Ascension Resurrection Life
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 7370 West Talcott Avenue, Chicago, Illinois 60631
- CMS Provider Number
- 145960
- Inspections on file
- 32
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Ascension Resurrection Life during CMS and state inspections, most recent first.
A resident with anemia and type 2 DM with hyperglycemia, recently positive for COVID-19 and previously on contact/droplet precautions, was observed in a wheelchair with a nebulizer mask not in use and not contained as required. The resident reported receiving nebulizer treatments daily when short of breath. The Quality Director/Infection Preventionist confirmed the mask should be stored in a labeled plastic bag when not in use to avoid contamination. Review of the POS showed an active order for DuoNeb inhalation every shift for congestion, and facility policy required dried nebulizer equipment to be stored in a plastic bag with the resident’s name and date, which was not followed.
Staff failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene requirements for three residents on EBP due to Foley catheter use and wounds. CNAs provided morning care and incontinence care without donning required gowns, despite posted EBP signage and care plans specifying gown and glove use for high-contact care. Another CNA assisted a resident with feeding in the room without wearing a gown and without performing hand hygiene upon exit, and stated she did not need a gown for feeding. The facility’s infection preventionist and written policy both specified that staff must perform hand hygiene and wear gowns and gloves for direct care activities, including incontinence care, wound-related care, handling indwelling devices, and feeding in the room for residents on EBP.
Surveyors found that opened bags of hot dog buns, hamburger buns, and white bread in the dry storage area were not labeled with the date opened or an expiration date, contrary to the facility’s Food and Supply Storage Policy requiring open packages to be covered, labeled, and dated. The Dining Services Director confirmed that opened foods are expected to be labeled in this manner, and this deficient practice had the potential to affect all residents receiving food services.
Surveyors identified multiple failures in pharmaceutical services, including an unattended, unlocked medication cart with narcotics accessible and keys left on top, an inaccurate controlled drug count for clonazepam, and a resident’s medication left at the bedside that the resident ingested without knowing what it was. A resident with CHF experienced significant weight gain while ordered bumetanide doses were not documented as given on several occasions, and MARs for several other residents showed multiple medications not documented as administered according to physician orders. Facility policies required locked storage of medications, strict controlled substance key control and shift-to-shift counts, direct observation of residents during medication administration, and immediate documentation on the MAR/eMAR after each dose.
A resident was initially admitted with a Level I PASARR indicating no known or suspected mental health diagnoses and no psychotropic medications, so no Level II PASARR was required. Over time, the resident’s record was updated to include diagnoses of major depressive disorder, GAD, PTSD, and adjustment disorder, along with physician orders for antidepressants (Remeron and Escitalopram). Despite these changes, facility leadership confirmed that staff did not resubmit the resident for a Level II PASARR and were unaware that new serious mental health diagnoses required resubmission. The facility’s PASRR policy also lacked a process for resubmitting residents for Level II PASARR when new serious mental disorders or related conditions are identified.
A resident admitted for hip fracture/hip replacement with intact cognition and non-ambulatory status, requiring maximal assistance for bed mobility and transfers, reported that staff often took about three hours to respond to her call light and that the call light was frequently not within reach. During observation, the call light was found on the floor several meters away from the resident, who remained bedbound and dependent on staff, and a CNA was seen leaving the room while the call light was still on the floor before returning to clip it to the resident’s linen. The resident described remaining in wet incontinence briefs for hours while waiting for help. The DON confirmed that staff are required to keep call lights within reach, and facility policy states that residents confined to bed or chair must have call lights within reach and that calls should be answered as soon as possible.
Two residents experienced deficiencies in medication management and monitoring when nursing staff failed to follow physician orders and document administration of key medications. A resident with type 2 DM had multiple undocumented doses of an oral hypoglycemic, missing blood glucose checks despite orders, and received Humalog Lispro without a contemporaneous BG check, with insulin timing not aligned to the scheduled mealtime. Another resident with CHF had significant weight gain consistent with fluid retention while multiple doses of ordered Bumetanide were not documented as given. These issues occurred despite facility policies requiring safe, timely, and prescribed medication administration and expectations from the DON that nurses follow physician orders.
A nurse failed to follow medication administration policies and MD orders for a resident, resulting in a 19.35% med error rate. Multiple oral meds were mixed together in applesauce and given at once instead of one at a time, the nurse left before confirming all tablets were swallowed, and some tablets were spit out and discarded. The resident had an order to crush appropriate meds, but whole tablets were initially given until a family member intervened. A nebulized albuterol treatment was administered with the resident improperly positioned and the nebulizer not kept vertical, leaving visible medication in the chamber that was then discarded. Insulin lispro and glimepiride ordered to be given with meals, and pantoprazole ordered before breakfast, were not timed with meals per orders and facility policy, and insulin was given without a contemporaneous blood glucose check.
Surveyors found multiple failures to securely store and manage medications, including an unlocked, unattended med cart in a hallway, unsecured medications and a wound cart in a clean utility room accessible to CNAs and unlicensed staff, and numerous medications for a former resident left in an unlocked cabinet. Additionally, an open vial of Lantus insulin remained in use past its discard date and a Humalog KwikPen lacked an open date and was not refrigerated as required, all contrary to facility policy for safe, locked, and orderly drug storage.
Surveyors found that staff failed to follow PPE protocols for two residents on Enhanced Barrier Precautions (EBP). One resident with cellulitis, open lower-extremity wounds, and IV therapy had a nurse remove and discard PPE in the hallway after exiting the room, despite facility policy requiring removal and disposal of gowns and gloves inside the room. Another resident with a stage 3 sacral wound and documented EBP orders had a CNA enter the room and change bed linens without donning a gown and gloves, even though EBP signage was posted and the CNA later acknowledged that PPE was required for linen changes. Facility policies and the infection preventionist’s statements confirmed that PPE must be worn for high-contact care activities under EBP and discarded inside the resident’s room, which did not occur in these instances.
