Amberwood Care Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockford, Illinois.
- Location
- 2313 North Rockton Avenue, Rockford, Illinois 61103
- CMS Provider Number
- 145908
- Inspections on file
- 32
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Amberwood Care Centre during CMS and state inspections, most recent first.
A cognitively impaired, high fall-risk resident with Alzheimer's and dementia, who required substantial/maximal assistance with toileting, was left alone in the bathroom after requesting privacy while her daughter was in the room. The CNA relied on the daughter’s assurance that she would stay, then left to pass drinks to other residents. The daughter later informed the CNA in the hallway that she was leaving and that the resident remained on the toilet, but the CNA continued passing drinks before returning to the room. When the CNA and an LPN returned, the resident was found on the bathroom floor after an unwitnessed fall while attempting to self-transfer, and was later found to have sustained a finger fracture.
A resident with multiple medical conditions, including diabetes and peripheral vascular disease, was not seen by a podiatrist for about six months despite repeated requests and visible signs of severe toenail overgrowth. Staff acknowledged the resident's need for podiatry care, but the resident was not added to the podiatry list or seen during scheduled visits, contrary to facility policy.
During an extended air conditioning outage, the facility failed to maintain safe and comfortable room temperatures, with logs showing multiple areas exceeding 80°F for several days. Several residents with complex medical conditions reported discomfort and worsening symptoms due to the heat, and staff confirmed the environment was excessively hot. Temperature monitoring was inconsistently performed and relied on inadequate equipment, and not all residents were offered fans or room changes as required by facility policy.
Surveyors identified that the facility did not consistently date or discard expired foods, and failed to maintain complete temperature logs for food storage and meal preparation. Multiple undated and expired food items were found in kitchen refrigerators, and temperature records were missing for several days. Dietary staff confirmed these lapses, and several residents and CNAs reported frequent issues with cold or overcooked meals, with many residents leaving food uneaten.
A resident with severe cognitive impairment was found to have acute rib fractures, with no clear cause identified. Staff confirmed the resident had no pain or injury following a previous fall, and pain only developed days later. Despite facility policy requiring reporting of injuries of unknown origin, no such report was filed, and the incident was not properly documented to authorities.
A resident with severe cognitive impairment developed acute rib fractures of unknown origin, and the facility failed to conduct a formal investigation as required. Despite staff noting no pain or incidents between an earlier fall and the onset of pain, and the physician questioning the link between the fall and the fractures, the DON confirmed that only informal notes were made and no formal investigation was completed.
A resident with severe cognitive impairment and multiple medical conditions did not have their pain and anxiety medications documented on the eMAR, despite being administered by LPNs. The facility's policy requires immediate documentation, which was not followed, leading to a deficiency.
The facility failed to maintain a clean and homelike environment for several residents. One resident's room had chipped paint, stains, and a strong urine odor, while another's power of attorney noted moldy ceiling tiles and dirty walls. Two residents experienced water pooling from air/heating units, with one unit missing a thermostat cover. The Maintenance Director acknowledged these issues, which contradicted the facility's policy for a clean and orderly environment.
A resident with insomnia and other medical conditions did not receive a scheduled sleep study due to logistical issues and a canceled order by the ADON without physician consultation. Despite options for in-house testing or staff assistance, the study was not completed, contrary to facility policy.
Two residents in an LTC facility suffered from inadequate pressure injury care. One resident developed a Stage 2 pressure injury due to insufficient repositioning and incontinence care, while another with pre-existing Stage 3 and 4 injuries was not provided with appropriate pressure-relieving surfaces. These deficiencies highlight the facility's failure to adhere to care plans and policies.
The facility failed to provide adequate range of motion (ROM) services to two residents. One resident with a history of stroke was not placed on a restorative program or given a device for contractures until prompted by a surveyor. Another resident, part of the restorative services program, did not receive the prescribed twice-daily ROM exercises consistently. These actions were contrary to the facility's policy on restorative nursing services.
The facility failed to prevent a resident with cognitive deficits from attempting to exit through a fire exit door due to a malfunctioning alarm and inadequate supervision. Additionally, a CNA improperly transferred a resident with Multiple Sclerosis by not using a gait belt, contrary to the resident's care plan and facility policy.
