Aliya Of Crestwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Crestwood, Illinois.
- Location
- 13259 South Central Avenue, Crestwood, Illinois 60418
- CMS Provider Number
- 145681
- Inspections on file
- 46
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Aliya Of Crestwood during CMS and state inspections, most recent first.
A resident with epilepsy was admitted on multiple anti-seizure medications, but the evening doses of three ordered drugs were not administered because two were not available and one, although present in the dispensing system, was not given. The nurse did not document the missed doses on the MAR or notify the NP that the medications were unavailable and not administered, despite facility policy requiring notification and documentation when orders cannot be followed. The next morning, the resident experienced a seizure and was sent to the hospital.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a deficiency.
Multiple residents experienced significant medication errors due to staff failing to administer the correct dose or to provide scheduled medications on time. In one case, a resident was only given part of a prescribed antidepressant dose, while others missed doses of critical medications such as anticoagulants and hypoglycemics. These errors were confirmed through medication records and staff interviews, indicating a failure to follow established medication administration procedures.
Staff failed to follow medication administration procedures, resulting in a medication error rate above 5%. Errors included administering the wrong dose of Escitalopram, giving an enteric-coated Aspirin instead of the prescribed chewable form, and dispensing Calcium Carbonate and Lactobacillus without proper dose verification. Nurses did not consistently check orders or ensure the correct medication and dose before administration.
A resident who was cognitively intact but dependent on staff for toileting and repositioning was left soiled and saturated with urine for extended periods on multiple occasions. Staff confirmed that incontinence care was not provided in a timely manner, with call lights left unanswered and care intervals exceeding facility policy. The resident expressed distress and concern for safety due to these lapses.
Three high-risk residents with significant cognitive and physical impairments experienced multiple falls, including one resulting in a facial fracture and intracranial hemorrhage, due to staff failing to provide adequate supervision, not following care plan interventions such as two-person assistance and proper chair positioning, and not effectively modifying fall prevention strategies after repeated incidents.
A facility failed to provide a written notice and explanation for a room change to a resident's representative, as required by their policy. The resident's sister and POA reported not being informed about the room change, and the facility could not produce documentation of the notice. The policy mandates written notification and an explanation for room transfers.
A facility failed to report an allegation of abuse involving a resident with dementia. A visitor informed an RN that a CNA allegedly slapped the resident on the knee, but the RN did not report this to the DON or Administrator. Consequently, the DON was unaware of the incident until several days later. The facility's policy requires immediate reporting of such allegations, which was not followed, leading to a deficiency.
The facility failed to maintain the roof's integrity, leading to ceiling cracks and water collection in two residents' rooms. Additionally, there was a significant accumulation of dust in ventilatory outlets throughout the facility, with no cleaning schedule in place. The maintenance staff acknowledged the roof issue had persisted for three years, and the medical director highlighted the potential health risks of excessive dust for residents.
The facility failed to follow its policies for food storage, cleaning, and hand hygiene, affecting all residents receiving food. Observations revealed a foul odor in the cooler, unlabeled food items, and improper hand hygiene practices. The Registered Dietitian confirmed the importance of labeling food and maintaining hygiene, which was not adhered to, compromising food safety.
The facility failed to store and label insulin pens according to its pharmacy policy. Unopened insulin pens for two residents were not refrigerated, and an opened pen for another resident lacked an open and expiration date. LPNs acknowledged the oversight, and the DON stressed the importance of proper labeling for drug safety.
A facility failed to notify a resident's family about a newly acquired sacral wound in a timely manner, despite the resident being at high risk for skin breakdown. The wound care nurse noted the resident's decline in condition and the development of moisture-associated skin damage, but documentation of timely family notification was lacking. The facility's policy requires educating the resident's representative about pressure ulcer prevention and treatment.
A facility failed to follow its skin care prevention policy and develop a care plan for a resident at risk of skin breakdown. The resident, who was readmitted from a hospital stay, developed a facility-acquired MASD sacral wound due to fragile skin, loose stools, and moisture in briefs. Despite being dependent on all ADLs and unable to reposition themselves, the resident's care plan did not address the risk for skin integrity alteration or actual skin impairment.
A facility failed to follow its tube feeding policy by not checking a resident's G-tube for residual before administering medications and bolus feeding. An RN was observed administering medications and feeding without checking the G-tube for residual or placement, contrary to the facility's policy and the resident's physician order. Interviews with LPNs and the ADON confirmed the expectation to check for residual before such procedures.
