Alden Terrace Of Mchenry Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Mchenry, Illinois.
- Location
- 803 Royal Drive, Mchenry, Illinois 60050
- CMS Provider Number
- 145453
- Inspections on file
- 32
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Alden Terrace Of Mchenry Rehab during CMS and state inspections, most recent first.
The facility failed to notify a resident’s state-appointed guardian of the resident’s death, despite the guardian being listed as the resident representative on the face sheet. Nursing notes documented the resident’s death with family and a hospice nurse present and the subsequent removal of the body, but there was no record that the guardian was contacted. An LPN and the DON both stated that facility practice requires notifying the physician, POA/emergency contacts, guardian, and hospice as applicable, and documenting the time of death and all notifications. The hospice director confirmed that a new hospice nurse at the bedside did not verify or notify additional contacts, and hospice records also lacked any documentation of guardian notification, contrary to the facility’s change-of-condition policy requiring notification of the responsible party.
A resident with dementia and a known history of verbal and physical aggression toward peers and staff approached another cognitively impaired resident who was seated in the memory care dining area. Witnesses reported that the seated resident tapped the aggressive resident on the shoulder and asked for space, leading to an argument during which the seated resident placed a hand on the other resident’s chest to push away. The aggressive resident then slapped the seated resident in the face, causing a minor nosebleed. The aggressive resident later claimed being stabbed, though witnesses denied seeing any stabbing or hitting by the seated resident. The administrator substantiated that this incident met the facility’s definition of physical abuse under its abuse policy.
A resident with multiple sclerosis and left-sided weakness, who required two staff for mechanical lift transfers, was transferred by only one agency CNA. Despite being reminded of the need for two staff, the CNA proceeded alone, resulting in the resident and shower chair tipping over and falling to the floor. The incident was confirmed through interviews and record review, showing a failure to follow the care plan and ensure safe transfer procedures.
A resident diagnosed with pneumonia and started on antibiotics was not reported to have her designated representative, her daughter, notified of this change in condition, despite facility policy and updated contact information. Staff confirmed the representative should have been informed and that the contact details were current.
A resident with multiple medical conditions, who was cognitively intact and assessed as not at risk for elopement, left the facility without staff knowledge or supervision. Staff became aware of the departure after a door alarm and a report from another resident, but did not notify police as required by facility policy. Instead, staff and the administrator searched for the resident and contacted his family, with police only being notified several hours later by the family member. The resident was later found safe in another state.
A resident with a history of aggressive behavior did not receive their prescribed depakote upon re-admission to the facility after a hospital stay, leading to aggressive behavior towards a roommate. The facility failed to reconcile the medication discrepancy with the physician, resulting in the resident being sent to the hospital for a psychiatric evaluation.
The facility failed to provide coffee between meals as per resident preferences, affecting their social interactions. Several residents expressed concerns about the absence of coffee service, which was previously a part of their social routine. Despite activities staff being present, coffee was not available, and the issue was raised in resident council meetings without resolution.
The facility failed to provide nutritional supplements as ordered for residents experiencing significant weight loss. One resident did not receive fortified pudding despite a physician's order, while another resident, who had undergone a leg amputation, did not receive a mighty shake as required. Additionally, a resident with Alzheimer's disease lost weight without receiving the ordered mighty shake, and another resident did not receive fortified pudding as prescribed. The dietitian confirmed the importance of following dietary recommendations.
A facility failed to follow proper infection control protocols during incontinence care for four residents. CNAs did not change gloves or perform hand hygiene after handling soiled materials and before touching clean items. The Director of Nursing confirmed the requirement for glove changes and hand hygiene, as outlined in the facility's Infection Prevention and Control Manual.
Two residents experienced privacy breaches during personal care in the facility. One resident was exposed to a roommate during incontinence care due to a partially pulled privacy curtain. Another resident's room door was left open while her urinary drainage bag was emptied and her buttocks were cleaned, allowing visibility from the hallway. The facility's policy requires staff to ensure privacy by closing doors and pulling curtains.
The facility failed to protect residents from physical abuse in a locked memory care unit. A resident with dementia was involved in multiple incidents of aggressive behavior, including hitting another resident. The facility did not conduct abuse investigations or document these events in the residents' care plans or electronic medical records, leaving gaps in addressing the aggressive behaviors and risks for abuse.
The facility failed to follow its abuse policy by not investigating or documenting several physical altercations between residents. Despite incidents occurring over a four-month period, the administrator admitted to not having any abuse investigations, indicating a lapse in compliance with procedures meant to protect residents.
The facility failed to report and investigate allegations of physical abuse involving four residents. Incidents included physical altercations and hitting, but no abuse investigations or documentation were provided. A nurse was unsure if reports were made, while another claimed to have informed the Administrator and DON. The Administrator did not conduct investigations, as incidents were reported as behaviors, not abuse.
The facility failed to investigate allegations of physical abuse involving four residents. Despite incidents where a resident hit another and a physical altercation occurred between two residents, no abuse investigations or documentation were provided. The administrator stated that the incidents were reported as behaviors, not physical exchanges, and thus were not considered abuse allegations.
A facility failed to provide timely incontinence care to a resident with dementia and bladder incontinence. The resident's care plan required frequent checks, but it was observed that her incontinence brief was saturated and had not been changed for several hours, contrary to the facility's policy of providing care every two hours. The DON confirmed the policy, indicating a lapse in care.
The facility failed to follow care plans and physician orders for three residents. One resident continued to receive stool softeners despite having loose stools, another had a neglected nail condition, and a third was not weighed as required, missing several scheduled weigh-ins. These deficiencies indicate lapses in care and monitoring protocols.
A resident with a stage 4 pressure injury to the sacrum was observed with her heels flat on the mattress, despite care plan instructions to offload heels using protectors or pillows. The wound nurse confirmed the absence of an order for padded heel boots, and the resident's care plan highlighted her risk for further skin breakdown due to impaired cognition, decreased mobility, and incontinence.
