Arcadia Care Auburn
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Illinois.
- Location
- 304 Maple Avenue, Auburn, Illinois 62615
- CMS Provider Number
- 145136
- Inspections on file
- 48
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Arcadia Care Auburn during CMS and state inspections, most recent first.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident was found with a medication cup, inhaler, and nasal spray left unsecured on the bedside table, despite no physician order or authorization for self-administration. The RN confirmed leaving the medications at the bedside, and the DON stated the resident was not on a self-administration program. Facility policy required medications to be administered and recorded by licensed nurses, with no provision for bedside storage without specific authorization.
Multiple residents with chronic health conditions and staff reported that the dining and visiting rooms were uncomfortably cold, with temperature readings in these areas consistently below 68°F. Despite the thermostat being set to 70°F, residents were observed wearing extra clothing and using blankets during meals and activities. The facility lacked a specific policy for maintaining internal temperatures outside of its emergency plan.
A deficiency occurred when the facility failed to provide hot water for 21 residents on one hallway, resulting in residents being unable to wash their hands or face with hot water and missing showers. Staff and resident interviews, as well as direct observations, confirmed the ongoing lack of hot water due to a malfunctioning water heater and delays in replacement. Alternative measures for personal hygiene were inconsistently provided, and maintenance records documented the prolonged outage.
A prolonged hot water outage affected multiple residents, who were unable to wash with hot water or receive regular showers. Staff attempted to use alternative methods, such as transporting residents to other shower rooms and providing basins with warm water, but these measures were inconsistently applied. The facility lacked a clear policy for handling hot water heater failures, resulting in extended disruption of basic hygiene services.
A resident was found unresponsive, and facility staff failed to initiate CPR immediately despite the resident's full code status. A CNA and ADON did not check for a pulse until prompted by surveyors, delaying life-saving measures. CPR was eventually started by an RN, but the resident was declared deceased after emergency services arrived.
The facility failed to effectively monitor and track infections and antibiotic use for five residents, leading to discrepancies and incomplete documentation. The infection control logs lacked specific details about infections and antibiotics used, and the Director of Nursing admitted challenges in obtaining cultures for residents on antibiotics. The facility's policy emphasized the need for an Antibiotic/Antimicrobial Stewardship program, but the current system was insufficient.
A resident with severe cognitive impairment and behavioral disturbances was involved in multiple incidents of aggression towards other residents, resulting in physical altercations and minor injuries. Despite known triggers for the resident's agitation, the facility failed to prevent these incidents, demonstrating a lack of effective management of the resident's behaviors.
A resident with a left hip surgical incision did not receive proper dressing changes or monitoring for infection, as required by physician orders and facility policy. The dressing was observed to be torn and saturated, yet facility staff failed to change it or assess the incision, leading to a deficiency in care.
Two residents in the facility experienced significant medication errors due to improper timing of Carvedilol administration. One resident received doses late due to sleeping in, while another's doses were delayed due to staffing issues. The facility's policies were not followed, leading to these errors.
A resident with a history of mental health issues and trauma overdosed on medication due to the facility's failure to implement necessary interventions. Despite being under psychiatric care, the resident's declining mental status was not communicated to the appropriate medical professionals. The facility lacked psychosocial programs and did not adequately monitor or support the resident's mental health needs, leading to hospitalization and death.
A resident with a history of depression and anxiety overdosed on medication due to the facility's failure to implement interventions and notify the Psychiatry Nurse Practitioner of her declining mental status. Despite signs of worsening mental health, the facility did not provide psychosocial support or secure the resident's medications, leading to her hospitalization and subsequent expiration.
The facility failed to provide an RN on duty for 8 hours a day, 7 days a week. The nursing schedule showed no RN on duty on two specific dates, which was confirmed by the DON. The administrator stated that the facility staffs according to census needs and does not have a staffing policy. At the time, the facility had 59 residents.
The facility failed to notify a resident's family or POA of a fall and did not discuss the resident's declining condition, hindering informed medical decisions. The resident, with severe diagnoses and significant pain, experienced a fall and worsening health, but the family was not informed despite multiple staff members documenting the decline and assuming others had communicated with the family.