A facility failed to follow its enteral tube medication administration policy and physician orders for a resident with a gastrostomy tube. An RN did not flush the tube with water between medications and omitted a scheduled dose of omeprazole, failing to inform the resident. The resident, with a history of gastric ulcer and esophageal obstruction, later reported stomach discomfort. The medication administration record inaccurately documented the administration of omeprazole.
A resident with multiple health conditions, including osteoarthritis and obesity, fell out of bed due to inadequate assistance during bed mobility. The CNA provided care alone, despite the resident's care plan requiring three-person assistance. This resulted in the resident sustaining a rib fracture, shoulder contusion, and knee sprain.
The facility failed to respond promptly to call lights, affecting four residents. A family member reported a 45-minute wait for assistance, while another resident waited three hours. Observations showed staff passing by an illuminated call light without responding. The facility's policy requires prompt response, which was not followed.
Failure to Administer Ordered Anti-Seizure Medications and Notify Practitioner
Penalty
Summary
The deficiency involves the facility’s failure to follow its Medication Administration Policy by not ensuring timely availability and administration of a resident’s ordered anti-seizure medications and not notifying the practitioner when the medications were not available. A resident with epilepsy was discharged from the hospital with orders for three anti-seizure medications: topiramate 200 mg twice daily, phenytoin (Dilantin) 200 mg twice daily, and oxcarbazepine 1,200 mg twice daily, with the next scheduled doses due in the evening. Record review showed that none of these medications were administered that evening as directed by the hospital discharge medication list. The DON stated that due to a holiday pharmacy delivery cut-off, only phenytoin was available in the facility’s medication dispensing system, and that the nurse should have attempted to obtain medications from the dispensing system and, if not available, notify the physician and family. The DON confirmed that the nurse did not notify the nurse practitioner that two of the three anti-seizure medications were not available and that no anti-seizure medications were given that evening. The nurse practitioner reported being notified only of the resident’s admission and not of the unavailability of the anti-seizure medications or the missed evening doses, and stated he was unaware of the pharmacy’s holiday cut-off. Review of the MAR confirmed that the ordered anti-seizure medications were not administered as scheduled on the evening in question, and there was no progress note documenting notification to the practitioner about the missed doses or unavailable medications. The following morning, a progress note documented that the resident’s concerned party insisted on calling 911 because the resident had a seizure, and later documentation showed the resident was admitted to a local hospital with seizure activity. The facility’s Medication Administration Policy required that if medication is not given as ordered, the reason must be documented on the MAR and the health care provider notified, that staff should obtain medications from contingency sources if not present, and that the physician must be notified in a timely manner if an order cannot be followed, with documentation in the medical record. These policy requirements were not followed in this case.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving missed or incorrect medication administration. In one instance, a resident with a physician order for Escitalopram 30mg daily was only dispensed a 20mg tablet by an LPN, despite the order specifying the need for both a 20mg and a 10mg tablet. The medication administration record indicated that 30mg was documented as given, but only 20mg tablets were available and dispensed for several days. This discrepancy was confirmed by both the LPN and the medication records. Additionally, several residents did not receive their scheduled morning medications on time, as indicated by the electronic medication administration record showing overdue doses for medications such as Eliquis, Tizanidine, Lamotrigine, Metformin, Baclofen, and Metoprolol Tartrate. Another resident, who was cognitively intact, reported missing medications during a night shift, including Xarelto, which was confirmed by the medication administration record and the Director of Nursing. Facility policy required verification of the right medication, dose, route, resident, and time, but these procedures were not followed, resulting in significant medication errors for multiple residents.