A resident with a recent surgical history and an ileostomy was left with an overfilled ostomy bag for an extended period, despite multiple notifications to staff. During delayed care, staff discovered an undocumented surgical wound hidden under a skin fold, which was not identified during the initial skin assessment. The incident involved delayed response by a CNA, lack of documentation by the admitting RN, and was confirmed by the DON after the wound began leaking.
The facility did not notify the Office of the State Long-Term Care Ombudsman about residents who were transferred or discharged to the community or another facility, as required by policy. Only notifications of hospitalized residents were sent, omitting other types of discharges and transfers, which could affect all residents in the facility.
A resident with severe cognitive impairment and a history of dementia was transferred from a toilet to a wheelchair using a sit-to-stand lift by a CNA alone, despite facility policy requiring two staff for such transfers. The CNA did not wait for the RN to assist, citing the resident's agitation, and the RN was not present at the time. Facility documentation and staff interviews confirmed the expectation for two-person assistance with mechanical lifts to ensure safety.
The facility did not develop individualized, person-centered discharge care plans for several residents, instead using nearly identical templates that lacked specific discharge details and measurable objectives. Residents and their families reported not being informed or involved in discharge planning, and staff confirmed that care plans did not reflect each resident's unique needs or preferences.
A resident with severe dementia fell and sustained serious injuries after a CNA left him unattended on a raised bed during incontinence care. The resident, who required two-person assistance due to a low air loss mattress, was left on his side while the CNA retrieved supplies. This failure to follow the Care Plan and safety protocols resulted in the resident falling and suffering bilateral subdural hemorrhages and a right parietal subarachnoid hemorrhage.
The facility failed to properly label and store food items, affecting all 132 residents. Observations showed mislabeled, expired, or improperly stored food in the kitchen, including mashed potatoes, oatmeal, soy sauce, breadcrumbs, barley, and dried milk. The facility's policy requires labeling and discarding expired items, but these procedures were not followed.
The facility failed to properly store and dispose of medications, including leaving a medication cart unlocked, not refrigerating an insulin pen, and improperly handling controlled substances. Eye drops were not discarded after the discard date, and controlled medications were not stored under double lock as required.
The facility failed to follow Enhanced Barrier Precautions (EBP) by not wearing appropriate PPE during high-contact care activities for residents with conditions like wounds and MDROs. Staff, including CNAs and a former DON, did not wear gowns as required, despite EBP signage. This non-compliance was observed in multiple instances, indicating significant lapses in infection control protocols.
A resident with multiple health issues and severely impaired cognition was found twice with their call light out of reach, contrary to their care plan and facility procedures. Staff confirmed the importance of keeping call lights accessible to prevent falls and ensure residents can request assistance.
A resident with multiple medical conditions left the facility against medical advice shortly after admission, assisted by a nephew. The facility failed to document an attempt to have the resident or representative sign a Release of Responsibility form, as required by policy, or to document their refusal to sign. The Director of Nursing acknowledged the lack of documentation, which constitutes a failure to follow the discharge policy.
A facility failed to complete a PASARR screening before admitting a resident with mental health diagnoses, contrary to policy. The screening was done post-admission because the resident came from home, as confirmed by the Business Development Coordinator and Administrator.
A resident with a DNR and comfort-focused treatment directive was transferred to the hospital against their wishes. The facility failed to inform the family before the transfer, and the resident received treatment for sepsis, contrary to their preference for comfort care only. The facility's policies on respecting advance directives and resident rights were not followed.
A resident's air loss mattress was incorrectly set for a weight of 250 pounds, despite the resident weighing only 108.2 pounds. This error was due to a lack of communication between the nursing and maintenance departments, with the nursing staff failing to adjust the mattress setting based on the resident's actual weight. The resident, who had multiple medical conditions and was at moderate risk for skin breakdown, was at risk due to the incorrect mattress setting.
A resident with severe cognitive impairment and a history of falls was not provided with the necessary fall prevention measures as outlined in their care plan. Despite being at significant risk for falls, the required floor mats and bolster pads were absent from the resident's room. Staff interviews revealed a lack of awareness and implementation of these interventions, highlighting a communication gap in the facility's adherence to its fall prevention policy.
The facility failed to follow respiratory care procedures for two residents. One resident's oxygen equipment was not dated, and the oxygen rate did not match the physician's order. Another resident's nebulizer equipment was not stored properly, lacking labeling and appropriate storage. Both residents had significant medical conditions requiring respiratory support.
A resident with essential hypertension did not receive a scheduled dose of Losartan Potassium, a medication for high blood pressure, due to an oversight by an agency RN. The omission was confirmed by the former DON, who noted the missed dose was not signed off in the eMAR, contrary to the facility's medication administration policy.
A resident on a mechanical soft diet was mistakenly served a regular salad with raw vegetables and unground meat, contrary to their dietary needs. The resident, who has severe cognitive impairment and other health conditions, struggled to chew the meal. The facility's dietitian and dining services director confirmed the error, noting that the resident should have received a ground chicken salad as per their dietary order.
