Avantara Lincoln Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1366 West Fullerton Avenue, Chicago, Illinois 60614
- CMS Provider Number
- 145510
- Inspections on file
- 41
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Avantara Lincoln Park during CMS and state inspections, most recent first.
A newly admitted resident with dementia, confusion, multiple comorbidities, and a documented history of recent falls was not accurately identified as high fall risk, despite hospital PT notes and nurse-to-nurse report indicating unsteady gait, need for a gait belt, walker, and at least contact guard to minimal assist for transfers and ambulation. The facility’s post-fall assessment documented that the resident was not at risk for falls and had no fall history, and no fall interventions were in place. Shortly after admission, the resident, who was on an anticoagulant, repeatedly got up without using the call light and was observed ambulating alone in the hallway with a walker before lifting the walker to turn, losing balance, and falling, striking the head. Family reported they had informed staff of the resident’s fall risk and prior use of bed and chair alarms in the hospital, and that staff said alarms could not be used until therapy assessed the resident, while the resident was placed several rooms away from the nurses’ station.
Two residents at high risk for falls were not provided with effective fall prevention interventions or adequate supervision. One resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall after a malfunctioning bed alarm failed to alert staff, resulting in a fatal subdural hematoma. Another resident with impaired mobility fell in a hallway blind spot after another resident pulled their wheelchair, leading to a subdural hemorrhage. Staff interviews and records indicated that equipment issues and lack of supervision in high-risk areas contributed to these incidents.
A resident who had consented to receive the COVID-19 vaccine did not receive the vaccination, and there was no documentation of administration or declination. The resident, who had multiple medical conditions and later tested positive for COVID-19, was involved in a facility outbreak traced through contact with a staff aide. The facility's infection control procedures were not followed regarding vaccine documentation and administration.
A resident with cognitive impairment and a history of frequent falls was not consistently provided with required fall prevention interventions, such as accessible call light, bed alarm activation, and appropriate footwear. Staff observations and interviews confirmed that essential items were out of reach, alarms were not activated, and activity interventions were not provided as outlined in the care plan. Facility policy requiring individualized interventions after each fall was not followed, resulting in repeated falls and hospital evaluations.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, leading to incomplete planning and documentation of care needs.
A resident with multiple medical conditions and documented food allergies and dislikes was served a meal containing dairy and other items they could not tolerate, despite clear documentation and facility policy requiring accommodation. Staff confirmed that the resident should not have received these foods, and the facility's policy prohibits serving items that cause allergic or intolerance reactions.
Multiple high-risk residents with cognitive impairment and mobility issues experienced serious injuries after falls that occurred when required interventions and supervision were not provided. Staff interviews and record reviews revealed that residents were often left unsupervised or allowed to ambulate alone, care plans were not consistently followed, and call lights were not always accessible, resulting in repeated falls and hospitalizations.
The facility failed to provide adequate staffing, resulting in residents not receiving timely incontinence care and monitoring. Observations showed residents with unchanged briefs since the night shift, and staff interviews confirmed chronic understaffing, particularly on the dementia care floors. The staffing schedule revealed a significant shortfall in CNA numbers, impacting the quality of care and increasing fall risks.
A resident expressed dissatisfaction with his unkempt beard and mustache, which were not trimmed due to staffing shortages. Despite the facility's policy to offer daily grooming assistance, the resident was not provided with the necessary help, as the facility was operating with fewer CNAs than required. The resident, who has multiple medical conditions, was unable to manage grooming independently and was not offered assistance by the staff.
The facility failed to provide incontinence care every two hours for three dependent residents, as required by its policy. Observations and interviews revealed that residents were left in soiled briefs for extended periods, with staff citing staffing shortages as a barrier to providing timely care. The facility was operating below the required number of CNAs, impacting the quality of care for residents with various medical conditions.
A resident with a sacral pressure ulcer was found without a wound dressing, and their incontinence brief was saturated, indicating a lapse in care. The LPN confirmed the dressing should have been applied, and the CNA admitted to not checking the resident since the start of their shift. The resident's treatment plan required specific wound care, which was not followed, leading to the deficiency.
The facility failed to serve food at appropriate temperatures, affecting three residents who reported consistently receiving cold meals. Observations revealed that breakfast trays lacked heated palates and plates, and a test tray confirmed substandard food temperatures. The Director of Dietary acknowledged the issue, citing short staffing and equipment problems as contributing factors.
