Aliya Of Oak Lawn
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Lawn, Illinois.
- Location
- 6300 West 95th Street, Oak Lawn, Illinois 60453
- CMS Provider Number
- 145087
- Inspections on file
- 42
- Latest survey
- January 25, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Aliya Of Oak Lawn during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including prior femur fracture and dependence on hemodialysis, experienced a bathroom fall resulting in an acute, displaced right femoral neck fracture confirmed by CT and X-ray. The cognitively intact resident reported falling while getting ready, with no staff present, and was transported to the hospital by paramedics. The DON stated the incident was not reported to the State Agency because they believed only unwitnessed falls required reporting, and the administrator believed a pathological fracture did not need to be reported. This conflicted with facility policy requiring all incidents and accidents with serious physical injury to be reported to the State Agency within 24 hours, with a full written investigative report within seven days.
A resident with end-stage heart failure and cognitive deficits died after staff failed to monitor and change the batteries of a Left Ventricular Assist Device (LVAD) according to facility policy and manufacturer guidelines. Multiple nurses and aides did not perform required checks or ensure the device was connected to wall power at night, and documentation revealed a lack of adequate training and care planning for LVAD management. The batteries were allowed to fully deplete, causing the heart pump to stop and resulting in the resident's death.
A resident with an LVAD was found unresponsive, and staff failed to follow emergency protocols by not checking the device or its batteries. None of the responding nurses or CNAs had received LVAD emergency training, and the facility lacked individualized care planning for the resident's device management. The LVAD batteries were depleted, and the device was nonfunctional, contributing to cardiac arrest and death.
A resident with a history of heart failure and an LVAD was admitted without an individualized baseline care plan or physician orders addressing LVAD care and monitoring. The initial care plan and orders did not include required interventions such as VAD parameter checks, alarm monitoring, or device self-tests, despite facility policy and staff training requirements. The omission was only addressed after surveyor inquiry, and staff were unclear on the specific baseline care needs for LVAD management.
Two residents with LVADs were affected when staff failed to properly assess, monitor, and intervene regarding LVAD battery levels, resulting in one resident's device losing power and a cardiac arrest. Staff did not consistently perform required system checks or battery changes, lacked adequate training, and did not follow facility policy. Care plans and physician orders for both residents did not include necessary instructions or interventions for LVAD management, particularly for night shifts, and the facility failed to ensure orders were in place for a newly admitted resident with an LVAD.
The facility did not ensure that staff received required training to care for residents with left ventricular assist devices (LVADs), despite having residents with complex cardiac conditions and LVADs in place. Multiple staff members, including RNs, LPNs, and CNAs, reported not receiving LVAD training, and one nurse was unable to demonstrate basic LVAD battery checks. The facility's own assessment tool required such training, but there was no documentation or evidence of hands-on instruction, leaving staff unprepared to provide competent care for these residents.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report does not specify the actions of staff or the condition of any residents involved.
Several residents requiring moderate to total staff assistance did not receive regular showers or complete bed baths, and experienced significant delays in toileting care, including one resident left on a bedpan for 35 minutes. Residents reported long wait times for call light responses and an inability to recall their last bath, while documentation of bathing was not provided for review. Facility policy required at least weekly bathing, but this was not consistently followed.
The facility did not ensure enough direct care staff were available to meet resident needs, resulting in multiple residents not receiving showers, timely toileting assistance, or personal hygiene care. Staff assignments were inconsistent, with frequent changes and high resident-to-CNA ratios, leading to delays in care and unmet needs for residents requiring substantial or total assistance.
Two residents were found with medications stored at their bedside without required physician orders or documented assessments for self-administration. One cognitively intact resident had eye drops at the bedside but relied on nurses for administration, while another with moderate cognitive impairment had antidiarrheal medication provided by a family member due to lack of facility supply. Facility policy requiring interdisciplinary assessment and physician orders for self-administration and bedside storage was not followed.
The call light system on the North unit was non-functional for several weeks due to an electrical issue, affecting 28 residents. Temporary measures like hand bells and frequent rounding were implemented, but residents expressed dissatisfaction and difficulty in using these alternatives. Observations confirmed the system's failure, with residents unable to summon staff effectively.
A resident expressed dissatisfaction with meals provided, as the facility failed to adhere to their food preferences despite daily menu reviews. The resident's breakfast tray included items they disliked, such as bacon and cereal, which were not consumed. The Dietary Manager confirmed the resident should not have received these items, indicating a failure in respecting the resident's dietary preferences.
Two residents in a LTC facility experienced delays in receiving necessary toileting assistance, leading to prolonged discomfort. One resident, who requires a two-person assist, waited over 34 minutes for help, while another was found in a soiled condition by family. Staff were aware of the needs but failed to coordinate effectively, and documentation was incomplete. Both residents have significant medical conditions requiring substantial assistance.
A lack of adequate supervision during a smoking break led to an altercation between two residents, one with legal blindness and depression, and the other with PTSD and major depressive disorder. The incident occurred on the smoking patio, where derogatory and racist words were exchanged, and one resident accused the other of physical aggression. The activity aide was inside conducting activities and only monitoring from a distance, resulting in ineffective supervision.
The facility failed to follow food safety and sanitation protocols, including improper labeling of food, non-compliance with hair restraint policies, and inadequate infection control measures. Staff were observed not using standardized recipes or measuring ingredients, and the sanitizer concentration in the sink was below required levels.
The facility failed to properly label and store insulin pens for five residents, as observed during a survey. Insulin pens were not labeled with open dates and were not stored in the appropriate refrigerator, contrary to pharmacy policy. Staff were unsure of the duration the pens had been stored improperly, and the Director of Nursing confirmed the importance of proper labeling and storage.
