Aperion Care Chicago Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago Heights, Illinois.
- Location
- 490 West 16th Place, Chicago Heights, Illinois 60411
- CMS Provider Number
- 145180
- Inspections on file
- 50
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Aperion Care Chicago Heights during CMS and state inspections, most recent first.
Two residents with psychiatric histories, one with a known violent criminal background and one at moderate risk for abuse/neglect, became involved in an altercation in the dining room during which one resident struck the other in the head and face multiple times with a closed fist. Staff accounts and documentation focused primarily on the aggressor’s agitation and transfer to the hospital, while key personnel did not interview the victimized resident about the event, did not verify whether physical contact occurred, and did not document the altercation in that resident’s record. An undated statement purportedly from the victimized resident was later disputed by the resident, who denied making or signing it and demonstrated a signature that did not match, all in contrast to the facility’s abuse policy that prohibits and defines physical abuse such as hitting.
Two residents with psychiatric diagnoses, one with a known history of violent criminal behavior and care-planned risk for aggression, were involved in a dining room altercation in which one resident admitted to hitting the other in the head with a closed fist after an exchange of words. A behavior aide reported seeing the aggressor deliver several closed-fist "taps" and stated this met the definition of physical abuse and was reported to the administrator, while other staff acknowledged being told of aggression but did not directly verify with the alleged victim whether physical contact occurred. The administrator conducted an internal review, characterized the event as horseplay, relied on an undated statement attributed to the alleged victim that the victim later denied signing, and concluded there was no need to report the incident externally. The alleged victim’s clinical notes contained only wellness checks indicating he felt safe, there was no documentation of the altercation in his record, and review of abuse reportables showed no incident report submitted to the state survey agency, despite facility policy and staff statements that resident-to-resident hitting constitutes abuse requiring reporting.
A resident with multiple chronic conditions, including anemia, Type 2 DM, HTN, and hyperlipidemia, had these diagnoses documented in the comprehensive assessment and was receiving related medications such as sodium chloride, carvedilol, hydralazine, metformin, and atorvastatin. However, review of the admission and current care plans showed that these medical conditions were not included, and there were no measurable objectives or timeframes addressing them. During interview, the MDS coordinator confirmed the resident’s diagnoses and medications and acknowledged that these issues were not reflected on the care plan, despite facility policy requiring a person-centered comprehensive care plan based on identified needs.
A resident with diabetes and multiple comorbidities was found unresponsive with elevated blood glucose. An RN administered both scheduled and sliding scale insulin to the unresponsive resident before initiating emergency procedures or contacting a physician. Facility leadership and the physician confirmed this was not appropriate, and the facility lacked a specific policy for insulin administration during emergencies.
A resident with epilepsy continued to receive Keppra alongside Brivaracetam despite multiple orders from a neurologist to discontinue Keppra. The neurologist's instructions were communicated to facility staff by phone and fax, but there was no documentation that the order was relayed to or verified with the attending physician, and the resident continued to receive the medication for several weeks.
A resident with multiple medical conditions did not receive prescribed pain and acid reflux medications as ordered, despite repeated requests to the nurse on duty. The nurse did not document administration or provide a reason for withholding the medications in the eMAR, and the facility's policy requires such documentation and adherence to physician orders.
A resident with schizophrenia and other disorders was involuntarily discharged after assaulting staff, but the facility failed to provide a written notice of discharge to the resident's representative, as required by policy. The guardian received only a verbal notice, and the opportunity for a hearing was not communicated in writing.
A facility failed to report an incident where a resident displayed aggression and made threats towards another resident and staff. The resident was not easily redirected, refused medication, and required police intervention. Despite the facility's policy requiring such incidents to be reported, the administrator did not report it, citing it did not involve a peer altercation.
A facility failed to notify a resident's guardian when the resident was transferred to the hospital for a psychiatric evaluation due to increased agitation and delusions. The nurse on duty did not inform the guardian because the resident was under observation and not admitted by the end of her shift. The facility's policy requires timely notification of the resident's power of attorney or guardian during transfers, which was not followed in this case.
A resident's Link card was misappropriated by a former staff member who failed to return it after being entrusted to make a purchase. The incident was reported to the facility's psychosocial rehabilitation director and the police, leading to the card's cancellation. The card was eventually retrieved and returned to the resident, highlighting a failure to protect the resident's property as per the facility's policy.
The facility failed to implement its abuse prevention policies, affecting four residents. A resident with schizophrenia and bipolar disorder did not receive an abuse assessment upon admission or after an altercation. Another resident involved in the incident also lacked an updated care plan. Staff interviews revealed non-compliance with policies requiring incident reports and care plan updates after altercations.
