Allure Of Peru
Inspection history, citations, penalties and survey trends for this long-term care facility in Peru, Illinois.
- Location
- 1301 21st Street, Peru, Illinois 61354
- CMS Provider Number
- 145044
- Inspections on file
- 24
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Allure Of Peru during CMS and state inspections, most recent first.
Surveyors found that controlled substances were not reconciled or secured according to facility policy. A nurse kept a resident’s taped hydrocodone-acetaminophen bottle on a med cart without visually verifying pill counts and acknowledged the tape could be removed and reapplied undetected. In the med room, stock Schedule II–V drugs, including opioids and benzodiazepines, were stored in plastic containers on top of a refrigerator rather than in a permanently affixed locked cabinet. Another nurse accessed a resident’s lorazepam from an unlocked storage closet, checked only the outer box, and returned it to a refrigerator that all staff could access and that was not continuously visible, creating multiple lapses in controlled substance accountability and security for all residents.
A resident with a PRN order for Lorazepam oral concentrate for anxiety had a 30 ml bottle of the controlled medication delivered and signed in by an RN, with documentation showing only two 0.25 ml doses administered. When an RN later went to give another dose, she found less than 1 ml remaining in a bottle that should have been nearly full and notified the ADON, who confirmed the discrepancy and shared a photo showing the low volume. The DON verified that the narcotic count was inaccurate and that no undocumented doses or spills were identified. All staff with access to the medication denied giving, spilling, or accessing it, and the facility was unable to determine what happened to the missing Lorazepam, indicating a failure to prevent misappropriation of the resident’s medication.
A resident with significant mobility and health issues was left in the bathroom without access to a functioning call light, as the call string was broken and on the floor. Staff did not notice or report the broken call light, and the resident, unable to summon help, called 911 using her personal phone. The police responded and found the resident still waiting for assistance.
A registered nurse left electronic medical records open and unlocked on a medication cart in a busy hallway while administering medications to two residents. During this time, staff and other residents passed by the cart, potentially exposing confidential health information.
A resident's care plan did not include fingernail care, despite facility policies requiring all aspects of care, including nail care, to be documented with specific details such as frequency, type, and responsible staff. Staff confirmed that nail care was not routinely added to care plans, resulting in this omission.
Two residents who required substantial assistance with personal hygiene were observed with long, dirty, and jagged fingernails, despite facility policy and documentation indicating nail care should have been provided. Staff confirmed the inadequate nail care, and one CNA admitted to only wiping a resident's hands without proper cleaning or trimming. The DON also acknowledged that nail care had not been performed as required.
A registered nurse did not change gloves between removing a soiled dressing and cleansing a stage III pressure ulcer on a resident's left heel, contrary to facility policy requiring glove change and hand hygiene between these steps.
Two residents were not administered medications according to physician orders and pharmacy instructions, resulting in a medication error rate above 5%. In one case, a nurse gave Carafate with other medications and food, contrary to label instructions. In another, Carbidopa/Levodopa was given mixed in applesauce instead of being allowed to disintegrate on the tongue, as directed.
A registered nurse left multiple medication bubble cards unattended on top of a medication cart in a busy hallway while administering medications to two residents. During these periods, the medications were not under direct observation or locked, contrary to facility policy, and were accessible to staff and residents passing by.
Two residents experienced deficiencies related to inaccurate medical record documentation and medication order entry. In one case, a CNA documented that a resident's nails were trimmed without confirming the task was completed. In another case, a medication was administered in a manner inconsistent with pharmacy instructions due to an error in the order entry by the DON.
The facility failed to report allegations of theft involving two residents to local law enforcement, as required by their policy. One resident reported missing money and a blank check left in a medication cart, while another reported $27 missing from a change purse. The administrator did not notify the police, citing the residents' circumstances and a lack of awareness of the reporting obligation.
The facility failed to utilize proper infection prevention and control measures, including the use of PPE, hand hygiene, and equipment sanitization, affecting six residents and potentially impacting 79 residents. Staff did not follow enhanced barrier precautions or facility policies, as confirmed by observations and interviews.
