Arc At Hickory Point
Inspection history, citations, penalties and survey trends for this long-term care facility in Forsyth, Illinois.
- Location
- 565 West Marion Avenue, Forsyth, Illinois 62535
- CMS Provider Number
- 146148
- Inspections on file
- 32
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Arc At Hickory Point during CMS and state inspections, most recent first.
A resident who was assessed as alert, oriented, and always continent of bowel and bladder reported feeling embarrassed and degraded after staff performed an incontinence urine bed check despite the resident’s clear statement that they were continent and did not need the bed checked. Facility staff, including a CNA and an LPN, acknowledged that care plans and policies require staff to recognize continent status and ask if assistance to the restroom is needed rather than insisting on incontinence checks for alert, continent residents. Leadership confirmed that residents have the right to dignity and to make choices about whether they are checked and changed or assisted to the bathroom, consistent with the facility’s resident rights policy and bowel/bladder program guidelines.
Staff failed to consistently respond to resident call lights in a timely manner, as evidenced by multiple grievances and Resident Council reports of extended wait times for assistance. One resident with multiple chronic conditions, including COPD, diabetes, Parkinsonism, and joint replacements, reportedly waited over 30 minutes for a call light to be answered while several call lights were visibly and audibly active and staff were observed going on break. A CNA acknowledged that call lights are not always answered promptly, while an LPN, the administrator, and a corporate nurse stated that call lights should be answered within 10–15 minutes and that staff should not leave the unit or go on break while call lights are active, in contrast to the events described.
A resident with severe cognitive impairment, multiple comorbidities, impaired mobility requiring a walker, and significant hearing and vision deficits was not properly assessed or identified as an elopement risk when admitted. The elopement evaluation was incompletely done but locked as finished, indicating no elopement risk, and the resident was not included in the elopement alert system. Overnight, the resident was last seen in bed by an LPN and was not discovered missing until a CNA on the next shift noted the empty room while doing morning vitals. The resident had exited the building unsupervised, without coat or shoes, and was later found by family and a CNA in a restaurant parking lot near major highways, with hypothermia, frostbite to toes and fingers, a forehead hematoma with laceration, abrasions to both knees, and a fractured great toe, requiring hospital treatment and IV antibiotics for a UTI.
A resident with dementia, a history of falls, and documented need for supervision with toileting and transfers experienced an unwitnessed fall while ambulating barefoot with a walker to the bathroom without assistance, resulting in multiple injuries including a forehead laceration, abrasions, and a finger injury with a foreign body. The care plan identified fall risk and interventions such as use of a gait belt and appropriate footwear, and the DON later stated a urinal should have been kept at bedside, yet observations showed the urinal repeatedly left in the bathroom and the call light out of reach. CNAs reported they had been told the resident did not need assistance walking and allowed the resident to ambulate independently, and one CNA had not checked on the resident for several hours before the fall. The DON acknowledged she did not interview staff or verify call light and footwear status during the fall investigation and confirmed the investigation could have been more thorough.
The facility failed to properly investigate and follow up on multiple residents’ grievances regarding missed showers and bed baths. Cognitively intact residents who were dependent on staff for ADLs reported not receiving scheduled showers or bed baths for extended periods, and stated that staff either claimed they had no time, would return and did not, or said they did not perform bed baths or know how to use the mechanical lift for shower transfers. Concern forms that were completed for some residents documented the complaints and listed limited corrective actions, but the sections for follow-up with the complainants were left blank, and one resident’s grievance was not documented at all. Nursing leadership later acknowledged that they shared responsibility for nursing-related grievances, were aware showers were a problem, and had not followed up with the residents, despite a written grievance policy requiring timely resolution and oversight by a grievance official.
A resident with multiple fractures and bilateral arm casts, cognitively intact but fully dependent on staff for toileting and hygiene, developed an open, red, bleeding wound in the intergluteal cleft that was not entered on the wound log or otherwise documented. The resident reported episodes of old stool being found during incontinence care and described significant pain when a CNA applied cream to the area during a shower. The CNA stated she observed the open, bleeding area, applied an unknown cream available in the room, and informed an LPN, but the ADON and DON later confirmed they were not notified and no wound assessment, documentation, or physician notification occurred, contrary to facility policy requiring daily skin observations, prompt reporting, and weekly assessment of non-pressure skin conditions.
Two residents receiving catheter and perineal care did not receive appropriate infection control practices. For one resident with a history of urinary retention and UTI, a CNA performed front perineal care, handled a trash can, and then completed perianal care without changing gloves or performing hand hygiene, and did not cleanse the catheter tubing. For another resident with multiple comorbidities including CHF, DMII, and prior UTI, a CNA used gloves from a box that had fallen to the floor and then provided catheter/perineal care, during which the resident’s penis was noted to be red, swollen, and sore. The DON confirmed that items touching the floor are considered contaminated and that staff are expected to avoid cross-contamination during perineal care.
A resident at risk for pressure ulcers developed a Stage 2 ulcer on the tailbone after staff failed to identify and report changes in skin integrity. Despite a care plan requiring regular monitoring and repositioning, documentation did not reflect any skin issues, and nursing staff were unaware of the wound until it was discovered after a fall. Hospice and wound care assessments later confirmed the presence of a pressure ulcer that had developed weeks prior.
Two residents with known fall risks suffered unwitnessed falls resulting in injuries, including swelling, skin tears, and a fractured collarbone, after the assigned CNA was repeatedly found asleep or absent from her post. The facility's policy requiring regular resident checks was not followed, and required safety measures, such as keeping beds in the low position, were not maintained.
A bathroom used by two residents was found to have a slimy, fuzzy, black substance resembling mold above the shower and on the ceiling, which had been present for some time. A housekeeper reported notifying maintenance, but the administrator could not find any record of a work order being submitted for the issue. The presence of the black material was confirmed by both the administrator and a corporate administrator.
