Arcadia Care Morris
Inspection history, citations, penalties and survey trends for this long-term care facility in Morris, Illinois.
- Location
- 1095 Twilight Drive, Morris, Illinois 60450
- CMS Provider Number
- 145623
- Inspections on file
- 34
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Arcadia Care Morris during CMS and state inspections, most recent first.
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 diagnoses and a history of falls was frequently left unsupervised, leading to repeated fall attempts and incidents. Despite ongoing agitation and risky behaviors, the care plan was not updated to include enhanced supervision or personalized fall prevention interventions. Staff and family confirmed insufficient monitoring, and facility leadership acknowledged that required care plan revisions and safety monitoring were not implemented.
A resident did not receive her monthly personal needs allowance after admission because the facility failed to promptly transfer and process her social security benefits from a previous facility. Despite the resident and her family raising concerns, the necessary application for representative payee was delayed, and the facility lacked a policy for handling such transfers.
A resident with multiple diagnoses, including a pressure ulcer with infection, did not receive the first scheduled doses of prescribed antibiotics due to delays in obtaining hospital discharge paperwork and medication orders. Despite having the medications on hand, staff did not administer them at the correct times, and the required orders were not promptly secured, resulting in a failure to follow physician instructions for medication administration.
Staff did not consistently follow infection control protocols, including hand hygiene and the use of gowns and gloves for residents on enhanced barrier precautions with indwelling devices or wounds. Multiple staff members provided care, such as perineal care, wound care, and blood sugar testing, without proper PPE and failed to perform hand hygiene after glove removal, leading to contamination of clean surfaces and equipment.
The facility failed to follow its water management plan for legionella and did not adhere to infection control protocols, including contact isolation and enhanced barrier precautions. Staff were observed not wearing appropriate PPE and not practicing proper hand hygiene during resident care, leading to deficiencies in infection prevention.
The facility failed to assist residents with personal hygiene and grooming, leaving several with long, dirty fingernails and unkempt appearances. Despite residents' requests for help, staff did not adequately address these needs, and observations showed that routine care tasks like nail trimming and changing soiled clothing were not consistently performed.
The facility failed to provide food in the correct consistency for residents on mechanically altered diets. Pureed chicken and vegetables were not properly processed, resulting in a grainy texture unsuitable for pureed diets. Additionally, residents on mechanical soft diets received meals with whole mushrooms and unpeeled potatoes, contrary to guidelines. These deficiencies affected nine residents and were confirmed by dietary staff during meal service observations.
A resident with multiple medical conditions, including cervical disc degeneration and morbid obesity, was unable to reach her call light and had to yell for help after a bowel movement. Despite her calls, a housekeeper did not respond, and the call light was found on the floor, out of reach. The facility's policy requires call lights to be accessible at all times, but this was not followed, as confirmed by the DON.
A resident with hemiplegia and hemiparesis was not assessed or provided with necessary splints to prevent further reduction in ROM. Despite being cognitively intact and requiring assistance with ADLs, the resident had contractures in her right arm, hand, and wrist, and expressed a desire for a therapist's assessment. An OT evaluation confirmed the need for orthoses to prevent further decline, but these were not initially provided.
A resident with a suprapubic and nephrostomy catheter had their catheter tubing and bag improperly positioned above the bladder by CNAs, contrary to the care plan and facility policy. This failure to maintain the catheter bag and tubing below the bladder level was confirmed by the DON, highlighting a deficiency in catheter care.
A resident with Parkinson's, acute kidney failure, and dementia did not receive breakfast meals on dialysis days due to a schedule change. The facility failed to adjust meal provisions, leading to significant weight loss. Staff were unaware of the need for meals or supplements, and no policy existed for dialysis sacked meals.
The facility failed to maintain proper central line dressing and assessment for two residents. One resident had a non-transparent, dirty dressing on her IV central line, while another had a loose PICC line dressing exposing the catheter. Required assessments and documentation were not conducted, contrary to facility policy.
A resident with dementia and severe cognitive impairment was prescribed Risperidone for restlessness without proper indications. The facility's documentation did not support the use of antipsychotic medication, as the resident showed no behavioral symptoms warranting such treatment. The DON acknowledged the lack of a valid diagnosis for the medication, and the consultant pharmacist had requested clarification on the antipsychotic usage.
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.