A facility failed to monitor and implement interventions for a resident with a left hand contracture due to a stroke. The resident reported occasional use of a washcloth in her palm, but no splint or brace was provided. The Restorative LPN was unaware of any therapy recommendations, and the care plan lacked documentation or interventions for the contracture. An Occupational Therapy Discharge Summary had recommended a splint, but this was not followed through.
The facility failed to implement fall interventions for three residents at risk for falling. A resident with a history of falls was observed in a wheelchair without appropriate footwear and a fall mat not positioned correctly. Another resident's wheelchair lacked anti-tippers, leading to a fall incident. A third resident's call light was out of reach, increasing fall risk. These oversights indicate a failure to execute the facility's Fall Management Program effectively.
A facility failed to maintain a urinary drainage bag below a resident's bladder, violating catheter care protocols. The resident, with multiple diagnoses including neuromuscular dysfunction of the bladder, had a care plan requiring the drainage bag to be kept below bladder level. However, CNAs lifted the bag above the bladder while assisting the resident, contrary to the care plan. The DON confirmed the correct procedure.
A facility failed to implement appropriate interventions for a resident with an excoriated G-tube site. The site lacked a dressing and showed red excoriation, which was not previously documented or addressed. The wound nurse obtained treatment orders only after being informed of the issue, and the facility's policy to prevent irritation and excoriation was not effectively executed.
A resident with heart failure and other conditions missed doses of Sacubitril-Valsartan due to the facility's failure to order medications in a timely manner. The DON was unaware of the issue, and the physician noted that missing a single dose would not harm the resident.
A facility failed to administer medications on time for two residents, resulting in a medication error rate of 6.67%. An RN identified the delay and obtained permission from doctors to administer the medications late. One resident with psychosis received her 9:00 AM medications over an hour late, while another resident with respiratory issues expressed concerns about the timing of her inhaler. The facility's policy requires timely administration according to physician orders.
The facility failed to meet the dietary preferences of two residents. One resident, who can eat despite having a tube feeding, was not consistently provided with preferred items like soup and apple juice, despite these being documented preferences. Another resident, on a weight loss plan requiring double portions of scrambled eggs and milk, frequently received incorrect meals. These deficiencies highlight issues in the facility's dietary service processes.
The facility failed to provide a clean, sanitary, and odor-free environment for multiple residents. Observations revealed stained bed sheets and strong odors in residents' rooms over several days. Staff interviews indicated inconsistencies in linen-changing practices, and the facility lacked a formal policy for linen changes.
The facility failed to ensure a safe environment and adequate supervision for several residents, leading to multiple deficiencies. One resident with severe cognitive impairment was observed tipping his wheelchair backwards without staff intervention. Another resident was improperly transferred without the required equipment. Additionally, two residents lacked proper smoking assessments, despite their significant health issues.
The facility failed to ensure a resident's request for Advance Directives regarding CPR was accurately documented, resulting in conflicting 'full code' and 'Do Not Resuscitate' (DNR) statuses in the medical record. Staff members confirmed the discrepancy, highlighting the importance of accurate documentation to honor the resident's wishes in an emergency.
The facility failed to provide adequate bathing assistance for a resident with severe cognitive impairment and left another resident unattended in her wheelchair for over an hour, resulting in significant discomfort and frustration. Staff acknowledged the deficiencies and the need for better adherence to care protocols.
The facility failed to complete dressing changes for a resident with non-pressure wounds and did not implement preventative measures for another resident with non-pressure wounds. One resident's dressing changes were not completed as ordered, and another resident's heels were not offloaded despite having a history of pressure injuries and diabetic ulcers. The facility's staff confirmed the lack of adherence to care plans and policies.
A resident with Alzheimer's and other conditions was observed without pressure-relieving devices on her feet, contrary to her care plan. Both the LPN and DON confirmed the need for offloading to prevent further pressure injury, but staff failed to adhere to this requirement.
The facility failed to ensure proper urinary catheter care for two residents, leading to potential infection risks. One resident experienced repeated instances of urine backing up into the catheter tubing, while another had her catheter drainage bag mishandled during a transfer, violating infection control protocols.
A resident with severe cognitive impairment and a history of aggression was not appropriately managed during an episode of agitation. Despite staff presence, no intervention was made to address the resident's behavior, which included yelling and throwing objects. Interviews with staff confirmed that the facility's behavior management protocols were not followed.
A resident did not receive a scheduled losartan potassium tablet, and a docusate sodium capsule was not documented as given, resulting in an 8% medication error rate. The RN acknowledged the errors, and the Director of Nurses confirmed that medications should be documented immediately and administered within a one-hour window.
The facility failed to label and store medications properly for two of four medication carts reviewed. Unlabeled pills and prepackaged medications without resident information were found, posing risks of incorrect dosing and administration mistakes. The DON emphasized the importance of proper labeling and daily review of medication carts.
The facility failed to provide proper incontinent care and infection control for two residents. One resident's groin area was not cleaned thoroughly, and her hands were not washed after contamination. Another resident with a catheter did not receive care in accordance with enhanced barrier precautions, as staff did not wear the required gowns. The facility's policies on perineal care, hand hygiene, and enhanced barrier precautions were not followed.
