Alden Poplar Creek Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hoffman Estates, Illinois.
- Location
- 1545 Barrington Road, Hoffman Estates, Illinois 60169
- CMS Provider Number
- 145403
- Inspections on file
- 29
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Alden Poplar Creek Rehab & Hcc during CMS and state inspections, most recent first.
A resident with dementia and a left elbow fracture experienced delayed diagnostic evaluation and incomplete care planning. After returning from a pass with family, the resident later complained of left elbow pain with limited movement and swelling; an RN notified an NP, who ordered an X‑ray, but the test was not completed until the following evening and the nurse did not follow up on the delay. When the X‑ray showed a fracture, the NP ordered transfer to the ER, but ambulance transport was delayed and the RN did not inform the NP; the resident was ultimately taken to the hospital by family. Following cast application and later ORIF surgery, hospital discharge instructions for cast care, limb elevation, ice application, dressing management, and parameters for contacting emergency services or the MD were not transcribed into active physician orders or incorporated into the comprehensive care plan, and ADL limitations related to the cast were not added to the resident’s care plan.
A resident with severe cognitive impairment and a history of wandering was able to leave a secured memory care unit unsupervised by exiting with a visitor who had elevator access. Staff did not notice the resident's absence until later, and there was no alarm to alert staff of the exit. The resident was found nearly a mile away, having crossed a busy intersection without her walker, and was taken to the hospital for evaluation. Family members raised concerns about delayed notification to law enforcement and lack of monitoring devices.
A facility failed to honor a hospice resident's healthcare POA decision to make the resident NPO due to her inability to swallow. Despite initial agreement from the hospice provider and ADON, the facility discontinued the NPO order without consulting the hospice care plan or the POA form, citing ethical concerns. The resident's end-of-life wishes were not respected, leading to a deficiency in resident rights.
A facility failed to ensure effective communication and coordination between staff, a hospice resident's POA, and the hospice provider. The resident, who was severely cognitively impaired, experienced a decline in condition, leading to a request for NPO status. However, inconsistent messages from staff and lack of access to hospice care plans resulted in confusion about the resident's care. The facility did not have a designated liaison for hospice communication, contributing to the deficiency.
A facility failed to ensure a POLST form was signed by a physician for a resident who wished to change their advance directive to DNR. The resident and their family member signed the form, but the facility did not follow up to obtain the necessary physician's signature, leaving the form invalid. The Director of Social Services confirmed the process but was unaware of the resident's status, and no documentation of follow-up was provided.
The facility failed to report and investigate allegations of sexual abuse involving two residents. A resident reported inappropriate touching by another resident to a social worker, who no longer works at the facility. The administrator was unaware of the allegation, and no investigation was conducted, violating the facility's abuse policy.
The facility failed to report allegations of sexual abuse to the Administrator immediately. A resident reported inappropriate touching by another resident to a social worker who did not inform the Administrator. The alleged perpetrator has a care plan noting socially inappropriate behaviors, but there is no documentation of the incident in the medical records.
The facility failed to investigate an allegation of sexual abuse involving two residents. A resident reported inappropriate touching by another resident to a social worker, who did not report it to the administrator. As a result, no investigation was conducted. The resident is cognitively intact, while the alleged perpetrator has a mild cognitive impairment and a history of inappropriate behaviors. There is no documentation of the incident in the medical records, and the facility did not provide any investigation.
The facility failed to properly store Schedule II controlled substances for two residents. Both had orders for Hydromorphone, which was found in an unlocked refrigerator in the medication room. The DON confirmed that such medications should be stored in a double-locked system, as per facility policy.
A facility failed to ensure staff wore PPE when providing care to a resident on enhanced barrier precautions (EBP) due to a feeding tube. Two CNAs provided incontinence care and changed the resident's bedding without wearing gowns, despite the care plan and a sign on the door indicating the need for EBP. The facility's policy requires gown and gloves for high-contact care activities for residents with indwelling medical devices. The infection preventionist confirmed the requirement for PPE use in such cases.