A resident did not receive their prescribed appetite stimulant medication as ordered, despite an LPN claiming it was administered. The medication bottles were found unopened, and the resident confirmed no medication was given before lunch. The facility's policy requires medication to be administered as prescribed and refusals to be reported, which was not followed in this case.
The facility failed to maintain a functional eyewash station in areas with hazardous chemicals, affecting all units reviewed. The Maintenance Director noted the station had not been logged since February due to broken caps, initially reported in January. The Infection Preventionist and Administrator were unaware of the issue, and the facility's policy requiring weekly checks was not followed, as shown by empty logs.
A resident was physically assaulted by another resident over a candy bar, resulting in an eye injury. The incident was reported to staff, and the aggressor admitted to the altercation. The injured resident received medical attention, and the aggressor was sent for psychiatric evaluation. The facility's policy against abuse was not upheld.
Failure to Protect Resident From Peer Physical Abuse and Inadequate Incident Assessment
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to properly assess and document the incident. One resident (R1), with diagnoses including schizophrenia and bipolar-type schizoaffective disorder and a documented history of criminal behavior (aggravated battery with great bodily harm and attempted murder), physically struck another resident (R2) in the dining room. R2, who has major depressive disorder, post-traumatic stress disorder, nonsuicidal self-harm, and a moderate risk score for abuse/neglect, reported being hit multiple times in the head and face by a heavy-set Black man after an exchange of words. R1 confirmed hitting R2 in the head with a closed fist because R1 believed R2 was making fun of R1’s laugh, and a behavior aide reported seeing R1 give R2 “a couple taps” with a closed fist, which the aide stated would be considered physical abuse. Following the altercation, facility staff did not adequately investigate or document the event from R2’s perspective. The PRSC stated being told there was verbal back-and-forth between residents but denied being informed that any resident had gotten physical and denied speaking with R2 about the incident. An LPN reported being told that R1 was aggressive toward R2 and that R1 tried to hit R2, but did not ask staff whether the residents made contact and did not ask R1 if R1 hit R2, relying only on what others reported. There was no documentation of the altercation in R2’s notes, despite R2’s later account that there was definite physical contact and multiple hits before staff intervened, and that the touching was unwanted. The facility’s documentation and statements also show inconsistencies regarding R2’s involvement and the nature of the incident. Social service notes for R2 on the days following the event only record wellness checks, stable mood, and R2 reporting feeling safe, with no mention of the physical altercation. The administrator provided an alleged written statement from R2 about the incident, but the document was undated, and R2 denied ever seeing or signing it. When shown the document, R2 stated the signature was not his and demonstrated his usual signature, which did not match the one on the paper. The facility’s abuse prevention policy defines abuse as willful infliction of injury and specifies that physical abuse includes hitting and other non-accidental infliction of injury, yet the facility failed to ensure that R2 was free from physical abuse by R1 and failed to accurately assess, interview, and document R2’s experience of the incident.
Failure to Report Resident-to-Resident Physical Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of resident‑to‑resident physical abuse to the state survey agency. One resident with schizophrenia and bipolar-type schizoaffective disorder (R1), who had a documented history of aggravated battery with great bodily harm and attempted murder and was care planned as an identified offender with potential for physical/verbally aggressive behavior, became agitated toward another resident (R2) in the dining room. R2 had diagnoses of major depressive disorder, PTSD, and nonsuicidal self-harm, was assessed as at moderate risk for abuse/neglect, and had no cognitive impairment. R2 later reported that a heavy-set Black male resident hit him in the head and face more than once in the dining room after an exchange of words, describing the contact as unwanted touching and stating there was definite physical contact and multiple hits before staff intervened. R1 admitted to the surveyor that he hit R2 in the head with a closed fist because he believed R2 was making fun of his laugh, acknowledging he knew he should not be hitting anyone but was very mad at the time. A behavior aide (V16) reported hearing commotion, going to the area, and seeing R1 give R2 “a couple taps” with a closed fist, and stated this would be considered physical abuse and that all altercations must be reported to a supervisor or administrator. V16 stated that he informed the administrator (V18) about the incident and described the altercation as he later did to the surveyor. Nursing and social service notes for R1 on the date of the incident documented increased agitation toward a peer, responding to internal stimuli, inability to be redirected, 1:1 