A long-term care facility failed to administer medications as ordered for three residents, leading to significant lapses in care. One resident did not receive Norco pain medication and other routine medications, while another missed critical medications for anemia and diabetes. A third resident experienced inconsistencies with medication patches and anxiety medication, and lacked compression hose for a swollen leg. Staff interviews revealed procedural failures in obtaining and documenting medications.
A resident with a history of chronic conditions and an indwelling urinary catheter was admitted to a facility without proper physician orders for catheter care. The facility failed to implement care plan interventions for monitoring urinary tract infection symptoms, resulting in the resident's hospitalization for septic shock. Staff interviews revealed inconsistencies in documentation and communication regarding the resident's condition and catheter care.
A resident with a history of atrial fibrillation and other conditions was hit in the head by another resident with a history of violent behavior during a group activity. The incident occurred without staff present, and the resident reported not being examined afterward, although an RN claimed to have assessed her. The facility's failure to protect the resident and ensure proper follow-up care was identified during a survey.
A facility failed to protect residents from mental abuse and intimidation by staff, affecting three residents. During a survey, residents reported being instructed by staff not to speak with surveyors, fearing retaliation or neglect if they did not comply. One resident noted delayed care when staff were upset, while another felt infantilized by a CNA's directive to remain silent. The residents did not disclose staff identities, and the facility's policies emphasize respecting resident rights and define mental abuse as including humiliation and threats.
A resident's cell phone was stolen by a visitor, leading to unauthorized access to a financial account and theft of $300. The facility lacked adequate security measures, and the visitor was not logged in the visitor log. The incident violated the facility's policy against misappropriation of property.
A resident with multiple sclerosis and quadriplegia expressed a desire to paint, but the facility failed to provide activities that met her needs. Despite having intact cognition, she was not assisted to attend activities due to the lack of a wheelchair. Staff were unaware of her ability to use her right hand partially, and her interest in painting was not addressed, contrary to the facility's policy of providing tailored activities.
A facility failed to follow its care plan for a resident, resulting in maggots found in wounds, and did not administer prescribed medications to three residents. The resident, with multiple sclerosis and quadriplegia, was readmitted after maggots were discovered. Staff confirmed the presence of maggots, but documentation was inconsistent. Additionally, three residents did not receive prescribed medications, with no clear reasons provided. These deficiencies highlight significant lapses in care and medication protocols.
The facility failed to follow its abuse prevention policy and report an allegation of physical abuse immediately. A resident with a bruise on their left arm and subarachnoid bleeding reported that staff had been hitting and pinching them. The DON did not inform the administrator or the state agency of the abuse allegation in a timely manner, leading to this deficiency.
The facility failed to implement fall prevention interventions for a high-risk resident with a history of falls. The resident was found in a high bed position, unattended, contrary to the care plan requiring the bed to be in the lowest position. The CNA left the resident in this unsafe condition while preparing to get a mechanical lift.
A facility failed to provide timely incontinence care for a dependent resident, who was found soaked in urine after waiting all morning for assistance. The CNA assigned to the resident did not provide care despite observing the resident wet at 7 am, and the facility's policy requires rounds every two hours and as needed.
The facility failed to sign the shift-to-shift controlled substance count sheet, affecting one of four medication carts reviewed. On multiple occasions, numerous nurse's signatures were missing, despite the policy requiring both off-going and on-coming nurses to sign after counting the narcotic/controlled substance count sheet.
The facility failed to monitor and document medication refrigeration temperatures and did not date a tuberculin purified protein vial after opening, as per manufacturer recommendations. The medication refrigerator temperature logs were incomplete for several days, and an opened tuberculin vial was found without a date.
The facility failed to offer and document influenza, pneumococcal, and COVID-19 vaccinations for three residents, as required by their policies. Record reviews and staff interviews revealed incomplete immunization records and a lack of adherence to vaccination documentation protocols.
Failure to Report Serious Injury from Resident Fall to State Agency
Penalty
Summary
The facility failed to notify the State Agency of both the initial and final reports after a resident was emergently transferred to a local hospital and diagnosed with an acute and displaced right femoral neck fracture. The resident is an adult female with medical diagnoses including a prior left femur fracture, anxiety disorder, bipolar disorder, lupus, and dependence on hemodialysis. Her MDS showed a BIMS score of 13/15, indicating she was cognitively intact. The resident reported that she fell in the bathroom at 5:15 AM while getting ready for the day, with no staff present at the time of the fall, and that paramedics picked her up from the floor and transported her to the hospital. Hospital documentation from the same morning described the resident as very tearful and in severe right hip and thigh pain, with CT and X-ray imaging confirming a basicervical fracture of the right femoral neck and an acute, displaced right femoral neck fracture. During interviews, the DON stated that the incident was not reported to the State Agency because they only report unwitnessed falls and believed this fall was observed by the nurse on the floor. The administrator stated that, because the resident had a pathological fracture, they believed it did not need to be reported to the State Agency and expressed uncertainty about the policy. The facility’s written fall prevention and management policy, however, requires that all incidents and accidents with serious physical injury be reported to the State Agency within 24 hours, with a full written investigative report submitted within seven days of the incident.
