resident's medical information visible to others, including five other residents and two visitors. Another incident involved a resident with vascular dementia and cognitive impairment, who required assistance with personal care. On March 24, 2025, a certified nursing assistant, V12, was observed providing personal care to this resident without drawing the privacy curtain, exposing the resident to their roommate. The Director of Nursing confirmed that privacy should be maintained during personal care activities. The facility's policy on residents' rights emphasizes the importance of privacy in medical and personal care, which was not upheld in these instances.
Deficiencies in Urinary Catheter Management
Penalty
Summary
The facility failed to ensure proper management of indwelling urinary catheters for two residents, leading to potential infection risks. For one resident, the certified nursing assistants lifted the urinary catheter bag above the bladder during incontinence care, causing urine to flow back towards the bladder. This resident had a history of urinary tract infection (UTI) and was under treatment for an acute UTI, with lab results showing significant bacterial presence. The care plan for this resident required the catheter bag to be positioned below the bladder, which was not adhered to during the observed care. For another resident, the urinary catheter bag was observed touching the floor while inside a privacy bag, which was not attached to the bed frame. The resident's catheter tubing contained dark yellow urine with brown sediments, indicating potential issues with catheter management. The Director of Nursing acknowledged that the catheter bag should not touch the floor to maintain infection control and prevent UTIs. These observations highlight deficiencies in catheter care practices within the facility.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 6.9%, which exceeds the acceptable threshold of 5%. This deficiency was identified during a medication pass review for one of the residents. On March 24, 2025, a staff member, V19, checked the blood sugar level of a resident, R34, which was 207 mg/dl. According to the sliding scale order, R34 should have received 17 units of Insulin Novolog. However, V19 administered only 4 units, citing discomfort with the higher dose due to concerns about the resident's blood sugar potentially dropping too low. V19 did not notify the physician before making this decision. Additionally, V19 failed to administer a scheduled dose of Nystatin-Triamcinolone ointment to R34, although she signed off on the medication administration record as if it had been given. This omission, along with the incorrect insulin dosage, contributed to the medication error rate. The facility's policy requires medications to be administered according to the physician's written orders, which was not adhered to in this instance. The nurse practitioner was informed of the partial insulin dose after the fact, but this did not mitigate the initial failure to follow the prescribed medication orders.
Infection Control Lapses in Incontinence Care and Isolation Room
Penalty
Summary
The facility failed to adhere to standard infection control practices during incontinence care and while providing physical therapy in an isolation room. In the first instance, two CNAs provided incontinence care to a resident with a bowel movement without changing gloves or performing hand hygiene between tasks. The CNAs handled soiled items and touched various surfaces while wearing the same soiled gloves, contrary to the facility's hand hygiene policy, which requires hand hygiene before gloving, when moving from dirty to clean tasks, and after glove removal. In the second instance, a physical therapist provided care to a resident on contact isolation for C-diff without wearing the required PPE. Despite a contact precaution sign indicating the need for gloves and a gown, the therapist only wore gloves. The facility's contact precaution policy mandates the use of appropriate PPE to prevent the transmission of infections like C-diff, as recommended by CDC guidelines. The Director of Nursing confirmed that the staff should have followed the posted signage to prevent potential infection spread.
Improper Administration and Disposal of Narcotics
Penalty
Summary
The facility failed to properly administer, store, and dispose of narcotics according to its policy, resulting in the inappropriate use of a discharged resident's medication for another active resident. Specifically, two Hydrocodone/APAP 5-325 mg tablets from a discharged resident's supply were used for an active resident who was experiencing pain and had run out of her prescription. The discrepancy was noted when the Controlled Drug Receipt/Record/Disposition Form showed a mismatch in the count of tablets that were supposed to be destroyed after the resident's discharge. The incident involved two registered nurses who administered the medication from the discharged resident's supply without proper authorization. The nurses cited the active resident's uncontrolled pain and the absence of her prescription as reasons for their actions. They did not follow the facility's protocol for obtaining a new order or accessing the emergency medication supply, which would have involved contacting an after-hours physician service and obtaining a code from the pharmacy. The facility's policies clearly state that narcotics should not be shared between residents and that any discrepancies in controlled drug counts must be reported immediately.
Failure to Follow Wound Care Orders and Notify Physician
Penalty
Summary
The facility failed to follow a physician's treatment order for a resident with a stage 3 pressure injury to the sacrum and did not inform the physician of a newly identified pressure injury wound. The resident's electronic medical record indicated a chronic stage 3 pressure injury to the sacrum, and a Braden Scale assessment showed a high risk for pressure injuries. The care plan included wound interventions such as treatment and wound care consultation as ordered. During an observation, the wound care nurse did not follow the prescribed treatment order, opting instead for an ABD dressing, which she believed provided more cushion than the ordered foam dressing. The nurse also failed to notify the wound physician of a new deep tissue injury on the resident's right buttock, which was identified during the survey. The wound physician expected to be informed of any skin alterations immediately and confirmed that the nurse had not notified him of the new wound. The wound physician emphasized the importance of following his treatment orders, which included using a foam dressing for better protection. The facility's job description for the wound care coordinator outlined the responsibility to ensure nursing procedures and protocols are followed, including administering wound treatments as ordered by the physician and updating the physician on any changes in wound assessments.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident by not using a gait belt, which is a critical safety measure for residents requiring assistance with ambulation. The resident in question, a female with a history of gait abnormalities, muscle weakness, and falls, was not provided with the necessary support during a transfer to the bathroom. Despite the resident's care plan indicating a risk for falls and the need for assistance with activities of daily living, the staff did not utilize a gait belt during the incident on November 17, 2024. The incident report and interviews with staff revealed that the resident had experienced multiple falls within a short period, including the fall on November 17, 2024, when a CNA attempted to assist the resident to the bathroom. The CNA admitted to not using a gait belt, which was confirmed by the Restorative Nurse and Therapy Director as a requirement for the resident. The facility's policy on gait belt use, dated September 2020, mandates the use of a gait belt for weight-bearing residents needing hands-on assistance, highlighting the oversight in this case.
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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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