Medication Error Rate Exceeds 5% Due to Failure to Follow Medication Orders and Procedures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 4 errors out of 37 opportunities, resulting in a 10.81% error rate. Staff did not follow policy and procedures for medication administration, including ensuring that medication orders included a prescribed dose and verifying the correct medication, dose, and form before administration. In one instance, an LPN prepared to administer only 20mg of Escitalopram to a resident whose order required a total daily dose of 30mg, as specified in the physician order sheet and EMAR. The nurse confirmed the discrepancy after being questioned by the surveyor. Another LPN dispensed an enteric-coated Aspirin 81mg tablet to a resident whose order specified a chewable form, and the nurse confirmed the difference between the prescribed and dispensed forms after reviewing the EMAR. Additionally, a third nurse prepared to administer a 500mg Calcium Carbonate tablet to a resident whose order was for 600mg with Vitamin D, and also administered a Lactobacillus capsule without a specified dose in the order. The medication administration policy required verification of the right medication, dose, route, resident, and time, and checking orders in case of discrepancies, but these procedures were not followed.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was cognitively intact but dependent on staff for toileting and repositioning was not provided timely incontinence care. The resident was frequently incontinent and required substantial or maximal assistance to roll and reposition in bed. On multiple occasions, the resident reported being left soiled and saturated with urine for extended periods, including one instance of 3.5 hours and another of over two hours. The resident expressed feelings of stress, frustration, and concern for safety due to being left in this condition and having to rely on a single staff member for care instead of the required two-person assist. Certified nursing assistants confirmed that the resident was found soiled and saturated with urine and bed linens on at least two separate occasions, with call lights left unanswered for over an hour. Documentation and staff interviews indicated that the resident was not a heavy wetter, and the amount of urine present suggested a lack of overnight care. Facility policy required incontinence care every two hours and appropriate skin care to prevent breakdown, but these standards were not met for this resident, as evidenced by the resident's own written complaints and staff observations.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure that residents identified as high risk for falls were adequately supervised and that fall prevention interventions were properly implemented and modified after incidents. One resident with dementia, muscle wasting, and a history of falls was dependent on staff for all activities of daily living and required two-person assistance with transfers using a mechanical lift. Despite these needs, the resident was left unattended in a reclining chair while staff turned away to retrieve an item, resulting in the resident attempting to get up, falling forward, and sustaining a facial fracture and intracranial hemorrhage. Documentation and staff interviews revealed uncertainty about whether the chair was properly reclined, which was necessary due to the resident's poor trunk control, and that only one staff member was assisting at the time, contrary to care plan interventions requiring two-person assistance. Another resident with central nervous system cancer, muscle wasting, and morbid obesity, also identified as high risk for falls, experienced multiple unwitnessed falls both in her room and in common areas. Despite repeated incidents, interventions primarily consisted of reminders to staff to monitor and redirect the resident, with no significant modification to the care plan or supervision practices. Staff were educated not to leave the resident unattended, but the resident continued to be found on the floor after attempting to self-transfer, indicating that supervision and monitoring interventions were not effectively implemented. A third resident with dementia and generalized muscle weakness also experienced several falls, including unwitnessed incidents and falls from a reclining chair in common areas. The interventions following these falls were limited to reminders for staff to monitor the resident more frequently, but staff could not define what constituted adequate monitoring. The facility's fall prevention policy required evaluation and modification of care plans after falls, but the records and interviews indicated that interventions were not sufficiently individualized or adjusted in response to repeated incidents, and residents continued to be left unsupervised despite known risks.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to adhere to its policy regarding room changes by not providing a written notice and explanation for a room change to a resident's representative. The deficiency involved one resident, identified as R2, whose sister and Power of Attorney (POA) reported that the facility did not discuss the room change with her, nor did she receive a copy of the room change notice. Despite requests made to the Director of Nursing, Administrator, and Social Worker, the facility was unable to present documentation of the written notice or explanation for the room change. The facility's policy, dated November 1, 2023, requires that residents and their representatives be notified in writing of room transfers, including an explanation of the move, and be given the opportunity to see the new location and meet the new roommate.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not reporting an allegation of abuse involving a resident with dementia. On February 21, 2025, a visitor informed a Registered Nurse (RN) that a Certified Nursing Aide (CNA) allegedly slapped a resident on the knee. Despite this report, the RN did not communicate the allegation to the Director of Nursing (DON) or the Administrator. As a result, the DON was unaware of the incident until February 27, 2025. The facility's abuse prevention policy, dated March 2022, mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a designated individual in their absence. This failure to report the allegation promptly constitutes a deficiency in the facility's compliance with its internal reporting requirements.