A resident with a history of repeated falls, weakness, and partial paralysis was assessed as high risk for falls but did not have adequate fall prevention interventions in place. Staff confirmed that aside from ensuring appropriate footwear and occasionally lowering the bed, no other interventions were implemented. The resident was found on the bathroom floor and sustained multiple rib fractures, a hemothorax, and a collapsed lung, with staff and medical leadership acknowledging that proper fall protocols could have changed the outcome.
A resident with paraplegia and a history of pressure ulcers developed a new sacral pressure ulcer that was not promptly identified or treated. There was a delay in obtaining and implementing physician orders, and the care plan was not updated in a timely manner. The resident did not consistently receive pressure-relieving interventions, and staff reported delays in repositioning due to being busy. The resident experienced pain from the worsening ulcer, and observations confirmed a lack of appropriate off-loading devices.
Two residents experienced unsafe transfers when staff failed to follow required protocols, including not using a gait belt, transferring without a second staff member, and using a mechanical lift incorrectly. One resident sustained a skin tear during a transfer, while another was left in a wheelchair for an extended period, resulting in skin breakdown and pain. Staff interviews revealed that care plans were not reviewed or updated, and facility policy on safe transfers was not followed.
Three residents developed or experienced worsening pressure ulcers due to the facility's failure to perform required skin checks under immobilizers, inadequate wound assessment, and lack of timely physician notification. In one case, a wound under an immobilizer was not identified or treated promptly, while another resident's wound was not documented or communicated to the wound nurse. Additionally, a resident with a deep tissue injury did not receive appropriate wound care or physician orders in a timely manner.
A resident with a physician's order for Tramadol-Acetaminophen for moderate pain was left without pain medication after the supply ran out and staff failed to request a timely refill. The resident experienced severe pain, canceled a doctor's appointment, and was observed in discomfort, while staff confirmed the lapse in medication management and delayed action to obtain a new prescription.
The facility did not have a qualified infection preventionist consistently overseeing the infection prevention and control program, with the designated individual only present one day per week and lacking time for essential duties such as staff education. Additionally, two residents were on prophylactic antibiotics without proper assessment or care planning, and required infection surveillance and documentation were not completed.
Staff failed to follow medication administration protocols by leaving medications, including controlled substances, at the bedsides of several residents and pre-pouring unlabeled medications in a cart. Nursing staff acknowledged that medications should be administered as poured and not left unattended, but these procedures were not followed.
A resident's request to be a DNR was not properly documented or implemented, as required by facility policy. Although the resident and staff confirmed the DNR wishes and an Advance Directive form was signed, there was no physician order, POLST form, or care plan update reflecting this status in the medical record or code status binder. As a result, the resident would be treated as a full code and receive CPR.
A resident who was severely cognitively impaired and dependent on staff for transfers was moved from the toilet to a wheelchair using a sit-to-stand mechanical lift by only one CNA, despite the care plan requiring two staff for such transfers. Interviews with LPNs and another CNA confirmed that two staff are needed for these transfers, but this protocol was not followed.
A facility failed to follow its Mechanical Lift Policy, requiring two staff members for transfers, leading to a resident's femur fracture during a transfer by a CNA. The resident, who was severely cognitively impaired, experienced leg pain and was later found to have a displaced fracture, requiring hospitalization and surgery. The orthopedic surgeon suggested the injury might have occurred during the transfer.
The facility failed to complete fall risk assessments and post-fall monitoring for three residents, as required by its Fall Prevention policy. This included missing assessments upon admission, readmission, and after falls, as well as incomplete post-fall follow-up notes. Staff confirmed these deficiencies in the residents' medical records.
The facility failed to provide timely and appropriate pressure ulcer care for two residents, leading to significant deterioration in their conditions. One resident's elbow wound progressed to an infected stage 4 pressure sore due to delayed physician notification and inadequate monitoring. Another resident developed a deep tissue injury on her heel that was not promptly reported, resulting in an unstageable pressure sore. The facility did not adhere to its policies for reporting changes in condition, leading to inadequate care and worsening of the residents' conditions.
The facility failed to implement a comprehensive training program for CNAs on essential topics such as Communication, Resident Rights, Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health. Five CNAs had not completed the required training in the past year, despite actively providing care to residents. The administrator acknowledged the lack of documentation and specific training policy, potentially affecting all 55 residents.
The facility failed to ensure five CNAs completed the required twelve hours of annual education, including dementia care and abuse prevention training. This deficiency was due to a lapse in monitoring caused by a change in the HR position, potentially affecting all 55 residents.
The facility failed to notify the physician and POA about pressure sores in two residents. One resident developed a severe elbow wound, and the other a heel deep tissue injury, both without timely physician notification. The facility's policy mandates such notifications for significant condition changes.
The facility failed to review their Infection Control policies annually, affecting all 60 residents. Key policies such as 'Infection Surveillance' and 'Antibiotic Stewardship' had not been reviewed since 2017. The Infection Preventionist and Administrator acknowledged the issue, but no recent review dates were available.
The facility failed to document fluid intake and output for a resident with an indwelling urinary catheter, as required by the facility's policy and the resident's care plan. Despite the care plan's directive, the resident's medical records lacked documentation, and staff interviews confirmed this deficiency.
A facility failed to prevent cross-contamination during pressure ulcer treatment for a resident with multiple pressure ulcers. An RN applied medihoney ointment directly from the tube to the wounds without using an applicator, contaminating the ointment tube and then using it on other wounds. This action was against the facility's policy, which requires separate applicators for each wound to prevent contamination.