Failure to Monitor and Maintain LVAD Results in Resident Death
Penalty
Summary
The facility failed to follow established clinical protocols, manufacturer’s guidance, internal training guidelines, and its own policies and procedures for the care of a resident with a Left Ventricular Assist Device (LVAD). Staff did not monitor or change the LVAD batteries when they reached 50% capacity, as required by policy, resulting in the batteries depleting and the heart pump stopping. The resident was subsequently found unresponsive, sent to the hospital for cardiac arrest, and expired. Multiple staff members on duty during the relevant shifts did not check, change, or ensure the LVAD batteries had adequate voltage, despite having the opportunity and responsibility to do so. The resident involved had a complex medical history, including end-stage heart failure, coronary artery disease, cognitive deficits, and the presence of a heart assist device. Documentation and interviews revealed that staff did not receive adequate training on LVAD care, and several nurses and aides were unfamiliar with the required procedures for monitoring and maintaining the device. The care plan and physician orders lacked specific interventions and monitoring instructions for the LVAD, particularly for the night shift, and there was no comprehensive plan of care developed for the device. Staff interviews confirmed that LVAD checks were not performed as required, and some staff were unaware of how to assess battery status or perform system checks. Facility policy required that LVAD batteries be changed at 50% capacity and that the device be connected to wall power at night. However, staff failed to follow these protocols, and the resident’s LVAD batteries were allowed to fully deplete. Video surveillance and documentation review confirmed that staff did not enter the resident’s room to perform necessary checks during critical periods. The facility’s abuse and neglect policy was not followed, as the failure to provide necessary care and monitoring resulted in neglect, contributing to the resident’s death.
Removal Plan
- In-serviced the Administrator regarding the facility's Abuse/Neglect Policy and Procedure, including neglect.
- Ensured all residents are free from neglect.
- Reported neglect incident to the Illinois Department of Public Health and initiated an investigation.
- Suspended the nurse identified as the alleged perpetrator pending investigation.
- Terminated the nurse from the facility due to failure to provide a clear and accurate report regarding the incident.
- In-serviced facility staff on the neglect/abuse policy and on properly rounding and checking on residents.
- Conducted in-services regarding LVADs and properly checking for batteries and alarms.
- Conducted LVAD training with licensed staff that included ensuring LVADs are connected to the wall outlet to ensure proper battery levels.
Failure to Follow LVAD Emergency Protocols Resulting in Resident Death
Penalty
Summary
The facility failed to provide appropriate, person-centered care and treatment for a resident with a Left Ventricular Assist Device (LVAD), resulting in a critical incident. The resident, who had multiple complex medical diagnoses including heart failure, diabetes, and cognitive deficits, was found unresponsive. Staff did not follow the facility's emergency response protocol for LVAD management, which required checking the device for functioning and battery status during emergencies. Instead, staff initiated CPR without assessing the LVAD, and none of the responding nurses or CNAs checked whether the device was operational or if the batteries were charged. Interviews with staff revealed that none of the personnel involved in the emergency response had received training on LVAD emergency procedures. Several staff members admitted to not checking the LVAD or its batteries, and some were unaware of the specific steps required to manage an LVAD during a code situation. The Director of Nursing confirmed there was no documentation of LVAD training for staff, and the Assistant Director of Nursing stated that hands-on training was not provided. The facility's own policy required immediate assessment of the LVAD's function and battery status during emergencies, but this was not followed. Medical records and device logs indicated that the LVAD batteries had been depleted for an extended period prior to the resident being found unresponsive, and the device had stopped functioning, contributing to cardiac arrest and subsequent death. The lack of individualized care planning for the resident's full code status and LVAD management further contributed to the deficiency. The failure to follow established protocols and provide necessary staff training directly led to the adverse outcome.
Removal Plan
- Regional Nurse Consultant in-serviced the Director of Nursing regarding the facility's Emergency Protocol and Procedure for a resident with an LVAD.
- The Director of Nursing and Nurse Managers completed education with nurses on the facility's Emergency Protocol and Procedure for a resident with an LVAD.
- The Director of Nursing and Nurse Managers completed the education provided by the manufacturer to the facility nurses.
- The Director of Nursing was in-serviced by the Regional Nurse Consultant regarding emergency response for LVAD system and specialized device care.
- The Director of Nursing provided education to licensed and unlicensed nursing personnel on emergency response for LVAD system.
- The emergency response procedure will be placed in the resident care plan and at the bedside.
- The Director of Nursing and/or Nurse Managers will provide education to current nursing department staff with competency exams when facility admits any specialty care resident specifically LVAD.
- This process will be included in the new hire onboarding/orientation process.
- The facility nurses will also receive training competencies for staff caring for residents with specialty care needs.
- The facility has revised its staffing protocols to ensure that at least one staff member trained in LVAD management is always on duty when there is an LVAD in the facility.
- The schedule is now maintained to verify proper coverage and trained staff assigned are being routinely audited by DON/designee.
- The Director of Nursing and/or designee has educated licensed nursing staff on recognizing and appropriately responding to LVAD-related emergencies including prioritization of device functions assessment during a code situation.
- Mock code drills incorporating LVAD scenarios will be conducted with documentation and debriefing to reinforce staff knowledge and readiness.
Failure to Develop Baseline Care Plan for Resident with LVAD
Penalty
Summary
The facility failed to develop and implement an individualized baseline care plan for a resident with a left ventricular assist device (LVAD) within 48 hours of admission, as required by facility policy. Upon admission, the resident had a documented history of chronic systolic congestive heart failure, atrial fibrillation, and an LVAD. Despite these significant medical needs, the baseline care plan and physician orders did not include specific interventions or monitoring parameters for the LVAD, such as checking VAD parameters every shift, performing controller and power module self-tests, or monitoring alarms and batteries. Interviews and record reviews revealed that the initial stabilization visit and subsequent documentation focused on general medication review and stabilization, but did not address the LVAD care requirements. The admission evaluation acknowledged the presence of the LVAD, but failed to include goals or interventions specific to the device. Staff interviews indicated a lack of clarity regarding the necessary baseline care needs and orders for residents with an LVAD, and the comprehensive care plan was only revised to include LVAD care after the surveyor's inquiry, not as part of the initial baseline plan. Facility policies required that baseline care plans be person-centered and based on admission orders, including all necessary instructions for effective care. However, the facility did not ensure that orders and interventions for LVAD care were in place upon admission, and staff were unable to specify what those orders should be. The LVAD policy, which outlined required monitoring and care procedures, was not presented to the surveyor until later in the survey, and was not referenced or implemented in the resident's initial care planning.