The facility failed to maintain proper catheter care for three residents, with drainage bags positioned incorrectly, leading to potential infection risks. One resident's bag was at bladder level, another's was above the bladder causing backflow, and a third's was placed on the floor. Staff acknowledged the need for bags to be below bladder level, as per facility policy.
The facility failed to follow infection control protocols for two residents. A CNA did not change gloves or wash hands after providing incontinence care to a resident, and another CNA did not wear a gown while caring for a resident on Enhanced Barrier Precautions due to a urinary catheter. These actions were against the facility's policies on glove use, hand hygiene, and EBP.
The facility failed to provide correct meal portion sizes to residents, as observed during a lunch meal. The dietary aide used incorrect serving utensils, resulting in portions that did not meet the facility's dietary guidelines. The Certified Dietary Manager and Registered Dietician confirmed the discrepancies, noting that the facility's policies on portion control and nutritional adequacy were not followed.
Failure to Supervise High Fall-Risk Resident During Toileting
Penalty
Summary
Failure to ensure adequate supervision during toileting occurred when a cognitively impaired, high fall-risk resident with Alzheimer's disease and dementia was left alone in the bathroom and subsequently sustained a fall with injury. The resident’s records, including a Morse Fall Scale dated 2/16/26, identified her as high risk for falls due to a history of falling, impaired gait, and a tendency to overestimate or forget her limits. Her MDS indicated she was not cognitively intact and required substantial/maximal assistance with toileting, and her care plan documented impaired cognitive function, confusion, impaired balance, and high fall risk related to gait/balance problems. Staff interviews confirmed that she was “pleasantly confused,” frequently tried to get up on her own, and was considered a high fall risk who should not be left alone in the bathroom. On the evening of the incident, a CNA assisted the resident to the toilet while the resident’s daughter was present in the room. The resident requested privacy, and the daughter told the CNA it was acceptable to leave because she would remain in the room. The CNA left the room and began passing drinks to other residents. The daughter then informed the CNA in the hallway that she was leaving and that the resident was still on the toilet, explaining she did not want her mother to see her leave. The CNA continued passing drinks to a few more residents before returning to check on the resident, at which time the resident was found on the bathroom floor sitting on her buttocks. The nurse’s assessment and the facility’s incident report documented that the fall was unwitnessed, occurred in the bathroom while the resident was attempting to self-transfer, and resulted in a left 4th finger fracture identified on ER imaging.
Failure to Provide Timely Podiatry Care for Resident with Foot Complications
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, COPD, type 2 diabetes with diabetic peripheral angiopathy with gangrene, anxiety, and peripheral vascular disease was admitted to the facility and had not been seen by a podiatrist for approximately six months. The resident reported to several staff members the need to see a podiatrist, and staff responses indicated he would be added to the list for a podiatry visit. Upon observation, the resident's left big toenail was found to be extremely overgrown, curved, thickened, jagged, and discolored, with additional overgrown toenails and a prior amputation of the left third toe digit. A Licensed Practical Nurse confirmed the resident's request for podiatry care and acknowledged the toenails were overgrown. The Director of Nursing stated that the facility sends a census to the podiatrist before their bimonthly visits and notifies them of new admissions, but confirmed the resident had not yet been seen. The facility's policy requires residents with foot disorders or medical conditions associated with foot complications to be referred to qualified professionals, but this was not followed in this case.
Failure to Maintain Safe Ambient Temperatures During Air Conditioning Outage
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment by not ensuring that ambient room temperatures remained within acceptable ranges during an extended air conditioning outage. Multiple temperature logs documented that temperatures in resident rooms and common areas consistently exceeded 80 degrees Fahrenheit, with some readings as high as 91 degrees. The facility's own policy required action when temperatures rose above 80 degrees, but logs showed that this threshold was repeatedly surpassed over several days. Despite the ongoing issue, temperature monitoring was not consistently performed, and the last available log was not current for the final days of the outage. Residents with significant medical conditions, including multiple sclerosis, congestive heart failure, chronic obstructive pulmonary disease, and cognitive impairments, reported discomfort and adverse effects due to the heat. One resident with multiple sclerosis stated that the heat exacerbated his symptoms, causing him to remain in bed for several days to avoid worsening his condition. Other residents described the environment as "really hot," with some noting increased fatigue, sweating, and respiratory discomfort. Staff interviews confirmed that the facility was "drastically hot" and that many residents stayed in their rooms with fans, though not all residents were offered fans or room changes to cooler areas. The facility's maintenance and administrative staff acknowledged the air conditioning failure and described efforts to contact repair services and monitor temperatures. However, it was revealed that temperature checks were being conducted using surface thermometers rather than devices capable of accurately measuring ambient air temperature. The administrator was unaware that this method was insufficient for monitoring room conditions. The facility's policies required routine monitoring and specific actions when temperatures exceeded safe levels, but these procedures were not fully implemented, and documentation of temperature monitoring was incomplete for the final days of the incident.