Facility Fails to Maintain Roof Integrity and Ventilatory Cleanliness
Penalty
Summary
The facility failed to maintain the integrity of its roof, resulting in ceiling cracks and rusty discoloration in two residents' rooms, with water collection buckets placed underneath the cracks. Additionally, there was an abundant collection of black and dark grey powder-like particles on the ceilings, around and in the ventilatory outlets, and on smoke detectors in these rooms. These conditions were observed by the surveyor over two consecutive days, indicating a persistent issue that had not been addressed. The maintenance staff acknowledged the roof leakage and the need for repairs, stating that the issue had persisted for about three years. Furthermore, the facility failed to ensure dust-free ventilatory outlets in all residents' rooms throughout the facility. The housekeeping director admitted that there was no cleaning schedule in place at the time of the survey, although dusting was supposed to be done weekly. The medical director emphasized the importance of a homelike environment for the elderly residents, noting that excessive dust could lead to allergic reactions or exacerbate preexisting respiratory conditions. The facility's housekeeping guidelines were not being followed, as there were no daily cleaning assignments to maintain a clean and orderly environment.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to adhere to its policies and procedures for dietary food storage, cleaning, and hand hygiene practices, affecting all 123 residents receiving food from the facility. Observations in the main kitchen revealed a strong foul odor in the cooler, with two large boxes of meat covered in a red substance, indicating possible spoilage. Several food items, including a black bean burger, boxes of tomatoes, lettuce, cucumbers, dry cereals, and bagels, were found without labeled dates. Additionally, a large unmarked can of food was stored with other canned goods, and sauces from a previous event were not discarded. In the second kitchen, ham sandwiches and milk cartons were improperly labeled, and salad dressings were spilled, creating unsanitary conditions. A bin of clean serving ladles was found with a sticky brown substance, and a dietary aide was observed not performing hand hygiene after handling soiled dishes. The Registered Dietitian confirmed that dietary staff should not transition from handling soiled to clean dishes without performing hand hygiene and emphasized the importance of labeling food with received and used by dates to prevent serving expired foods. The facility's policies on food storage, kitchen operations, and hand washing were not followed, as evidenced by the presence of odors, unlabeled food items, and improper hand hygiene practices. These deficiencies highlight a failure to maintain a clean and sanitary environment in accordance with state and federal guidelines, potentially compromising food safety for the residents.
Improper Storage and Labeling of Insulin Pens
Penalty
Summary
The facility failed to adhere to its pharmacy policy regarding the storage and labeling of insulin, as observed during a survey. Specifically, unopened insulin pens for two residents were not stored in the medication refrigerator as required by the facility's policy. Additionally, these insulin pens were not labeled with an open date, which is necessary to track their usage and expiration. The surveyor noted that the pharmacy's prescription bags clearly indicated that the insulin should be stored in the refrigerator until opened, yet this was not followed. The Licensed Practical Nurse (LPN) on duty was unaware of when the insulin was received and acknowledged the oversight in storage and labeling. Furthermore, an opened insulin pen for another resident was found without an open and expiration date label. The LPN confirmed the absence of these labels and intended to contact the pharmacy for the expiration date. The Director of Nursing (DON) emphasized the importance of labeling insulin pens with both open and expiration dates to ensure drug safety and effectiveness. The facility's pharmacy policy mandates that unopened insulin should be refrigerated and labeled with an open date once used, but these procedures were not followed, leading to the deficiency.
Failure to Notify Family of Resident's Wound Development
Penalty
Summary
The facility failed to adhere to its skin prevention policy by not notifying a resident's family about a newly acquired wound in a timely manner. The resident, who was at high risk for skin breakdown, developed a moisture-associated skin damage (MASD) sacral wound due to factors such as loose stools, moisture in briefs from sweating, and fragile skin. The wound care nurse acknowledged the resident's high risk and noted a decline in the resident's overall medical condition, which included starting dialysis treatments after a hospital readmission. Despite discussing potential skin impairments with the family on an earlier date, the facility did not document timely notification to the family about the wound's development and changes in the treatment plan. The resident's medical records indicate that a skin assessment was conducted in the presence of a family member, and no skin impairments were noted at that time. However, subsequent evaluations revealed moisture-associated skin damage, and treatment was applied as ordered. It was not until a later date that another family member was informed of the wound status and treatment orders. The facility's skin care prevention policy emphasizes educating the resident's representative about pressure ulcer prevention and treatment, yet there was no documentation of timely communication regarding the wound's deterioration and treatment changes.