A resident with multiple comorbidities experienced a decline in health due to the facility's failure to provide a timely vascular consult. Despite recommendations from healthcare providers, the facility did not secure an appointment, leading to severe pain, septic shock, and gangrene, ultimately resulting in the resident's death.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Medications Left Unsecured at Bedside Without Authorization
Penalty
Summary
A deficiency occurred when a registered nurse (RN) left a medication cup containing medication, along with a Trelegy Ellipta inhaler and Fluticasone Propionate nasal spray, on a resident's bedside table while the resident was asleep in a chair. The resident's Medication Administration Record (MAR) indicated that multiple medications were prescribed to be administered in the morning, but there was no documentation authorizing the resident to have medications at the bedside or to self-administer medications. The MAR showed that all medications were documented as administered by the RN, and the physician's orders did not include any instructions for self-administration or bedside storage of medications. The RN confirmed that she left the medications at the bedside for this resident and also allowed the resident to keep the nasal spray and inhaler at the bedside, a practice not extended to other residents. The Director of Nursing (DON) verified that the resident was not on a self-administration program. Facility policy specified that only licensed nurses may prepare, administer, and record medication administration, with no provision for residents to keep medications at their bedside unless specifically authorized. This resulted in a failure to ensure drugs and biologicals were stored in locked compartments and administered as ordered.
Failure to Maintain Comfortable Temperatures in Common Areas
Penalty
Summary
The facility failed to maintain comfortable temperatures in the dining room and visiting room, as evidenced by multiple resident and staff reports, as well as direct temperature measurements. Several residents, including those with chronic conditions such as heart failure, COPD, diabetes, and dementia, reported that while their individual rooms were at a comfortable temperature, the dining room and common areas remained cold. Residents described discomfort during meals and activities, with some observed wearing extra clothing and blankets to stay warm. Staff members, including CNAs and the Activity Assistant, confirmed that residents frequently complained about the cold temperatures in these areas and that they often provided blankets to help residents stay warm. The Maintenance Director stated that the dining room thermostat is located in the kitchen and is set to 70°F, but temperature readings taken by both facility staff and the surveyor in the dining and visiting rooms ranged from 67.3°F to 68°F. The Administrator confirmed that all 57 residents use the common areas and that the facility does not have a specific policy for maintaining internal temperatures outside of the emergency disaster plan. The lack of a clear policy and the observed low temperatures in communal areas contributed to the deficiency in providing a comfortable environment for residents.
Failure to Provide Hot Water for Resident Use
Penalty
Summary
The facility failed to provide hot water for 21 residents on the south hallway, as observed and confirmed through resident interviews, staff interviews, and record reviews. Multiple residents reported not having hot water in their bathrooms for an extended period, with some stating they had not received a shower in a week and were unable to wash their hands or face with hot water. Residents also indicated that they were not provided or offered warm wet washcloths as an alternative for personal hygiene. Direct observations by surveyors confirmed that the hot water in affected residents' bathrooms and the south hall shower room remained cold even after running for several minutes. Staff interviews revealed that residents from the affected hallway were taken to another shower room for bathing, and staff attempted to use water basins or obtain hot water from other areas for handwashing. However, some staff reported using cold water for handwashing due to the lack of hot water access. Maintenance records and staff interviews indicated that the hot water heater on the south hallway had been malfunctioning since at least 3/24/2025, with repeated issues relighting the pilot light and delays in obtaining a suitable replacement unit. Resident council meeting minutes and maintenance work orders corroborated the ongoing lack of hot water. The facility's own documentation and residents' care plans confirmed the need for assistance with bathing and personal hygiene, which was not adequately met due to the hot water outage.
Failure to Maintain Hot Water Supply for Residents
Penalty
Summary
The facility failed to maintain a functioning hot water heater for a period of 16 days, resulting in the lack of hot water for 21 residents on the south hallway. Multiple residents reported being unable to wash their hands or faces with hot water, and some stated they had not received a shower in over a week. Observations confirmed that the hot water in resident bathrooms and the shower room was cold to the touch after running for several minutes. Staff interviews revealed that residents were not consistently provided with alternative means, such as warm wet washcloths, to maintain personal hygiene during this period. The breakdown of the hot water heater began when the pilot light repeatedly went out, and attempts to repair it were unsuccessful. The facility ordered a replacement, but the wrong type was delivered, causing further delays. Internal communications documented the timeline of the breakdown, the ordering process, and the challenges in obtaining the correct replacement unit. During this time, staff had to use other areas of the facility to provide showers and attempted to use basins and rags with hot water, though this was not consistently implemented for all residents. The facility did not have a specific policy for responding to a hot water heater failure and did not activate its emergency water supply process, as the water supply itself was not lost. The Emergency Operations Plan referenced an emergency water supply process but did not provide guidance for a loss of hot water. As a result, residents on the affected hallway experienced prolonged periods without access to hot water for basic hygiene needs.