The facility failed to administer an influenza vaccine to a resident after admission, despite having a signed consent form, due to a lack of proper documentation of the refusal by the resident's legal representative. Additionally, another resident was not offered a second pneumonia vaccine as required by facility policy, due to previous vaccinations and a lack of follow-up for consent. These deficiencies highlight lapses in adherence to vaccination policies.
A resident reported being touched inappropriately by a CNA and informed staff, but the facility did not report the incident to the police, contrary to its abuse policy. The resident, who is cognitively intact, expressed feeling nervous around the CNA. The facility's administrator and DON confirmed the lack of police notification, citing the resident's sister's wishes.
A facility failed to release a resident's trust funds in a timely manner after discharge. The resident was discharged, and their remaining balance was to be sent in two checks. The first check was not cashed, and the issue was not addressed until months later, resulting in a significant delay in the resident receiving their funds. The facility's policy requires funds to be returned within 30 days, but this was not adhered to, leading to a prolonged resolution process.
A resident with heart failure was shocked by a Defibrillator Vest, but the facility failed to notify the physician. The CNA found blue gel on the resident, indicating a treatment was delivered. The LPN assessed the resident but did not contact the physician or DV company, contrary to the facility's change of condition policy.
A resident with heart failure was admitted to a facility wearing a defibrillator vest (DV), which was not communicated in the admission summary. The staff were untrained and unaware of the DV, leading to a delay in recognizing its need for service. The DV delivered a shock unnoticed until technical support was contacted. The first training on the DV occurred six days after admission, highlighting a deficiency in care management.
A facility failed to monitor a resident's Defibrillator Vest (DV) after it delivered a shock and did not set up the DV's cellular hotspot for remote monitoring. The resident, with heart failure and mitral insufficiency, experienced a shock from the DV, but there was no immediate follow-up or documentation of vital signs for six hours. The DV company was not receiving data due to the lack of a hotspot setup, which was only rectified days later.
A staff member stored their bag in a resident's closet, violating the resident's right to personal space. The resident's daughter discovered the bag and later realized it belonged to a staff member. The facility's administrator and a registered nurse confirmed that staff should not store personal items in resident rooms.
A resident fell and sustained injuries when a CNA failed to safely transport him in a wheelchair over a door threshold. The incident occurred around midnight, and the CNA, who was on her first night at the facility, was not aware of the threshold bump. The resident's spouse confirmed that the CNA should have known to go over the threshold backward to prevent the fall.
Delay in Post-Fall Evaluation and Failure to Update Care Plan for Cast and ADL Needs
Penalty
Summary
The deficiency involves a failure to provide timely treatment and care following an unwitnessed fall and to update the comprehensive care plan for cast management and ADL limitations. A resident returned from an out‑of‑facility pass with family and was observed in the dining room without complaints of pain that afternoon. Later that evening, a CNA reported the resident complained of left elbow pain with limited movement and slight swelling during evening care. The RN on duty assessed the resident, noted confusion and inconsistent accounts of a fall, and contacted the NP, who ordered an X‑ray of the left elbow along with laboratory tests. The X‑ray was not performed until the following evening, more than 24 hours after the reported onset of pain, and the RN who received the order did not follow up on the delay, stating that X‑ray services usually arrived after her shift. When the X‑ray was finally completed, it showed a fracture of the left elbow, and the NP ordered the resident sent to the hospital ER for further evaluation. The RN notified the family member and arranged ambulance transport but was informed there would be a two‑hour delay because it was considered non‑emergent. The RN did not notify the NP of this delay. The family member then chose to transport the resident to the hospital by private car around 10:00 PM. The DON later stated he was not aware that the family, rather than an ambulance, transported the resident. The NP stated it was expected that the resident should be transported immediately to the hospital for evaluation once the fracture was identified, given that the report of fall and pain had already been present for over 24 hours. The facility also failed to carry over hospital discharge instructions and revise the resident’s comprehensive care plan for cast management and ADL limitations after the fracture and subsequent ORIF surgery. Hospital discharge instructions after cast application included elevation of the arm, use of ice packs, keeping the cast dry, and pain management parameters, and post‑surgical instructions included limb elevation on a pillow, maintaining dressings, parameters for calling 911 or the MD, and scheduled ice application. These instructions were not transcribed into the active physician orders or incorporated into the comprehensive care plan. The restorative nurse stated she only updated the fall care plan and believed floor nurses were responsible for ADL and cast management updates, while the care plan coordinator stated the care plan should be updated with changes in condition or treatment. The resident’s comprehensive care plan and active orders did not reflect the cast management needs or ADL limitations related to the left arm cast, despite the resident having dementia, a history of fracture, and ongoing functional limitations.