Failure to Follow Professional Standards for LVAD Care and Monitoring
Penalty
Summary
The facility failed to follow professional standards of care for residents with Left Ventricular Assist Devices (LVADs), affecting two residents. For one resident, the facility did not adequately assess or monitor the LVAD battery levels, nor did staff intervene when the batteries became depleted. This resident had a complex medical history including heart failure, diabetes, and cognitive deficits, and required regular LVAD checks. Despite policy requiring battery changes at 50% capacity, staff did not consistently check or change the batteries, and the LVAD was found to be without power, resulting in a cardiac arrest event. Documentation and interviews revealed that multiple staff members on duty did not perform required LVAD system checks, did not change or charge the batteries, and some staff lacked training or competency in LVAD care. Video surveillance confirmed that staff did not enter the resident's room to perform necessary assessments during critical periods. Additionally, the resident's care plan and physician orders did not include comprehensive instructions or interventions for LVAD management, particularly for night shifts. The baseline and comprehensive care plans lacked goals and interventions specific to the LVAD, and there were no orders for monitoring or managing the device overnight. Staff interviews indicated confusion about responsibilities and a lack of hands-on training, with some staff unaware of how to check battery levels or perform system checks. The facility's own policies required regular monitoring and battery changes, but these were not followed, and the LVAD policy was not readily available when requested by surveyors. For the second resident with an LVAD, the facility failed to ensure that physician orders were in place for LVAD management upon admission. The initial stabilization visit and baseline care plan did not address the LVAD, and there were no orders for monitoring alarms, system checks, or battery status. The comprehensive care plan was only updated after surveyor inquiry, and staff could not specify the baseline care needs for a resident with an LVAD. The facility's policies required the development of a person-centered care plan within 48 hours of admission, but this was not done for the resident with the LVAD.
Failure to Train Staff on LVAD Care and Emergency Response
Penalty
Summary
The facility failed to follow its own facility assessment and did not ensure that staff received in-service and training necessary to provide care for residents with a left ventricular assist device (LVAD). This deficiency affected two residents, both of whom had significant cardiac histories and required specialized care for their LVADs. Interviews with multiple staff members, including RNs, LPNs, and CNAs, revealed that they had not received training on the care or emergency response for residents with LVADs. One RN was unable to demonstrate how to check the LVAD battery capacity and admitted to not checking the LVAD system or batteries during her shift. The Director of Nursing confirmed there was no documentation of staff receiving LVAD training, and the Medical Director stated that at least one nurse per shift should be trained on LVAD care. The facility's assessment tool indicated that LVAD care was among the services offered and that mandatory in-services related to specific diagnoses or equipment, including LVADs, were required. Despite this, several staff members, including those in supervisory roles, reported not receiving any LVAD training, and there was no evidence of hands-on or return demonstration training. The Assistant Director of Nursing, who was identified as the preceptor for LVAD training, expressed that video training alone was insufficient and that hands-on training was necessary. The lack of training and documentation directly contradicted the facility's stated policies and assessment, resulting in staff being unprepared to competently care for residents with LVADs during both routine and emergency situations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report. No further information about the circumstances or individuals affected is included.
Failure to Provide Timely Bathing and Toileting Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing and timely toileting care, for residents who required moderate to total staff assistance. Multiple residents reported not receiving showers or complete bed baths as required, with some unable to recall the last time they were bathed. One resident was observed with a brown substance embedded under their fingernails, and another reported not receiving a bed bath since returning from the hospital. Residents also described significant delays in staff response to call lights, with one resident waiting up to an hour for assistance and another left on a bedpan for approximately 35 minutes before being attended to. Documentation supporting the provision of showers or bed baths was not made available for review during the survey, despite requests. Assessments indicated that the affected residents required substantial to total assistance with bathing and toileting. The facility's own policy required that all residents be offered a bath or shower at least once per week, with more frequent bathing as needed or requested. The DON stated that residents receive showers or bed baths twice a week, but this was not corroborated by resident interviews or available records.
Failure to Provide Sufficient Direct Care Staff
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and record reviews. On one occasion, no CNA was assigned to residents in rooms on the east and northeast unit, affecting thirteen residents. Staff assignments changed multiple times during the morning, and staff who were not scheduled for direct care, such as a restorative aide and a dialysis transporter, were reassigned to cover care duties. Staff reported frequent assignment changes, lack of clear assignments at the start of shifts, and high resident-to-CNA ratios, with some CNAs responsible for 17 or more residents. The staff scheduler confirmed that staffing is based on census and budget, but could not explain the lack of coverage or frequent assignment changes. Several residents reported not receiving showers or complete bed baths since admission or return from the hospital, with some stating they had to wait extended periods for assistance with toileting and hygiene. One resident was observed with a brown substance under their fingernails and a pile of dirty linens in their room, and both the resident and their family member reported long wait times for staff response and no improvement after concerns were raised. Other residents described similar experiences, including waiting up to an hour for call lights to be answered and attempting to perform self-care due to lack of staff assistance. Resident assessments indicated that those affected required substantial to total assistance with bathing, toileting, and personal hygiene. Staff interviews corroborated the residents' accounts, with CNAs stating that high resident assignments made it impossible to complete all required care tasks, including showers, incontinence care, and timely response to call lights. The lack of consistent and adequate staffing directly resulted in unmet care needs for multiple residents across different units.