Failure to Properly Contain Nebulizer Mask per Facility Policy
Penalty
Summary
The facility failed to contain a resident’s nebulizer mask according to its own policy for administering medications through a small-volume handheld nebulizer. A resident with diagnoses including anemia and type 2 diabetes mellitus with hyperglycemia was observed sitting in a wheelchair in her room with her nebulizer mask not in use and not contained. The resident reported she had flu and COVID-19 about a week prior and that staff provide her nebulizer machine and mask daily when she feels short of breath. The Quality Director/Infection Preventionist confirmed that the nebulizer mask should be stored in a plastic bag when not in use to avoid contamination and stated that the resident had recently been positive for COVID-19 and was last on contact/droplet precautions about one week earlier. The resident’s active physician order dated 2/1/26 showed an order for DuoNeb inhaler solution every shift for congestion via inhalation, and the facility’s policy dated 2/2025 specified that when nebulizer equipment is completely dry, it should be stored in a plastic bag labeled with the resident’s name and date, which was not done in this case. This deficiency involved one resident reviewed for oxygen equipment out of a total sample of 11 residents and was identified through observation, interview, and record review, demonstrating noncompliance with the facility’s infection control and nebulizer equipment storage procedures.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Requirements
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring staff consistently performed hand hygiene and donned required PPE, specifically gowns and gloves, when caring for residents on Enhanced Barrier Precautions (EBP). One resident with severe cognitive impairment, an indwelling Foley catheter, and a wound was care planned for EBP due to risk of acquiring or transmitting infection. The care plan required staff to wear gowns and gloves for high-contact care and to provide catheter care per facility protocol. During observation, a CNA provided morning care to this resident without wearing a gown, later acknowledging she was supposed to wear one and that the resident was on EBP because of the Foley catheter. Another resident with a diagnosis including basal cell carcinoma and an order for EBP due to a wound had an EBP sign posted on the room door instructing everyone to clean their hands before entering and leaving and for providers and staff to wear gloves and a gown for high-contact resident care activities. A CNA was observed performing ADL incontinence care for this resident without wearing a gown. When questioned, the CNA stated that EBP required a gown and gloves when providing care, admitted she did not have a gown on, and explained she had been moving too fast and forgot, while also acknowledging that EBP is intended to protect residents and staff from spreading infection. A third resident with diagnoses including anxiety, severe protein-calorie malnutrition, and a healing pubic fracture had physician orders for EBP due to a wound and a care plan identifying risk for acquiring or transmitting infection, directing staff to follow infection prevention protocols including EBP. The resident’s room displayed an EBP sign with instructions for hand hygiene and use of gown and gloves for high-contact care. The resident was observed in bed, awake, being assisted with feeding by a CNA who was not wearing a gown and did not perform hand hygiene upon leaving the room. When the observation was brought to her attention, the CNA stated she did not have to wear a gown while feeding the resident in the room. The facility’s infection preventionist later described that residents are placed on EBP for MDRO risk and that staff performing direct patient care, including incontinence care, wound care, handling indwelling devices, and assisting with feeding in the room, are required to use gowns and gloves and perform hand hygiene, consistent with the facility’s written Standard and Transmission-Based Precautions policy.
Failure to Label Opened Bread Products With Open and Expiration Dates
Penalty
Summary
Surveyors identified a deficiency in food storage and labeling practices when inspecting the facility’s dry food storage room during an annual and licensure certification survey. At approximately 10:22 AM, in the presence of the Dining Services Director, surveyors observed an opened bag of hot dog buns, an opened bag of hamburger buns, and an opened bag of white bread that were not labeled with the date they were opened and did not have an expiration date indicated. During the inspection, the Dining Services Director acknowledged that opened foods should be labeled with the date opened and the date the food expires. The facility’s Food and Supply Storage Policy, revised 01/2024, states that all food used in food preparation shall be stored to prevent contamination and maintain safety and wholesomeness, and that unused portions and open packages are to be covered, labeled, and dated. These failures had the potential to affect 131 residents living in the facility. No specific residents were individually identified or described in terms of medical history or condition at the time of the deficiency, only that the deficient practice had the potential to affect all 131 residents in the facility.
Improper Controlled Drug Security and Medication Administration/Documentation Failures
Penalty
Summary
The deficiency involves multiple failures in pharmaceutical services, including improper storage and security of controlled substances and inaccurate controlled drug documentation. A nurse left an unlocked medication cart unattended in a hallway outside a resident’s room, with the cart’s lock not engaged and the narcotic bin accessible. The surveyor was able to open the drawers, including the drawer containing the locked narcotic bin, and observed a set of keys with a blue spring keychain left on top of the cart. When the nurse returned, the nurse confirmed responsibility for the cart, acknowledged that only nurses should have access, and verified that the keys left on top of the cart included the keys to both the medication cart and the narcotic bin, which contained multiple controlled medications such as tramadol and morphine. This conduct did not follow the facility’s policies requiring all drugs and biologicals to be stored in locked compartments and controlled substance keys to be maintained by the nurse who confirmed the count. The facility also failed to maintain accurate controlled substance records for a resident receiving clonazepam, a controlled medication. During a review of the narcotic count on a medication cart serving about 15 residents, the Controlled Drug Receipt/Record/Disposition Form for one resident’s clonazepam documented that 26 tablets should remain, but the blister pack contained only 25 tablets. The agency nurse stated that the medication was an evening dose and had not been administered by that nurse, and that the narcotic count had been done with the outgoing nurse at shift change without noticing the discrepancy. The facility’s policies require controlled substances to be counted at the end of each shift by the oncoming and outgoing nurses together, with any discrepancies documented and reported, and the count confirmed against individual controlled substances. Another deficiency involved improper medication administration practices, including leaving medication at the bedside and failing to ensure medications were administered and documented as ordered. One resident was observed lying in bed with a medication cup containing a white oval tablet on the bedside table. The resident stated not knowing what the medication was and believed it had been placed there while sleeping. When informed there was medicine present, the resident picked up the tablet and ingested it, again stating not knowing what the medication was and that they take medications even when they do not know what they are. The assigned RN confirmed that medication should not have been left at the bedside. The facility’s policies require that medications be administered safely and timely as prescribed, that nurses stay with residents until medications are swallowed, and that administration be documented immediately after giving each medication. The report further documents failures to administer medications as ordered by the physician and to document administration on the medication administration record (MAR/eMAR). One resident with congestive heart failure had a physician’s order for bumetanide (Bumex) 3 mg with varying frequencies over the stay. The resident’s weight increased from 115 lbs to 127 lbs in one day and remained elevated over subsequent days. The MAR showed that bumetanide 3 mg was not documented as administered twice on one date and once on each of two subsequent dates, despite orders for twice-daily dosing during that period. Educational material from the American Heart Association included in the record describes edema and weight gain as common in heart failure and identifies diuretics such as bumetanide as medications used to reduce excess fluid. Additionally, MARs for multiple residents over December and January showed multiple medications not documented as administered (not initialed or signed) in accordance with physician orders. The DON stated that medications must be administered as ordered, that nurses must document administration immediately after giving medications on the eMAR, and that blank documentation means administration cannot be proven. The facility’s Documentation of Medication Administration and Administering Medication policies require that a nurse or certified medication tech document each medication after it is given and before administering the next medications, and that only appropriately licensed or permitted personnel prepare, administer, and document medications. These documented omissions and failures in storage, administration, and documentation form the basis of the cited pharmaceutical services deficiencies affecting several residents receiving medications in the facility.