Failure to Honor Continent Resident’s Dignity During Incontinence Check
Penalty
Summary
The deficiency involves staff failing to honor a resident’s right to be treated with respect and dignity and to make choices about incontinence care. The resident, admitted with multiple medical diagnoses including COPD, autoimmune hepatitis, asthma, hypoxemia, type 2 diabetes, Parkinsonism, and joint replacements, was documented on the admission assessment as always continent of bowel and bladder and as alert and oriented to person, place, time, and situation, with verbally appropriate responses. Facility policies and the bowel and bladder program state that continent residents should not be placed on incontinence programs or subjected to incontinence checks, and that residents have autonomy and choice in how they receive care, as long as facility rules and regulations are followed. Despite this, staff conducted an incontinence urine bed check at approximately 4:00 a.m. after the resident had stated to staff that they were continent of urine and did not need the bed checked. The resident’s family member reported that the resident felt embarrassed, degraded, and experienced low self-esteem as a result of staff continuing the incontinence check after the resident’s statement. A CNA and the admission LPN both stated that staff should follow the care plan, recognize when a resident is continent, and ask if assistance to the restroom is needed rather than insisting on checking the bed for incontinence when an alert resident reports being dry. The administrator and corporate nurse acknowledged that residents have the right to be treated with dignity and to choose whether they are checked and changed or assisted to the restroom, consistent with the facility’s resident rights policy.
Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
Surveyors identified a deficiency related to residents' rights to a dignified existence, self-determination, communication, and exercise of rights when call lights were not answered in a timely manner. Grievance forms dated December 8 and 28, 2025, and February 3 and 26, 2026, documented residents having to wait extended periods for assistance with various activities. Resident Council minutes from February 6, 2026, recorded that six residents attended and reported that staff needed to answer call lights more quickly. The facility’s Call Light policy dated January 2026 stated that resident call lights would be answered in a timely manner, that all staff should assist in answering call lights, that nursing staff should promptly respond and cancel call lights upon entering the room, and that bathroom lights should be treated as emergencies requiring immediate attention. For one resident (R76) reviewed for call light response, the medical record showed admission on February 21, 2026, with multiple diagnoses including seasonal allergic rhinitis, polyneuropathy, COPD, autoimmune hepatitis, asthma, hypoxemia, type 2 diabetes mellitus without complications, Parkinsonism, and the presence of right artificial knee and left artificial shoulder joints following joint replacement surgeries. On March 3, 2026, a CNA (V27) stated that staff should answer call lights in a timely manner but acknowledged that this does not always occur. On the same date, a family member (V30) reported that on February 25, 2026, the resident’s call light was not answered for over 30 minutes, and when the family member approached the nurse’s station, multiple staff members were going on break while multiple call lights were activated and visible above resident doors and sounding at the nurse’s station. On March 4, 2026, an admission nurse/LPN (V6) and the Administrator (V1) with the Corporate Nurse (V23) stated that staff should answer call lights within 10–15 minutes and should not leave the unit or go on break while call lights are activated, and they reported being unaware of staff failing to respond to call lights before going on break.
Failure to Identify and Supervise High-Risk Resident Resulting in Elopement and Injury
Penalty
Summary
The deficiency involves the facility’s failure to identify a newly admitted resident as an elopement risk and to provide adequate supervision and interventions to prevent elopement. The resident was a 99‑year‑old with severe cognitive impairment documented on the MDS, and an undated care plan listing multiple diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, delirium, COPD, atherosclerotic heart disease, and other significant medical conditions. The care plan also documented current skin impairment, increased fall risk related to gait imbalance requiring a walker and gait belt, impaired cognitive function, impaired communication, impaired hearing requiring hearing aids, and impaired vision requiring glasses. Despite these factors, the initial elopement evaluation was not completed in full before the Social Service Director locked the assessment as completed, which then indicated the resident was not an elopement risk. The resident had a documented unwitnessed fall in the room shortly after admission, with neuro checks ordered for several days, and later a community survival skills assessment showed the resident had no safety awareness or survival skills if outside the facility alone and recommended the resident not be unsupervised outside. On the night of the elopement, the resident was last seen in bed in the room at approximately 11:00 p.m. by an LPN, who reported not hearing any door alarms during the night. The facility’s daily assignment sheet shows that two LPNs and four CNAs were assigned on the overnight shift, but the resident was not identified as missing until the following morning when a CNA arriving for the day shift noticed the resident was not in the room while doing morning vital signs and alerted the LPN. The receptionist reported that there is an elopement alert binder at the front desk identifying residents at risk of elopement and that the front entrance is monitored and locked during certain hours, but the resident had not been properly identified and listed as an elopement risk. As a result of these failures, the resident left the facility unsupervised on foot, without a coat or shoes, during below‑freezing temperatures. The resident was found approximately 0.6 miles away in a restaurant parking lot near two major highways, crouched by a wall, wearing only a T‑shirt, sweatshirt, jeans, and socks, and without a coat, hat, or shoes. Family and staff accounts, along with hospital records, document that the resident had a visible hematoma and laceration on the right forehead, abrasions to both knees, discoloration of the hands, frostbite to both great toes and additional digits, a comminuted fracture of the left great toe, hypothermia, and a urinary tract infection. The resident reported being cold, stated that the wind was very bad, and indicated having fallen several times during the night. The facility’s nurse practitioner stated the resident had poor cognition, was extremely hard of hearing, had poor vision, and no safety awareness, underscoring the resident’s vulnerability at the time of the elopement.
Removal Plan
- Reassess R1 for risk of elopement and community survival skills and update R1's Plan of Care to include current risk of elopement and associated behavioral needs; place R1 on one-to-one observation upon return.
- Review the incident and confirm door alarms/system functional status.
- Review and update the elopement binder.
- Provide Code Pink education and rounding expectations to all staff.
- Assess all residents for risk of elopement and community survival.
- Reevaluate all residents for elopement risk at admission, readmission, quarterly, annually, with significant change, and when at-risk behaviors are identified; assign responsibility; conduct audits and have results reviewed by the administrator or designee.
- In-service all staff regarding wandering/exit-seeking behavior and when to implement increased supervision for residents exhibiting these behaviors.
- In-service all staff regarding door alarms as a required safety measure; ensure alarms are never turned off, silenced, or disabled; require immediate reporting of issues and prompt response; allow the front entrance door alarm to be disabled only when the door is being monitored by staff.
- Conduct an elopement drill.
- Implement an in-servicing plan to include elopement policy, wandering/exit-seeking behavior, and door alarms upon hire and ongoing.
- In-service agency staff regarding Code Pink and rounding expectations prior to working at the facility.