Failure to Revise Care Plan and Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to revise and implement care plan interventions to prevent falls and provide adequate supervision for a resident identified as high risk for falls. The resident had multiple diagnoses, including metabolic encephalopathy, diabetes, lack of coordination, cognitive communication deficit, muscle wasting, spinal stenosis, Parkinson's disease, a history of falls, and altered mental status. Despite these risk factors, the resident experienced frequent episodes of agitation, restlessness, and behaviors that could result in falls, as documented in progress notes and observed by staff. On several occasions, the resident was observed in common areas, such as the dining room and hallways, without staff supervision. The resident repeatedly attempted to stand, walk, or manipulate wheelchair footrests, often requiring redirection. In the absence of staff, another resident took it upon herself to watch over and redirect the resident, stating that there was not enough staff to provide supervision. Staff interviews confirmed that one-to-one care had been discontinued due to staffing shortages, and that supervision was provided only when possible. The resident's family member reported numerous falls since admission and was unaware of any new interventions to prevent further incidents. Review of the resident's care plan revealed that, despite multiple falls, interventions were not updated to address supervision, monitoring, or specific fall risk behaviors. The care plan did not reflect changes or personalized preventative measures after each fall, contrary to the facility's own Fall Prevention Program policy, which requires care plans to be revised with each incident. Facility leadership acknowledged that the resident was not on safety monitoring and that care plan interventions had not been reviewed or adjusted as required.
Failure to Transfer and Process Resident's Social Security Benefits for PNA
Penalty
Summary
The facility failed to ensure the timely transfer and processing of a resident's social security benefits from a previous facility, resulting in the resident not receiving her monthly personal needs allowance (PNA) after admission. The resident, who was alert and oriented, reported not receiving her $60 monthly allowance since her admission in June and stated that repeated requests to the former Business Office Manager yielded no results. The resident only learned recently that the transfer of her social security benefit had not been filed, which caused her distress. The family also raised concerns about the missing funds, and it was discovered that the previous facility had returned the resident's social security checks to Social Security upon her discharge. Interviews with facility staff revealed that attempts were made to contact the previous facility and Social Security, but these efforts were unsuccessful or not clearly documented. The facility did not have a policy regarding representative payee procedures, and the application to become the resident's representative payee for social security benefits was only submitted several months after admission. As a result, the resident's Medicaid payments were only partial, and the facility had not received the social security benefits to manage the resident's PNA as requested.
Failure to Obtain Orders and Administer Medications as Prescribed
Penalty
Summary
The facility failed to obtain necessary orders and administer prescribed medications as required for a resident who was admitted with multiple diagnoses, including a pressure ulcer with infection. After the resident returned from the hospital, there was a delay in receiving discharge paperwork and medication orders, as neither the family nor the hospital initially provided the necessary documentation. Despite the family informing staff that the hospital would fax the paperwork and later providing pill bottles, the facility did not promptly secure the required orders or administer the antibiotics as prescribed. As a result, the resident did not receive the first scheduled doses of Bactrim DS and Cephalexin at the prescribed times. The medication administration record confirmed that the initial doses were missed, and the antibiotics were not started until later than ordered. Staff interviews revealed that it was not standard procedure to call the hospital for paperwork, and the Director of Nursing acknowledged that the first dose should not have been missed, especially since the medications were available in the facility. The facility's policy requires medications to be administered according to physician orders, which was not followed in this instance.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols, specifically regarding hand hygiene and the use of enhanced barrier precautions (EBP) for residents with indwelling medical devices or wounds. In multiple observed instances, certified nursing assistants (CNAs) and licensed nursing staff provided care to residents on EBP without wearing required gowns. During perineal care and wound care, staff did not change gloves between tasks, did not perform hand hygiene after removing gloves, and touched various surfaces and equipment with contaminated hands or gloves. For example, after providing perineal care to a resident with a urinary catheter, a CNA did not remove soiled gloves or perform hand hygiene before handling clean linens and touching the door. Similarly, a nurse performed wound care without changing gloves between tasks and failed to perform hand hygiene before leaving the room and handling clean supplies. Additional observations included staff performing blood sugar testing and other care for residents on EBP without wearing gowns, failing to perform hand hygiene after glove removal, and contaminating shared equipment such as medication carts and laptops. Facility policy required the use of gowns and gloves for care involving wounds or indwelling devices and emphasized hand hygiene as the primary method to prevent infection transmission. Despite this, staff did not consistently adhere to these protocols, as confirmed by interviews with the Director of Nursing and other staff.