Failure to Resubmit PASARR for Newly Identified Serious Mental Disorders
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program by not referring a resident for a Level II PASARR evaluation after the development or identification of serious mental health conditions. At admission on 10/10/2024, the Admissions Director completed a Level I PASARR for the resident and indicated there were no known or suspected mental health diagnoses and no mental health medications, resulting in a determination that no Level II PASARR was required. The original Profile Face Sheet reflected this initial assessment. However, the resident’s current Profile Face Sheet later documented multiple mental health diagnoses, including major depressive disorder, recurrent severe without psychotic features; generalized anxiety disorder; post-traumatic stress disorder; and adjustment disorder with mixed anxiety and depressed mood. The resident’s physician orders also showed prescriptions for Remeron and Escitalopram, both antidepressant medications, indicating active treatment for mental health conditions. When surveyors requested updated PASARR documentation, the Executive Director confirmed that the facility had not resubmitted the resident for a Level II PASARR evaluation despite these new or newly identified mental health diagnoses. The Executive Director further stated that the Admissions Director and Social Services staff submit PASARR information to the state-designated authority but had not done so for this resident and were not aware that resubmission for Level II PASARRs was required when new serious mental disorders are identified. The facility’s PASRR policy, last revised in April 2025, did not include a process for resubmitting residents for a Level II PASARR when newly evident or possible serious mental disorders, intellectual disabilities, or related conditions are identified.
Failure to Keep Call Light Within Reach and Respond Timely for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible and that call lights were answered in a timely manner, as required by facility policy. The resident was an older adult admitted for a femoral neck fracture and right hip pain following hip replacement surgery, with intact cognition and a perfect BIMS score of 15. She required substantial or maximal assistance for bed mobility and transfers and did not ambulate, leaving her dependent on staff for in-bed needs. During an observation, the resident reported that she could not get out of bed and relied on staff, but stated that it often took staff about three hours to respond to her call light. She further stated that her call light was usually not attached where she could reach it, and during the surveyor’s visit, both the resident and the surveyor had to look for the call light, which was found on the floor approximately 2 to 3 meters away from her. The resident described remaining in wet incontinence briefs for three hours while waiting for assistance. In a subsequent observation, a CNA was seen exiting the resident’s room while the call light remained on the floor and out of the resident’s reach. When questioned in the hallway, the CNA initially stated that the resident could use the call light and that it was within reach, but upon re-entering the room, the CNA found the call light on the floor, picked it up, and clipped it to the resident’s linen, then acknowledged that the call light had not been reachable and needed to be clipped to the resident’s gown, clothing, or linen to be accessible. The DON later stated that nursing staff are required to ensure that call lights are always within reach so staff can attend to residents’ needs. The facility’s written “Answering the Call Light” policy, dated 12/2017, requires that when a resident is in bed or confined to a chair, the call light must be within reach and that call lights should be answered as soon as possible. These observations and interviews demonstrate that staff did not follow the facility’s call light policy for this resident.
Failure to Follow Physician Orders and Document Medication Administration for Diabetic and Heart Failure Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure pharmaceutical services and medication administration met professional standards for two residents with significant medical conditions. One resident with type 2 diabetes mellitus was transitioned from Metformin to Glimepiride, but the MAR showed Glimepiride was not documented as administered on multiple ordered days. The same resident’s MAR also lacked documentation of ordered blood glucose checks on several specific dates, despite physician orders for monitoring. The resident’s blood sugar levels subsequently increased to over 300 starting on a noted date, leading to additional orders for Humalog Lispro insulin and an increased Glimepiride dose. After the physician ordered blood sugar monitoring three times daily with insulin administration based on results, an RN administered Humalog Lispro insulin without performing a contemporaneous blood sugar check, stating it had been checked earlier with a result of 200. Facility policy required medications to be administered in a safe and timely manner and as prescribed, and the DON stated that medications scheduled with meals must align with breakfast time, which did not occur when insulin was given around 10:05 AM instead of with breakfast. A second resident with congestive heart failure was ordered Bumetanide (Bumex) 3 mg at varying frequencies over the stay to treat edema associated with heart failure. The resident’s weight increased from 115 lbs to 127 lbs in one day and remained elevated over subsequent days. The MAR showed that Bumetanide doses were not documented as administered on several occasions, including two missed doses on one day and single missed doses on two subsequent days, despite ongoing weight gain. Nursing notes later documented that the resident was transferred to the hospital after a family member expressed concern that the resident might be experiencing fluid overload. Reference materials from the facility pharmacy and the American Heart Association described Bumetanide as a diuretic indicated for treatment of edema in heart failure and explained that edema and weight gain are common symptoms of heart failure. The DON stated that the expectation is for nurses to follow and implement physician orders, and facility policy on administering medication required that medications be given as prescribed.