Failure to Assess and Obtain Orders for Self-Administration and Bedside Medication Storage
Penalty
Summary
The facility failed to follow its policy regarding self-administration of medications by not ensuring that residents had physician orders for medications stored at the bedside and were properly assessed for their ability to self-administer. One resident was observed with a bottle of refresh eye drops on the bedside table and reported that nurses had been administering the medication since admission, stating an inability to self-administer and waiting for nursing staff to provide the drops. This resident was found to be cognitively intact with a BIMS score of 15, but there was no physician order for the eye drops or for self-administration or bedside storage. Another resident was observed with a container of oral antidiarrheal medication at the bedside and reported intermittent diarrhea due to a medical condition. The resident stated that the facility did not provide the medication when requested, so a family member brought it in for self-administration as needed. This resident had a BIMS score of 12, indicating moderate cognitive impairment, and there was no physician order for the medication, self-administration, or bedside storage. The facility's policy requires an interdisciplinary team assessment and a physician order before allowing self-administration or bedside storage, which was not followed in these cases.
Non-Functional Call Light System on North Unit
Penalty
Summary
The facility failed to maintain a functioning call light system on the North unit, affecting 28 residents. The call light system had been non-operational for several weeks due to an electrical issue, which was more complex than initially anticipated. The administrator acknowledged the problem and mentioned that a part had been ordered to fix the issue. However, the maintenance assistant and director revealed that the problem was due to a shortage in the main power line, and the system had been down since mid-February. Despite the implementation of hand bells and frequent rounding as temporary measures, residents expressed dissatisfaction and difficulty in using these alternatives. One resident, diagnosed with multiple sclerosis and quadriplegia, reported having to yell for assistance as she could not use the hand bell provided. Another resident stated that the staff did not respond to the bell when used, indicating its ineffectiveness. Observations confirmed that the call light system was not functioning, as pressing the call light did not activate any light or sound at the nurse station. The maintenance director documented the failure of the call light system in 24 resident rooms over several weeks, emphasizing the importance of a functioning call light system for residents to summon staff when needed.
Failure to Follow Resident's Food Preferences
Penalty
Summary
The facility failed to adhere to a resident's food preferences, leading to a deficiency in meeting the nutritional needs of the resident. On March 8, 2025, a resident (R2) expressed dissatisfaction with the meals provided, stating that the facility consistently failed to deliver the correct meal despite daily menu reviews. The resident's breakfast tray contained items that were not consumed, including two boiled eggs, two slices of bacon, unopened milk, and a bowl of hot cereal. The resident's meal ticket indicated dislikes for bacon, cereal, mushrooms, and scrambled eggs, yet these items were still included in the meal. The care plan for the resident required dietary consultation to modify meals and snacks according to known food allergies or intolerances and to honor food preferences. The Dietary Manager confirmed that the resident should not have received food items they disliked, indicating a failure in the facility's processes to respect and follow the resident's dietary preferences.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely bathroom and toileting assistance to two dependent residents, R1 and R8, as observed and documented by surveyors. On 2/18/25, R8's call light was activated at 10:34 AM, and despite multiple requests for assistance from R8's family, the resident was not assisted to the toilet until after 11:08 AM. R8, who requires a two-person assist for toileting, was left waiting for over 34 minutes, during which time the call light was turned off without providing the necessary assistance. The staff, including a CNA and a nurse, were aware of R8's needs but failed to coordinate effectively to provide timely care. R8's medical conditions include Disc Disorder with Myelopathy, Cognitive Communication Deficit, and Dementia, which necessitate dependence on staff for toileting hygiene. The facility's assessment and care plan did not indicate the need for a mechanical lift, yet there was confusion among staff regarding the appropriate method of assistance. The CNA charting for the day showed R8 was incontinent of bowel and bladder, indicating a lack of timely intervention. Similarly, R1 experienced a delay in receiving assistance after having a bowel movement in bed. On 2/7/25, R1's family found the resident in a soiled and wet condition, which had been left unaddressed for some time. R1's care plan required regular rounding and assistance with toileting, but documentation for the shift was incomplete, and staff did not recall any concerns being reported. R1's medical history includes Benign Neoplasm of Left Ovary, Unsteadiness on Feet, and Protein-Calorie Malnutrition, requiring substantial assistance with bed mobility and transfers. The facility's failure to adhere to care plans and provide timely assistance resulted in discomfort and distress for the residents involved.