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its water management plan for legionella, as evidenced by the lack of documentation for critical maintenance activities. The Environmental Services Director, V27, admitted to not keeping records of the temperatures of the hot water boiler/storage tanks, the thermostat of the mixing valve, and inspections of the eye wash stations, ice machines, and cooling towers. The facility's policy required weekly verification and documentation of these elements to prevent Legionella growth, but there were significant gaps in the records, including missing temperature logs for specific weeks and months. The facility also failed to implement proper infection control measures, particularly concerning contact isolation and enhanced barrier precautions. Residents with infections requiring contact precautions, such as R27 and R41, were not consistently managed according to CDC guidelines. Staff members were observed interacting with these residents without wearing the necessary personal protective equipment (PPE), such as gowns and gloves, during high-contact activities. This non-compliance was noted during interactions with residents who had multidrug-resistant organisms, where staff failed to follow the facility's infection prevention and control program. Additionally, there were multiple instances of inadequate hand hygiene practices among staff members during the provision of care. Staff were observed not changing gloves or performing hand hygiene between tasks, which is critical to preventing the spread of infections. For example, during incontinence care for residents like R38 and R6, staff did not follow proper hand hygiene protocols, such as washing hands or using hand sanitizer after glove removal and before donning new gloves. These lapses in infection control practices were contrary to the facility's policies and contributed to the deficiencies identified during the survey.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene and grooming for several residents who were identified as needing such assistance. Observations revealed that multiple residents had long, jagged fingernails with black substances underneath, indicating a lack of proper nail care. For instance, one resident with dementia and macular degeneration was observed with long, dirty fingernails while eating, and another resident with hemiplegia had similar issues along with long facial hair, which they found embarrassing. The deficiency was further highlighted by the residents' own requests for assistance, which were not adequately addressed by the staff. One resident, who was cognitively intact but physically impaired, expressed the need for help with nail care and removal of facial hair, yet these needs were not met. Another resident, who was dependent on staff for hygiene due to musculoskeletal impairment, was observed with overgrown facial hair and dirty nails, despite having a care plan that included regular nail care. Additionally, the facility's staff failed to maintain the residents' dignity by not changing soiled clothing in a timely manner. One resident was left with a chunk of dried oatmeal on their shirt for several hours, and instead of changing the shirt, the staff merely removed the oatmeal. The Director of Nursing acknowledged that nail care and shaving should be part of the routine care provided during shower days, but the observations indicated that these tasks were not consistently performed, leading to the residents being unkempt and with dirty fingernails.
Inappropriate Food Consistency for Mechanically Altered Diets
Penalty
Summary
The facility failed to provide food in the appropriate consistency for residents on mechanically altered diets, affecting nine residents. During meal service observations, it was noted that pureed chicken and vegetables were not properly processed, resulting in a grainy texture with pieces that required chewing, which is not suitable for residents on pureed diets. The facility's guidelines specify that pureed foods should have a smooth, pudding-like consistency, similar to mashed potatoes. However, the pureed chicken and vegetables served did not meet these standards, as confirmed by taste tests conducted by the Regional Dietary Certified Manager and the Contract Dietary Consultant. Additionally, residents on mechanical soft diets received meals that included whole sautéed mushroom slices and roasted potatoes with skin, contrary to the facility's guidelines for mechanical soft diets. These guidelines require that vegetables be chopped or diced into bite-sized pieces and that potato skins be excluded. The menu and recipe for the meal in question indicated that ground baked chicken with sauce and mashed potatoes should have been served, but this was not followed. The oversight affected residents who were on mechanical soft, ground meat diets, as well as those on mechanical soft diets.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was always within reach, leading to a situation where the resident, identified as R12, was unable to call for assistance. R12, who has multiple medical diagnoses including cervical disc degeneration, spinal stenosis, and morbid obesity, is totally dependent on staff for dressing and toileting hygiene. On the morning of October 1, 2024, R12 was observed repeatedly yelling for help because she needed to be changed after a bowel movement and was wet with urine. Despite her calls for help, a housekeeper continued with her tasks outside R12's room without responding. Upon inquiry, R12 stated she did not know where her call light was, and it was found on the floor, out of her reach. The facility's policy requires that call lights be within easy accessibility to residents at all times, and that staff respond to residents' requests in a timely and courteous manner. However, this policy was not adhered to in the case of R12, as evidenced by the call light being out of reach and the lack of response to her calls for help. The Director of Nursing confirmed that all staff are responsible for responding to calls for help and that call lights should always be within reach of residents. This incident highlights a failure in the facility's adherence to its own policies regarding resident care and call light accessibility.