Failure to Initiate Immediate CPR for Unresponsive Resident
Penalty
Summary
The facility failed to provide immediate basic life support, including CPR, to a resident identified as unresponsive. On the morning of the incident, a CNA attempted to arouse the resident without success and did not check for a pulse until prompted by the survey team. The Assistant Director of Nursing (ADON) was called into the room and also failed to check for a pulse immediately, instead opting to perform a blood sugar test and instructing the CNA to take vital signs. The vital signs machine did not register a pulse or blood pressure, and it was only after the surveyor's intervention that the CNA checked for a pulse and found none. The Director of Nursing (DON) and other staff members arrived subsequently, with the DON bringing a crash cart and applying oxygen. Despite the presence of multiple staff members, CPR was not initiated until several minutes after the resident was first found unresponsive. The Registered Nurse (RN) eventually began chest compressions, and the ADON provided breaths using a resuscitation bag. The Social Service Director confirmed that the resident was a full code, meaning CPR should have been initiated immediately upon finding the resident unresponsive. Emergency medical services arrived shortly after CPR was started by the facility staff, but the resident was declared deceased shortly thereafter. The resident's medical history included several chronic conditions, and their POLST form indicated they were a full code, requiring all life-saving measures. The delay in initiating CPR and the failure to follow the facility's CPR policy contributed to the deficiency identified by the survey team.
Deficiency in Infection Monitoring and Antibiotic Tracking
Penalty
Summary
The facility failed to implement a system to monitor and track infections effectively, as evidenced by the lack of documentation and tracking of antibiotic use for five residents. For Resident 3, the facility's infection control log did not document the organism associated with a urinary tract infection treated with Fosfomycin. Similarly, Resident 8's infection control log failed to specify the infection type when Amoxicillin was prescribed for cellulitis, and there was a discrepancy in the documentation of antibiotics used, with both Ceftriaxone and Amoxicillin being administered. Resident 47 was prescribed Cephalexin for a possible urinary tract infection, but the infection control log inaccurately documented the use of Acyclovir for a bacterial UTI. Resident 22 was treated with Levofloxacin for cellulitis, and while the infection control log noted a bacterial skin infection, the facility's tracking system did not ensure comprehensive documentation. Resident 30 received Sulfamethoxazole-Trimethoprim for prophylactic use, but the infection control log inaccurately recorded the condition as bacterial cellulitis. The Director of Nursing acknowledged the use of a computer program for tracking and trending antibiotic use but admitted that the facility struggled to obtain cultures when residents arrived on antibiotics without them. The facility's policy emphasized the importance of an Antibiotic/Antimicrobial Stewardship program to ensure appropriate antibiotic use, but the lack of a robust system led to deficiencies in monitoring and tracking infections and antibiotic use.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving three residents, identified as R24, R36, and R109, in a sample of 34. Resident R20, who has severe cognitive impairment and behavioral disturbances due to dementia, was involved in multiple incidents of aggression. On one occasion, R20 grabbed R109 by the shirt, although no injuries were noted. In another incident, R20 attempted to take a broom from R24 and subsequently put his arms around R24's head, resulting in an abrasion to R24's ear. Additionally, R20 was observed ramming his wheelchair into R36's wheelchair and grabbing her arm, causing her to scream in pain, although no injuries were reported. The facility's records indicate that R20 becomes agitated in noisy environments or when he feels threatened, leading to aggressive behaviors such as bumping into others or grabbing them. Despite these known triggers, the facility's interventions were insufficient to prevent these incidents of abuse. The facility's policy affirms residents' rights to be free from abuse, yet the repeated incidents involving R20 demonstrate a failure to adequately protect residents from abuse and to manage R20's behavioral issues effectively.