- Hold an ad hoc QA meeting with the IDT regarding the Elopement Policy and Procedure.
- Have the QA committee review elopement policy and procedure as part of the Quality Assurance Process.
- Review elopement during each quarterly meeting for four meetings.
Failure to Supervise High Fall-Risk Resident and Ensure Access to Toileting Aids
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough fall investigation, implement fall interventions, and provide adequate supervision for a high fall-risk resident. The resident had diagnoses including encephalopathy, vascular dementia with behavioral disturbance, anemia, weakness, a history of falls, and a pacemaker, and was documented as moderately cognitively impaired. The MDS showed the resident required supervision with toileting, bathing, dressing, bed mobility, and transfers, and the fall care plan identified the resident as at risk for falls with interventions such as use of a gait belt for transfers and ensuring appropriate footwear. An incident fall assessment documented 1–2 prior falls in the past three months and intermittent confusion. On the date of the fall, nursing documentation showed the resident was found on the bathroom floor after an unwitnessed fall, barefoot and using a walker without assistance, with the call light not used. The resident sustained a forehead laceration, abrasions to the right knee and left foot, and was on blood thinners. Hospital records documented left ankle swelling, a foreign body and laceration of the left fifth finger, and a closed head injury with a hematoma to the right forehead, with the resident noted to have dementia and be a poor historian. Subsequent observations showed the resident repeatedly seated in his room with the urinal placed in the bathroom and not within reach, and the call light lying across the bed and not within the resident’s reach. The resident stated he did not know where his urinal was and that he would just get up and go to the bathroom if needed. CNAs reported hearing a thud and finding the resident on the floor on his right side, barefoot, with the walker on its side and blood on the floor from the finger injury. One CNA stated she had been instructed that the resident did not need assistance walking and that he walked independently with his walker to the bathroom and was not considered a fall risk. Another CNA, who was assigned to the resident on the morning of the fall, stated she had not checked on the resident for a few hours and that the resident got up independently and did not need staff assistance for toileting. The DON stated the resident should have had appropriate footwear and that the intervention for the fall was to place a urinal at the bedside and keep it within reach, but acknowledged she did not interview staff during the fall investigation, did not determine whether the call light was within reach, and did not determine the status of the resident’s footwear at the time of the fall, confirming the fall investigation could have been more thorough.
Failure to Investigate and Follow Up on Resident Grievances About Bathing and Showers
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and receive prompt resolution regarding bathing and shower services. One cognitively intact resident with multiple fractures and dependence on staff for all ADLs reported not receiving scheduled showers. A concern form documented this resident’s complaint about missed showers and indicated the complaint was only partially substantiated, with an action to monitor shower sheets and check in with the resident on shower days. However, the section for follow-up with the complainant was left blank, and the resident later stated that staff were marking shower sheets as if showers had been provided when they had not, and that no one from management had followed up with him about his grievance. Another cognitively intact resident, who required maximum assistance with toileting, bathing, and dressing, reported not receiving showers or bed baths for weeks. A concern form documented this resident’s complaint of not having had a bed bath and noted that a bath was given the following day, but again the follow-up section with the complainant was left blank. The resident stated staff told her they did not have time or would return to assist with a bath but did not come back. A friend and a family member confirmed that the resident had not been bathed for weeks and that staff repeatedly stated they would get to it but did not. A third cognitively intact resident, also requiring maximum assistance for toileting, bathing, dressing, and bed mobility, reported not receiving showers or bed baths for weeks and stated she had reported this to the DON before Christmas without any response. The facility was unable to provide any concern or grievance documentation for this resident’s report. This resident stated staff told her they did not know how to transfer her with the total body mechanical lift to the shower chair, and another staff member told her they do not provide bed baths or wash hair in bed. Facility leadership later acknowledged that nursing grievances were shared between the DON and ADON, that showers were a known problem, and that no follow-up had been done with these residents regarding their grievances, despite a written grievance policy requiring timely resolution and oversight by a grievance official.
Failure to Identify and Document Intergluteal Cleft Wound
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, document, and report an open wound in a cognitively intact resident who was dependent on staff for all ADLs, including toileting and perineal care, due to bilateral arm fractures in hard casts. The resident’s EMR listed multiple traumatic fractures and functional dependence, and the MDS documented that the resident relied on staff for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. Despite this, the facility wound log did not include an open wound in the resident’s intergluteal cleft. The resident reported that he could not wipe himself and described episodes where staff found old stool during incontinence care, including an instance when a CNA applied cream to an area he described as red, open, bleeding, and very painful. The resident stated that on at least two occasions staff discovered old stool when he had not used the bathroom for several hours or since the prior day. On the date of the surveyor’s interview, the ADON, who oversees the wound program, stated she had not been aware of any skin alterations other than those related to the resident’s initial trauma and later learned from the resident that there had been an unreported open area in the intergluteal cleft that had never been assessed or treated. A CNA confirmed that during a shower she observed the resident’s buttock crease to be open, bleeding, and red, and that she applied an unknown cream from the resident’s room and informed an LPN, but there was no documentation of this wound in the record or on the wound log. The DON and ADON both stated staff should have documented the open area and notified the physician and the ADON per facility policy. The facility’s written policy required CNAs to observe for skin breakdown daily and on bath days, promptly report changes to the charge nurse, and required licensed nurses to initiate and document wound assessments for non-pressure skin conditions, with notification of the resident, representative, and physician at the earliest sign of skin problems. These required assessments, documentation, and notifications did not occur for this resident’s intergluteal cleft wound.