Failure to Properly Store, Date, and Monitor Food Temperatures
Penalty
Summary
Surveyors found that the facility failed to ensure proper food storage, dating, and temperature monitoring in the kitchen, affecting all residents. During observation, multiple food items in both the reach-in and walk-in refrigerators were found without dates, including salads, butter, cheese, fruit cocktail, shredded lettuce, turkey breast, pudding cups, and cut watermelon. Some items were past their expiration dates, such as cottage cheese and sour cream. Dietary staff confirmed that undated or expired food should be discarded, and that all foods must be labeled and dated according to facility policy. Additionally, review of refrigerator and freezer temperature logs revealed multiple missing entries for both June and July, with dietary staff unable to locate current temperature records. Food temperature logs for prepared meals also had multiple missing entries, particularly for evening meals. Interviews with residents revealed frequent complaints about the quality and temperature of the food, with several stating that meals were often served cold, overcooked, or inedible. Certified Nurse Aides corroborated these complaints, noting that residents regularly left food uneaten and that staff had to address kitchen errors. Review of facility policies confirmed the requirement for food to be covered, labeled, and dated, and for temperatures to be recorded and monitored. The lack of adherence to these procedures led to the deficiency cited by surveyors.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident who was reviewed for accidents. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and metabolic encephalopathy, was found to have acute, minimally displaced fractures of the right 10th and 11th ribs. Staff interviews and record reviews revealed that the resident had a documented fall on one date, with no injury or pain noted at that time or in the days following. Several staff members, including LPNs and CNAs, confirmed that the resident did not complain of pain or show signs of injury until a week later, when he began to guard his right side and express pain during movement. Upon discovery of the rib fractures, the Director of Nursing attributed the injuries to the earlier fall, despite the absence of pain or symptoms in the intervening period. The nurse practitioner and physician both expressed doubt that the fractures could have resulted from the earlier fall, given the delayed onset of pain and the typical presentation of rib fractures. The facility did not file a separate report for the injury of unknown origin, and the incident log did not list any other accidents or injuries for the resident between the fall and the discovery of the fractures. The facility's Abuse and Prevention Program requires that injuries of unknown source be reported to the Department of Public Health, especially when the source is not observed or cannot be explained and the injury is suspicious due to its extent. Despite this policy, the facility was unable to provide a report regarding the injury of unknown origin, and the only report submitted referenced the earlier fall, which staff and medical review could not conclusively link to the rib fractures.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident who was found to have acute, minimally displaced right lateral fractures of the 10th and 11th ribs. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and metabolic encephalopathy, was noted to have fallen on one occasion, but did not exhibit pain, bruising, or complaints immediately following the fall. Staff interviews confirmed that the resident had no pain or abnormal findings in the days following the fall, and no further incidents or injuries were reported until the resident began complaining of pain several days later. On the day the pain was first reported, staff observed the resident guarding his right side and expressing discomfort during movement. A body check was performed, and an X-ray was ordered, which revealed the rib fractures. Multiple staff members, including LPNs and CNAs, stated that the resident had not experienced any new falls, injuries, or incidents between the initial fall and the onset of pain. The physician also noted the unusual delay in the onset of pain and questioned the attribution of the fractures to the earlier fall, given the absence of symptoms immediately after the incident. Despite the discovery of the fractures and the lack of a clear cause, the facility did not conduct a thorough investigation into the injury of unknown origin. The Director of Nursing acknowledged that there was no formal investigation, only informal notes about staff conversations. The facility was unable to provide an investigation report as required by its own Abuse and Prevention Program, which mandates a formal process for injuries of unknown source, including interviews, documentation review, and a final report.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of pain and anxiety medications for a resident with severe cognitive impairment and multiple medical conditions, including Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and anxiety disorder. The resident's January 2025 Physician Order Sheet prescribed Ativan for anxiety and Norco and Tylenol for pain, but the electronic Medication Administration Record (eMAR) showed no documentation of these medications being administered. However, the Narcotic Count Sheets indicated that doses of Ativan and Norco were signed out on specific dates. Interviews with facility staff revealed that the medications were administered but not documented on the eMAR as required by the facility's policy. An LPN confirmed administering Ativan to the resident on two occasions due to anxiety and restlessness, while the Director of Nursing acknowledged the importance of documenting medication administration on the eMAR for continuity of care. The facility's policy, revised in April 2007, mandates immediate documentation of medication administration, which was not adhered to in this case.