The facility failed to complete accurate fall risk assessments and implement fall prevention interventions for residents at risk. A resident with dementia and mobility issues had an incomplete assessment and non-functioning alarms. Another resident's fall risk was initially unrecognized, and necessary interventions were not in place. A third resident's fall report lacked contributing factors, and staff were unaware of prevention measures. These deficiencies highlight lapses in policy adherence and staff communication.
A resident with a history of falls and Alzheimer's disease experienced two fall incidents, one resulting in a fracture. The facility failed to complete required monitoring and documentation post-fall and did not conduct a significant change assessment after the second fall, which led to a notable decline in the resident's condition. This highlights deficiencies in adhering to standard nursing practices and facility policies.
A resident with obstructive sleep apnea and other health conditions did not receive the necessary CPAP equipment due to a missing mask, which was known to the facility staff. The resident reported difficulty breathing at night without the CPAP mask, and the facility's policies emphasize the importance of providing compliant respiratory equipment.
The facility failed to maintain proper food safety and sanitation standards, including not dating opened food items, improper storage of cleaning chemicals near food, and inadequate dishwasher temperatures. Additionally, a dietary aide was observed serving food without gloves, and some food items did not maintain the required temperature, potentially affecting 204 residents.
The facility failed to assist residents with cognitive impairments in dressing in their own clothes, leaving them in hospital gowns, which compromised their dignity. Observations showed many residents in bed wearing gowns, and some were unaware of available activities. Staff interviews revealed inconsistencies in care routines, such as the absence of a 'get-up list' for certain shifts, contributing to residents remaining in bed. This failure to provide equal access to quality care and uphold residents' rights was evident in the survey findings.
The facility failed to ensure that four residents had access to the call light system, which is essential for them to request assistance. Observations revealed that the call lights were not within reach, despite the facility's policy requiring accessibility. Staff acknowledged the issue, and the deficiency affected residents with varying physical and cognitive impairments.
The facility failed to accurately account for narcotic medications and adhere to labeling and storage policies. Discrepancies were found in the documentation and actual count of Lorazepam and Clonazepam. Insulin vials lacked proper labeling, expired tuberculin vials were stored, and expired house stock medications were found. Topical medications were stored near oral supplements, posing contamination risks. These issues were observed in multiple medication carts and rooms.
A resident with intact cognitive abilities reported receiving food that was warm but not hot, contrary to the facility's policy requiring hot food to be served above 135°F. Observations confirmed the food temperature was below standard. Staff interviews revealed inconsistencies in reheating procedures, contributing to the deficiency.
The facility failed to accurately complete MDS assessments for two residents, leading to deficiencies in the assessment process. One resident was observed to be toothless and reported difficulties eating, but their dental status was not documented in the MDS. Another resident was admitted to hospice care, but this was not reflected in their MDS. The Clinical Care Coordinator highlighted the importance of accurate MDS assessments for reliable care planning.
The facility failed to refer three residents with serious mental disorders for PASRR Level II screenings, as required. One resident had new diagnoses of psychotic disorder, depression, and anxiety, another had major depressive disorder, and a third had anxiety disorder with moderate cognitive impairment. Despite these conditions, the necessary screenings were not conducted, contrary to facility policy.
The facility failed to accurately account for narcotic medications and adhere to policies on labeling and storing medications. Discrepancies were found in the documentation and actual count of Lorazepam and Clonazepam. Insulin vials lacked proper labeling, expired medications were stored improperly, and topical medications were stored near oral supplements. These issues were observed in multiple medication carts and rooms, highlighting lapses in medication management.
A facility failed to administer the correct medication and dosage, resulting in a 10.71% error rate. An LPN administered incorrect nasal spray and eye drops to a resident, contrary to the physician's orders. Another resident received the wrong type of eye drops due to unavailability in the medication cart. These errors were noted during a survey and reported to the DON.
The facility failed to ensure proper use of PPE for residents under isolation precautions, leading to potential cross-contamination. Staff and family members were observed not following guidelines, such as not wearing PPE when required and improperly exiting isolation rooms. This was evident in cases involving residents with wounds, C-Diff, and indwelling medical devices. Interviews indicated a lack of consistent education on infection control policies.
The facility failed to implement effective fall precautions for two residents at risk, resulting in multiple falls and injuries. One resident with cognitive impairments experienced several falls due to inadequate supervision and improper placement of a walker. Another resident's bed was not kept in the lowest position as required, increasing the risk of falls. The facility's policies on fall risk assessment and intervention were not properly followed, contributing to these deficiencies.