Inadequate Supervision During Smoking Break Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision during a smoking break, leading to an altercation between two residents, R2 and R3. The incident occurred on the smoking patio, where R2 and R3 exchanged derogatory and racist words. R2 accused R3 of lifting her by the shirt and throwing her against a wall, while R3 claimed he merely moved R2's hand out of his face. The altercation was not witnessed by staff as the activity aide, V12, was inside conducting activities and only monitoring the residents from a distance. R2, a resident in her 50s with diagnoses of legal blindness and depression, has a history of noncompliance with smoking regulations and periods of agitation. Her care plan indicates she should be monitored or placed in a supervised smoking program due to her impaired memory and decision-making difficulties. R3, also in his 50s, has diagnoses of PTSD and major depressive disorder, with a care plan noting his verbal aggression and agitation episodes. Both residents have a history of cursing at staff and other residents. The facility's smoking policy requires staff supervision for residents who may need more intensive monitoring while smoking. However, during the incident, the activity aide was not outside with the residents, and the supervision was deemed ineffective. The Director of Nursing and other staff acknowledged the lack of proper supervision, which contributed to the escalation of the situation between R2 and R3.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to several food safety and sanitation protocols, as observed during a survey. One significant issue was the improper labeling and dating of food items in the freezer. A clear bag of food, identified as potatoes, was found without a label or open date, which is against the facility's policy that requires all opened food packages to be re-dated with the date they were opened. This lapse in procedure was acknowledged by the Dietary Manager, who admitted uncertainty about when the bag was opened. Additionally, the facility did not enforce its policy on the use of hair restraints in the kitchen. Multiple staff members, including dietary aides and the Director of Rehab, were observed entering the kitchen without wearing hair nets or beard restraints, despite having facial hair. This non-compliance with the hair restraint policy poses a risk of hair contamination in food preparation areas. The Dietary Manager confirmed that all staff should wear hair nets and beard covers to prevent hair from contaminating food. The facility also failed to maintain proper infection control and sanitation standards. Oven gloves and a package of gravy were found inside clean and sanitized pots, and a whisk used during meal preparation was not properly cleaned between uses. Furthermore, the facility did not follow its policy on using standardized recipes, as observed with a staff member preparing mashed potatoes and gravy without measuring ingredients or using a recipe. The concentration of the quaternary sanitizer solution in the three-compartment sink was also below the required level, indicating a failure to maintain proper sanitation levels. The Dietary Manager was unable to provide a kitchen infection control policy when requested, highlighting a lack of adherence to established guidelines.
Failure to Properly Label and Store Insulin Pens
Penalty
Summary
The facility failed to adhere to its pharmacy policy regarding the labeling and storage of insulin pens for five residents. During an inspection of the medication cart on the first floor, it was observed that insulin pens for residents were not labeled with open dates as required by protocol. Additionally, these insulin pens were not stored in the appropriate facility/medication refrigerator, contrary to the pharmacy policy that mandates all unopened insulin should be refrigerated. The surveyor noted that the insulin pens for the residents were sent from the pharmacy without clear records of when they were received or how long they had been stored in the medication cart. Licensed Practical Nurse (LPN) and Registered Nurse (RN) staff were unsure of the duration the insulin pens had been in the cart and acknowledged that insulin pens should be labeled with open and expiration dates. The prescription bags from the pharmacy were labeled with instructions to store the insulin in the fridge until opened, but this was not followed. The Director of Nursing (DON) confirmed the importance of labeling insulin pens with open and expiration dates to maintain their efficacy. The DON also stated that unopened insulin pens should be stored in the appropriate refrigerator until needed. The facility's medication protocol, as per the pharmacy policy, requires that refrigerated products, including insulin, be stored properly upon delivery. However, this protocol was not followed, leading to the deficiency noted by the surveyor.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its medication administration policy, resulting in residents not receiving medications and treatments as ordered by their physicians. This deficiency was observed in three residents, each with significant medical histories requiring consistent medication management. Resident 1, a male with a history of pulmonary embolism, deep vein thrombosis, and other conditions, reported not receiving his Norco pain medication as ordered, with the facility lacking the medication in stock. Additionally, multiple routine medications were not signed as given, indicating they may not have been administered. Resident 2, who had a history of sepsis, end-stage renal disease, and other serious conditions, also experienced lapses in medication administration. The electronic medication administration records showed that several routine medications were not signed as given across different days and shifts. This included critical medications such as epoetin alfa for anemia and insulin glargine for diabetes, which were not documented as administered according to the physician's orders. Resident 3, a female with partial paralysis and other complex medical needs, reported inconsistencies in the application of her medication patch and the availability of her anxiety medication. She also noted the absence of compression hose for her swollen leg, which was ordered by her physician. The medication administration records for Resident 3 showed missing information for multiple scheduled medications, including Heparin and Alprazolam, and the facility's staff failed to document the administration of these medications properly. Interviews with facility staff revealed a lack of adherence to procedures for obtaining and documenting medications, contributing to these deficiencies.
Failure in Urinary Catheter Care Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to obtain and implement physician orders for urinary catheter care for a resident, leading to a significant health event. The resident, a male with a history of schizophrenia, heart disease, chronic kidney disease, and obstructive uropathy, was admitted with an indwelling urinary catheter. However, there were no physician orders documented for the catheter or its care. The facility also did not implement care plan interventions related to monitoring for urinary tract infection symptoms, which contributed to the resident's emergent hospitalization and diagnosis of septic shock. On the day of the incident, a registered nurse noted the resident had a fever and administered fever medication. Despite the resident's elevated temperature and subsequent confusion, the nurse delayed sending the resident to the hospital, hoping the fever would subside. The nurse did not assess the urinary catheter that morning, as it was considered special and not to be handled by nurses. The resident's urinary catheter care was supposed to be documented every shift, but there was no record of such assessments during the resident's stay. Interviews with facility staff revealed inconsistencies in the documentation and communication of the resident's condition. A wound care nurse observed a brown discharge from the resident's penis, indicating a possible infection, but this was not promptly addressed. The nurse practitioner had ordered a urinalysis and urine culture the day before the incident, but there was no record of these orders being executed. The lack of proper catheter care and monitoring, combined with inadequate documentation and communication, led to the resident's severe health decline and subsequent hospitalization.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, which was identified during a survey. The incident involved a female resident with a history of atrial fibrillation, chronic obstructive pulmonary disease, protein calorie malnutrition, heart failure, and osteoarthritis, who was hit in the back of the head by a male resident with a history of bipolar disorder, major depressive disorder, vascular dementia, and violent behavior. The incident occurred during a group activity, and the female resident reported that no staff were present at the time of the incident. She stated that she was startled but not hurt and that no nurse examined her afterward. A Registered Nurse (RN) later stated that she was nearby and assessed the female resident immediately after the incident, finding her to be fine but startled. The RN reported the incident to the doctor, Assistant Administrator, and the resident's family, and the male resident was sent to the hospital. Despite the RN's account, the female resident maintained that no nurse checked her after the incident. The facility's records and interviews with staff, including a Social Worker and Director of Social Services, indicated that the female resident had no concerns following the incident. However, the lack of immediate staff presence and the conflicting accounts of the incident highlight the facility's failure to protect the resident from abuse and ensure proper follow-up care.