monitoring, and transfer to the hospital for psychiatric evaluation, but did not document the physical assault itself. Despite these accounts, the administrator (V18) stated that his internal investigation concluded the incident was “horse playing,” that R1 only admitted to tapping R2 on the shoulder, and that under facility policy there was no need to report the incident. V18 provided an alleged written statement from R2 about the incident, which contained a signature without a date; R2 denied ever seeing or signing the document, and when R2 signed the paper in the surveyor’s presence, the two signatures did not match. Staff who were aware of the event, including the PRSC (V7) and an LPN (V10), either believed or were told it was an attempted hit or verbal altercation and did not confirm with R2 whether physical contact occurred; neither spoke directly with R2 about the incident. There was no documentation of the altercation in R2’s notes, only wellness checks indicating R2 felt safe, and review of abuse reportables for the prior three months showed no incident report submitted to the state agency, despite facility policy requiring employees to report any incident, allegation, or suspicion of potential abuse to the administrator and defining physical abuse as hitting and similar acts. The facility’s abuse prevention and reporting policy affirmed residents’ rights to be free from abuse and required immediate internal reporting of any incident, allegation, or suspicion of potential abuse, neglect, exploitation, mistreatment, or misappropriation. The policy defined abuse as willful infliction of injury or intimidation with resulting physical harm, pain, or mental anguish, and physical abuse as non-accidental infliction of injury requiring medical attention, including hitting and slapping. Multiple staff, including V10 and V16, acknowledged that if a resident hits or touches another resident in this manner it is considered abuse and must be reported. Nonetheless, the facility did not treat the event as a reportable allegation of abuse and did not submit an incident report to the state survey agency, resulting in the cited failure to timely report suspected abuse and the results of the investigation to the proper authorities.
Failure to Develop Comprehensive Care Plan for Resident’s Chronic Medical Conditions
Penalty
Summary
Surveyors identified that the facility failed to develop a person-centered comprehensive care plan with measurable objectives and timeframes for a cognitively intact resident with multiple active medical diagnoses. The resident, who has Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Anemia, Pyothorax without Fistula, Emphysema, Paranoid Personality Disorder, Pneumonia, and Paranoid Schizophrenia, had these conditions documented in the admission comprehensive assessment and active diagnoses section. Despite this, the resident’s admission and current care plans did not include the medical conditions of Anemia, Type 2 Diabetes Mellitus, Hypertension, and Hyperlipidemia, even though these needs were identified in the comprehensive assessment. Record review showed that the resident was receiving multiple physician-ordered medications related to these diagnoses, including Sodium Chloride for anemia, Carvedilol and PRN Hydralazine for hypertension, Metformin for Type 2 diabetes, and Atorvastatin for hyperlipidemia, all administered as prescribed over several months. During an interview, the MDS Coordinator acknowledged that the resident had these diagnoses and related medications, and confirmed that they were not reflected on the care plan. The MDS Coordinator stated that the resident should have a care plan so caregivers know the diagnoses and how to provide appropriate care. This omission occurred despite the facility’s written comprehensive care plan policy, which requires development and implementation of a person-centered care plan with measurable objectives and timeframes for all medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.
Insulin Administered to Unresponsive Resident Without Emergency Response
Penalty
Summary
The facility failed to provide care in accordance with professional standards for medication administration during an emergency when a resident was found unresponsive and subsequently administered insulin. The resident, who had a history of Type 2 Diabetes Mellitus, epilepsy, seizures, unsteadiness, and schizoaffective disorder, was found unresponsive at 5:30am with a blood glucose level of 290 mg/dL. The nurse on duty documented administering both a scheduled dose and a sliding scale dose of Humalog insulin to the unresponsive resident before initiating emergency procedures such as calling a code, 911, or notifying a physician. The nurse's documentation was inconsistent and could not be clarified, as she was no longer employed at the facility at the time of the investigation. Interviews with facility leadership and the resident's physician confirmed that insulin should not have been administered to an unresponsive resident and that emergency services should have been contacted first. The facility did not have a specific policy regarding insulin administration during an emergency crisis, and the general medication administration policy only stated that medications are to be administered as prescribed and in accordance with good nursing practices. The physician and DON both indicated that the nurse's clinical judgment and documentation were inappropriate in this situation.