Failure to Develop Skin Care Plan for At-Risk Resident
Penalty
Summary
The facility failed to adhere to its skin care prevention policy and develop a person-centered care plan for a resident at risk of skin breakdown. The resident, who was readmitted from a hospital stay in November, experienced an overall decline in medical condition and developed a facility-acquired moisture-associated skin damage (MASD) sacral wound. The wound care nurse identified the resident as being at risk due to fragile skin, loose stools, moisture in briefs from sweating, and loose skin. Despite being dependent on all activities of daily living and unable to reposition themselves, the resident's comprehensive care plan did not include a risk for alteration in skin integrity or a care plan for actual skin impairment. The facility's policy required the nursing department to review all new admissions and re-admissions to implement a prevention plan based on the resident's activity level, comorbidities, mental status, and risk assessment, which was not done in this case.
Failure to Check G-Tube Residual Before Medication and Feeding
Penalty
Summary
The facility failed to adhere to its tube feeding policy by not checking a resident's gastrostomy tube (G-tube) for residual before administering medications and bolus feeding. This deficiency was observed when a registered nurse (RN) administered medications and a bolus feeding to a resident without checking the G-tube for residual or placement. The facility's policy, as well as the resident's physician order sheet, required checking for residual before such procedures. Interviews with licensed practical nurses (LPNs) and the assistant director of nursing (ADON) confirmed that the standard practice is to check for residual before administering medications and feedings. The failure to follow these procedures was noted during a survey, affecting one resident out of three reviewed for gastrostomy tubes in a sample of five.
Failure to Follow Enteral Tube Medication Administration Policy
Penalty
Summary
The facility failed to adhere to its enteral tube medication administration policy and physician orders for a resident, leading to a deficiency. On January 22, 2025, a registered nurse (RN) was observed preparing and administering medications for a resident with a gastrostomy tube. The RN crushed the medications and dissolved them in water but did not flush the gastrostomy tube with 5-10ml of water between each medication, as required by the facility's policy. Additionally, the RN did not administer the resident's scheduled omeprazole medication because it was not present in the medication cart and failed to inform the resident of this omission. The resident, who has a medical history including gastric ulcer, esophageal obstruction, and gastrostomy, later complained of stomach discomfort to a licensed practical nurse (LPN). The resident's physician order sheet indicated that omeprazole 20mg was to be administered via G-tube twice daily, with specific instructions to flush the G-tube with 30ml of water before and after medications, and 5ml between each medication. Despite this, the medication administration record inaccurately documented that the omeprazole was administered. The facility's failure to follow its medication administration policy and physician orders resulted in a deficiency.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the plan of care for a resident requiring assistance with bed mobility, resulting in an avoidable accident. The resident, who was diagnosed with generalized osteoarthritis, repeated falls, neuropathy, morbid obesity, and other conditions, was assessed to need three-person assistance for bed mobility. However, on the day of the incident, a Certified Nursing Assistant (CNA) attempted to provide care alone, which led to the resident falling out of bed. The incident occurred when the CNA was changing the resident's bed linens. The resident was positioned on her right side, and as the CNA pushed the linen under her, the resident slid out of bed and fell to the floor. The resident, who was cognitively intact, reported pain and was subsequently diagnosed with a non-displaced left rib fracture, a left shoulder contusion, and a sprained left knee at the hospital. Interviews with facility staff revealed that the CNA did not check the resident's care card, which indicated the need for three-person assistance. The Director of Nursing and other staff members confirmed that the resident required significant assistance with bed mobility, and the failure to provide the appropriate level of assistance was identified as the root cause of the fall.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to monitor and respond to its call light system in a timely manner, affecting four residents. A family member of one resident, who was severely cognitively impaired and dependent on assistance for activities of daily living (ADL), reported waiting 45 minutes for staff to respond to a call light. The family member had to seek help at the nurses' station, and the administrator was informed of the delay. The call light system was noted to be visual only, without an audible alert, which may have contributed to the delay in response. Another resident, who was cognitively intact but dependent on ADL care, reported waiting three hours for assistance after pressing the call light. This resident's experience highlights a significant delay in response time, which was corroborated by the resident's account of pressing the call light at 9 AM and not receiving assistance until 12 PM. Additionally, another resident, also cognitively intact and requiring substantial assistance, reported waiting over an hour for help after a CNA turned off the call light and promised to return, but did not do so until the shift change. The surveyor observed a call light illuminated for a resident with mild cognitive impairment and dependent on ADL care, which was not addressed by several staff members passing by. The call light was eventually turned off by a CNA who admitted noticing it five minutes prior but was busy at the time. The facility's policy, which mandates prompt response to call lights, was not adhered to, as evidenced by the documented delays and resident complaints.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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