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, a history of wandering, and multiple diagnoses including vascular dementia, ataxia, and a history of falls, was not adequately supervised and was able to elope from a secured memory care unit. The resident's care plan identified her as being at risk for elopement and requiring frequent checks, supervision, and staff or family escort when off the secured unit. Despite these interventions, the resident was able to leave the dining room unaccompanied after dinner, and staff did not notice her absence until later. The resident exited the secured unit by getting on the elevator with another resident's family, who had the access code. There was no alarm system in place to alert staff when a resident was attempting to exit the secured unit. The receptionist observed the resident leaving the building with what appeared to be family members but did not recognize her as a resident or consult the elopement binder, which contained photos and names of at-risk residents. Staff interviews revealed that the resident was not on the wandering list, and there was a lack of communication and supervision during the transition from the dining room to her room. The resident was found approximately 0.8 miles away from the facility, outside a local grocery store, having crossed a busy intersection without her walker. She was subsequently taken to the hospital for evaluation. Family members expressed concern that the facility did not notify law enforcement promptly and that there was no monitoring device to alert staff when a resident was leaving the building. The facility's policy required immediate notification and search procedures for missing residents, but these were not followed in a timely manner.
Failure to Honor Resident's POA Decisions
Penalty
Summary
The facility failed to honor the decisions of a hospice resident's healthcare Power of Attorney (POA), leading to a deficiency in the resident's rights. The resident, who was under hospice care due to severe cognitive impairment and other medical conditions, had a care plan that required coordination between facility caregivers and the hospice company to ensure all needs were met. The resident's POA, a family member, had requested that the resident be made NPO (nothing by mouth) due to the resident's inability to swallow and declining condition. This request was initially agreed upon by the hospice provider and the Assistant Director of Nursing (ADON), and an order was placed by the hospice physician to make the resident NPO. However, the facility later discontinued the NPO order without consulting the hospice care plan, progress notes, or the resident's healthcare POA form. The ADON stated that the order was discontinued because it was considered unethical to not feed the resident if she wanted to eat, despite the resident's inability to swallow. The facility's administrator also did not review the relevant documents and attempted to justify the decision to the POA by suggesting that pleasure feeds were necessary. The hospice nurse confirmed that the facility, not the hospice, discontinued the NPO order, leading to a situation where the resident's end-of-life wishes, as expressed by the POA, were not honored by the facility.
Lack of Communication and Coordination in Hospice Care
Penalty
Summary
The facility failed to designate a staff member or implement a process to ensure effective communication and collaboration between the facility, a hospice resident's Power of Attorney for health care (POA), and the hospice provider. This deficiency was identified in the case of a resident who was under hospice care due to severe cognitive impairment and other medical conditions. The resident's care plan required coordination between facility caregivers and the hospice company to meet all resident needs, including obtaining and incorporating advanced care planning wishes into the plan of care. The resident's POA expressed concerns about inconsistent communication from the facility staff regarding the resident's care, particularly when the resident began having difficulty swallowing. Despite the POA's request for the resident to be NPO (nothing by mouth) due to the resident's declining condition, there was confusion and conflicting information provided by different staff members. The facility's Assistant Director of Nursing initially agreed with the NPO request, but later stated it could not be implemented due to unspecified regulations or corporate rules. This lack of clear communication and coordination led to uncertainty about the resident's care plan. Additionally, the facility did not have access to the resident's hospice plan of care or hospice progress notes, which were not included in the resident's electronic medical records or available in a binder at the facility. The Director of Nursing confirmed that the facility had to request this information from the hospice provider. The facility's policy required a coordinated plan of care between the facility, hospice agency, and resident/family, but this was not effectively implemented, contributing to the deficiency.