Improper Infection Control During Catheter and Perineal Care
Penalty
Summary
The deficiency involves failures in infection control and proper catheter/perineal care for two residents during incontinence care. One resident with a history of urinary retention and prior UTIs, who was cognitively intact and dependent on staff for most ADLs including toileting, reported fear of getting another UTI and stated staff did not always clean her as often as they should. During observed catheter and perineal care, a CNA provided front perineal care, then walked to the other side of the bed to perform perianal care without changing gloves or performing hand hygiene after handling the trash can. The CNA also did not cleanse the resident’s catheter tubing during care. The CNA later acknowledged she had cross-contaminated the perianal area by not changing gloves and that she should have cleansed the catheter tubing to the junction of the drainage bag tubing. For a second cognitively intact resident with multiple medical diagnoses including CHF, DMII, and a history of UTI, a CNA prepared supplies for catheter/perineal care and had a glove box with several gloves protruding from the top. The CNA accidentally knocked the glove box to the floor, then picked it up, washed her hands, and obtained gloves from the same box to perform catheter/perineal care. The CNA used these potentially contaminated gloves while providing care. During this care, the CNA observed and verbally noted that the resident’s penis was very red, swollen, and sore, and the resident confirmed soreness. The DON later stated that staff should not cross-contaminate during perineal care, that gloves or items that touch the floor are considered contaminated and should not be used, and that existing incontinence/catheter/perineal care policies did not address these specific concerns, although the expectation was that staff would avoid cross-contamination of residents’ perineal areas.
Failure to Identify and Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to identify and report an alteration in skin integrity for a resident at risk for pressure ulcers, resulting in the development of a Stage 2 pressure ulcer on the resident's tailbone. The resident's care plan included interventions for monitoring, turning, and repositioning at least every two hours, and required immediate nurse notification of any new skin breakdown. However, CNA documentation over a one-month period did not note any skin issues, and the Assistant Director of Nursing was unaware of the sore until it was discovered following a fall. The LPN stated that CNAs were responsible for repositioning, but expressed uncertainty about how to reposition a resident in a geriatric chair, which the resident used most of the day. Subsequent assessments by hospice and wound care staff identified a pressure ulcer on the resident's tailbone, with the wound care provider determining it was a Stage 2 ulcer that had developed three to four weeks prior, not as a result of the fall. The facility's own policy required assessment, monitoring, and documentation of skin breakdown, but these steps were not effectively carried out, leading to a failure to prevent the pressure ulcer.
Failure to Provide Adequate Supervision Resulting in Resident Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents who were identified as being at risk for accidents. Both residents had documented histories and care plans indicating fall risk, with one resident having physical limitations, weakness, and cognitive impairment, and the other having Parkinson's disease. Despite these risks, both residents experienced unwitnessed falls resulting in injuries, including localized swelling and a displaced collarbone fracture. Observations and medical records confirmed that both residents were found with significant injuries, such as swelling and discoloration to the forehead, and in one case, a saturated incontinence garment and a bed that was not in the low position as required. Staff interviews revealed that the CNA assigned to the relevant hall was repeatedly found asleep or missing from her assigned area during the night when the falls occurred. The LPN on duty reported being unable to locate the CNA several times and did not observe her performing required rounds. The facility's policy required residents to be observed approximately every two hours to ensure safety, but this was not followed. The CNA involved was later terminated for failure to adhere to facility standards. The lack of supervision and failure to follow established protocols directly contributed to the residents' falls and subsequent injuries.
Failure to Maintain Clean and Safe Resident Bathroom
Penalty
Summary
A private bathroom with a shower shared by two residents was observed to have a slimy, fuzzy, black material resembling black mold on the grout line above the shower head and where the ceiling meets the drywall. The affected areas measured approximately 5 inches by half an inch and 12 inches by 6 inches, respectively. A housekeeper confirmed that the black substance had been present for an extended period and stated that a work order had been submitted, with maintenance being aware of the issue. However, the administrator later reviewed records from the past three months and found no evidence of a work order being submitted for this problem. Both the administrator and a corporate administrator verified the presence of the black material during their inspection.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place for a resident identified as high risk for falls. The facility's Fall Prevention Program policy outlines the need for individualized assessment and implementation of appropriate interventions, but in this case, the resident's care plan only included ensuring appropriate footwear and did not address other necessary fall prevention measures. Multiple staff members, including CNAs and nursing staff, confirmed that no additional fall interventions were in place, aside from occasionally placing the bed in a low position. The care plan coordinator acknowledged that more interventions should have been included, and the regional nurse consultant cited an IT issue that contributed to the lack of interventions. The resident had a medical history of repeated falls, weakness, and partial paralysis on one side of the body following a stroke, and was assessed as high risk for falls. The Minimum Data Set (MDS) assessment indicated the resident required partial to moderate assistance with toileting hygiene. Despite these risk factors, the resident was found on the bathroom floor by a CNA, and subsequent medical evaluation revealed multiple left-sided rib fractures, a collection of blood in the chest cavity, and a collapsed lung. The resident's condition worsened, as documented by follow-up imaging. Interviews with staff confirmed that the resident was known to be at high risk for falls, but there was a lack of communication and implementation of fall prevention interventions. The Director of Nursing and the former Medical Director both stated that having proper fall protocols and precautions in place could have changed the outcome for the resident. The deficiency was attributed to the failure to assess and implement appropriate fall prevention measures as required by the facility's own policy.
Failure to Identify, Treat, and Prevent Worsening of Pressure Ulcer
Penalty
Summary
A resident with a history of pressure ulcers, paraplegia, urinary tract infection, and osteomyelitis was admitted to the facility with existing Stage Four pressure ulcers on the right ischium and left knee. The resident was identified as high risk for developing additional pressure ulcers and was dependent on staff for bed mobility, toileting, dressing, and required maximum assistance with bathing and personal hygiene. Despite these risk factors, the facility failed to promptly identify and treat a newly acquired sacral pressure ulcer, which was first documented as a Stage Two ulcer and rapidly progressed to Stage Four with significant necrotic tissue. There was a delay in obtaining and implementing physician orders for the sacral ulcer, as the wound was identified on 4/7/25 but treatment orders were not entered into the electronic medical record until 4/11/25. During this period, no treatment was provided for the sacral ulcer, and the care plan was not updated to reflect the new wound. The wound nurse acknowledged forgetting to obtain and implement the necessary dressing orders, and communication between floor nurses and the wound nurse regarding the new wound was lacking. Documentation confirmed that no treatment was provided for the sacral ulcer prior to the entry of orders. Observations revealed that the resident was not consistently provided with pressure-relieving interventions, such as off-loading with pillows or blankets, despite facility policy requiring dependent residents to be turned and positioned approximately every two hours. Staff interviews indicated that residents, including the affected individual, often waited longer than two hours to be repositioned due to staffing constraints. The resident experienced significant pain associated with the sacral ulcer, particularly during dressing changes, and was observed without appropriate off-loading devices in place.