Failure to Discontinue Medication as Ordered by Physician
Penalty
Summary
The facility failed to follow its Physician's Order Policy by not discontinuing a medication as ordered by the resident's neurologist. A resident with a diagnosis of symptomatic epilepsy and complex partial seizures was admitted with several anti-seizure medications, including Brivaracetam and Levetiracetam (Keppra). The neurologist communicated on multiple occasions, both by phone and fax, that Keppra should be discontinued because it should not be prescribed concurrently with Brivaracetam. Despite these communications, the medication administration records show that the resident continued to receive Keppra for several weeks after the discontinuation order was given. Interviews and record reviews revealed that the neurologist's office contacted the facility to clarify the medication list and specifically instructed discontinuation of Keppra. The Assistant Director of Nursing (ADON) stated that she did not recall receiving follow-up communication from the neurologist's office after sending the medication list, and there was no documentation that the discontinuation order was relayed to or verified with the attending physician. Progress notes did not reflect any action taken regarding the neurologist's order, and the resident continued to receive Keppra alongside Brivaracetam, contrary to the specialist's instructions.
Failure to Administer and Document Prescribed Medications
Penalty
Summary
A resident with a medical history including bipolar disorder, schizophrenia, hemiplegia, and traumatic brain injury did not receive prescribed pain and acid reflux medications as ordered. On the night in question, the resident reported not receiving pain medication despite repeated requests to the nurse on duty, who stated the medication was unavailable. The resident experienced significant pain throughout the night until the morning nurse administered the medication. The nurse responsible did not document the administration of the medication or the reason for not providing it in the electronic medical administration record (eMAR). The facility administrator confirmed that the nurse on duty was responsible for administering the medications and that there was no documentation to support that the medications were given or withheld for a documented reason. The Director of Nursing stated that nurses are required to follow physician orders and document any reasons for not administering medications, and that emergency medication storage is available for such situations. Review of the resident's records confirmed that the pain and acid reflux medications were not administered as ordered, and the facility's policy requires medications to be administered and documented according to prescriber orders.
Failure to Provide Written Discharge Notice to Resident's Representative
Penalty
Summary
The facility failed to adhere to its discharge policy by not providing a written notice of involuntary transfer or discharge to the resident's representative. The resident, who has a diagnosis of schizophrenia, anxiety disorder, schizoaffective disorder, and non-compliance with medication regimen, was involuntarily discharged after physically assaulting staff, which was deemed to endanger the safety of individuals in the facility. Although the resident's guardian received a verbal notice of the transfer and discharge, they were not given a written copy of the notice or informed of the opportunity for a hearing, as required by the facility's policy. The facility's policy mandates that prior to discharge or transfer, the resident and their representative must be notified in writing, in a language and manner they understand, and a copy of the notice should be sent to the long-term care ombudsman. However, the staff member responsible for the discharge confirmed that the written notice was not provided to the resident's representative, despite having checked the box indicating that it was. This oversight resulted in a failure to comply with the required notification procedures, as outlined in the facility's policy.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency, involving two residents. On 12/18/24, a resident (R292) displayed increased agitation, making verbal threats towards peers and staff, and was not easily redirected. The resident refused medication and targeted female staff, resulting in physical aggression. The situation escalated to the point where police assistance was required, and the resident was transported to the hospital for a psychiatric evaluation. Despite these events, the facility did not report the incident to the State Survey Agency as required by their policy. The facility's administrator, V1, did not consider the incident reportable because it did not involve a peer altercation, despite evidence that R292 threatened another resident (R105) with physical violence. The facility's policy mandates that any allegation of abuse or incident resulting in serious bodily injury be reported immediately, or within 24 hours if it does not involve abuse or serious injury. The failure to report this incident was a violation of the facility's abuse prevention and reporting policy, as the incident involved threats and aggression towards another resident, which should have been reported to the Department of Public Health.
Failure to Notify Guardian of Resident's Hospital Transfer
Penalty
Summary
The facility failed to adhere to its notification policy by not informing the responsible party of a resident's transfer to the hospital. This deficiency was identified during a review of three residents, affecting one resident who was discharged to the hospital without proper notification to their guardian. The incident involved a resident who exhibited increased agitation and delusions, leading to a decision by the nurse practitioner to send the resident to the hospital for a psychiatric evaluation. However, there was no documentation of notification to the resident's guardian in the electronic record prior to the transfer. Interviews conducted with the staff revealed that the nurse on duty, V29, did not notify the resident's guardian because the resident was under observation and not yet admitted to the hospital by the end of her shift. The facility's administrator confirmed the absence of any notification in the resident's electronic record. The facility's policy, dated October 1, 2015, mandates that the resident's power of attorney or guardian should be notified in a timely manner when a resident is transferred or discharged from the facility. This oversight in communication represents a failure to comply with the established notification procedures.