The facility failed to protect a resident from physical abuse by another resident, resulting in a laceration that required five sutures. The incident occurred when a resident with moderate cognitive impairment hit another resident with a walker. Staff provided immediate care, and the incident was classified as physical abuse, highlighting a failure in the facility's ability to prevent such occurrences.
A resident experienced swelling of the right leg and a decline in activity, which was repeatedly reported by the resident's daughter. The nursing staff attributed the symptoms to arthritis and did not take appropriate action, leading to the resident continuing with a swollen leg for several days. This inaction resulted in an acute right hip fracture that required surgical intervention.
The facility failed to prevent falls and ensure resident safety, resulting in severe injuries for two residents with dementia. Despite being identified as high fall risks, the facility did not implement effective interventions such as bed alarms or increased supervision, leading to multiple falls and significant injuries, including fractures and subdural hematomas.
A cognitively impaired resident with a history of a right femur fracture and other conditions was not consistently assessed for pain as required by physician orders. Despite frequent expressions of pain, staff did not document or address these complaints, and the March 2024 MAR showed no pain assessments. The Director of Nursing confirmed the lack of assessments, acknowledging that nurses are supposed to assess pain every shift.
Inaccurate Fall Risk Assessment and Lack of Assisted Ambulation for High-Risk New Admission
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate fall risk assessment and to identify a newly admitted resident as high risk for falls, despite a documented history of falls, unsteady gait, and dementia with confusion. The resident’s diagnoses included polyneuropathy, peripheral vascular disease, hypertension, dementia, osteomyelitis of the left ankle and foot, and cellulitis of the left lower limb. Hospital physical therapy records used by the facility documented that the resident required a gait belt, 2-wheeled walker, and at least contact guard to minimal assist for transfers and ambulation, with noted unsteady gait, decreased cadence and step length, heavy reliance on upper extremities, narrow base of support, and impaired balance, cognition, strength, and safety awareness. The nurse-to-nurse report from the hospital also indicated dementia, confusion, forgetfulness, and a need for +1 assist with mobility. The admitting RN’s assessment documented the resident as confused and forgetful, alert and oriented only x1–2, requiring partial/moderate assist with transfers, and that walking was not attempted due to medical or safety concerns. Despite this information, the facility’s fall risk assessment completed after the fall documented that the resident was not at risk for falls and had no history of falls, and that no fall interventions were in place prior to the incident. The DON stated that the fall risk assessment for a new admission is expected to be completed within four hours of admission to establish a baseline for the plan of care and that, hypothetically, a resident who had fallen in January and was admitted in February would be considered a fall risk. The DON also stated that the fall assessment for this resident was considered accurate based on the history that the resident had a fall in the past, even though the post-fall investigation form indicated “No” for history of falls and “No” for being at risk for falls. The resident’s inventory did not identify a walker, and the DON did not know where the walker used at the time of the fall came from. The fall coordinator explained that a history of falls reported by family would identify a resident as a fall risk and that the facility has a fall risk assessment and interventions such as floor mats and alarms, but there is no indication these were implemented for this resident. Interviews with staff and the resident’s wife further described the circumstances leading to the fall. The RN on duty reported being told at shift report that the resident was a fall risk and used a walker, and that the resident was alert and oriented x2–3. The RN stated that the resident was new, had some confusion, was getting up frequently, and did not use the call light. The RN assisted the resident with toileting about an hour before the fall and later observed the resident ambulating alone in the hallway with a walker, wearing non-skid socks and a gown, and then attempting to turn by lifting the walker, losing balance, and falling onto his buttocks and hitting his head. A CNA reported seeing the resident get himself up from bed and walk toward the nurse’s cart before the fall, and that the other CNA assigned to the floor was not in the area at the time. The resident’s wife reported that the resident had fallen several times at home, including off the toilet, and that in the hospital he had bed and chair alarms. She stated that a full-time caregiver informed a group of staff at the desk that the resident was at risk for falls and had alarms in the hospital, and that staff responded they could not implement alarms until he was assessed the next day. She also reported that no one from the facility called her for history or questions during admission and that the resident was placed in a room several rooms away from the nurses’ station. The incident and change in condition forms documented the fall time as 3:10 a.m., while the post-fall investigation documented 4:10 a.m., indicating a discrepancy in the recorded time of the event. The post-fall investigation’s root cause analysis stated that the resident, admitted within 24 hours and baseline alert/oriented x1, lifted his walker in an attempt to turn, lost balance, and fell on his buttocks, then hit his head. The RN reported that the resident was on a blood thinner (Xarelto), hit his head, and was sent to the hospital by 911. The DON confirmed that the resident had wounds on the left ankle and a healed amputated toe on admission and that the resident did not return to the facility after transfer to the hospital. Staff interviews confirmed that CNAs are issued gait belts at hire and trained in their use, and that extra gait belts are available at nurses’ stations, but the report does not document that a gait belt or one-person assist was used when the resident was ambulating independently in the hallway at the time of the fall. The combination of inaccurate fall risk assessment documentation, failure to recognize and document the resident’s history of falls and need for assistance, and lack of implementation of fall interventions contributed to the resident ambulating alone and experiencing a fall with head impact shortly after admission.
Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that fall prevention interventions were in place and adequate supervision was provided for two residents identified as high risk for falls. One resident with a history of falls, severe cognitive impairment, and multiple comorbidities experienced several falls within the facility. Despite being care planned for interventions such as placement near the nurse's station and use of a bed alarm, the resident was found on the hallway floor after an unwitnessed fall. Staff interviews revealed that the bed alarm was not functioning properly due to a low battery, which had been reported but not addressed, resulting in the alarm being too faint to alert staff. The resident sustained a severe intracranial subdural hematoma and was hospitalized, ultimately expiring due to the injuries sustained from the fall. Another resident, also at high risk for falls due to impaired mobility and a history of falling, was found on the floor in a hallway area not visible from the nurse's station. Staff interviews indicated that this area was a known blind spot and not considered safe for unsupervised residents. The fall was unwitnessed, and it was reported that another resident had pulled the wheelchair from under the resident, causing the fall. The resident was sent to the hospital and diagnosed with a subdural hemorrhage. The care plan for this resident included the use of a chair alarm to alert staff of independent transfers, but the incident occurred in an area where staff could not provide adequate supervision. Facility policies and job descriptions reviewed in the report emphasized the responsibility of staff to ensure resident safety, maintain functioning equipment, and provide supervision according to individualized care plans. However, the failure to maintain equipment such as bed alarms and to supervise residents in high-risk areas directly contributed to the falls and subsequent injuries. The documented deficiencies were based on staff interviews, record reviews, and hospital records, which detailed the sequence of events and the lack of effective interventions at the time of the incidents.
Failure to Administer and Document COVID-19 Vaccine for Consenting Resident
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to a resident who had provided consent for vaccination. Despite the resident's family member confirming that consent was given, there was no documentation of the vaccine being administered or declined for this resident. The resident was admitted with multiple diagnoses, including cerebral infarction, hyperlipidemia, essential hypertension, chronic atrial fibrillation, insomnia, protein calorie malnutrition, and a history of COVID-19. The infection control nurse and the Director of Nursing both acknowledged that the process for obtaining consent and documenting vaccine administration or declination was not followed for this resident. During a COVID-19 outbreak in the facility, contact tracing revealed that a staff aide who worked directly with the resident tested positive, and the resident subsequently tested positive for COVID-19. The facility's infection prevention and control policy requires identification, recording, and documentation of infections and corrective actions, as well as compliance with public health recommendations. However, the lack of documentation and failure to administer the vaccine as consented represented a lapse in following these procedures for the affected resident.
Failure to Implement and Maintain Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for a cognitively impaired resident with a history of repeated falls. The resident, diagnosed with hydrocephalus, dementia, type II diabetes, and essential hypertension, experienced 11 falls over several months. Despite being identified as a high fall risk, the resident's care plan interventions, such as keeping essential items within reach, ensuring a working and accessible call light, providing appropriate footwear, and activating a bed alarm, were not consistently implemented. On multiple occasions, fall interventions were missing or not updated following each fall, contrary to facility policy. Direct observations and interviews revealed that the resident was left unsupervised, with the call light tangled and out of reach, the bed alarm not activated, and essential items like water and tissues not accessible. Staff acknowledged that the bed alarm was not turned on and that the call light should have been within reach. The resident was also observed walking around the room in socks, which was not in accordance with the care plan specifying appropriate footwear. Activity interventions were not provided as required, and the resident was not engaged in activities despite this being a listed intervention for fall prevention. Documentation and staff interviews confirmed that the facility's fall prevention policy, which requires individualized interventions after each fall and consistent implementation of care plan measures, was not followed. The resident continued to experience falls, some resulting in hospital evaluations, and staff admitted to not always being able to provide the required level of supervision. The deficiency was further substantiated by the lack of timely updates to the care plan and failure to ensure all interventions were in place after each incident.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus, muscle weakness, major depressive disorder, essential hypertension, and blindness in one eye was not provided with food that accommodated their documented allergies and preferences. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14. On observation, the resident received a lunch tray containing shrimp, rice, corn on the cob, and apple pie alamode. The meal ticket on the tray documented allergies to cheese, dairy products, ice cream, milk, and yogurt, as well as dislikes for apple, applesauce, bratwurst sausage, and corn. Staff interviews confirmed that the resident should not have been served ice cream due to a dairy allergy, nor apples or corn due to documented dislikes. The Director of Dietary stated that residents' food allergies and dislikes should not be served, and that the diet card for each resident should be followed. The facility's Food Preference Policy requires identification and accommodation of resident allergies, intolerances, and preferences, and prohibits serving foods that cause allergic or intolerance reactions. Despite these policies, the resident was served food items that did not accommodate their allergies and preferences.