Failure to Protect Residents from Mental Abuse and Intimidation
Penalty
Summary
The facility failed to protect residents from mental abuse and intimidation by staff, affecting three residents. During a complaint survey, these residents expressed concerns about staff instructing them not to speak with the survey team or participate in survey activities. The residents feared retaliation or neglect if they did not comply. One resident reported that when staff were upset, they would delay care or not respond to call lights promptly. Another resident described being told by a CNA to remain silent when surveyors were nearby, feeling infantilized and afraid of potential mistreatment. The third resident mentioned CNAs warning them not to cooperate with the survey team to avoid getting the staff in trouble. The residents did not disclose the identities of the staff members involved. The Assistant Director of Nursing and the Regional Clinical Consultant were informed of the allegations and stated they were unaware of such concerns. They initiated an investigation and provided residents with information about their rights. The facility's policies emphasize respecting resident rights and define mental abuse as including humiliation, harassment, and threats of punishment. The report highlights the facility's failure to prevent mental abuse and intimidation, as evidenced by the residents' experiences and the staff's actions.
Failure to Protect Resident's Belongings from Theft
Penalty
Summary
The facility failed to protect a resident's belongings from theft, resulting in the misappropriation of a cell phone and unauthorized access to a financial account. A resident, who was alert and oriented, reported that her cell phone was missing and suspected it was taken by a visitor of another resident. The incident involved a family member of another resident who was not logged in the visitor log and was seen exiting the resident's room. This unauthorized access led to the theft of approximately $300 from the resident's mobile payment application. The facility's Director of Customer Experience and Administrator confirmed the incident, acknowledging that visitors should not enter rooms of residents they are not visiting. The facility lacked security measures such as escorts for visitors or surveillance cameras, which contributed to the inability to monitor visitor activities effectively. The facility's abuse policy prohibits misappropriation of property, yet the incident occurred, highlighting a lapse in ensuring the safety and security of residents' personal belongings.
Failure to Provide Appropriate Activities for Bed-Bound Resident
Penalty
Summary
The facility failed to provide activities that met the needs and interests of a resident who was bed-bound with deformities. The resident, who had multiple sclerosis, severe-protein malnutrition, and quadriplegia, expressed a desire to participate in activities, specifically painting, which she loved to do. However, she reported not being able to attend activities because she did not have a wheelchair and was not assisted to attend them. Despite having intact cognition, as indicated by a BIMS score of 14, the resident was not provided with activities that accommodated her physical limitations. Interviews with staff revealed a lack of awareness regarding the resident's ability to use her right hand partially. The Activity Director was unaware of the resident's interest in painting and did not know she could move her hand. The facility's policy emphasized providing activities tailored to each resident's needs and interests, yet the resident's request for painting was not addressed. The Activity Director mentioned that the resident was on a one-to-one weekly conversation schedule, but no specific activities were conducted in her room, highlighting a gap in meeting her individual needs.
Failure in Resident Care and Medication Administration
Penalty
Summary
The facility failed to adhere to its policy and resident care plan concerning skin care and activities of daily living for a dependent resident, resulting in a severe incident involving maggots found in the resident's wounds. The resident, who has multiple sclerosis and quadriplegia, was readmitted to the facility after being sent to a hospital due to maggots being discovered in her wounds. Despite the facility's claims that the maggots were due to fruit in the resident's bed, multiple staff members confirmed the presence of maggots, which were found in various areas of the resident's body. The facility's documentation and interviews revealed inconsistencies and a lack of proper documentation regarding the incident. Additionally, the facility failed to administer prescribed medications to three residents, as evidenced by the absence of documentation in the Electronic Medication Administration Record (EMAR). One resident did not receive Diazepam for several days, and the staff could not provide a clear reason for the omission. Two other residents had multiple medications not administered, with signature boxes left blank in the EMAR, indicating the medications were not given. The facility's policy requires documentation and notification to healthcare providers if medications are not administered, which was not followed in these cases. The deficiencies in care and medication administration affected four residents in total, highlighting significant lapses in the facility's adherence to care plans and medication protocols. The lack of proper documentation and communication among staff members contributed to these failures, impacting the residents' health and well-being. The facility's policies on skin care, activities of daily living, and medication administration were not effectively implemented, leading to these serious deficiencies.