Failure to Ensure Safe Transfer Practices and Adequate Supervision
Penalty
Summary
The facility failed to provide safe transfer practices for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. One resident with hemiplegia, left foot drop, and cognitive intactness was transferred by a CNA without the use of a gait belt and without a second staff member, despite care plan requirements. The CNA was also using earbuds and talking on the phone during the transfer, which led to the resident sustaining a skin tear on her left lower leg. The incident was not documented in the nurse's progress note, and the care plan was not updated to reflect the injury or provide interventions for the skin tear. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, required two-person assistance and a mechanical lift for transfers. On the day of the incident, two CNAs used the wrong sling configuration during a transfer, placing the long ends of the sling at the resident's head instead of crossing them between the legs. This improper use of equipment created a risk of the resident falling from the lift. The resident was also left sitting in a wheelchair for nearly three hours, resulting in significant skin breakdown and complaints of pain, as staff were unable to meet resident needs promptly due to low staffing levels. Facility policy mandates the use of a gait belt for all physical transfers and requires a mechanical lift for residents needing two-person assistance. Staff interviews confirmed that these policies were not followed, and that care plans were not reviewed or updated as required. The failures in following transfer protocols and providing timely care directly contributed to the residents' injuries and discomfort.
Failure to Prevent and Manage Pressure Ulcers Under Immobilizers and Inadequate Wound Assessment
Penalty
Summary
The facility failed to properly identify, assess, intervene, and treat pressure wounds for three residents, resulting in the development of facility-acquired unstageable wounds, particularly under immobilizers. According to the facility's own policy, daily skin checks and prompt reporting of skin changes are required, but these procedures were not consistently followed. For one resident, a pressure ulcer developed on the right calf under an immobilizer, and the wound nurse confirmed that the immobilizer was not removed for daily skin checks. Additionally, the same resident had an undocumented wound on the buttock that the wound nurse was unaware of, indicating a breakdown in communication and documentation. Another resident was admitted with a deep tissue injury on the right buttock, which remained unchanged in size for several weeks according to wound assessments. However, on observation, the wound was found to be larger and covered with slough, and the wound nurse applied zinc paste directly to the wound without a physician's order or notification of the wound's change in condition. The first treatment order for this wound was not obtained until several days after the wound's deterioration was observed, demonstrating a delay in appropriate intervention and physician notification. A third resident, who was dependent on staff for activities of daily living and assessed as high risk for pressure ulcers, developed a facility-acquired pressure ulcer on the right lower extremity under a leg immobilizer. Physician orders required skin checks under the immobilizer every shift, but the treatment administration record showed multiple days where these checks were not documented, despite the resident being present in the facility. The wound nurse admitted to not reviewing the treatment record for compliance with skin checks and was unaware of missed documentation, further contributing to the failure to prevent and manage pressure ulcers as required.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A resident identified as being at risk for pain was not provided with effective and timely pain management. The resident had a physician's order for Tramadol-Acetaminophen to be administered every 8 hours as needed for moderate pain, and the care plan included interventions to administer pain medications and evaluate their effectiveness. However, the facility failed to ensure the medication was available, resulting in the resident running out of the prescribed pain medication. Documentation showed the last dose was given on 4/15/25 at 7:00 AM, and no further doses were available after that time. As a result of the medication not being refilled in a timely manner, the resident experienced significant pain, reporting pain levels as high as 8 out of 8 and was observed grimacing and unable to move comfortably. The resident canceled a doctor's appointment due to pain and had to rely on non-prescribed interventions such as positioning for comfort. Staff interviews confirmed that the medication had run out and that agency nurses did not request a refill or new orders. The DON acknowledged that the prescription should have been refilled when four doses remained, but the facility did not attempt to refill it until after the medication was depleted.
Failure to Maintain Comprehensive Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain a comprehensive Infection Prevention and Control Program, as required by policy and regulatory guidelines. The Director of Nursing (DON) was initially identified as the Infection Preventionist but clarified that she did not hold this role and lacked the necessary infection control training and certification. Instead, a nurse from another facility, who also serves as an Administrator elsewhere, was designated as the Infection Preventionist and only present one day per week. This individual reported being unable to complete essential duties such as staff education due to limited time on-site and was unaware of residents on prophylactic antibiotics. The facility's infection surveillance and tracking practices were not fully implemented, as required by their own policy. Additionally, there were lapses in infection monitoring for residents on prophylactic antibiotics. One resident had a physician's order for Bactrim for urinary tract infection (UTI) prophylaxis, and another had an order for daily Cephalexin for prophylactic use. However, the medical record for the latter did not contain an assessment or care plan to support the use of a prophylactic antibiotic. The Regional Nurse Consultant was unable to locate documentation justifying this antibiotic use. These deficiencies in infection prevention oversight and documentation had the potential to affect all 63 residents in the facility.
Improper Storage and Administration of Medications
Penalty
Summary
Facility staff failed to properly store and administer medications according to policy and professional standards. Medications were observed left at the bedsides of four residents, with some residents stating they had not yet taken the medications, and in one case, a family member identified a specific pain medication left unattended. Additionally, pre-poured medications were found in a medication cart without any identifying labels, and the responsible nurse could not recall which medications were in the cup. The facility's Medication Administration Policy prohibits pre-pouring medications and requires that medications be administered as they are poured. Interviews with nursing staff and the Director of Nursing confirmed that medications should not be left at the bedside or in the cart and should be administered directly to residents. Medication administration records indicated that controlled substances and other prescribed medications were documented as given, despite being left unattended. These actions were observed for four residents, and staff acknowledged awareness of the correct procedures but did not follow them during the incidents.