Failure to Provide Splints for Resident with Contractures
Penalty
Summary
The facility failed to assess and provide necessary splints to a resident, identified as R63, to prevent further reduction in range of motion (ROM). R63, who has multiple diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed to have weakness and contractures in her right arm, hand, and wrist. Despite being cognitively intact and requiring maximum assistance with activities of daily living, R63 was not provided with any splint or positioning device for her right hand and wrist. The resident expressed a desire to be assessed by a therapist for potential use of a splint or positioning device. An occupational therapy evaluation conducted on October 1, 2024, confirmed that R63 had contractures in her right hand, fingers, wrist, and elbow. The occupational therapist recommended the use of an elbow extension orthosis and a resting hand orthosis with finger separators to prevent further decline in function. The therapist also suggested that R63 should wear these orthoses initially for one hour, gradually increasing to eight hours as tolerated. The Director of Nursing stated that nursing staff are expected to report any changes in residents' ROM to ensure timely therapy evaluation and implementation of necessary interventions.
Improper Positioning of Catheter Tubing and Bag
Penalty
Summary
The facility failed to ensure proper positioning of urinary catheter tubing and bags for a resident, identified as R3, who has a suprapubic catheter and nephrostomy catheter due to multiple sclerosis and other medical conditions. During an observation, two Certified Nursing Assistants (CNAs) were seen providing care to R3, and they positioned the catheter tubing and bag on top of a pillow above the resident's bladder. This improper positioning was noted again later in the day, indicating a failure to maintain the catheter bag and tubing below the bladder level as required. The Director of Nursing confirmed that the urinary tubing and bag should be positioned below the bladder to ensure proper drainage and prevent backflow, which could lead to infection. The resident's care plan, which included specific instructions to position the catheter bag and tubing below the bladder, was not followed. The facility's policy on urinary catheter care also emphasized maintaining a downhill flow of urine to prevent backflow, which was not adhered to in this instance.
Failure to Provide Adequate Nutrition for Dialysis Resident
Penalty
Summary
The facility failed to provide adequate nutrition to a resident undergoing dialysis treatment. The resident, who has a history of Parkinson's disease, acute kidney failure, and dementia, was not given breakfast meals on days when dialysis was scheduled early in the morning. Despite a change in the dialysis schedule from afternoon to early morning, the facility did not adjust meal provisions accordingly. On multiple occasions, the resident returned from dialysis without having eaten, and staff were unaware of the need to provide meals or nutritional supplements. The resident experienced significant weight loss since admission, indicating a failure to meet nutritional needs. Staff interviews revealed a lack of communication and coordination regarding the resident's dietary needs and dialysis schedule. The dietitian was not informed of the resident's poor meal intake and had not assessed the resident in person. Additionally, there was no policy in place for providing sacked meals for dialysis patients, leading to further neglect in meal provision. The resident's power of attorney noted the resident's weight loss and attempted to supplement nutrition with Boost drinks, but the facility did not consistently provide these supplements. The lack of a structured plan for meal provision before and after dialysis contributed to the resident's inadequate nutrition and weight loss.
Failure to Maintain Proper Central Line Dressing and Assessment
Penalty
Summary
The facility failed to ensure that the central line insertion sites for two residents were visible under a transparent dressing for proper assessment and monitoring. One resident, with multiple diagnoses including discitis and osteomyelitis, had an IV central line on her right chest covered with non-transparent tape, and the dressing was not clean or intact, with edges curling up and dirt present. The dressing had not been changed since September 26, 2024, despite being observed in poor condition on multiple occasions. Another resident, with diagnoses including osteomyelitis and a chronic ulcer, had a PICC line with a dressing that was loose and exposing the catheter. The dressing was not changed but only secured with tape, and the resident continued to have the same dressing for several days. There was no documentation of necessary assessments such as arm circumference and catheter length to ensure the catheter had not migrated. The facility's policy required a transparent dressing and regular assessments, which were not followed.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident did not receive antipsychotic medications without proper indications for use. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, congestive heart failure, and dementia without behavioral disturbance, was prescribed Risperidone for restlessness. However, the resident's Minimum Data Set indicated severe cognitive impairment without any behavioral symptoms, and the behavior monitoring documentation did not show any agitation or restlessness, except for one episode of grabbing others. The Director of Nursing acknowledged that restlessness is not a valid diagnosis for the use of antipsychotic medication. The resident's care plan and consultant pharmacist recommendations highlighted the need for a specific diagnosis for antipsychotic usage, which was not provided. Progress notes from hospice doctors indicated that the resident experienced intermittent restlessness but could be redirected and had periods of lethargy, sleeping for extended hours. Despite these observations, the facility continued the antipsychotic medication without appropriate justification, leading to the deficiency identified by the surveyors.
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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