Failure to Ensure POLST Form Signed by Physician
Penalty
Summary
The facility failed to ensure that a signed Physician Orders for Life-Sustaining Treatment (POLST) form was followed up with and signed by the physician for one resident. The resident, identified as R96, had a current advance directive of Full Code and expressed a desire to change to Do Not Resuscitate (DNR) status. The resident's family member, who is also the healthcare surrogate, expressed interest in completing a POLST form, and both the resident and the family member signed the form. However, the facility did not ensure that the form was signed by the physician, which is necessary for the POLST to be valid. The Director of Social Services acknowledged that obtaining a resident's preferred Advanced Directive status is part of the admission process and that the POLST form is not valid until signed by the physician. Despite this, there was no documentation showing that the facility followed up with the resident's family member or physician between the time the form was signed and the resident's hospitalization. The facility also failed to provide documentation of any follow-up after the resident's readmission, indicating a lapse in ensuring the resident's wishes were properly documented and respected.
Failure to Report and Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy by not reporting and investigating allegations of sexual abuse involving two residents. Resident R56 reported that Resident R115 had touched her inappropriately while they were on the patio last summer. R56 informed the social worker, V14, who assured her that the matter would be addressed. However, V14 no longer works at the facility, and the allegation was not reported to the administrator, V1, who confirmed that no investigation had been conducted. The facility's abuse policy, dated September 2020, mandates the immediate reporting and investigation of any allegations of mistreatment. Employees are required to report any potential mistreatment to a supervisor or the administrator, who is then responsible for initiating an investigation. Despite these procedures, the facility did not follow through with the necessary steps to investigate the reported incident, resulting in a failure to comply with its own policy and protect the residents' rights to be free from abuse.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to ensure that staff reported allegations of sexual abuse to the Administrator immediately, affecting two residents. One resident reported being inappropriately touched by another resident last summer and informed a social worker who no longer works at the facility. The Administrator, who is the designated abuse coordinator, was not informed of this allegation by the social worker. The resident who allegedly committed the inappropriate behavior has a care plan indicating a history of socially inappropriate behaviors, including attempting to or actually touching females in the facility. There is no documentation of the incident in the electronic medical records of either resident involved.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving two residents. Resident R56 reported that during the previous summer, another resident, R115, touched her inappropriately on the patio. R56 informed the social worker, V14, who no longer works at the facility, but the incident was not reported to the administrator, V1, who is the abuse coordinator. Consequently, no investigation was conducted into the allegation. R56 is cognitively intact, while R115 has a mild cognitive impairment and a care plan indicating a history of socially inappropriate behaviors. There is no documentation of the incident in the electronic medical records of either resident, and the facility did not provide any abuse investigation regarding the allegation.
Improper Storage of Schedule II Controlled Substances
Penalty
Summary
The facility failed to ensure that Schedule II controlled substances were stored in a separately locked compartment for two residents, R54 and R92. Both residents had physician orders for Hydromorphone solution, a Schedule II controlled substance, to be administered as needed for pain or shortness of breath. On the morning of September 9, 2024, bottles of Hydromorphone belonging to both residents were found in a refrigerator located in the medication room on the second floor. Although the refrigerator had a lock, it was not secured at the time of observation. The Director of Nursing confirmed that Hydromorphone should be stored in a double-locked medication cart or a locked refrigerator, and acknowledged that the refrigerator should have been locked. The facility's policy, dated January 2022, mandates that Schedule II controlled medications be stored under a double-lock system accessible only to licensed staff.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that personal protective equipment (PPE) was worn by staff when providing care to a resident on enhanced barrier precautions (EBP). The deficiency was identified during an observation where two certified nursing assistants (CNAs) entered the room of a resident who was on EBP due to the use of a feeding tube and provided incontinence care and changed the resident's bedding without wearing gowns. The resident's care plan indicated the need for EBP during high-contact care activities, and a sign on the resident's door also indicated the requirement for EBP. The facility's policy on EBP, dated 12/14/24, specifies that gown and gloves should be used during high-contact care activities for residents with indwelling medical devices, such as a feeding tube. The infection preventionist confirmed that staff should wear PPE, including gloves and gowns, when providing care to residents on tube feeding.