Failure to Document and Implement Resident's Advance Directive and DNR Status
Penalty
Summary
The facility failed to honor a resident's right to have their advance directive wishes accurately documented and implemented. Upon admission, the resident expressed a desire to be a Do Not Resuscitate (DNR) and signed an Advance Directive form. Both the resident and staff confirmed these wishes. However, the resident's physician orders did not include any documentation of the Advance Directive, and the care plan was not updated to reflect the resident's DNR status. The facility's policy requires that a written physician's order be included in response to advance directives and that this information be incorporated into the care plan. Despite the resident's wishes and the facility's policy, there was no POLST (Physician Orders for Life-Sustaining Treatment) form or Advance Directive present in the resident's electronic health record or in the code status binder at the nurse's station. Staff interviews confirmed that the POLST form had been sent to the physician for signature but had not been returned or uploaded into the system. As a result, the resident would be considered a full code and would receive CPR, contrary to their stated wishes.
Failure to Follow Two-Person Mechanical Lift Transfer Protocol
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for transfers, was transferred using a sit-to-stand mechanical lift by only one Certified Nursing Assistant, despite the resident's care plan specifying that two staff members were required for such transfers. The incident was observed while the resident was being moved from the toilet to a wheelchair. Interviews with two Licensed Practical Nurses and another Certified Nursing Assistant confirmed that facility protocol and the resident's care plan required two staff members for mechanical lift transfers. The failure to follow the care plan and facility policy resulted in the resident being transferred without adequate supervision.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to adhere to its Mechanical Lift Policy, which mandates the presence of two staff members during a mechanical lift transfer. This policy breach occurred when a Certified Nursing Assistant (CNA) assisted a severely cognitively impaired resident, identified as R1, in transferring from bed to wheelchair using a mechanical lift without the assistance of a second staff member. This incident led to R1 sustaining an oblique displaced fracture of the distal right femur, necessitating hospitalization and surgical intervention. The incident was documented in the resident's Nurse Progress Note, which detailed that R1 began experiencing leg pain shortly after the transfer. The Licensed Practical Nurse (LPN) on duty assessed R1 and observed that the resident's right leg appeared displaced. Despite the absence of any recent falls or trauma, the orthopedic surgeon later suggested that the fracture might have occurred during the transfer. The resident's family member expressed concerns about the lack of communication from the facility regarding the incident.
Incomplete Fall Risk and Post-Fall Assessments
Penalty
Summary
The facility failed to adhere to its Fall Prevention- Steady Steps policy, resulting in incomplete fall risk assessments and post-fall monitoring for three residents. The policy mandates that residents be evaluated for fall risk upon admission, quarterly, and after significant changes in condition, using the MAHC-10 Fall Risk Assessment Tool. Additionally, post-fall interventions require immediate and 72-hour monitoring, including neuro checks for unwitnessed falls or head injuries. However, the records for three residents showed missing or incomplete fall risk assessments and post-fall documentation. One resident experienced multiple falls, with missing fall risk assessments and incomplete post-fall follow-up notes. Another resident's records lacked the required fall risk assessments upon admission and readmission. A third resident's records were missing both the admission fall risk assessment and a quarterly evaluation, along with incomplete post-fall follow-up notes for several incidents. The facility's staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed these deficiencies in the residents' medical records.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to implement appropriate pressure ulcer care for two residents, leading to significant deterioration in their conditions. One resident, with a history of Alzheimer's Disease, Parkinson's Disease, and other medical conditions, developed an open wound on her left elbow that was not promptly reported to her physician. Despite being at moderate risk for skin breakdown, the resident's care plan did not include specific interventions for the pressure sore until several days after it was first noted. The wound progressed to an infected stage 4 pressure sore, requiring hospitalization, surgery, and intravenous antibiotics. The facility's nursing staff did not consistently monitor or document the condition of the wound, and there was a delay in notifying the physician and obtaining appropriate treatment orders. Another resident, who was admitted with a high risk for pressure ulcers, developed a deep tissue injury on her right heel that was not immediately reported to the physician. The facility's initial assessment did not identify any pressure areas, and the resident's care plan was not updated with appropriate interventions until several days after the injury was discovered. The delay in treatment contributed to the deterioration of the injury into an unstageable pressure sore. The facility's staff failed to notify the physician promptly, and there was a lack of consistent monitoring and documentation of the resident's condition. The facility's policies required that changes in a resident's condition, such as the onset of pressure ulcers, be reported to the attending physician and responsible party. However, in both cases, the facility did not adhere to these policies, resulting in inadequate care and worsening of the residents' conditions. The facility's failure to provide timely and appropriate pressure ulcer care led to significant harm to the residents, highlighting deficiencies in communication, documentation, and adherence to care protocols.
Removal Plan
- The facility completed skin audits of 100% of the residents.
- Administrator and the Interdisciplinary Nursing Team inserviced licensed nursing staff on Wound Protocols, Change of Condition, Skin Evaluations, Pressure Ulcer Risk Evaluations, Wound assessment and management and Skin Check Policy.
- Administrator and the Interdisciplinary Team inserviced Certified Nurse Aides on Skin Checks and following the resident careplan.
- A Quality Assurance Performance Improvement (QAPI) Ad hoc meeting was held for QAPI team to discuss concerns and plan of action.
- Senior President of Operations, who is wound care certified, provided training to current Wound Nurse/Licensed Practical Nurse (LPN).
- Weekly assessments of all skin conditions and pressure injuries were completed. Wound Physician completed weekly wound assessments/treatments.
- Clinical Documentation Specialist confirmed daily clinical meetings have occurred and will continue.
- Interim DON stated she has reviewed all residents with skin alterations and Wound Physician will review all residents with any kind of skin alteration on an ongoing basis.
- Administrator stated daily and weekly clinical meetings have been completed and will be ongoing.
- Audits of five residents per week for pressure interventions have been completed and will be ongoing. Audits of three residents per week for any skin conditions have been completed and will be ongoing. Monthly skin audits were initiated and will be ongoing.