Failure to Notify Resident’s Guardian of Death
Penalty
Summary
The facility failed to notify a resident’s state-appointed guardian of a significant change in status, specifically the resident’s death, for one of four residents reviewed. The resident’s face sheet identified a state guardian as the resident representative. Nursing documentation showed that the resident expired during the night with family and a hospice nurse present at the bedside, and that the body was later picked up by a funeral home. However, there was no documentation in the resident’s progress notes that the guardian was notified of the death, nor any additional entries regarding the death beyond the initial note. Interviews with facility staff and hospice personnel confirmed that the guardian was not notified. An LPN stated that when a resident dies, the nurse is responsible for notifying the physician, the resident’s POA, emergency contacts, and guardian if applicable, and for documenting the time of death and who was notified in the progress notes. The DON similarly stated that upon a resident’s death, nursing must notify hospice if applicable, emergency contacts/POA or guardian, and the physician, and document these notifications. The hospice director reported that a hospice nurse was present at the time of death but was new, lacked access to the electronic medical record, and did not think to ask about additional emergency contacts or a guardian; there was no hospice documentation that the guardian was notified. The facility’s Change of Condition policy requires notification of the responsible party for changes in condition, but this did not occur for the resident’s guardian in this case.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident slapped another in the face following a verbal altercation. Both residents involved had dementia; the aggressor was care planned as mildly cognitively impaired with a documented history of verbal and physical aggression toward peers and staff, including striking another resident with a television remote and pushing a CNA on prior occasions. On the date of the incident, the aggressor approached the other resident, who was seated at a table in the memory care unit dining room. Witnesses reported that the seated resident tapped the aggressor on the shoulder and asked the aggressor to move away, which led to an argument. According to a CNA and an Activity Aide who witnessed the event, the seated resident then placed her hand on the aggressor’s chest in an attempt to push the aggressor away, at which point the aggressor slapped the seated resident in the face. The impact caused a minor bloody nose for the seated resident. The aggressor later stated that the other resident had “stabbed” his arm, but was unable to identify with what, and both witnesses stated they did not see the seated resident stab or hit the aggressor at any time. The seated resident, who was severely cognitively impaired, had no recollection of the incident when interviewed. The facility’s abuse policy affirms residents’ rights to be free from abuse, including physical abuse such as hitting and slapping, and the administrator substantiated that the aggressor physically abused the other resident.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis and left-sided weakness, who was assessed as requiring two staff members and a mechanical lift for safe transfers, was transferred by only one agency CNA using the mechanical lift. Despite the resident reminding the CNA that two staff were needed, the CNA proceeded alone. During the transfer to the shower chair, the chair moved and tipped over, causing both the resident and the chair to fall to the floor. The resident reported that the mechanical lift sling broke the fall, preventing injury. Facility records and staff interviews confirmed that the resident consistently reported being transferred by one staff member, contrary to the care plan which required two staff for safety. The incident was reported to the nursing staff the following morning, and the assistant administrator confirmed that the agency CNA involved was placed on do not return status. The facility's failure to follow the resident's care plan and provide adequate supervision during the transfer resulted in an accident hazard and an actual fall.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition. Specifically, a resident who was diagnosed with pneumonia and prescribed antibiotics did not have her designated representative, her daughter, informed of this change. The resident's electronic face sheet clearly listed her daughter as the resident representative, emergency contact, care conference person, and customer care representative, with updated contact information. Both the Director of Nursing (DON) and a Registered Nurse confirmed that the daughter was the appropriate person to notify for any changes in the resident's condition, including new medication orders. Despite the facility's policy requiring notification of the responsible party in the event of a change in condition, there was no documentation in the medical record that the resident's daughter was informed about the pneumonia diagnosis or the initiation of antibiotic treatment. The resident herself expressed a desire for her daughter to be kept informed about her health status. Staff interviews confirmed that the notification should have occurred and that the contact information was current at the time of the incident.
Failure to Follow Missing Resident Policy After Unsupervised Departure
Penalty
Summary
The facility failed to follow its own policy for reporting and responding to a missing resident when a cognitively intact resident, with multiple medical diagnoses including COPD, malnutrition, anemia, alcohol dependence, mood disorder, and hypertension, left the facility without staff knowledge or supervision. The resident was allowed to go out on a community pass alone and was assessed as not at risk for elopement, but on the day of the incident, he left the facility at 4:45 AM with his belongings without notifying staff. The door alarm was triggered, and staff became aware of his absence only after another resident reported seeing him leave. Staff searched for the resident and notified the administrator, but did not contact the police as required by facility policy. Instead of immediately reporting the resident missing to law enforcement, staff and the administrator attempted to locate the resident by visiting his family member's home and other local places. The family member eventually encountered police and filed a missing person report several hours after the resident's departure. The resident was later found in another state, determined to be of sound mind, and not at risk to himself or others. The facility's documentation and interviews confirmed that the required steps of notifying police and filing a missing person report were not followed, despite the facility's written policy mandating these actions for any missing resident who did not sign out or notify staff.
Failure to Reconcile Medication Leads to Aggressive Behavior
Penalty
Summary
The facility failed to ensure that a discrepancy with a resident's psychotropic medication was reconciled with a physician upon re-admission after a hospitalization. This involved a resident with a history of depression, anxiety, traumatic brain injury, and suicidal behavior, who was previously prescribed depakote for aggressive behaviors. Upon re-admission to the facility after a hospital stay for hypertension, the resident did not receive depakote as previously prescribed, leading to aggressive behaviors towards another resident. The resident's medical records indicated that depakote was part of their medication regimen to manage anger and aggressive behaviors. However, after returning from the hospital, the medication was not administered from the date of re-admission until a week later. The resident expressed aggression towards a roommate, resulting in a threat and subsequent hospitalization for a psychiatric evaluation. The facility's physician noted that discrepancies in medication orders should be clarified with the hospital or prescribing physician, especially for critical medications like depakote.