Failure to Administer Influenza and Pneumonia Vaccines
Penalty
Summary
The facility failed to ensure that a resident received an influenza vaccine following admission. The resident, identified as R116, had an informed consent form for the influenza immunization vaccine for the 2023-2024 season, which was signed by the legal representative, the resident's son, on 10/25/23. However, the Infection Preventionist, V9, stated that the son later refused the vaccine, but this refusal was not properly documented in the resident's electronic medical record (EMR) beyond marking it as refused. Consequently, R116 did not receive the influenza vaccine in 2023, contrary to the facility's policy that requires documentation of consent or declination in the resident's medical records. Additionally, the facility failed to offer a second pneumonia vaccine to another resident, R90. The resident's informed consent form indicated that they had already received the PCV13 vaccine. The Infection Preventionist, V9, acknowledged the need to obtain consent for the other vaccine, but noted that the resident could not receive it for another five years due to previous vaccinations. The facility's policy on pneumococcal vaccination requires offering immunization in accordance with the Advisory Committee on Immunization Practices (ACIP) recommendations, which was not adhered to in this case.
Failure to Report Alleged Sexual Abuse to Police
Penalty
Summary
The facility failed to report allegations of sexual abuse to the police for one resident, despite the facility's policy requiring such action. A resident reported that a CNA touched her breast behind the curtains and informed a nurse and a social worker about the incident. However, the resident stated that no follow-up investigation or communication of a plan occurred. The resident, who is cognitively intact and her own decision maker, expressed feeling nervous when seeing the CNA in the facility. The facility's administrator and director of nursing confirmed that the police were not notified, citing the resident's sister's wishes as the reason. The facility's abuse policy mandates reporting reasonable suspicion of a crime to local police, but no police report was filed or documented in the investigation records.
Failure to Timely Release Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to release a resident's trust funds after discharge, as evidenced by the case of a resident who was discharged on March 10, 2024. Despite the facility's policy stating that any outstanding funds should be returned within 30 days, the resident's trust funds were not fully returned in a timely manner. The resident's remaining balance was supposed to be sent to another facility in two checks. The first check, dated April 15, 2024, for $5288.14, was not cashed, and the second check, dated April 18, 2024, for $1685.00, was cashed. However, the first check was not followed up on until August 12, 2024, when it was voided and reissued. The delay in addressing the uncashed check resulted in the resident not receiving the full amount of their trust funds 22 weeks after discharge. The facility's staff, including the Administrator, Business Office Manager, and Director of Financial Service, were involved in the process, but there was a lack of communication and follow-up regarding the uncashed check. The resident's son and the Business Office Manager at the new facility had been trying to resolve the issue since the resident's move, but the funds were not fully transferred as required by the facility's policy.
Failure to Notify Physician After Defibrillator Vest Shock
Penalty
Summary
The facility failed to notify a resident's care provider after the resident received a shock from a Defibrillator Vest (DV). The resident, an elderly man with acute on chronic heart failure and rheumatic mitral insufficiency, reported being shocked by the vest approximately a week prior to the survey. A Certified Nursing Assistant (CNA) discovered blue gel on the resident's neck and pillow, which was indicative of a treatment being delivered by the DV. The CNA informed a Licensed Practical Nurse (LPN), who assessed the resident but did not notify the physician or the DV company about the incident. The LPN acknowledged being informed about the blue gel and the DV's alert for a battery change but did not take further action to contact the resident's physician or the DV company. The facility's Director of Nursing confirmed that the LPN should have contacted the physician due to the possibility of a treatment being delivered. The cardiologist confirmed not receiving any notification about the incident. The facility's change of condition policy requires notifying the physician of all changes in condition, but the facility did not have a specific policy regarding the DV.