Failure to Follow Medication Administration Policies and Physician Orders
Penalty
Summary
The deficiency involves failure to follow the facility’s medication administration policies and physician orders, resulting in a medication error rate of 19.35% (6 errors out of 31 opportunities) for one resident. A registered nurse (V25) prepared and administered multiple oral medications for resident R61 by placing 12 tablets together in a small cup, transferring them to a larger cup, and mixing them with applesauce, rather than administering them one at a time as outlined in the facility’s oral medication policy. During administration, the resident had difficulty swallowing, repeatedly spit out tablets, and the nurse left the room before ensuring all medications were swallowed, contrary to policy requiring the nurse to remain until all medications are taken. Two partially dissolved tablets were spit out onto the bed, identified by the nurse as vitamin C and aspirin, and then discarded in a sharps container. The facility also failed to follow physician orders and internal procedures regarding medication form, positioning, and timing. R61 had a physician order to crush appropriate medications, but the nurse initially administered whole tablets mixed in applesauce until the family member reminded her that medications needed to be crushed for the resident to tolerate swallowing. For the ordered albuterol nebulizer treatment, the nurse placed the resident leaning to the right and kept the nebulizer in a position that did not allow full delivery of the medication; visible mist stopped partway through the treatment while liquid medication remained in the nebulizer chamber. The nurse then discarded the remaining medication in the sink, despite the facility’s nebulizer policy requiring the resident to be in semi-Fowler position and the nebulizer to be kept vertical and used until the medication is gone. In addition, the nurse did not adhere to physician orders and facility policy regarding insulin and other time-sensitive medications. The nurse administered 2 units of insulin lispro subcutaneously without performing a blood sugar check immediately prior to administration, stating that the blood sugar had been checked earlier and was 200. Physician orders required insulin lispro and glimepiride to be given with meals, and pantoprazole to be given before breakfast, but these medications were not administered in alignment with the facility’s mealtime schedule and the allowed 60-minute window before and after the scheduled time. Specifically, pantoprazole ordered before breakfast was scheduled at 9:00 a.m., after the 7:45 a.m. breakfast, and glimepiride and insulin lispro were not administered with meals as ordered, despite the resident having elevated blood sugars on multiple recent dates. These actions and inactions collectively demonstrate noncompliance with the facility’s medication administration policies and physician orders for R61.
Improper Medication Storage, Security, and Expired Insulin Management
Penalty
Summary
The deficiency involves failure to store and secure medications in accordance with facility policy and accepted professional standards. A surveyor observed an unattended medication cart left outside a resident’s closed room with the lock not engaged, allowing the drawers to be opened. The nurse responsible for the cart confirmed it contained medications for 22 residents and acknowledged that only nurses should have access to the cart and that the keys, which had been left on top of the cart, were for that cart. The nurse then placed the keys in a scrub pocket and re-entered the resident’s room to continue care, again leaving the cart unlocked and unattended in the hallway. In a clean utility room on a locked dementia unit, which was accessible to CNAs and unlicensed staff, the surveyor found an unlocked cabinet above the sink containing individually packaged medications such as Losartan, Metoprolol ER, Potassium Chloride, and Tylenol, as well as a reusable bag with 15 medication bottles labeled for a former resident who had discharged nearly a year earlier. The nurse present did not know why these medications were stored there. An unlocked wound cart in the same room contained multiple prescribed medicated creams and ointments. Review of another medication cart revealed an open vial of Lantus insulin with a discard date that had already passed and a Humalog KwikPen without an open date that should have been refrigerated if unopened, contrary to the facility’s policy requiring all drugs and biologicals to be stored in locked compartments, under proper temperature controls, and routinely inspected for outdated or discontinued medications.
Failure to Follow PPE Protocols for Residents on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program related to proper use and disposal of PPE for residents on Enhanced Barrier Precautions (EBP). One resident, identified as R42, had diagnoses including cellulitis of the right lower limb, lymphedema, and sepsis, with physician orders for midline insertion, wound care to the right knee and right lower leg, and IV therapy, and was placed on EBP. The care plan documented right lower extremity cellulitis with open wounds and antibiotic therapy for cellulitis on both lower extremities. On 01/13/26 at 11:35 AM, a registered nurse (V16) exited this resident’s room still wearing PPE, removed the PPE in the hallway, and placed it in a hamper located in the hallway. V16 stated that the resident was on isolation for a wound and described a practice of removing PPE outside the resident’s room, including for COVID rooms, contrary to facility policy and EBP expectations. A second deficiency was identified involving another resident, R69, who had diagnoses including metabolic encephalopathy, dementia, and adult failure to thrive, with physician orders for sacral wound care and EBP. The care plan documented impaired skin integrity related to a pressure ulcer on the sacrum and left buttock excoriation. On 01/13/26 at 11:50 AM, a CNA (V18) was observed entering R69’s room carrying linen without donning PPE, despite EBP signage posted on the door. The surveyor observed V18 making the resident’s bed without wearing a gown and gloves. When questioned, V18 acknowledged that a gown and gloves should be worn when changing linen for a resident on EBP and stated there was a potential for infection and transmission between residents. Interviews with other staff and review of facility policies confirmed that the observed practices did not align with established procedures. A CNA (V17) stated that for isolation or EBP rooms, PPE should be donned before entering and discarded inside the resident’s room. The Quality Director/Infection Preventionist (V14) described the expected donning and doffing sequence, emphasizing that gowns and gloves must be removed and discarded inside the resident’s room before exiting, and that gown and glove use is required for high-contact resident care activities such as changing linen, incontinence care, wound care, and IV care under EBP. Facility policies on infection prevention, standard and transmission-based precautions, PPE use, and EBP specified that PPE is to be removed and discarded before leaving the resident’s room and that gown and glove use is required for high-contact activities, including changing linens, with disposal of used PPE in receptacles located inside the room. The observed staff actions with R42 and R69 were inconsistent with these policies and expectations.