Failure to Provide Coffee Between Meals
Penalty
Summary
The facility failed to honor the residents' preferences for having coffee available between meals, impacting their social interactions and self-determination. Four residents expressed concerns about the lack of coffee service between meals, which they previously enjoyed as a social activity in the dining room. The residents reported that the kitchen stopped providing coffee until just before meal times, disrupting their routine of gathering early to socialize over coffee. One resident even attempted to address this by using a personal coffee maker in their room, but it was removed by the facility due to safety concerns. The Activities Director confirmed that residents had raised this issue in resident council meetings, and it was communicated to the Administrator. Despite the presence of activities staff in the dining room during the times when coffee was previously served, coffee was not made available. The Administrator acknowledged the need for staff to monitor residents with hot liquids and mentioned plans to introduce a coffee social activity, but no such activity had been implemented at the time of the survey. The lack of coffee service between meals was noted in the resident council minutes, indicating ongoing dissatisfaction among the residents.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for residents with significant weight loss and did not ensure weekly weights were obtained for a newly admitted resident. This deficiency affected four residents who were reviewed for nutrition. For instance, one resident, who was admitted on a specific date, experienced a weight loss from 100 pounds to 95 pounds over a month. Despite a physician's order for fortified pudding twice a day, the resident did not receive the pudding with meals on multiple occasions. The dietitian confirmed that the dietary department should follow the nutritional orders, but the resident's meal ticket did not reflect the order for fortified pudding. Another resident, who had undergone a right leg amputation, expressed concern about weight loss from 149 pounds to 128 pounds. Although a mighty shake was ordered as a nutritional supplement, it was not provided during meals as required. The dietitian had recommended the shake due to the resident's increased calorie needs for wound healing, but the dietary recommendations were not followed. A third resident, diagnosed with Alzheimer's disease and other conditions, lost 12.4 pounds in 27 days. Despite an order for a mighty shake twice a day, the resident did not receive it with meals. The dietitian emphasized the importance of receiving the supplements daily. Similarly, another resident with multiple diagnoses experienced a weight loss of 8.7 pounds over two months. Although fortified pudding was ordered twice a day, it was not provided during meals. The dietitian confirmed that the resident should receive all supplements with every meal as ordered.
Infection Control Deficiency in Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in changing gloves and performing hand hygiene, during the provision of incontinence care for four residents. Resident 60, diagnosed with heart failure and vascular dementia, was observed receiving incontinence care from a CNA who did not change gloves or perform hand hygiene after handling soiled materials and before touching clean items and the resident's environment. Similarly, Resident 85, with diagnoses including Parkinson's disease and respiratory failure, received peri care from CNAs who also failed to change gloves or perform hand hygiene after contact with soiled materials. Additionally, Resident 27, diagnosed with vascular dementia and malnutrition, and Resident 62, with sepsis and heart failure, were provided incontinence care by a CNA who did not change gloves or perform hand hygiene between handling soiled and clean items. The Director of Nursing confirmed that gloves should be changed and hand hygiene performed when switching from dirty to clean tasks. The facility's Infection Prevention and Control Manual mandates changing gloves and performing hand hygiene after contact with body fluids and before touching non-contaminated items.
Privacy Breach During Personal Care
Penalty
Summary
The facility failed to ensure privacy during personal care for two residents, R60 and R85, as observed by surveyors. R60, who was admitted with diagnoses including heart failure and vascular dementia, was receiving incontinence care from a CNA while the privacy curtain was only half pulled, exposing her private areas to a roommate who was facing her bed. This lack of privacy was noted during an observation on March 24, 2025, and was a concern expressed by R60's daughter, who hoped that her mother's personal care was being conducted privately. Similarly, R85, who has multiple diagnoses including Parkinson's disease and respiratory failure, experienced a breach of privacy when her urinary drainage bag was being emptied and her buttocks were being cleaned. During this process, the door to her room was left open, allowing visibility from the hallway. The Assistant Director of Nursing entered the room to assess an open area on R85's buttocks while the door remained open, further compromising her privacy. The Director of Nursing later confirmed that staff should ensure privacy by closing doors and pulling curtains during personal care, as per the facility's Resident Rights Policy.
Failure to Protect Residents from Physical Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving residents in a locked memory care unit. Resident R32, diagnosed with dementia, delirium, mood disorder, and unspecified psychosis, was involved in several incidents where she exhibited aggressive behavior. On January 19, 2025, R32 was observed hitting another resident, R92, in an attempt to take his coffee. Despite this incident, the facility did not conduct an abuse investigation or document the event in R92's electronic medical record. Additionally, R32's care plan indicated a history of aggressive behaviors, yet there was no documentation of interventions to address these behaviors. Further incidents involved R32 hitting another resident on December 22, 2024, and R105 being involved in a physical altercation with R80 on January 19, 2025. R105, who has Alzheimer's disease, dementia, mood disorder, and anxiety disorder, was noted to be a 'grabber,' yet her care plan did not reflect any aggressive behaviors or risk for abuse. Similarly, R80, diagnosed with bipolar disorder, major depressive disorder, dementia, alcohol dependence, and unspecified psychosis, was involved in the altercation with R105. The facility failed to document these incidents properly or conduct investigations, leaving gaps in the residents' care plans and electronic medical records.
Failure to Investigate and Document Abuse Incidents
Penalty
Summary
The facility failed to adhere to its own abuse policy, resulting in a deficiency related to the handling of abuse incidents among residents. Specifically, the facility did not conduct abuse investigations or provide documentation for several incidents involving physical altercations between residents. On December 22, 2025, a resident hit another resident, and on January 16, 2025, a different resident was involved in a physical altercation with another. Additionally, on January 19, 2025, the same resident from the December incident hit yet another resident. Despite these occurrences, the facility did not produce any abuse investigations, incident reports, or related documentation. The facility's abuse policy, dated September 2020, outlines the requirement for employees to immediately report any potential mistreatment to a supervisor or the administrator. It also mandates the appointment of an investigator to look into allegations and obtain relevant documentation. However, during an interview on March 26, 2025, the administrator admitted to not having any abuse investigations for the past four months, indicating a clear lapse in following the established policy. This failure to investigate and document abuse incidents highlights a significant deficiency in the facility's compliance with its own procedures designed to protect residents from abuse and neglect.