Failure to Provide Adequate Fall Prevention and Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that fall interventions and adequate supervision were in place for multiple residents identified as high risk for falls. Several residents, all with significant medical histories including dementia, unsteady gait, and previous falls, experienced unwitnessed or inadequately supervised falls that resulted in serious injuries such as femoral fractures, vertebral fractures, and lacerations. In multiple instances, residents were found on the floor by staff after the fact, and documentation revealed that required interventions, such as ensuring call lights were within reach, were not consistently implemented. For example, one resident was found on the floor with a laceration and a fractured right femur after attempting to ambulate unsupervised, with staff later confirming that the call light was not accessible and that the resident was known to walk independently despite being high risk. Interviews with staff and review of records indicated that high-risk residents were often left unsupervised or allowed to ambulate alone, despite care plans and assessments indicating the need for supervision. Staff statements confirmed that some residents, due to cognitive impairment and poor safety awareness, would attempt to walk or toilet themselves without assistance, and that supervision was not always provided. In several cases, staff were not present or were engaged in other tasks when falls occurred, and some staff were unclear about the specific supervision needs of the residents in their care. Additionally, the facility lacked a clear policy on resident supervision, and staff relied on informal communication or personal knowledge rather than standardized protocols. Documentation further showed inconsistencies in incident reporting and care plan implementation. For example, one resident's fall with injury was not accurately documented in the injury report, and another resident's care plan interventions, such as purposeful rounding and environmental safety measures, were not reliably followed. The facility's own records indicated a pattern of repeated falls among high-risk residents, with multiple incidents occurring over a short period. Despite the presence of care plans and fall risk assessments, the necessary interventions and supervision were not consistently provided, directly leading to multiple residents sustaining serious injuries.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to ensure that residents' needs were met, particularly in monitoring and providing timely incontinence care. Observations and interviews revealed that residents were not being checked every two hours as required. For instance, a resident was found with a saturated incontinence brief that had not been changed since the night shift, which ended at 7:00 AM. This lack of timely care was echoed by other residents who reported not being checked on since early morning hours, leading to discomfort and potential health risks. Staff interviews highlighted the chronic understaffing issue, with CNAs expressing that they were unable to meet the care needs of residents due to insufficient numbers. On the 4th floor, only two CNAs were available when there should have been four, leading to delays in care and increased risk of falls, especially for residents with dementia who require more supervision. The staffing shortage was further exacerbated by the need to pull restorative aides from their duties to cover basic care needs, leaving other essential services unmet. The facility's staffing schedule and policy indicated a clear discrepancy between the required and actual number of CNAs on duty. The staffing scheduler confirmed that the facility was operating below the necessary staffing levels, which impacted the quality of care provided. The Director of Nursing acknowledged that insufficient staffing could potentially affect resident care, aligning with concerns raised in the Resident/Food Council Meeting Minutes about the need for more CNA staff.
Failure to Provide Grooming Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide grooming assistance to a resident, identified as R9, who expressed dissatisfaction with the condition of his beard and mustache. On observation, R9's facial hair was described as bushy, shaggy, and untamed, with the mustache growing into his mouth. R9 stated that he would like to have his beard and mustache trimmed but was not offered assistance by the staff. He mentioned that the facility's barber charges too much and that he was unable to reach an external barber due to fatigue. R9 expressed a need for staff assistance as he did not believe he could manage the grooming himself. Interviews with facility staff revealed that it is the responsibility of CNAs to offer shaving and grooming assistance daily. However, due to staffing shortages, this was not consistently done. The facility was operating with fewer CNAs than required, which contributed to the oversight in R9's grooming needs. The facility's policies emphasize the importance of providing hygienic care and maintaining resident dignity, but these were not adhered to in R9's case, leading to the deficiency.