Misappropriation of Resident's Link Card by Former Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of his property, specifically his Link card, which was given to a staff member to purchase beverages. The staff member, who was no longer employed at the facility at the time of the report, did not return the card to the resident. The resident expressed concern about the missing card and the involvement of the police, which caused him distress. The incident was reported to the facility's psychosocial rehabilitation director, who then informed the superiors and took steps to address the issue. The resident's progress notes indicate that the incident was reported to the police, and the card was canceled to prevent further misuse. The facility's activity aide eventually retrieved the card from the former employee and returned it to the resident. The corporate psychosocial rehabilitation director confirmed that the card was taken while the staff member was still employed, but it was not returned until after her employment ended. The facility's policy on abuse prevention and reporting emphasizes the residents' right to be free from misappropriation of property, which was not upheld in this case.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and theft, affecting all four residents reviewed in the sample. Resident R192, admitted with diagnoses including schizophrenia and bipolar disorder, did not receive an abuse/neglect screening assessment upon admission or after a resident-to-resident altercation. Despite being involved in a physical altercation with another resident, R192's care plan was not updated to address abuse prevention. The incident was reported to the hospital, but inconsistencies in R192's account were noted, and no incident report was completed by the facility. Resident R81, also involved in the incident with R192, was admitted with schizoaffective disorder and was assessed as a moderate risk for abuse. However, the abuse prevention care plan was not updated following the allegation of physical/sexual abuse. Similarly, Resident R103, with a history of physical altercations, did not have an updated care plan or abuse/neglect screening assessment after an altercation with R192. Resident R29, who had a previous altercation resulting in injury, did not receive an abuse assessment or care plan update until two months after the incident. Interviews with facility staff revealed a lack of adherence to the facility's policies on abuse prevention and incident reporting. The Social Service Director and Administrator acknowledged the failure to conduct necessary assessments and update care plans following incidents. The Director of Behavioral Services incorrectly believed that no incident report was needed if no physical injury occurred. The facility's policies require incident reports for all resident-to-resident altercations, regardless of injury, and mandate that abuse assessments and care plans be updated after each incident or allegation.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for one resident, identified as R135, during a survey. On July 17, 2024, an LPN, referred to as V13, claimed to have administered an appetite stimulant to R135 in the morning and discarded the bottle, stating that the next dose was not due until the following morning. However, upon inspection, two bottles of the appetite stimulant were found with unbroken seals, indicating that the medication had not been administered. When questioned, R135 confirmed that no medication was given before lunch, and they did not refuse it. V13 later claimed that R135 had refused the medication, which was inconsistent with the resident's statement. The Director of Nursing, V2, stated that nurses are expected to administer medications as ordered and report any refusals to the physician. A review of R135's records showed a diagnosis of type 2 diabetes mellitus and an order for megestrol acetate oral suspension to be given before meals as an appetite stimulant. The facility's policy requires medications to be administered as prescribed and refusals to be reported after three doses are refused. The failure to administer the medication as ordered and the lack of proper documentation and reporting of refusal led to the deficiency.
Non-functional Eyewash Station in Hazardous Chemical Areas
Penalty
Summary
The facility failed to maintain a functional eyewash station in areas where hazardous chemicals are used, affecting all units reviewed for environmental safety. The Maintenance Director acknowledged that the eyewash station had not been logged since February 2024 due to broken caps, which were initially reported in January 2024. Despite an order being placed for replacement caps in January, no invoice was presented to confirm this, and no further logs were available after February. The Infection Preventionist was unaware of the eyewash station's non-functionality, highlighting a lapse in communication and oversight. The Administrator also expressed unawareness of the eyewash station's non-functionality since January 2024, only learning of the issue when the Maintenance Director mentioned it in July 2024. The facility's policy requires weekly activation and maintenance of eyewash stations, but this was not adhered to, as evidenced by the empty maintenance logs for February 2024 and beyond. This deficiency indicates a failure to ensure the safety equipment was operational and properly documented, as required by the facility's environmental health and safety policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved two residents, where one resident (R3) physically assaulted another resident (R4) by hitting her in the eye after R4 refused to share a candy bar. This altercation was reported by R4 to a staff member, and it was confirmed by R3 during an interview. The incident resulted in R4 having redness in her right eye, which was documented by a registered nurse (RN) and later evaluated by a physician. The facility's policy on abuse prevention and reporting affirms the right of residents to be free from abuse, yet this incident indicates a failure to uphold that policy. The incident was reported to the Social Services Director, who was the manager on duty at the time. The director took R4 to a nurse for assessment and then spoke with R3, who admitted to the physical altercation. Documentation in R4's chart confirmed the incident, and R3 was sent to the hospital for a psychiatric evaluation. Despite the facility's policy against physical abuse, the incident was not prevented, and the response involved medical attention for R4's injury and further evaluation for R3.
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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