Failure to Report and Investigate Allegations of Physical Abuse
Penalty
Summary
The facility failed to ensure that staff identified and reported allegations of physical abuse to the administrator, affecting four residents. On December 22, 2025, a resident's progress notes indicated that they hit another resident. On January 16, 2025, another resident was involved in a physical altercation with a different resident. On January 19, 2025, the same resident from the December incident hit yet another resident. Despite these incidents, the facility did not provide any abuse investigation, incident report, or documentation. Interviews revealed that a Registered Nurse was unsure if the incidents were reported, while a Licensed Practical Nurse claimed to have reported them to both the Administrator and the Director of Nursing. The Administrator stated that no abuse investigations were conducted in the past four months, as the incidents were reported to him as behaviors rather than physical exchanges, and thus not considered abuse allegations.
Failure to Investigate Allegations of Physical Abuse
Penalty
Summary
The facility failed to investigate allegations of physical abuse involving four residents. On December 22, 2025, one resident hit another, and on January 16, 2025, a different resident had a physical altercation with another. Additionally, on January 19, 2025, the same resident from the first incident hit yet another resident. Despite these incidents, the facility did not provide any abuse investigations, incident reports, or documentation regarding these events. The administrator stated that no abuse investigations had been conducted in the past four months, as the incidents were reported to him as behaviors rather than physical exchanges, and thus he did not consider them as abuse allegations.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate ADL assistance to a resident, identified as R60, who is dependent on staff for care. R60 was admitted with diagnoses including heart failure, vascular dementia, and a history of falling. Her care plan, initiated in 2019, indicated a need for assistance with ADL tasks and frequent checks for incontinence due to dementia-related bladder incontinence. On March 24, 2025, it was observed that R60's incontinence brief was saturated with dark urine and contained stool, and the incontinence pad was wet. The CNA, V9, stated that the brief was last changed at about 6:30 AM, indicating a lapse in the facility's policy of providing incontinence care every two hours and as needed. The Director of Nursing confirmed the care policy, highlighting the deficiency in adhering to the established care protocols.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for three residents. One resident experienced loose stools for approximately nine days, despite having a physician's order to administer loperamide and hold stool softeners. The resident continued to receive stool softeners and laxatives until the morning of March 26, 2025, indicating a delay in implementing the physician's recommendations. Another resident had a right thumb nail that was extremely long and partially detached, posing a risk of snagging. Despite being under wound care, the wound care nurse was unaware of the condition until March 25, 2025, and the resident's care plan included interventions to inspect and trim nails frequently, which were not followed. Additionally, a third resident, admitted with multiple diagnoses including sepsis and heart failure, had an order for weekly weights to monitor potential weight gain. However, the resident was not weighed on several occasions as required by the facility's policy, missing four scheduled weigh-ins in March 2025. This failure to adhere to the weight monitoring protocol could have impacted the resident's health management, as there was no record of the resident refusing care. These deficiencies highlight lapses in following care plans and physician orders, potentially compromising resident care.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for a resident at risk for pressure injuries. The resident, identified as R108, was observed in bed with her heels flat on the mattress, contrary to the care plan and wound doctor's recommendations to offload heels using heel protectors or pillows. Despite having a stage 4 pressure injury to the sacrum, first identified on 1/10/24, and a care plan indicating the need to avoid direct pressure on bony prominences, the resident did not have an order for padded heel boots. The wound nurse confirmed the absence of such an order and stated that the facility follows the wound doctor's treatment and intervention orders. The resident's care plan also highlighted her risk for further skin breakdown due to impaired cognition, decreased mobility, and incontinence, yet the necessary interventions to offload pressure from her heels were not implemented during the observations.
Failure to Monitor and Implement Interventions for Resident's Contracture
Penalty
Summary
The facility failed to monitor and implement necessary interventions for a resident with a contracture. The resident, who had a contracture in her left hand due to a stroke, reported that a washcloth was sometimes placed in her palm, but only upon her request. A Certified Nursing Assistant was unaware of any splint or brace for the resident's hand. The Restorative Licensed Practical Nurse (LPN) mentioned that the resident was seen by therapy some time ago, but no recommendations were known. The LPN also stated that the restorative quarterly assessment only noted if there was a splint, without assessing the contracture itself. The Occupational Therapy Discharge Summary from June 2023 recommended ordering a splint for the resident's left hand, but this was not followed through. The resident's care plan included a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, affecting the left non-dominant side, and noted a self-care performance deficit related to a past stroke and left hand contracture. However, there was no documentation or interventions listed for the contracture, and the most recent quarterly Restorative Nursing assessment did not indicate the use of a splint or brace.
Failure to Implement Fall Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall interventions for residents at risk for falling, as observed in three cases. Resident R403, who has a history of falling and a diagnosis of a nondisplaced intertrochanteric fracture of the right femur, was observed self-propelling in a wheelchair wearing regular socks, which are not appropriate footwear for fall prevention. Despite having a fall mat under his bed, it was not positioned correctly to prevent injury if he attempted to get out of bed. The resident frequently tried to get out of bed on his own, and the staff was not aware of this behavior, which could have prompted additional interventions. Resident R105, who has a history of falls, was observed in a wheelchair without anti-tippers during meals and activities. An incident report from January 22, 2025, documented that R105 fell backward in her wheelchair and hit her head, indicating the absence of anti-tippers as a contributing factor. The care plan for R105 included the use of anti-tippers, but this intervention was not implemented, leading to a fall incident. Resident R27, diagnosed with vascular dementia and other conditions, was identified as at risk for falls. The care plan included ensuring the call light was within reach, but during observation, the call light was attached to a teddy bear on the floor, out of the resident's reach. This oversight in implementing the care plan intervention could have contributed to an increased risk of falls for R27. The facility's Fall Management Program emphasizes proactive measures to identify and assess residents at risk for falls, but these were not effectively executed for the residents in question.