A resident with bilateral above-the-knee amputations was unable to see himself in the mirror from his wheelchair, preventing him from shaving and maintaining personal hygiene. The restorative nurse was unaware of this issue, and the resident's care plan included encouraging participation in personal hygiene activities.
The facility failed to implement person-centered baseline care plans for two residents within 48 hours of admission. One resident with multiple medical conditions and another with a history of suicidal ideations did not have their personalized needs addressed in their care plans.
A facility failed to ensure a resident with hemiplegia and hemiparesis wore a recommended splint to prevent tendon shortening and contracture. The resident's care plan and MDS assessment indicated the need for the splint, but it was not included in the current POS due to an oversight after hospitalization. Staff admitted to not putting the splint on the resident, and the splint was observed lying on the bedside table instead of being worn.
A facility failed to limit a PRN psychotropic medication to 14 days for a resident with Dementia and Adjustment Disorder. The resident's Physician Order Sheet included an order for Lorazepam to be given every 8 hours as needed for 90 days, without the required documentation for extended use by the physician. The Director of Nursing was unable to produce the necessary documentation, indicating non-compliance with the facility's policy.
The facility failed to administer medications as ordered by the physician for two residents, resulting in an 8% medication error rate. Errors included improper timing of Sucralfate administration and incomplete infusion of Vancomycin.
A resident with multiple diagnoses, including Osteomyelitis and MRSA, did not receive the full dose of Vancomycin due to a nurse's failure to adjust the IV fluid volume to account for an additional 50 mL of sterile water. The error was confirmed by a pharmacist as a significant medication error.
The facility failed to provide pureed bread for three residents on pureed diets during lunch. The cook/assistant manager did not prepare pureed bread, and it was confirmed by the dietary manager that it should have been made and served. Physician orders documented the need for pureed texture diets for the affected residents.
Failure to Reconcile and Secure Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to ensure that controlled substances were reconciled and stored in accordance with its own policies and accepted professional standards. The facility’s Medication Storage policy requires Schedule II drugs and back-up stock of Schedule III–V medications to be stored under double lock and key, and Schedule II medications stored in the same area as other medications (such as in a refrigerator) to be kept in a separately locked, permanently affixed compartment. The Controlled Substance Administration and Accountability policy requires that all controlled substances obtained from a non-automated cart or cabinet be recorded on a designated usage form, and that in areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. Despite these policies, surveyors observed multiple deviations during medication cart and storage reviews. During reconciliation of the west wing medication cart with a registered nurse, a taped prescription bottle of hydrocodone-acetaminophen 7.5 mg/325 mg for one resident was found; the nurse stated she did not open the taped bottle to count the remaining pills, acknowledged she could not see how many pills were inside, and noted that the tape could be removed and reapplied without detection. She also stated that the resident was no longer receiving the dose in that bottle. In the medication room, two plastic containers holding Schedule II–V stock medications were observed sitting on top of a small refrigerator, and the nurse confirmed these were not in an affixed locked cabinet, despite the facility’s control box inventory including multiple opioids, benzodiazepines, and other controlled substances. On the north medication cart, another registered nurse retrieved a resident’s lorazepam 2 mg/mL from an unlocked storage closet, looked only at the box, and returned it to the refrigerator without opening the box to check the bottle; this nurse stated that all staff had access to the refrigerator in the stock room and that the stock room was not continuously visible, making it possible for someone to remove the refrigerator. At the time of the survey, the midnight census documented 82 residents residing in the facility.