- All new agency and/or new hire nursing staff were to be provided training.
- Annual and as needed training conducted by Wound Nurse and/or Interim DON will be ongoing.
Facility Fails to Implement Required CNA Training Program
Penalty
Summary
The facility failed to implement a comprehensive staff training program for Certified Nurse Aides (CNAs) on essential topics such as Communication, Resident Rights, Abuse, Quality Assurance Performance Improvement (QAPI), Infection Control, Compliance and Ethics, and Behavioral Health. This deficiency was identified through interviews and record reviews, revealing that five CNAs (V26, V27, V28, V29, V30) had not completed the required training in the past twelve months. The facility's Course Completion History did not document these trainings as completed for the CNAs, despite their active roles in providing direct care to residents. The facility's administrator, V1, acknowledged the absence of documentation for the required trainings and confirmed that CNAs V26, V27, and V30 had recently worked at the facility, while V28 and V29 had not worked for two months but were previously providing regular care. The administrator also admitted that there was no specific policy for the training, although it was expected that staff be trained to understand the resident care model. This lack of training documentation and policy potentially affects all 55 residents residing in the facility.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) completed the required minimum of twelve hours of education annually, which includes training in dementia care and abuse prevention. This deficiency was identified through interviews and record reviews, revealing that the CNAs had not met the educational requirements. Specifically, one CNA completed only five hours, another completed four hours, two others completed four and zero hours respectively, and the last CNA also completed zero hours of required inservices in the past twelve months. The facility's administrator acknowledged the lapse in monitoring CNA trainings, attributing it to a change in the Human Resources (HR) position. The administrator confirmed that the facility was unable to provide documentation of the required educational trainings for the CNAs. This failure has the potential to affect all 55 residents residing in the facility, as the lack of adequate training could impact the quality of care provided to them.
Failure to Notify Physician and POA of Pressure Sores
Penalty
Summary
The facility failed to notify the physician and the resident's Power of Attorney (POA) about the development and worsening of pressure sores for two residents. Resident 1, who has severe cognitive impairment and multiple medical conditions including Alzheimer's and Parkinson's Disease, developed an open wound on the left elbow. The wound was first documented on 8/13/24, but neither the physician nor the POA was informed. The POA discovered the wound on 8/24/24, noting its severe condition with visible bone and drainage. The facility administrator and medical director acknowledged that the physician should have been notified earlier to prevent the infection from worsening. Resident 4, also severely cognitively impaired, was admitted with intact skin but developed a deep tissue injury (DTI) on the right heel, identified on 8/24/24. Although the POA and on-call manager were informed, the physician was not notified until 9/10/24. The facility's policy requires notifying the physician and responsible party of any significant change in condition, including pressure ulcers. The regional director and registered nurse admitted the oversight, and the medical director emphasized the need for timely physician notification to obtain treatment orders.
Failure to Review Infection Control Policies Annually
Penalty
Summary
The facility failed to review their Infection Control policies annually, which has the potential to affect all 60 residents residing in the facility. The 'Infection Surveillance' policy was last approved on 11/1/17, with no further review or revision dates. Similarly, the 'Antibiotic Stewardship' policy was also last approved on 11/1/17 without any subsequent reviews. The 'Guidelines for Infection Surveillance Procedures for Infection Preventionist' were dated 2020, but the specific month was unspecified. The 'Pneumococcal Vaccines' policy was dated 3/2022, and the 'Covid Vaccination' policy was approved on 11/29/21, with the most recent review for resident immunizations documented on 2/15/23. Despite these dates, there was no documented proof that these policies were reviewed annually at the QA meetings. On 05/16/24, the Infection Preventionist stated that they had asked the Administrator and the Regional Clinical Director about the infection control policy reviews but received the same policies without any updated review dates. The Administrator confirmed on 05/17/24 that they were aware of the concern and had scheduled a QA meeting for the following week to conduct the reviews. However, they could not provide any more recent review dates for the policies in question. This lack of annual review documentation was identified during the survey, highlighting a significant deficiency in the facility's infection control program.
Failure to Document Fluid Intake and Output for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to document fluid intake and output for a resident with an indwelling urinary catheter, as required by the facility's policy and the resident's care plan. The resident, who was admitted with chronic kidney disease, bladder neck obstruction, and diabetes mellitus, had a history of urinary tract infections and was observed with an indwelling urinary catheter. Despite the care plan's directive to monitor and document intake and output, the resident's medical records, including the Medication Administration Record and Treatment Administration Record, lacked documentation of fluid intake and output. Additionally, the Certified Nursing Assistants Task Sheet showed that fluid output was only recorded for 6 out of 36 shifts, with no documentation of fluid intake at all. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed the lack of documentation. The facility's policy on Intake and Output Measurement mandates that residents with indwelling catheters have their intake and output measured and documented every eight hours, with a 24-hour total and weekly evaluation. This policy was not followed, leading to a deficiency in the care provided to the resident, as the necessary monitoring and documentation were not performed consistently or accurately.
Failure to Prevent Cross-Contamination During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to prevent cross-contamination during pressure ulcer treatment for a resident with multiple pressure ulcers. The resident had a Stage III pressure ulcer on the sacrum, a Stage II pressure ulcer on the left heel, and a Deep Tissue Injury on the right heel. During a dressing change, the Registered Nurse (RN) applied medihoney ointment directly from the tube to the wounds without using an applicator, contaminating the ointment tube. The RN then used the same contaminated ointment tube on the resident's other wounds, thereby cross-contaminating them. This action was against the facility's policy, which requires the use of separate applicators for each wound to prevent contamination. The incident was observed and confirmed by the facility's Regional Clinical Consultant Nurse, who acknowledged that the RN should have used a separate applicator for each wound. The RN admitted to the mistake, stating that she was trying to ensure a good amount of ointment was applied to the wound beds. The facility's policy on aseptic treatments and dressing changes clearly outlines the need to prevent contamination and trauma to the wound or periwound areas, which was not followed in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