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as evidenced by multiple observations and interviews. One resident, seated in a wheelchair, was found in a room with chipped paint, grease-like stains, and black scuff marks on the walls. A urinal half-filled with urine was on the floor, and a strong odor of urine was present in the bathroom. The resident expressed dissatisfaction with the cleanliness of the room, stating that they had to empty the urinal themselves. Another resident's power of attorney noted the facility's uncleanliness, pointing out chipped and dirty walls and moldy ceiling tiles in the dining room. The Maintenance Director acknowledged the issues, stating that a painter had been hired due to complaints about the walls and that moldy ceiling tiles had been removed. Additionally, two residents reported problems with their air/heating units, which caused water to drip and pool on the floor. One resident's thermostat cover was missing, exposing internal wiring, and the air unit was damp with water droplets. The Maintenance Director confirmed that the units had issues with condensation, especially in hotter weather, and that towels and basins were used to manage the water. The facility's policy emphasized maintaining a clean, sanitary, and orderly environment, which was not upheld in these instances.
Failure to Conduct Sleep Study for Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident who required a sleep study. The resident, who was admitted with diagnoses including insomnia, dysarthria, dysphagia, and cerebrovascular accident with right arm/leg hemiplegia, was dependent on staff for various activities. Despite a physician order for a sleep study to rule out obstructive sleep apnea being placed in December 2023, the study was never completed. The resident's Power of Attorney (POA) expressed concerns about the inability to transport the resident for the study due to logistical challenges, including the POA's inability to physically assist the resident and the distance from the facility. The Assistant Director of Nursing (ADON) canceled the sleep study order in August 2024 without consulting the resident's physician, citing a possible attempt to clean up old orders. The Director of Nursing (DON) acknowledged that outpatient testing should be scheduled promptly and mentioned that sleep studies could be conducted in-house or with staff assistance if family members were unavailable. Despite these options, the sleep study was not completed, and the facility's policy required staff to arrange for necessary diagnostic tests as ordered by physicians.
Failure to Prevent and Address Pressure Injuries
Penalty
Summary
The facility failed to identify and address pressure injuries in two residents, leading to deficiencies in care. Resident R28, who was admitted with conditions such as dysarthria, dysphagia, diabetes mellitus, and hemiplegia due to a cerebrovascular accident, was dependent on staff for mobility and personal care. Despite a care plan that required regular skin checks and repositioning every two hours, R28 was left in a wheelchair for extended periods without being repositioned or provided incontinence care. This neglect resulted in a facility-acquired Stage 2 pressure injury on R28's sacrum, which was initially misidentified as moisture-associated skin damage by the wound nurse. Resident R120, admitted with pre-existing Stage 3 and Stage 4 pressure injuries, was not provided with appropriate pressure-relieving support surfaces as outlined in the facility's policy. Despite being at high risk for pressure injuries, R120 was found using a regular mattress and foam cushion, which were inadequate for the severity of her wounds. The facility's failure to provide a low air loss mattress and appropriate wheelchair cushion contributed to the lack of proper care for R120's advanced pressure injuries.
Failure to Provide Adequate ROM Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents with limited range of motion, specifically affecting two residents. One resident, who was admitted with a history of stroke and transient ischemic attack, exhibited right-sided limitations and contractures in the right hand. Despite being assessed for limited range of motion upon admission, the resident was not placed on any restorative program or provided with a device to address the contractures until the surveyor's intervention. This lack of timely intervention contributed to the resident's continued limitations. Another resident, who was part of the restorative services program, was supposed to receive active range of motion exercises twice daily. However, records indicated that the resident only received these exercises once on several occasions. The previous restorative nurse acknowledged that the resident should have been seen twice daily and that the services provided should have been documented accordingly. The facility's policy on restorative nursing services, which aims to promote optimal safety and independence, was not adhered to in these cases.