Unexplained Loss of Controlled Anxiolytic Medication for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property by not ensuring appropriate controls and interventions were in place to prevent the misappropriation of a controlled medication. The facility’s Abuse and Retaliation Policy Prevention Program affirms residents’ rights to be free from misappropriation of property. A Proof of Delivery form dated 2/7/26 shows that a 30 ml bottle of Lorazepam 2 mg/ml was delivered and signed in by a registered nurse (V4). The resident (R1) had an order for Lorazepam oral concentrate 0.25 ml by mouth every two hours as needed for anxiety for 14 days. The Controlled Drug Receipt/Record/Disposition form for R1, also dated 2/7/26, documents that the 30 ml vial was received and that only two doses of 0.25 ml each were signed out on 2/12/26 at 5:19 p.m. and 10:15 p.m., which should have left nearly the entire bottle remaining. On 2/13/26, the DON (V2) was notified by the ADON (V3) of an incorrect narcotic count for R1’s Lorazepam. V2 compared the remaining amount of medication in the bottle with the count sheet and confirmed the count was inaccurate. V2’s review did not identify any undocumented administered doses. V3 reported receiving a call from a registered nurse (V6) stating that R1’s Lorazepam was missing and that there was less than 1 ml in the bottle that was supposed to be full; V6 also sent V3 a picture showing less than 1 ml of liquid in the bottle. V6 stated she discovered the discrepancy when she went to administer a 0.25 ml dose and observed that there was less than 1 ml left, and verified that she had not given or spilled any of the medication and that it was gone before she attempted to administer it. Despite interviews with all staff who had access to the medication, everyone denied giving, spilling, or accessing the bottle, and the facility could not determine what happened to the resident’s Lorazepam.
Resident Left Without Accessible Call Light in Bathroom
Penalty
Summary
A resident with multiple diagnoses, including pneumonia, heart failure, COPD, atrial fibrillation, gait abnormalities, anxiety, unsteadiness, dependence on supplemental oxygen, and osteoarthritis, was placed in the bathroom by staff and left without access to a functioning call light. The resident reported that the bathroom call string was broken and lying on the ground, making it inaccessible. She waited on the toilet for an extended period without staff checking on her and ultimately used her phone, which she keeps on a lanyard, to call 911 for assistance. The police responded after 911 was unable to reach the facility by phone, and the resident was found still on the toilet, appearing anxious and expressing a fear of falling and a need for assistance with transfers. Staff interviews confirmed that the call light was not provided to the resident and that the broken call string was not reported or noticed by the staff responsible for her care. The facility's policy requires that call lights be accessible to residents at each toilet and that staff report any problems with the call light system immediately. The administrator confirmed that the call light was broken and that the resident was left in the bathroom without a means to call for help, despite being assessed as a fall risk.
Failure to Maintain Privacy of Residents' Health Information
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' health information for two residents. A registered nurse (RN) was observed administering medications in a dining room area, with the medication cart positioned in a high-traffic hallway. During medication preparation, the RN left the electronic medical record open and unlocked on a laptop atop the medication cart, displaying residents' clinical records. While the RN was away from the cart administering medications or retrieving water, staff and residents passed by the cart, potentially exposing confidential health information. The RN later confirmed awareness that the computer screen should not have been left unlocked and visible.
Failure to Include Nail Care in Resident Care Plan
Penalty
Summary
The facility failed to include fingernail care in the care plan for one resident, despite having policies that require all aspects of care, including nail care, to be addressed in each resident's comprehensive care plan. The facility's Comprehensive Care Plans policy mandates the development and implementation of a person-centered care plan that includes measurable objectives and timeframes for all identified needs, while the Nail Care policy specifically requires the care plan to document the frequency, type, and responsible person for nail care. Record review and staff interviews confirmed that the resident's current care plan did not address fingernail care, and staff acknowledged that nail care was not routinely added to care plans, contrary to facility policy.
Failure to Provide Nail Care for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to provide appropriate nail care for two residents who required assistance with activities of daily living. One resident was observed on multiple occasions with long fingernails and a dark brown substance under all nails, despite documentation indicating that nail care had been completed. The resident expressed dissatisfaction with the condition of their nails, and both an activity aide and a licensed practical nurse confirmed the nails were long and dirty. The CNA responsible for the resident's care stated that she only wiped the resident's hands with a washcloth and did not soak, clip, or clean under the nails as required by facility policy. Another resident, who was moderately cognitively impaired and required substantial assistance with personal hygiene, was observed with long, jagged, and sharp fingernails. The resident reported not knowing where to get their nails cut and that their nails were breaking off. The DON confirmed that the resident's nails were long, broken, and jagged and should have been clipped. These findings indicate that the facility did not follow its own nail care policy, which requires routine cleaning, trimming, and documentation of nail care for residents needing assistance.