Improper Positioning of Urinary Drainage Bag
Penalty
Summary
The facility failed to maintain a urinary drainage bag below the level of a resident's bladder, which is a deficiency in catheter care. The resident, identified as R85, was admitted with diagnoses including Parkinson's Disease, neuromuscular dysfunction of the bladder, bipolar disorder, anxiety disorder, urinary retention, and a history of falling. The care plan for R85, initiated in December 2023, required the use of an indwelling catheter with specific instructions to keep the collection bag below the bladder level. However, during an observation, two CNAs lifted the urinary drainage bag above the level of R85's bladder while preparing the resident to get out of bed using a mechanical lift. This action was repeated when placing the bag into the resident's pants, contrary to the care plan instructions. The DON confirmed that urinary drainage bags should be kept below the bladder level.
Failure to Implement Interventions for Excoriated G-tube Site
Penalty
Summary
The facility failed to implement appropriate interventions for a resident with an excoriated gastrostomy tube (G-tube) site. During an observation, a Certified Nursing Assistant (CNA) revealed that the resident's G-tube site lacked a dressing and exhibited noticeable red excoriation around the site. The CNA indicated that she would inform the nurse about the redness. The following day, the wound nurse confirmed the presence of red excoriation and obtained an order for zinc oxide and a drain sponge dressing. However, the wound nurse was not previously aware of any skin issues at the site. The resident's Treatment Administration Record indicated that the G-tube site was to be cleansed daily and as needed, with no documentation of skin breakdown noted the previous night. The resident's care plan required monitoring of the stoma site for size, color, and skin breakdown, but there was no documentation of the doctor or wound nurse being notified of the issue, nor were treatment orders implemented. The facility's policy on enteral feeding tube site care aimed to decrease potential irritation, excoriation, infection, or discomfort, but these measures were not effectively executed in this case.
Medication Ordering Deficiency
Penalty
Summary
The facility failed to ensure that medications were ordered in a timely manner, resulting in a resident missing doses of a critical heart medication. The resident, who has diagnoses including diabetes mellitus type two, systolic heart failure, hypertensive heart disease with heart failure, and cardiomyopathy, reported missing doses of Sacubitril-Valsartan, a medication prescribed for heart failure and heart disease. The resident's Medication Administration Records (MAR) for December 2024 and January 2025 indicated that the 9:00 PM doses on two separate occasions were not administered because the medication was unavailable. The Director of Nursing was unaware of the missed doses and stated that the process for ordering medications is through the electronic medical records system, which should ensure medications are ordered before they run out. The physician was notified of the missed doses at the time they occurred and acknowledged that while the resident should not have missed the dosage, missing a single dose would not cause harm. Despite the facility's process for medication ordering, the failure to maintain an adequate supply led to the resident missing critical medication doses.
Medication Administration Delays Result in High Error Rate
Penalty
Summary
The facility failed to ensure timely administration of medications for two residents, resulting in a medication error rate of 6.67 percent, which exceeds the acceptable threshold of 5 percent. On March 24, 2025, a registered nurse (RN) identified that medications for residents R30 and R97 were late, as indicated by a red background on the Electronic Medication Administration Record (EMAR). The RN subsequently contacted the residents' doctors and received permission to administer the medications late. R97, who has multiple diagnoses including psychosis, received her 9:00 AM medications at 10:07 AM, which included quetiapine, sertraline, and a multivitamin. Similarly, R30, with multiple respiratory and other chronic conditions, received her 9:00 AM medications at 10:15 AM, which included a range of medications such as aspirin, digoxin, and an inhaler. The delay in medication administration was further highlighted by R30's comments on March 25, 2025, expressing a desire to keep her inhaler at bedside to manage her respiratory condition effectively. R30 reported that medication passes had improved but noted that there were instances when 9:00 AM medications were administered as late as 2:00 PM. The facility's Medication Administration policy requires that drugs be administered according to the written orders of the attending physician, which was not adhered to in these instances, leading to the identified deficiency.