Failure to Provide Timely Ostomy Care and Accurate Skin Assessment
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident with an ileostomy, specifically by not cleaning and emptying the resident's ileostomy bag in a timely manner and failing to conduct an accurate skin assessment upon admission. The resident was admitted from the hospital with a recent surgical history, including a transverse incision in the right lower quadrant. On the day of the incident, staff were alerted multiple times by both physical therapy and the resident's family member that the ileostomy bag was soiled and overflowing. The Certified Nursing Assistant (CNA) delayed responding to the request, taking approximately 15-20 minutes to gather supplies and begin care after being notified. During care, it was observed that the ileostomy bag was overfilled, and the resident was left soiled for an extended period, as documented by the family member's email stating the resident waited an hour and a half to be changed. During the process of providing care, staff discovered a previously undocumented surgical wound on the resident's right lower abdomen, hidden under a skin fold. The wound was not visible unless the skin fold was lifted and was not documented in the initial skin assessment performed upon admission. The wound began leaking fluid mixed with blood, prompting further assessment by the Director of Nursing (DON), who confirmed the presence of a clean surgical slit with no sutures or ripped edges. The wound was only discovered after it began leaking, and its presence had not been communicated or documented by the admitting nurse, whose handwriting on the initial assessment was also noted to be illegible. The facility's policy on colostomy/ileostomy care requires review of the resident's care plan and assessment of special needs, but the failure to document the surgical wound and the delay in responding to the resident's hygiene needs resulted in deficiencies in care. The incident involved multiple staff members, including a Registered Nurse (RN), CNA, and DON, and was corroborated by interviews, record reviews, and family member communication. The resident's condition at the time included a recent surgical procedure, an ileostomy, and the presence of skin folds that obscured the surgical wound.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding residents who were transferred or discharged back to the community or to another nursing facility. According to interview and record review, the social worker reported only sending weekly email notifications to the ombudsman about residents who were hospitalized, excluding those who were discharged to the community or transferred elsewhere. Email records confirmed that only lists of hospitalized residents were sent on multiple occasions, and not all required transfers or discharges were reported. The facility's policy states that a copy of the notice should be provided to the ombudsman for all transfers or discharges, but this was not followed, potentially affecting all 124 residents currently residing in the facility.
Failure to Follow Two-Person Mechanical Lift Transfer Policy
Penalty
Summary
The facility failed to follow its policy requiring two staff members to assist with transfers using a mechanical sit-to-stand lift. On the observed date, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) initially transferred a resident from a wheelchair to a toilet using the sit-to-stand lift together. However, when the resident needed to be transferred back to the wheelchair, the CNA performed the transfer alone, without waiting for the RN as required by facility policy and procedure. The CNA stated she did not wait for the RN because the resident was becoming agitated. The RN confirmed she was not present and did not hear the CNA calling for assistance. The resident involved had a history of dementia with behavioral disturbances, late-onset Alzheimer's disease, and was assessed as having severely impaired cognitive status. The resident's care plan identified risks related to impaired mobility, cognitive impairment, poor safety awareness, and a need for two-person assistance with mechanical lift transfers. Facility policies, staff interviews, and documentation all confirmed that two staff are required for such transfers to ensure resident safety. The failure to follow this protocol resulted in a deficiency related to accident prevention and adequate supervision.
Failure to Provide Person-Centered Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered discharge care plans for five residents reviewed. Each resident's care plan related to discharge planning was found to be nearly identical, lacking individualized information about specific discharge plans, goals, or interventions tailored to the resident's needs and preferences. For example, one resident with multiple medical diagnoses, including atrial fibrillation and deep vein thrombosis, had a care plan that only generically stated support for a short-term stay and assistance with referrals, without any specific discharge planning details. Interviews with residents and their representatives revealed a lack of communication and understanding regarding discharge plans, with some stating they had not been informed or involved in the process, and no social worker had discussed discharge planning with them. Further review with facility staff confirmed that a template was used for all residents' discharge care plans, resulting in no meaningful differences between individual plans. The social worker acknowledged that the care plans did not reflect resident-specific information and that notes, rather than the care plan itself, were used to document differences in resident situations. The facility's own policies require comprehensive, person-centered care plans with measurable objectives and timetables, including discharge plans and resident preferences, but these requirements were not met in practice for the residents reviewed.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow the Care Plan for a resident, leading to a fall and serious injuries. The resident, a 92-year-old male with severe cognitive impairment due to dementia, was at moderate risk for falls as indicated by a Fall Risk Assessment. His Care Plan required extensive assistance with two-person staff support for bed mobility and toileting. However, during an incontinence care session, a CNA left the resident unattended on a raised bed, resulting in the resident falling and sustaining bilateral subdural hemorrhages and a right parietal subarachnoid hemorrhage. The incident occurred when the CNA, who was providing care, left the resident on his side on a high bed to retrieve additional supplies. The resident, who was on a low air loss mattress, required two-person assistance due to the mattress's instability. The CNA's decision to step away without repositioning the resident or lowering the bed led to the resident falling off the bed. The facility's policy required residents to be visualized for safety during routine rounds and per their Care Plan, which was not adhered to in this case. Interviews with the staff and family members revealed that the CNA was aware of the safety protocols but failed to follow them, resulting in the resident's fall. The facility's Interim Director of Nursing acknowledged that the CNA should have repositioned the resident and lowered the bed before stepping away. The facility's Administrator also recognized the incident as potentially preventable, although they did not believe it changed the resident's condition. The facility's policies on safety and supervision, as well as fall prevention, were not effectively implemented, leading to this serious incident.