Failure to Change Gloves During Pressure Ulcer Dressing Change
Penalty
Summary
A registered nurse failed to follow the facility's clean dressing change policy during the treatment of a resident with a stage III pressure ulcer on the left heel. The nurse removed the resident's soiled dressing while wearing gloves, but did not change gloves before cleansing the wound with gauze wet with normal saline. The same soiled gloves were used for both removing the dressing and cleansing the wound, contrary to the facility's policy, which requires glove removal and hand hygiene after dressing removal and before wound cleansing. The resident was observed sitting in a wheelchair at the time of the dressing change, and the wound was described as an open area approximately the size of a dime with a small amount of drainage.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and pharmacy instructions for two residents during medication administration, resulting in a medication error rate of 7.69%. In the first instance, a registered nurse administered multiple oral medications, including Carafate, to a resident while the resident was eating breakfast. The pharmacy label for Carafate specified that it should be given at least two hours before or after other medications and on an empty stomach, but the nurse confirmed that it was not administered as directed, and there were no alternative instructions from the physician. In the second instance, another resident received Carbidopa/Levodopa and Acetaminophen mixed in applesauce while eating breakfast. The pharmacy label for Carbidopa/Levodopa instructed that the medication should be placed on the tongue and allowed to disintegrate, but the nurse administered it mixed in applesauce, contrary to the label instructions. The nurse acknowledged this deviation from the pharmacy instructions and stated it was the first time administering the medication in this manner.
Medications Left Unsecured During Administration
Penalty
Summary
Surveyors observed that the facility failed to securely store medications during medication administration for two residents. Specifically, a registered nurse (RN) left multiple multi-dose medication bubble cards, including prescription and over-the-counter drugs, on top of a medication cart in a high-traffic hallway while administering medications to residents. During these times, the medication cart was unattended as the RN walked away to assist residents, and other staff and residents passed by the cart, leaving the medications accessible and unsecured. The facility's policy requires all drugs and biologicals to be stored in locked compartments or under the direct observation of the person administering medications. However, the RN confirmed that medications were left unattended on the cart, in violation of this policy. The medications left unsecured included Vitamin B-12, Carafate, Lipitor, Apixaban, Lasix, Zestril, Toprol XL, Potassium Chloride, Hydrodiuril, Preservision, and Zoloft. The events were confirmed through observation, interview, and review of facility policy.
Inaccurate Medical Record Documentation and Medication Order Entry
Penalty
Summary
The facility failed to ensure the accuracy of resident medical records for two residents. In the first instance, a resident was observed on two occasions to have long, sharp, and jagged fingernails, despite documentation by a Certified Nursing Assistant (CNA) indicating that the resident's nails had been trimmed. The CNA later confirmed that she had charted the task as completed without verifying that it had actually been done. The Director of Nursing (DON) stated that CNAs should not document care for residents unless they have direct knowledge of the care provided. In the second instance, a resident received Carbidopa/Levodopa medication administered with applesauce, contrary to the pharmacy label instructions, which specified that the medication should be placed on the tongue and allowed to disintegrate. Upon review, it was discovered that the medication order had been entered incorrectly as a dispersing type instead of an oral dose. The DON acknowledged that the error occurred during order entry, likely due to selecting the wrong template.