Failure to Meet Dietary Preferences for Two Residents
Penalty
Summary
The facility failed to accommodate the dietary preferences of two residents, leading to deficiencies in their care. One resident, who has a tube feeding but can eat, expressed dissatisfaction with being served pureed meals instead of the preferred items like soup and apple juice. Despite having specific dietary preferences documented, including apple juice, chicken broth, pudding, and ice cream, these items were not consistently provided. The resident reported having to repeatedly ask for apple juice and noted that the facility often failed to provide the requested items, leading to frustration and a sense of giving up on making requests. Another resident, who is on a weight loss plan and requires a double portion of scrambled eggs and milk to maintain muscle mass, frequently did not receive the correct meal portions. The resident reported receiving incorrect meals, such as French toast instead of the preferred scrambled eggs, and noted that the kitchen staff often made errors in fulfilling meal requests. The registered dietitian confirmed the importance of the double portion of eggs and milk for the resident's dietary needs, yet these preferences were not consistently met, indicating a failure in the facility's dietary service processes.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a clean, sanitary, and odor-free environment for multiple residents. Observations revealed that residents' fitted bed sheets and pillowcases were stained with yellow and brown marks, and rooms had strong urine and feces odors. Specifically, Resident R7's bed sheets had large yellow and brown stains over several days, and the room had a persistent urine odor. Resident R97's bed sheets also had large brown and yellow stains that remained unchanged over multiple days. Resident R99 was found with yellow stains on the bed sheets and urinals in the bed and on the garbage can, with additional brown stains appearing over time. Resident R120's bed sheets had yellow and brown stains, and the room had a strong odor that extended into the hallway. All four residents were not interviewable during the survey period. Staff interviews revealed inconsistencies in the facility's linen-changing practices. Certified Nursing Assistant V8 and Memory Unit Coordinator V5 stated that bedding is changed as needed and on shower days, even if a resident refuses a shower. However, during a tour with V5, it was acknowledged that the rooms had strong odors and that the stained sheets were unacceptable. The Director of Nursing, V2, confirmed that linens are changed when soiled and if a resident is perspiring heavily. The facility was unable to provide a policy regarding linen changes, indicating a lack of formal guidelines for maintaining a clean and sanitary environment for residents.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for several residents, leading to multiple deficiencies. One resident with severe cognitive impairment and a history of falls was observed tipping his wheelchair backwards on multiple occasions without staff intervention, despite being in the presence of multiple staff members. The resident's care plan indicated the need for close supervision to prevent falls, but this was not adhered to, resulting in a significant safety concern as acknowledged by the Director of Nursing and a Registered Nurse. Another deficiency involved the improper transfer of a resident who required the use of a sit-to-stand lift due to multiple medical conditions. The resident and her spouse reported that staff often did not use the required equipment, opting instead to manually lift her without a gait belt. This was confirmed during an observation where staff used a loose sling for the transfer, contrary to the care plan and facility policy. The Director of Nursing confirmed that not following the care plan for transfers posed a safety risk. Additionally, the facility failed to conduct proper smoking assessments for two residents. One resident, who had a left above-the-knee amputation and other significant health issues, was observed smoking without a documented smoking assessment in his electronic medical record. Another resident with chronic obstructive pulmonary disease and other serious conditions also lacked a smoking assessment. Staff confirmed that smoking assessments were necessary to determine residents' ability to smoke safely, but these assessments were not completed as required by the facility's smoking policy.
Failure to Accurately Document Resident's Advance Directives
Penalty
Summary
The facility failed to ensure a resident's request for Advance Directives regarding Cardiopulmonary Resuscitation (CPR) was accurately incorporated into the medical record. The resident's electronic medical record (eMAR) showed conflicting information, with both 'full code' and 'Do Not Resuscitate' (DNR) statuses documented. The resident's POLST (Practitioner Order for Life-Sustaining Treatment) indicated 'Do not attempt Resuscitation,' while the care plan documented the resident as a 'full code.' This discrepancy was confirmed during interviews with staff members, who acknowledged the importance of accurate code status documentation to honor the resident's wishes in an emergency situation. Staff members, including a Licensed Practical Nurse (LPN), the Memory Care Director/Social Services, and a Corporate Nurse Consultant, reviewed the resident's electronic record and identified the conflicting code statuses. The Memory Care Director/Social Services noted that any contradiction in code status would cause confusion during an emergency. The facility's Advance Directives policy requires that all advanced directive preferences be documented in the resident's care plan and updated regularly. However, the policy was not followed in this case, leading to the deficiency in accurately reflecting the resident's advance directive wishes in the medical record.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate bathing assistance for a resident diagnosed with severe cognitive impairment, dementia, and other medical conditions. The resident had not received a shower for 11 days, despite the facility's policy of providing showers twice a week. Observations revealed the resident had a strong urine and body odor, red and inflamed groin, and was unshaved. Staff interviews confirmed the resident's need for regular bathing assistance and the failure to provide it, even though the resident did not refuse care during the observed period. Another resident, who required two-person assistance for transfers and had recently undergone surgery, was left unattended in her wheelchair for over an hour after requesting to be transferred to bed. The resident's meal tray was left out of reach, and she was unable to eat without assistance. Despite multiple staff members passing by her room, the resident did not receive the necessary help until much later. Staff interviews corroborated the resident's need for assistance and the excessive delay in providing it. Both incidents highlight the facility's failure to adhere to care plans and policies designed to ensure residents' well-being. The lack of timely assistance with activities of daily living, such as bathing and meal setup, resulted in significant discomfort and frustration for the residents involved. Staff acknowledged the deficiencies and the need for better adherence to care protocols to prevent such occurrences in the future.
Failure to Complete Dressing Changes and Implement Preventative Measures
Penalty
Summary
The facility failed to complete dressing changes for a resident with non-pressure wounds and did not have preventative measures in place for another resident with non-pressure wounds. One resident, who had a left above-the-knee amputation and multiple diagnoses including PVD, diabetes, and chronic kidney disease, was observed with a gauze dressing extending from his shoe. The dressing changes for his right foot were not completed on several dates as per the physician's orders, and there were no progress notes documenting the dressing changes or refusals of care on those dates. The resident's wounds had 100% necrotic tissue, and the treatment plan was not followed as ordered, which was confirmed by the facility's staff during interviews. The facility's policy required the implementation of preventative measures and appropriate treatment modalities for skin alterations, which was not adhered to in this case. Another resident was observed with her heels resting on the mattress without offloading, despite having offloading boots available in her room. The resident had a history of pressure injuries and diabetic ulcers and was noted to have an open wound with drainage on her right heel. The care plan for this resident included elevating her heels off the bed and inspecting her skin daily, which was not followed. The Director of Nursing confirmed that heels should be offloaded at all times and that staff should offer alternatives if the resident does not want to wear offloading boots. The facility's policy also required the implementation of preventative measures and appropriate treatment modalities for skin alterations, which was not followed in this case. The facility's failure to adhere to physician orders for dressing changes and to implement preventative measures for skin alterations resulted in deficiencies in the care provided to these residents. The lack of documentation and adherence to care plans and policies contributed to the inadequate treatment and care of the residents' wounds, as observed and confirmed by the facility's staff during the survey.