Inadequate Incontinence Care Due to Staffing Shortages
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding incontinence care, resulting in inadequate care for three dependent residents. Observations and interviews revealed that these residents did not receive the required incontinence care every two hours. For instance, one resident was found with a saturated incontinence brief and underpad, indicating a lack of timely care. The resident was unable to recall the last time their brief was changed, and the assigned CNA admitted to not having checked on the resident since the start of their shift. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the facility's policy mandates incontinence care every two hours. However, staffing shortages were cited as a significant barrier to providing this level of care. Multiple staff members reported that the unit was understaffed, with only two CNAs working when there should have been at least three or four. This staffing issue was corroborated by the facility's staffing scheduler, who noted that the facility was operating below the required number of CNAs for the shift. The residents involved had various medical conditions that necessitated regular assistance with activities of daily living, including incontinence care. One resident, who was cognitively intact, expressed discomfort due to the lack of timely care. Another resident, with moderately impaired cognition, was dependent on staff for toileting and transfers. The facility's failure to provide adequate staffing and adhere to its care policies resulted in these residents not receiving the necessary care to maintain their dignity and comfort.
Failure to Maintain Wound Dressing and Incontinence Care
Penalty
Summary
The facility failed to ensure proper wound care for a resident with a sacral pressure ulcer. During an observation, it was noted that the resident's wound dressing was not in place, leaving the wound open to air. The Licensed Practical Nurse (LPN) accompanying the surveyor confirmed that the dressing should have been applied as per the treatment order. The resident, who was alert and able to communicate, reported discomfort due to a soiled incontinence brief, which was found to be saturated with urine and feces. The Certified Nursing Assistant (CNA) assigned to the resident admitted to not having checked or changed the resident's brief since the start of their shift, indicating a lapse in care since the night shift ended. The resident's medical records revealed a history of epilepsy and peripheral vascular disease, with a documented unstageable sacral pressure ulcer. The treatment plan required cleansing the wound with normal saline, applying medical-grade honey, and securing it with a bordered foam dressing three times a week and as needed. The Wound Care Coordinator emphasized the importance of keeping the resident clean and dry to promote healing and prevent further skin breakdown. The facility's policy mandates prompt identification and treatment of skin breakdown, yet the resident's care did not align with these guidelines, resulting in the deficiency.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature for three residents, as observed during a survey. Residents reported that their hot food was consistently served cold, which affected their willingness to eat. One resident consumed only the hot cereal from their breakfast, leaving the cold eggs and sausage untouched. Another resident ate the cold eggs out of hunger, while a third resident mentioned that they had never received hot food during their six-week stay, except for coffee. The surveyor observed that breakfast trays arrived on the 4th floor without heated palates or heated ceramic plates. A Certified Nursing Assistant confirmed that heated palates were not always used, and a test tray revealed that the scrambled eggs and sausage links were served at temperatures significantly below the expected range. The Director of Dietary acknowledged that the food temperatures were unacceptable and emphasized the importance of maintaining proper food temperatures to ensure resident satisfaction and adequate food intake. The facility's policy on food temperature maintenance requires hot food to be served above 135 degrees Fahrenheit and cold food at or below 41 degrees Fahrenheit. However, due to short staffing and equipment issues, these standards were not met. The kitchen staff admitted to not using heated palates consistently and not heating ceramic plates due to a malfunctioning warmer, contributing to the deficiency in food service quality.
Deficiencies in Fall Risk Assessment and Prevention
Penalty
Summary
The facility failed to ensure that fall risk assessments were completed accurately and that staff were aware of and implemented fall prevention interventions for residents at risk of falls. Specifically, the admission fall risk assessment for a resident with dementia, Parkinson's disease, and mobility issues was incomplete, lacking a score or conclusion indicating actual risk. Despite the resident's care plan including interventions such as bed and chair alarms, these were not functioning properly, as observed when the chair alarm failed to sound during a surveyor's inspection. Another resident, with a history of falls and chronic conditions affecting mobility, was found to have an incomplete fall risk assessment upon admission, which initially did not indicate a fall risk. However, a subsequent assessment confirmed a high fall risk. The resident's care plan did not include necessary interventions, such as keeping commonly used items within reach, which was observed to be neglected during the surveyor's visit. A third resident, also with dementia and a history of falls, had a high fall risk assessment score, but the incident report following a fall did not include predisposing factors that contributed to the fall. Additionally, a CNA assigned to the resident's unit was unaware of the resident's fall prevention interventions, indicating a lack of communication and training among staff. The facility's fall occurrence policy requires assessments and interventions, but these were not consistently followed or documented, leading to deficiencies in resident care.