Failure to Report Allegations of Theft to Law Enforcement
Penalty
Summary
The facility failed to report potential allegations of theft to local law enforcement for two residents, R1 and R2, who were reviewed for misappropriation of property. According to the facility's Abuse, Neglect, and Exploitation policy, any allegations of theft should be reported to the state survey agency and local law enforcement. However, the facility did not notify the police in either case. R1, a former resident, reported missing money and a blank check that were left in an envelope locked in a medication cart's narcotic box. Upon discharge, R1 contacted the facility to retrieve the envelope, only to find the money missing. Similarly, R2 reported $27 missing from a change purse in their room. The facility's administrator, V1, admitted to not notifying the police in both instances. V1 stated that R1 was already at home and declined the offer to involve the police, while for R2, V1 was uncertain if the money was lost or misplaced. V1 also acknowledged being unaware of the obligation to report such allegations to law enforcement, despite the facility's policy clearly stating this requirement. The failure to report these incidents to the police constitutes a deficiency in adhering to the facility's established policies and procedures for handling allegations of theft.
Infection Control Deficiencies
Penalty
Summary
The facility failed to utilize proper infection prevention and control measures for six residents, which has the potential to affect 79 residents. Specifically, staff did not use appropriate PPE, perform hand hygiene during medication administration, initiate enhanced barrier precautions, or sanitize equipment after use in enhanced barrier precaution rooms. For instance, CNAs entered a resident's room with only masks on and used a mechanical lift without cleaning or disinfecting it afterward. Additionally, a resident with a urinary catheter did not have an Enhanced Barrier Precaution sign on their door, and CNAs entered the room without performing hand hygiene. Furthermore, a registered nurse failed to perform hand hygiene before administering medications to multiple residents in enhanced barrier precaution rooms. The nurse also touched medication with bare hands before giving it to a resident. These actions are in direct violation of the facility's policies and CDC recommendations, as documented in the facility's Cleaning and Disinfection of Resident-Care Equipment and Medication Administration policies. The deficiencies were confirmed through observations, interviews, and record reviews conducted by the surveyors.
Failure to Provide Mirror for Self-Grooming
Penalty
Summary
The facility failed to provide a resident with a mirror to allow for self-grooming, which is necessary for maintaining personal hygiene. The resident, who has bilateral above-the-knee amputations and is at risk for an ADL Self Care Performance Deficit, was observed with visible facial hair and stated that he could not see himself in the mirror from his wheelchair, making it difficult for him to shave. The resident's care plan included encouraging him to participate in personal hygiene activities, but the restorative nurse was unaware that the resident could not see himself in the mirror. Despite adjusting his wheelchair, the resident was still unable to see his chin in the mirror, preventing him from shaving properly.
Failure to Implement Person-Centered Baseline Care Plans
Penalty
Summary
The facility failed to implement a person-centered baseline care plan for two residents within 48 hours of admission. Resident 281, admitted with multiple diagnoses including a fracture of the neck of the left femur, acute urinary tract infection, acute metabolic encephalopathy, dementia, hearing impairment, lacunar stroke, and mild aortic insufficiency, did not have a baseline care plan addressing their personalized needs. Similarly, Resident 283, who had a history of suicidal ideations and mental disorders, did not have these issues addressed in their current care plan. The Care Plan Director confirmed that the baseline care plans were generic checklists and not personalized, and the Social Service Director verified the omission of critical mental health concerns in Resident 283's care plan.