Failure to Offload Heels for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure a resident's heels were offloaded, leading to a deficiency in pressure ulcer care. The resident, who had diagnoses including Alzheimer's disease, aphasia, anxiety disorder, and psychotic disorder with hallucinations, was observed sitting in a geriatric hospice chair without any pressure-relieving devices on her feet. Both of her heels were touching the footrest, contrary to her care plan which required offloading to prevent pressure ulcers. The resident's husband confirmed that the pressure-relieving boots were not on her when he arrived and had to request staff to put them on. The Licensed Practical Nurse/Corporate Wound Consultant and the Director of Nursing both acknowledged that the resident's heels should have been offloaded to optimize blood flow and prevent further pressure injury. The resident's care plan, initiated on 4/8/2021, indicated a history of pressure injuries to her right heel, left heel, and sacral area. The current wound on her right heel was identified as a deep tissue injury with specific measurements. The facility's wound doctor had also noted the need for offloading as a preventative measure. Despite these documented requirements, the facility staff failed to adhere to the care plan, resulting in the resident's heels being in direct contact with the footrest, thereby compromising her pressure ulcer care.
Improper Urinary Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure proper urinary catheter care for two residents, leading to potential infection risks. One resident, diagnosed with stage 3 chronic kidney disease and other urinary conditions, experienced repeated instances where his catheter bag was not emptied in a timely manner. On multiple occasions, the catheter bag was observed to be full, causing urine to back up into the tubing. The resident reported feeling bladder pressure and had to use the call light to get assistance. Staff interviews confirmed that the catheter bag should be emptied before urine backs up to prevent infections, but this protocol was not consistently followed, as evidenced by the resident's care plan and staff statements. Another resident with multiple medical conditions, including neuromuscular dysfunction of the bladder, had her catheter drainage bag mishandled during a transfer. The catheter bag was placed on the floor and later on the bed, both of which are against infection control protocols. The staff involved acknowledged that the drainage bag should not be on the floor and must be kept below the bladder level to prevent urine reflux and potential infections. The resident's care plan lacked specific interventions for catheter care, despite her recent treatment for a urinary tract infection.
Failure to Intervene for Resident with Dementia
Penalty
Summary
The facility failed to intervene appropriately for a resident diagnosed with dementia who was experiencing aggressive behaviors. The resident, who has severe cognitive impairment and a history of physical aggression, was observed yelling at other residents, banging on a table, and throwing a plastic coffee mug. Despite several staff members being present in the dining area, no intervention was made to address the resident's behavior or to remove him from the situation. The resident's care plan indicated the need for behavior tracking and removal from potentially aggressive situations, but these measures were not followed during the incident. Interviews with staff, including a Registered Nurse and the Director of Nursing, revealed that the appropriate protocol for handling such behaviors was not implemented. The staff acknowledged that the resident's behaviors were not managed correctly and that the situation could have escalated to physical harm. The facility's policy on behavior symptom tracking and management emphasizes the importance of maintaining safety and intervening as necessary, but this was not adhered to in this case.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered, resulting in an 8% medication error rate. Specifically, a registered nurse (RN) administered a docusate sodium capsule but did not document it in the medication administration report (MAR). Additionally, the RN failed to administer a losartan potassium tablet at the scheduled time. This deficiency was observed during a medication pass for one resident diagnosed with heart failure, diabetes mellitus, irritable bowel syndrome, diverticulosis, and hypertension. The RN acknowledged the errors, stating that the docusate should have been documented immediately and was unsure how the losartan was missed. The Director of Nurses confirmed that medications should be documented immediately after administration and given within a one-hour window of the scheduled time to ensure effectiveness. The facility's Medication Administration policy supports these practices, stating that each dose should be recorded immediately following administration and that medications should be administered within one hour of the prescribed time. The failure to adhere to these procedures led to the observed deficiencies.
Failure to Label and Store Medications Properly
Penalty
Summary
The facility failed to label and store medications according to their policy for two of four medication carts reviewed. During an observation on the 100-hall medication cart, three medication cups filled with unlabeled pills were found. The RN present could not identify the pills or their intended recipients, acknowledging the potential for administration mistakes. Similarly, the memory unit medication cart contained prepackaged medications without any resident names or information, posing a risk of incorrect dosing or missed medications. The LPN present confirmed that the packets should be in individual resident's dispenser boxes and not loose in the drawer. The Director of Nurses stated that nurses should not dispense medications prior to the scheduled time and should destroy any medication that cannot be given immediately. The Director emphasized that unlabeled medications could be given to the wrong person and that medication carts should be reviewed daily. The facility's policy mandates that each resident's medications be stored in original containers and properly labeled, which was not adhered to in these instances.
Inadequate Incontinent Care and Infection Control
Penalty
Summary
The facility failed to provide proper incontinent care and infection control for two residents. For one resident with Alzheimer's disease and incontinence, staff did not follow proper procedures during incontinence care. The resident's groin area was not cleaned thoroughly, and her hands, which were contaminated during the process, were not washed. Additionally, no barrier cream was applied to her skin. The Director of Nursing and other staff acknowledged that the care provided was inadequate and did not meet the facility's policies for perineal care and hand hygiene. Another resident, who had a catheter and was on enhanced barrier precautions (EBP), did not receive care in accordance with the facility's infection control policies. Staff members providing care did not wear the required gowns, and there was no isolation bin or PPE supply visible near the resident's door. The staff admitted to not wearing gowns due to the lack of available PPE, despite the facility having an overflowing supply. The Corporate Nurse Consultant confirmed that the staff should have been wearing gowns and gloves during high-contact activities such as transfers, incontinence care, and catheter care. The facility's policies on perineal care, hand hygiene, and enhanced barrier precautions were not followed, leading to deficiencies in infection control. The staff's failure to adhere to these policies put the residents at risk of infection and skin breakdown. The facility's infection preventionist and other staff members acknowledged the importance of thorough cleaning and proper use of PPE to prevent the spread of infectious organisms and protect residents with indwelling medical devices or chronic wounds.
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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