Failure to Prevent Exit and Improper Transfer Technique
Penalty
Summary
The facility failed to ensure a resident did not attempt to exit the facility through a fire exit door and failed to transfer a resident using a gait belt, which are deficiencies identified during the survey. In the first incident, a male resident with moderate cognitive deficits and a history of traumatic brain injury attempted to exit the facility through a fire exit door in his wheelchair. The door alarm did not activate when the resident pushed the release bar, and there was no staff present in the hallway at the time. The Human Resources Manager was alerted and managed to stop the resident from exiting. Upon inspection, it was found that the door sensor was damaged, with a wire sticking out, possibly due to being hit by large boxes of personal protective equipment earlier that day. The Director of Nursing confirmed that the resident had no previous exit-seeking behaviors and that the door alarm should have been functional. In the second incident, a Certified Nursing Assistant (CNA) was observed transferring a resident with a terminal diagnosis of Multiple Sclerosis from the bed to a wheelchair without using a gait belt, despite the resident's care plan indicating the need for such assistance due to poor coordination and a history of falls. The CNA applied a gait belt around the resident's waist but did not use it during the transfer, instead pulling the resident up by the back of their pants. The Director of Nursing stated that staff should use gait belts for safe transfers, as outlined in the facility's policy on safe lifting and movement of residents.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to maintain proper catheter care for three residents, leading to potential risks of urinary tract infections. For one resident, the urinary catheter drainage bag was observed hanging on the resident's walker at the same level as the bladder, with urine and sediment present in the tubing. Another resident was found with the catheter drainage bag positioned at hip level, above the bladder, causing urine to backflow into the tube. Both the Director of Nursing and a Registered Nurse acknowledged that catheter bags should be kept below the bladder level to prevent infections. Additionally, a third resident's urinary catheter drainage bag was placed directly on the floor under the wheelchair seat by a Certified Nursing Assistant. The facility's policy, revised in 2014, clearly states that urinary drainage bags must be positioned lower than the bladder to prevent backflow and potential infections. Despite this policy, the facility did not adhere to the guidelines, resulting in improper catheter care for the residents involved.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for two residents. In the first instance, a Certified Nursing Assistant (CNA) provided incontinence care to a resident who had a bowel movement. The CNA did not change her soiled gloves after completing the care and proceeded to handle the resident's belongings and leave the room without washing her hands. This action was contrary to the facility's policy on glove use and hand hygiene, which emphasizes changing gloves and washing hands to prevent the spread of infection. In the second instance, a resident on Enhanced Barrier Precautions (EBP) due to having a urinary catheter was not properly managed. A CNA was observed repositioning the resident in a wheelchair and placing the urinary catheter drainage bag on the floor without wearing a gown, despite having performed catheter and peri-care. The CNA was unaware that the resident was on EBP, which requires staff to wear gowns and gloves during high-contact activities. The facility's policy mandates EBP for residents with indwelling medical devices, and the failure to follow this protocol was noted.
Incorrect Meal Portioning for Residents
Penalty
Summary
The facility failed to ensure that residents received the correct portion sizes of their meals, specifically fried potatoes, mixed vegetables, and pureed Italian sausage during a lunch meal. Observations revealed that the dietary aide, V5, used incorrect serving utensils and methods, such as using a 3-ounce spoodle instead of the recommended 4-ounce for mixed vegetables and measuring shredded potatoes with his hand instead of using a scoop. This resulted in residents receiving incorrect portion sizes, which did not align with the facility's dietary guidelines. The Certified Dietary Manager, V3, confirmed that the serving sizes used were incorrect and did not match the recommended sizes listed in the facility's dietary book. For instance, the pureed mixed vegetables were served in 2-ounce portions instead of the required 4 ounces, and the pureed Italian sausage and bun were served in a 2 and 3/4-ounce scoop instead of the correct 5 and 2/3 ounces. V3 acknowledged that the dietary staff should follow the serving sizes outlined in the menu and recipes provided. The Registered Dietician, V4, emphasized that the menus are designed to meet the nutritional needs of residents, and the facility is expected to adhere to the specified serving sizes using appropriate utensils. The Director of Nursing, V2, also agreed that the recommended serving sizes should be followed. The facility's policies on menu and nutritional adequacy, pureed food preparation, and portion control were not adhered to, leading to the deficiency in meal portioning.
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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