Failure to Provide Proper Surgical Site Care
Penalty
Summary
The facility failed to provide appropriate surgical site care for a resident, identified as R257, who was admitted with a left hip surgical incision. The resident's care plan indicated a risk for skin impairment, requiring monitoring and documentation of the surgical site. However, observations revealed that the dressing on the resident's left hip was torn and saturated with exudate, exposing the inner layers. Despite the resident's cognitive awareness and ability to communicate, the facility did not change the dressing or assess the incision for signs of infection, contrary to the physician's expectations and the facility's own policy. Interviews with facility staff, including the ADON and DON, indicated a lack of clarity and adherence to the physician's orders and facility policy regarding surgical site care. The orthopedic surgeon's office confirmed that the facility was expected to monitor the surgical site for infection and change the dressing if saturated. However, the facility staff did not perform these actions, leading to a potential risk of infection. The facility's policy required daily checks of the dressing for cleanliness and signs of infection, which were not conducted, resulting in a deficiency in the quality of care provided to the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer anti-hypertensive/cardiac medications at safe intervals for two residents, leading to significant medication errors. One resident, admitted with diagnoses including cerebral infarction, stage 4 chronic kidney disease, congestive heart failure, and essential primary hypertension, received their Carvedilol doses at inappropriate times. The morning dose was administered at 11:32 AM instead of 6:00 AM, and the afternoon dose was given at 3:52 PM. The LPN responsible stated that the delay was due to the resident sleeping in late, and there was no communication to the next nurse about the late administration. Another resident, with diagnoses of pulmonary heart disease, heart failure, and essential primary hypertension, also received their Carvedilol doses late. The morning dose was given at 1:14 PM instead of 6:00 AM, and the afternoon dose was administered at 4:32 PM. The LPN was unsure of the reason for the delay but mentioned being short-staffed and assisting nurse aides before passing medications. The Medical Director highlighted the risk of administering Carvedilol doses too close together, which could lead to hypotension and bradycardia. The facility's policies on medication administration were not adhered to, contributing to these errors.
Failure to Implement Interventions for Resident with Mental Health Issues
Penalty
Summary
The facility failed to implement necessary interventions for a resident, R2, who had a history of mental health issues and trauma, leading to an overdose of medication. R2 was admitted with diagnoses including Parkinson's Disease, depression, anxiety, and a history of spousal abuse. Despite being under the care of a Psychiatry Nurse Practitioner, the facility did not notify the practitioner or physician of R2's declining mental status. R2 had medications in her possession, which the staff was aware of, but failed to take appropriate action to prevent an overdose. R2's mental and psychosocial wellbeing were not accurately assessed, monitored, or supported by the facility. The resident had recently sustained physical abuse and was experiencing major depressive disorder and anxiety. The facility did not provide psychosocial programs, counseling services, or any specific interventions for residents with high psychosocial needs. R2 exhibited signs of worsening depression, such as hallucinations, anxiety, and fear, but these were not adequately addressed by the staff. The facility's inaction resulted in R2 overdosing on Xanax and Tylenol, leading to hospitalization and subsequent death. Staff interviews revealed that R2 had been hallucinating, expressing fear of her husband, and showing signs of depression, yet these were not communicated to the Psychiatry Nurse Practitioner. The facility lacked a system for monitoring and addressing the psychosocial needs of residents, contributing to the failure to prevent the overdose.
Removal Plan
- Facility ensured all residents are safe and not at risk and Psychosocial needs are being met.
- Evaluation of Risk for Suicide and Self Harm completed on the whole house.
- Trauma assessments completed.
- Assessment of Depression completed on the whole house.
- All trauma distress depression assessments are being completed on whole house to ensure appropriate services are in place.
- Directive has been posted at timeclock and Nurses' Station if any signs or symptoms of distress/depression to report to nurse.
- Staff educated if any signs or symptoms of depression/distress noted, facility will update Psychiatry for further orders.
- Staff education for signs and symptoms of depression completed.
- Staff education sheet posted by timeclock.
- Residents that have exacerbation of depression followed up with Psychiatry for guidance, for 1:1, 15-minute checks or hospitalization.
- Reviewed behavior monitoring.
- All staff educated on monitoring behavior per standards of practice.
- Education completed for medications at bedside and signs and symptoms of depression.
- Rooms were swept for meds with resident consent and education to residents at that time.
- All residents on Psychoactive Medications are referred to Psychiatry upon admission, this is ongoing.
- Visits have increased to every three weeks.
- Depression is assessed upon admission, quarterly, and with a significant change. Residents that have exacerbation of depression followed up with Psychiatry and Medical Physician for guidance, for 1:1, 15-minute checks or hospitalization.
- Policy for suicide watch was reviewed and no changes necessary.
- Behavior monitoring is documented per shift per CNA staff and reviewed by Interdisciplinary team daily in QA meeting which consist of nursing management, social services and administrator.
- All residents assessed to ensure resident based intervention care plan services are in place.
- Reviewed all residents for individualized care plan interventions for behaviors.
- Education provided to staff on trauma/mental disorder.
- All staff educated prior to taking shift.
- Audits completed weekly.
- All charts audited for psychosocial assessment, trauma assessments, self-harm/suicide risk assessment and the patient healthcare assessment.
- Regional team with complete weekly starting next week.
- QAPI meeting held to ensure compliance.
- Reviewed and discussed daily in morning meeting with Interdisciplinary team.
- QAPI completed.