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, which could potentially affect all 132 residents receiving food prepared in the facility's kitchen. Observations revealed that several food items in the Walk-In Refrigerator, Prep Area/Spice Rack, and Dry Storage Room were either mislabeled, expired, or not stored according to manufacturer guidelines. For instance, two containers of mashed potatoes and a bowl of cooked oatmeal were found with incorrect 'good thru' dates, indicating they should have been discarded earlier. Additionally, a container of Low Sodium Soy Sauce was not refrigerated as required by the manufacturer, and a large bin of panko breadcrumbs was expired. Further issues were identified in the Dry Storage Room, where an opened 25-pound bag of pearled barley lacked a label with an opened and expiration date, and an opened bag of dried milk was found with an expired label. The facility's policy on food and supply storage mandates that all food items be labeled with an opened and expiration date and discarded past their use by date. However, these procedures were not followed, as evidenced by the observations and statements from the Dining Services Director and Chef Manager.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and disposal protocols, resulting in several deficiencies. During a survey, it was observed that eye drops for a resident were not disposed of after the discard date, and an unopened insulin pen was not refrigerated as required. Additionally, a medication cart was left unlocked and unsupervised while a nurse administered medications to a resident, which is against the facility's policy for medication storage and security. The facility also failed to properly dispose of a controlled medication for a resident. A blister pack of Tramadol, a Schedule IV controlled substance, was found with a torn and taped slot, indicating improper handling. The nurse responsible did not dispose of the medication as required, nor was there a witness to the disposal, which is a breach of the facility's controlled substances policy. Furthermore, controlled medications for another resident were not stored under double lock as required. Two bags of Lorazepam syringes were found in a refrigerator with other medications, without an additional locked container. This oversight was acknowledged by the facility staff, who stated that controlled medications should be under double lock, highlighting a lapse in compliance with the facility's controlled substances policy.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not following Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, staff did not wear the appropriate Personal Protective Equipment (PPE), such as gowns, during high-contact resident care activities. This was observed in multiple instances, including care provided to residents with conditions like wounds, urinary catheters, and colonization with multidrug-resistant organisms (MDROs). For example, a certified nurse assistant (CNA) did not wear a gown while providing care to a resident with a wound, despite the EBP signage indicating the necessity of both gloves and gowns for such activities. In another instance, an agency nurse and a contracted CNA failed to don gowns while providing care to a resident with cellulitis and an indwelling urinary catheter, both of which required EBP. The nurse was observed carrying a soiled incontinence pad without containing it in a bag, further breaching infection control protocols. Additionally, the contracted CNA was unaware of the specific reasons for the resident's EBP status, indicating a lack of communication and understanding of the infection control measures required. Further observations revealed that a CNA provided incontinence care to a resident colonized with Vancomycin-Resistant Enterococci (VRE) without wearing the necessary gown. Similarly, a former Director of Nursing, while performing wound treatment for a resident with a stage 2 sacral pressure ulcer, did not wear a gown as required by EBP. These repeated failures to comply with established infection control protocols highlight significant lapses in the facility's adherence to its own policies, potentially affecting all residents on the affected units.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as observed during a survey. On two separate occasions, the resident was found lying in bed with the call light on the floor, out of reach. The resident, who relies on the call light to request assistance, was unaware of its location and unable to reach it. A registered nurse confirmed that the call light should be within reach and clipped to the bedding to prevent it from falling. The former Director of Nursing also emphasized the importance of keeping call lights accessible to prevent residents from attempting to get up on their own, which could increase the risk of falls. The resident involved has multiple diagnoses, including hemiplegia, cellulitis, hypertensive heart disease, and chronic heart failure, and is documented as having severely impaired cognition. The resident's care plan specifies that the call light should be within reach at all times and highlights the resident's risk for falls. The facility's procedure for answering call lights also mandates that call lights be within reach when residents are in bed or confined to a chair. Despite these guidelines, the resident's call light was not accessible, indicating a failure to accommodate the resident's needs and preferences as required.
Failure to Follow Discharge Against Medical Advice Policy
Penalty
Summary
The facility failed to adhere to its discharge against medical advice (AMA) policy for a resident identified as R120. R120 was admitted to the facility with multiple medical conditions, including epilepsy, asthma, and a recent head injury with staples. Shortly after admission, R120 left the facility AMA with the assistance of a nephew. The progress notes indicate that the resident was anxious and that the nephew was uncooperative with staff attempts to discuss the situation. The nurse on duty attempted to communicate with the nephew, who insisted on leaving with the resident, stating he only took orders from his aunt. The facility's policy requires that a Release of Responsibility form be signed by the resident or representative when leaving AMA, or that refusal to sign be documented and witnessed by two associates. In this case, there was no documentation of an attempt to have R120 or the nephew sign the AMA form, nor was there documentation of their refusal to sign. The Director of Nursing at the time acknowledged that such documentation should have been made. Attempts to interview the nurse involved were unsuccessful, and the lack of documentation constitutes a failure to follow the facility's discharge policy.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident's initial preadmission screening was completed prior to admission, as required by the Preadmission Screening and Resident Review (PASARR) process. This deficiency was identified for one resident who was admitted with diagnoses including Major Depressive Disorder, Bipolar Disorder, and Generalized Anxiety Disorder. The PASARR Level I Screen Outcome for this resident was reviewed after admission, which is contrary to the facility's policy that mandates the screening be completed before admission. The Business Development Coordinator acknowledged that the PASARR was conducted post-admission because the resident came from home. The Administrator confirmed that PASARR screenings are intended to be completed prior to admission to ensure eligibility and compliance with requirements, especially for individuals coming from the community.