Failure to Ensure Resident Wore Recommended Assistive Device
Penalty
Summary
The facility failed to ensure an order was placed and a resident was wearing a recommended assistive device for a resident with limited range of motion. The resident, who has hemiplegia and hemiparesis following a cerebrovascular disease, was observed without the required splint on multiple occasions. The resident stated that she had difficulty getting someone to put the splint on, and it was supposed to be worn for four hours on and four hours off. A CNA admitted to not putting the splint on the resident due to being in a hurry. The resident's care plan and MDS assessment indicated the need for the splint, but the physician's order for the splint was missing from the current POS due to an oversight after the resident's hospitalization in February. The Director of Rehab and the Restorative Nurse confirmed that the splint order was not re-entered into the POS after the resident's hospitalization. The resident's care plan included specific instructions for the use of the splint to prevent tendon shortening and contracture, but these instructions were not followed. The splint was observed lying on the bedside table instead of being worn by the resident, indicating a failure to provide the necessary care and interventions as per the resident's care plan and professional standards of practice.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a psychotropic medication ordered PRN (as needed) was limited to 14 days for one resident reviewed for Unnecessary Medications. The facility's policy states that PRN orders for psychotropic drugs should be used only when necessary to treat a diagnosed specific condition and for a limited duration of 14 days. If the attending physician believes the PRN order should be extended beyond 14 days, they must document their rationale in the resident's medical record and indicate the duration for the PRN order. However, the resident's Physician Order Sheet included an order for Lorazepam to be given every 8 hours as needed for 90 days, without the required documentation for extended use by the physician. The resident had diagnoses of Dementia with Psychotic Disturbance and Adjustment Disorder with Mixed Anxiety and Depressed Mood. The order for Lorazepam was dated 4/29/23, with an ending order date of 7/28/24. On 5/16/24, the Director of Nursing was unable to produce documentation from the resident's physician justifying the extended use of Lorazepam. This lack of documentation indicates non-compliance with the facility's policy on the use of psychotropic medications and PRN orders, leading to the identified deficiency.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered by the physician for two residents, resulting in an 8% medication error rate. For one resident, the nurse administered Sucralfate along with other medications, despite the physician's order to take it two hours before or after other medications. This error was observed when the nurse placed Sucralfate, Gabapentin, and Lasix in the same medication cup and handed it to the resident, who took all three pills together. The nurse later verified that Sucralfate should have been given separately. For another resident, the nurse incorrectly administered Vancomycin intravenously. The nurse mixed the Vancomycin powder with sterile water and injected it into a bag of Normal Saline, but did not account for the additional volume of sterile water when programming the IV pump. As a result, the IV bag still contained 50-60 mL of the Vancomycin mixture when the nurse disconnected it, meaning the resident did not receive the full prescribed dose. The nurse acknowledged the error upon verification.
Failure to Administer Full Dose of Vancomycin
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident (R72) of seven residents reviewed for medication administration. The resident had diagnoses including Osteomyelitis of the Vertebra, Thoracic Region, Methicillin-Resistant Staphylococcus Aureus Infection, and Type 2 Diabetes Mellitus. The physician's order required the administration of Vancomycin HCl Intravenous Solution 2500 mg in the morning. On 5/14/24, a registered nurse (V6) mixed 20 mL of Sterile Water into three vials of Vancomycin 1 GM powder and injected the mixed solution into a 500 mL bag of Normal Saline, resulting in a total of 550 mL with 2500 mg of Vancomycin. The nurse programmed the IV pump for 500 mL of fluid over 180 minutes, not accounting for the additional 50 mL of sterile water added to the solution. When the nurse returned to disconnect the IV Vancomycin, approximately 50-60 mL of the Vancomycin mixture remained in the bag. The nurse flushed the PICC line with Normal Saline and Heparin and disposed of the Vancomycin IV bag with the remaining fluid. The nurse acknowledged that the directions did not account for the additional 50 mL of sterile water, resulting in the resident not receiving the full dose of Vancomycin. A pharmacist (V14) confirmed that the volume of fluid to be infused should have been adjusted to compensate for the additional 50 mL, and considered this a significant medication error.
Failure to Provide Pureed Bread for Residents on Pureed Diets
Penalty
Summary
The facility failed to ensure pureed bread was provided for residents' lunch for three residents on pureed diets. The facility's policy required pureed bread to be served as a separate menu item and held at the appropriate temperature throughout the meal service. On the specified date, the cook/assistant manager pureed ham and Brussel sprouts but did not prepare pureed bread. During meal service, it was observed that there was no pureed bread on the steam table. The cook/assistant manager confirmed that pureed bread was not made for lunch that day. The dietary manager later stated that pureed bread should have been made and served. The physician order sheets for the three residents documented orders for regular diets with pureed texture and thin consistency.
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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