- For residents identified by the facility as requiring services for trauma/mental illness/depression facility will notify Psychiatry and Medical Physician for guidance for 1:1, 15-minute checks or hospitalization. Notifications will be made immediately by nursing or social services. This is ongoing.
Failure to Prevent Medication Overdose in Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent a resident from overdosing on medication. The resident, who had a history of Parkinson's Disease, depression, anxiety, and was a victim of spousal abuse, was admitted to the facility after being hospitalized for injuries inflicted by her husband. Despite being under the care of a Psychiatry Nurse Practitioner, the facility did not notify the practitioner or the physician about the resident's declining mental status and the presence of medications in her possession. This oversight led to the resident overdosing on Alprazolam and Tylenol, resulting in her hospitalization and subsequent expiration. The resident's mental health was deteriorating, as evidenced by her behavior charting and PHQ-9 assessment, which indicated moderately severe depression. Staff members were aware of the resident's hallucinations, anxiety, and paranoia, particularly concerning her abusive husband. Despite these signs, the facility did not provide psychosocial programs or counseling services, and the Psychiatry Nurse Practitioner was not informed of the resident's worsening condition. Additionally, the facility failed to secure the resident's medications, allowing her to access and consume them unsupervised. Interviews with staff revealed a lack of communication and awareness regarding the resident's possession of medications and her mental health status. The facility did not conduct an assessment to determine if the resident could safely keep medications at her bedside, nor did they implement frequent monitoring of her behavior. The absence of a coordinated care plan and failure to involve the Psychiatry Nurse Practitioner in the care process contributed to the tragic outcome.
Failure to Provide RN Coverage 8 Hours a Day, 7 Days a Week
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for 8 hours a day, 7 days a week, as required. This deficiency was identified through interview and record review. The facility's nursing schedule documented that there was no RN on duty on March 30, 2024, and March 31, 2024. The Director of Nursing (DON) confirmed that the facility did not have an RN on duty on these dates. Additionally, the facility's administrator stated that the facility does not have a staffing policy and staffs according to census needs. At the time of the deficiency, the facility had 59 residents, as documented in the Resident Census Report and the CMS 671 form dated April 22, 2024.
Failure to Notify Family of Resident's Decline and Fall
Penalty
Summary
The facility failed to notify the family or Power of Attorney (POA) of a resident's fall and did not fully discuss the resident's declining medical condition with the POA, which hindered the POA's ability to make informed decisions regarding the resident's medical treatment options. The resident, who was moderately cognitively impaired and had multiple severe diagnoses including end-stage renal disease and peripheral vascular disease, experienced a fall that was documented by a Registered Nurse. However, the family was not notified immediately, and attempts to contact the family were unsuccessful. The Director of Nursing later confirmed that the family was not informed of the fall on the day it occurred. The resident's condition continued to decline, with significant pain and necrotic changes in the lower extremities. Despite multiple progress notes documenting the resident's worsening condition and recommendations for hospice care or vascular surgery, there was no evidence that the family was informed or involved in discussions about the resident's care and prognosis. Interviews with various staff members, including the Social Service Director, Nurse Practitioner, and Primary Care Physician, revealed that none of them had communicated the resident's condition to the family, each assuming that someone else had done so. The facility's policies on change of condition and advance directives require consultation with the doctor and family for any changes in condition and informing resident representatives about the right to accept or refuse medical treatment. However, the facility did not adhere to these policies, resulting in a lack of communication with the family about the resident's severe pain, necrotic toes, and potential need for hospice care. This failure to notify and involve the family in critical medical decisions represents a significant deficiency in the facility's care practices.
Failure to Provide Timely Vascular Consult
Penalty
Summary
The facility failed to provide a timely vascular consult for a resident (R2) who was admitted with multiple comorbidities, including end-stage renal disease, malignant neoplasm of the kidney, peripheral vascular disease, and acute and chronic respiratory failure. Upon admission, R2 had an open wound on the left great toe and was noted to have very edematous legs. Over time, R2's condition worsened, with increasing pain and discoloration in the lower extremities. Despite multiple recommendations from healthcare providers for a vascular consult and diagnostic tests, the facility did not secure a timely appointment with a vascular specialist. This delay contributed to R2's progressive decline, severe pain, and eventual hospitalization for septic shock and gangrene, leading to R2's death. Interviews with staff revealed that there was a lack of communication and coordination regarding R2's care, with some staff members unaware of the severity of R2's condition and others unsure of who was responsible for notifying the family and securing the vascular consult. The facility's change of condition policy was not effectively followed, resulting in a failure to address R2's deteriorating condition promptly and appropriately.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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