Failure to Monitor and Assess Resident Post-Fall Incidents
Penalty
Summary
The facility failed to properly assess, monitor, and evaluate a resident, referred to as R2, after two fall incidents. R2 was admitted with multiple diagnoses, including a history of falling and Alzheimer's disease. On two separate occasions, R2 experienced falls, one of which resulted in a significant injury. The first fall on 3/13/24 was unwitnessed, and although R2 was ambulatory with no injury reported, the required documentation and monitoring every 8 hours for 72 hours post-fall were incomplete. Only one documentation entry was made on the first and third days, with no entry on the second day, indicating a lapse in the standard nursing practice of monitoring and documentation. The second fall occurred on 5/12/24 while R2 was out on pass with her daughter. R2 fell while running after her grandchildren, resulting in a left iliac fracture. This incident led to a significant change in R2's condition, as she became non-ambulatory and required more assistance with activities of daily living. Despite this change, the facility did not complete a significant change assessment, which is required when there is a notable alteration in a resident's physical or mental condition. The oversight in coordination and failure to conduct this assessment was acknowledged by the MDS coordinator. The facility's policy mandates that a significant change MDS be completed when there is a change in a resident's condition. However, this was not adhered to in R2's case, as evidenced by the lack of a significant change assessment following the fall that resulted in a fracture. The failure to properly document and assess R2's condition post-fall incidents highlights deficiencies in the facility's adherence to its own policies and standard nursing practices.
Failure to Provide CPAP Equipment
Penalty
Summary
The facility failed to provide a resident with the necessary equipment for their CPAP machine, as ordered by a medical doctor. The resident, who has a history of obstructive sleep apnea, chronic systolic heart failure, and other serious health conditions, reported not having their CPAP mask for two nights, which made it difficult for them to breathe at night. The CPAP machine was observed without a face mask on the resident's nightstand. The resident expressed the need for assistance with their CPAP machine, indicating that a piece was missing. The issue was known to the facility staff, as a registered nurse and the Director of Nursing were aware of the missing mask. The Director of Nursing had asked the Assistant Administrator to order the mask due to the absence of the person responsible for ordering supplies. The facility's respiratory therapist, who is a contractor, confirmed that the facility is responsible for ordering respiratory supplies. The resident's care plan and medication administration notes documented the need for the CPAP machine and the absence of the mask on specific dates. The facility's policy emphasizes the importance of ensuring that respiratory equipment is compliant with acceptable standards of practice.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its Sanitation & Safety Operations policy, resulting in several deficiencies related to food safety and hygiene. During a kitchen tour, it was observed that uncooked open waffle patties were stored in the walk-in fridge without an open date or use-by date. The Food Service Director acknowledged that all open food should be dated to prevent the use of stale or expired foods, which could lead to residents becoming ill. Additionally, kitchen cleaning chemicals were improperly stored in the food pantry alongside food items and food service containers, contrary to the facility's policy of keeping chemicals separate to avoid contamination. Further inspection revealed issues with the dishwasher's sanitizing process. The dishwasher failed to reach the required temperature of 160 degrees Fahrenheit, as indicated by the testing strips that did not turn black. The Assistant Dietary Manager confirmed that the testing strips should turn black to verify proper sanitization, but the facility's logs only recorded temperatures without attaching the strips. This practice was based on advice from the dishwasher servicing company, which led to a lack of verification that the correct sanitizing temperature was achieved. Additional observations included a dietary aide serving food without wearing gloves, which is necessary to prevent cross-contamination. The temperature of the food served was also inconsistent, with some items not maintaining the required temperature of 135 degrees Fahrenheit when reaching the residents. These deficiencies in food handling and sanitation practices have the potential to affect the health and safety of the 204 residents receiving meals from the kitchen.