Failure to Honor Resident's Advance Directives
Penalty
Summary
The facility failed to adhere to a resident's and their representative's wishes regarding hospitalization, resulting in a deficiency. The resident, identified as R64, had a documented Code Status of NO CPR and a POLST form indicating a Do Not Attempt Resuscitation (DNR) and a preference for comfort-focused treatment, with hospitalization only if comfort needs could not be met at the facility. Despite these directives, R64 was transferred to the hospital without the family's consent, where they were treated for sepsis, contrary to their wishes for comfort care only. The incident occurred when an agency nurse, V26, found R64 in a lethargic and nonverbal state with yellow mucous and decided to send the resident to the hospital for evaluation and treatment. The family was informed of the transfer only after it had occurred. The former Director of Nursing, V3, confirmed that the facility was aware of R64's wishes and did not know why the transfer was initiated. The facility's policies on advance directives and resident rights emphasize respecting residents' choices, which were not followed in this case.
Improper Air Loss Mattress Setting for Resident
Penalty
Summary
The facility failed to correctly set an air loss mattress based on the resident's weight, leading to a deficiency in pressure ulcer care. A resident, identified as R32, was observed lying on an air loss mattress set at a firmness level indicating a weight of 250 pounds, despite the resident weighing only 108.2 pounds. This discrepancy was noted during observations and interviews with facility staff, including a Registered Nurse (V6) and the Director of Facilities Management (V16), who both acknowledged that the mattress setting was incorrect and should be based on the resident's actual weight. The incorrect setting of the air loss mattress was attributed to a lack of communication and responsibility between the nursing and maintenance departments. The Director of Facilities Management stated that while their department delivers the mattress, it is the responsibility of the nursing staff to set the mattress according to the resident's weight. However, the Registered Nurse (V6) was unaware of the correct setting, indicating a gap in the process of ensuring the mattress is adjusted appropriately for each resident. The resident, R32, had a history of medical conditions including hemiplegia, cellulitis, and heart disease, and was at moderate risk for skin breakdown according to the Braden Scale Assessment. The resident's care plan highlighted the risk for skin integrity issues due to decreased mobility and other factors. Despite these risks, the air loss mattress was not set correctly, potentially compromising the resident's skin integrity and comfort. The facility's policy and the mattress owner's manual both emphasize the importance of setting the mattress based on the resident's weight to prevent pressure ulcers, which was not adhered to in this case.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to adhere to the fall care plan intervention for a resident diagnosed with unspecified dementia with agitation, repeated falls, and anxiety disorder. The resident, who has a history of multiple falls and severe cognitive impairment, was assessed to be at significant risk for falls. The care plan included interventions such as the use of floor mats and thick bolster mats to extend the sleeping area, which were not observed in the resident's room during multiple inspections. The absence of these safety measures was noted despite the resident's care plan specifying their necessity to minimize fall risk. Interviews with staff revealed a lack of awareness and implementation of the prescribed interventions. A Certified Nursing Assistant (CNA) assigned to the resident was unaware of the requirement for floor mats or bolster pads, indicating a communication gap regarding the resident's care plan. The Restorative Nurse confirmed that these interventions were essential for the resident's safety, yet they were not in place, suggesting a failure in executing the care plan. The facility's policy on falls emphasizes individualized care and regular evaluation of care plans, but this was not effectively applied in the resident's case.
Deficiencies in Respiratory Care Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing respiratory care, affecting two residents. For one resident, the oxygen equipment was not dated, and the oxygen administration rate did not match the physician's order. The resident was observed with an oxygen concentrator set between 3-4 liters per minute, while the physician's order specified 2 liters per minute. The humidifier bottle was not dated, and the oxygen tubing had not been changed weekly as required. The registered nurse acknowledged the discrepancy in the oxygen rate and the lack of dating on the humidifier bottle. The resident had multiple diagnoses, including dementia and dependence on supplemental oxygen, and was under hospice care. For another resident, the nebulizer equipment was not stored according to the facility's policy. The nebulizer machine was observed with tubing connected and hanging down to the floor, not labeled with a date, and not stored in a plastic bag. The nebulizer mask was also not stored in a plastic bag and lacked the resident's name and date. The resident, who was cognitively intact, had diagnoses including bronchitis and pneumonia and received nebulizing treatment multiple times a day. The facility's policy required nebulizer equipment to be stored in a plastic bag with the resident's name and date when not in use.
Medication Administration Error for Resident with Hypertension
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving a resident with a medical diagnosis of essential hypertension. The resident's care plan included the administration of medications as ordered to manage blood pressure. On the morning of October 1, 2024, an agency registered nurse prepared and administered several medications to the resident but omitted Losartan Potassium, a medication prescribed to treat high blood pressure. The omission was confirmed by the former Director of Nursing, who acknowledged that the dose was missed and not signed off in the electronic medication administration record (eMAR). The facility's policy requires medications to be administered according to established schedules, which was not adhered to in this instance.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a resident with a mechanical soft diet as ordered, resulting in the resident receiving a meal that was not suitable for their dietary needs. On the specified date, the resident was observed eating a large salad containing raw Romaine lettuce, tomato wedges, chopped hardboiled egg, bacon pieces, and chunks of chicken, which are not appropriate for a mechanical soft diet. The resident attempted to eat the salad but had difficulty chewing, as evidenced by the resident removing semi-chewed pieces of lettuce and bacon from their mouth. The resident's meal ticket indicated a mechanical soft diet, and a food substitution request was noted, but the meal provided did not adhere to these specifications. The registered dietitian confirmed that residents on mechanical soft diets should receive ground meats and no raw vegetables, as these residents often have difficulty chewing and swallowing. The dietitian acknowledged that the resident should not have received the Barbeque Chicken Salad, which was intended for regular diets, due to its inappropriate texture and ingredients. The dining services director also confirmed that the resident should have received a ground chicken salad instead. The resident's medical history includes severe cognitive impairment, dementia, and other conditions, necessitating a controlled carbohydrate diet with mechanical soft texture. The facility's policies emphasize the importance of following diet spreadsheets and ensuring the correct consistency of meals, which was not adhered to in this instance.
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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