Failure to Identify and Manage Resident's Defibrillator Vest
Penalty
Summary
The facility failed to identify and properly manage a resident's defibrillator vest (DV) upon admission, leading to a deficiency in care. The resident, who was admitted with a history of acute on chronic heart failure and rheumatic mitral insufficiency, was wearing a DV that was not noted in the facility's admission summary. The central intake process at the corporate level did not communicate the presence of the DV to the facility, resulting in staff being unprepared and untrained to handle the device. The admissions director and nursing staff were unaware of the DV until the resident's admission, and no in-service training had been provided to the staff regarding the DV's setup, monitoring, and troubleshooting. The lack of communication and training led to several issues, including a delay in recognizing the DV's need for service and the absence of data transmission from the device. The facility staff, including LPNs and RNs, were not informed or trained on the DV, and the first in-service training occurred six days after the resident's admission. During this period, the DV delivered a shock to the resident, which went unnoticed until the company was contacted for technical support. The facility's failure to ensure staff were trained and informed about the DV contributed to the neglect of the resident's care needs.
Failure to Monitor and Set Up Remote Monitoring for Defibrillator Vest
Penalty
Summary
The facility failed to ensure ongoing monitoring and proper setup for remote monitoring of a resident's Defibrillator Vest (DV) after it delivered a shock. The resident, an elderly man with acute on chronic heart failure and rheumatic mitral insufficiency, was admitted to the facility wearing the DV. Despite the DV delivering a shock, which the resident described as feeling like being shot, there was no immediate follow-up or documentation of vital signs and assessments in the resident's Electronic Medical Record (EMR) for approximately six hours after the event. The Certified Nursing Assistant (CNA) reported the presence of blue gel on the resident's neck and pillow to the Licensed Practical Nurse (LPN), who took vitals but did not contact the physician or document the incident. Additionally, the facility did not have the DV's cellular hotspot set up for remote monitoring, resulting in a lack of data transmission to the DV company until several days after the resident's admission. This oversight was discovered when another LPN contacted the DV company due to an issue with the vest, and it was revealed that no data had been received since the resident's admission. The DV company representative had to visit the facility to set up the cellular device to ensure timely data transmission. The facility was unable to provide a policy regarding the DV at the time of the survey.
Staff Member Stored Personal Items in Resident's Closet
Penalty
Summary
The facility failed to respect a resident's personal space when a staff member stored their bag in the resident's closet. This incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 5 out of 15. The resident's daughter discovered the staff member's bag hidden under the resident's clothing during a visit. The daughter initially believed the bag belonged to a family member but later realized it was a staff member's bag after finding personal items inside. The staff member subsequently contacted the daughter to request the return of the bag. The facility's administrator confirmed that the staff member admitted to storing their bag in the resident's closet, which is against the facility's policy. A registered nurse on the resident's floor also stated that staff should not store personal items in resident rooms, as these spaces are considered the residents' personal areas. The Illinois Long-Term Care Ombudsman Program Residents' Rights document supports that residents have the right to be treated with respect and dignity, which includes maintaining their personal space free from staff belongings.
Failure to Safely Transport Resident in Wheelchair
Penalty
Summary
The facility failed to safely transport a resident in a wheelchair, resulting in the resident falling and sustaining injuries. The incident involved a resident who was cognitively intact and being discharged home. As a CNA was pushing the resident's wheelchair through the main entrance, the wheelchair encountered a small bump at the door threshold, causing the resident to slip out and fall forward onto his knees and face. The resident suffered a nosebleed and a cut on his lower lip and was subsequently sent to the local Emergency Department for evaluation. The CNA involved was an agency staff member on her first night at the facility and was not aware of the threshold bump, which contributed to the accident. The incident occurred around midnight, and it was dark outside, further complicating the situation. The Assistant Director of Nursing stated that the method of traversing a threshold with a resident in a wheelchair should be determined on a case-by-case basis, considering factors such as the resident's strength and positioning. The resident's spouse also witnessed the incident and confirmed that the CNA should have known to go over the threshold backward to prevent the fall. The facility's outermost door had an automatic sliding door with a metal threshold approximately three-quarters of an inch in height, which posed a challenge for wheelchair transport. The failure to properly navigate this threshold led to the resident's fall and subsequent injuries.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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