Failure to Report Allegation of Physical Abuse Immediately
Penalty
Summary
The facility failed to follow its abuse prevention policy and report an allegation of physical abuse immediately. This deficiency affected one resident who was reviewed for reporting allegations of abuse. On 5/28/24, the Director of Nursing (DON) was made aware of an allegation of physical abuse involving a resident who claimed that staff had been hitting and pinching them. The resident had a bruise on their left arm observed on 5/15/24, and was admitted to the hospital on 5/16/24 with subarachnoid bleeding. The hospital records indicated that the resident had reported to both a family member and an emergency room tech that facility staff had been hitting and pinching them. However, the DON did not inform the administrator of the abuse allegation immediately as required by the facility's abuse prevention policy. The facility's abuse prevention policy, dated 10/2022, mandates that any incident or suspicion of abuse must be reported to a department head and the administrator immediately, and to the State Surveying and Certification Agency within two hours. Despite this policy, the DON failed to report the allegation of abuse involving the resident to the administrator or the state agency in a timely manner. The resident's medical records from the hospital also noted a small acute subarachnoid bleed and possible trace subdural bleed, further emphasizing the severity of the situation. The failure to report the abuse allegation promptly and follow the established policy led to this deficiency being cited by the surveyors.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident who is at high risk for falls and has a history of falls. On 4/9/24, the Restorative Nurse (V12) confirmed that the resident (R20) should be in the lowest bed position for safety. However, during rounds, R20 was found lying in a high bed position approximately 38 inches from the floor, alone in her room. The CNA (V13) assigned to R20 admitted to placing the bed in the highest position while preparing to get the mechanical lift, leaving R20 unattended in an unsafe condition. R20 was admitted with multiple diagnoses, including Encephalopathy, Dementia, Psychotic disturbance, Anxiety, and Cerebrovascular disease, and had a care plan indicating a high risk for falls due to weakness from a recent hospitalization. The care plan specifically required the bed to be kept in the lowest position. Despite this, R20 had a history of two unwitnessed falls in her room. The facility's policy on Fall Prevention and Management, reviewed in 1/2024, mandates that residents at risk for falls should have their fall risk identified on the care plan with interventions implemented to minimize fall risk. This policy was not followed in R20's case, leading to the deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a dependent resident, R13. On the morning of 4/9/2024, R13 reported waiting all morning for assistance with incontinence care and to be placed in her wheelchair. The last assistance she received was at 4:30 am when her blood glucose was checked. At 10:30 am, R13 was found with a soaked hospital gown, a soaked incontinence pad, and wet bed linens, indicating she had not received timely care. The Assistant Director of Nursing (ADON) and the Lead Certified Nursing Assistant (CNA) confirmed that nursing assistants are expected to make rounds every two hours and as needed, which had not been done in this case. Further investigation revealed that the CNA assigned to R13 had observed her wet at 7 am but did not provide incontinence care, opting instead to take vital signs and attend to other residents. The CNA informed R13 that she would return after breakfast but was unable to do so. The Director of Nursing (DON) reiterated that CNAs should round every two hours and as needed. R13's care plan indicated a need for assistance with personal care and specified interventions to prevent skin complications, including turning and repositioning every one to two hours and providing skin care after each incontinent episode. The facility's policy on incontinence care, revised in January 2024, emphasizes keeping residents dry, comfortable, and odor-free to prevent skin breakdown.
Failure to Sign Controlled Substance Count Sheet
Penalty
Summary
The facility failed to sign the shift-to-shift controlled substance count sheet, acknowledging that the actual count of controlled substances and the count sheet matches the quantity documented. This deficiency was observed on North Unit Medication cart 1, affecting one of four medication carts reviewed. On multiple occasions, including specific shifts on 4/2/24, 4/3/24, 4/4/24, and 4/8/24, numerous nurse's signatures were missing. The LPN confirmed that both off-going and on-coming nurses are supposed to sign after counting the narcotic/controlled substance count sheet. The Assistant Director of Nursing reiterated that the policy requires both nurses to count all controlled drugs together at each change of shift and sign. The facility's policy on controlled substances, reviewed on 1/10/2024, mandates that all scheduled II-controlled substances be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses, with both nurses signing the count sheet to acknowledge the match between the actual count and the documented quantity.
Failure to Monitor Medication Storage and Labeling
Penalty
Summary
The facility failed to monitor and document medication refrigeration temperatures and did not date a tuberculin purified protein vial after opening, as per manufacturer recommendations. During an inspection of the West unit medication room, an opened tuberculin purified protein vial was found without a date, which should have been discarded after 30 days. The LPN acknowledged that the vial should have been dated upon opening. In the North unit medication room, the medication refrigerator temperature was found to be 40F, but the temperature monitoring log was incomplete for several days in April and March. The LPN confirmed that the night shift is responsible for this task, but it had not been consistently performed. The facility's policy on medication storage, reviewed in January 2024, mandates that medications and biologicals be stored safely and securely, with proper temperature monitoring and dating of multi-dose vials. Despite this policy, the facility did not adhere to these procedures, as evidenced by the missing dates on the tuberculin vial and the incomplete temperature logs. The Assistant Director of Nursing confirmed that these practices should have been followed, indicating a lapse in adherence to the facility's own policies and procedures.
Failure to Offer and Document Required Vaccinations
Penalty
Summary
The facility failed to offer and document influenza, pneumococcal, and COVID-19 vaccinations as required for three of five residents reviewed for immunization. During a record review, it was found that two residents' immunization records did not indicate whether they had received or refused the pneumococcal, influenza, and COVID-19 vaccines. Another resident's record showed that the last pneumococcal vaccination was administered in 2022, with no documentation of any subsequent vaccinations or refusals. Interviews with the Director of Nursing and the Infection Preventionist revealed that all immunizations given or refused should be documented, and the Infection Preventionist, who had been in the position for two weeks, was responsible for ensuring residents' immunizations were up to date upon admission. Additionally, the Unit Manager confirmed that admitting nurses assess and document immunizations for all new residents. The facility's policies, reviewed in January 2024 and May 2023, state that all residents or their responsible parties should be screened and offered the pneumococcal vaccine within the first week of admission and annually, as well as the COVID-19 and influenza vaccines. If a resident or their responsible party declines a vaccine, this information should be documented in the electronic health record. However, the facility failed to adhere to these policies, resulting in incomplete immunization records for the three residents in question.
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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