Failure to Uphold Resident Dignity and Quality Care
Penalty
Summary
The facility failed to encourage and assist residents with cognitive impairments to dress in their own clothes, instead allowing them to remain in hospital-type gowns. This was observed in 22 residents, including those who were bedbound or had limited mobility. The surveyor noted multiple instances where residents were observed lying in bed wearing gowns, rather than being dressed in their personal clothing. This practice was not consistent with the residents' rights to dignity and self-determination, as outlined in the facility's own documentation. Additionally, the facility did not provide equal access to quality care for residents regardless of their diagnosis or severity of condition. Three residents were specifically noted for this deficiency. The surveyor observed that some residents were not aware of the activities available to them, and there was a lack of effort to engage them in these activities. For instance, one resident expressed unawareness of any activities and was unsure if they had their clothes available, indicating a lack of communication and support from the staff. Interviews with staff revealed inconsistencies in the implementation of care routines, such as the absence of a 'get-up list' for certain shifts, which contributed to residents remaining in bed. Staff members also indicated that some residents were not encouraged to get up due to their confusion or non-verbal status, despite the potential benefits of socialization and exercise. The facility's failure to uphold the residents' rights to dignity and quality care was evident in these observations and interviews.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that four residents had access to the call light system, which is essential for them to request assistance. During the survey, it was observed that the call lights for these residents were not within their reach, rendering them unable to call for help when needed. For instance, one resident was found with the call light dangling to the floor, and despite being cognitively able to use it, they could not reach it due to physical limitations. Another resident, who was legally blind, also had their call light out of reach, making it impossible for them to call for assistance independently. The surveyor's interactions with the staff revealed that the call lights were not consistently placed within reach of the residents. Certified Nursing Assistants and Licensed Practical Nurses acknowledged that the call lights were not accessible to the residents, and they were aware of the importance of keeping them within reach. Despite the facility's policy stating that call lights should be accessible to residents at all times, this was not adhered to, leading to the deficiency. The residents involved had varying degrees of physical and cognitive impairments, which necessitated the need for accessible call lights. One resident had a history of Parkinson's disease and spinal stenosis, requiring substantial assistance with activities of daily living. Another resident, although cognitively impaired, demonstrated the ability to use the call light when it was within reach. The failure to ensure the call lights were accessible compromised the residents' ability to communicate their needs effectively, highlighting a significant oversight in the facility's adherence to its own policies.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately account for residents' narcotic medications on two out of six medication carts reviewed. Specifically, discrepancies were found in the documentation and actual count of Lorazepam and Clonazepam. For Lorazepam, the recorded doses did not match the actual remaining amount in the bottle, leading to a discrepancy of four to five milliliters. Similarly, for Clonazepam, there was a mismatch between the number of tablets recorded and the actual count in the bingo card. Additionally, the shift change accountability record for controlled substances was not signed on a particular shift, indicating a lapse in the required documentation process. The facility also failed to adhere to policies regarding the labeling and dating of insulin vials and the storage of medications. Insulin vials were found without proper labeling, and expired tuberculin vials were stored in the refrigerator. Furthermore, expired house stock medications were found on medication carts, and topical medications were stored in proximity to oral supplements, posing a risk of contamination. These issues were observed in two out of three medication rooms and two out of six medication carts reviewed. The deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in the facility's medication management practices. The Director of Nursing acknowledged the need for accurate documentation and adherence to medication policies, emphasizing the importance of maintaining accurate narcotic counts and ensuring medications are within recommended use dates.
Failure to Provide Hot Food to Resident
Penalty
Summary
The facility failed to adhere to its hot food policy by not providing hot food to a resident, identified as R172, who was part of a sample of 35 residents reviewed. R172, who has intact cognitive abilities as indicated by a BIMS score of 15/15, reported receiving food that was warm but not hot. The facility's policy requires hot food to be served at a temperature above 135 degrees Fahrenheit. However, during an observation, the food temperature was recorded at 112 degrees Fahrenheit, which is below the required standard. R172 expressed dissatisfaction with the temperature of the food and mentioned that no staff offered to replace the meal with a hotter one, despite being informed by the Assistant Administrator that a new tray could be requested if the food was not hot enough. Interviews with staff revealed inconsistencies in the facility's approach to reheating food. The Assistant Administrator stated that staff could rewarm food using microwaves on the units, but a Certified Nursing Assistant (CNA) reported that management had instructed staff not to use microwaves due to safety concerns about overheating. Instead, the CNA stated that staff were told to call the kitchen for a new tray if a resident's food was cold. This discrepancy in communication and procedure contributed to the failure to provide hot meals to residents, as evidenced by R172's experience.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the resident assessment process. One resident, identified as R59, was observed to be toothless and reported difficulties eating without teeth. However, the MDS Section L for R59's annual comprehensive assessment did not document the resident's accurate dental status, despite a dental hygiene encounter form noting the resident's edentulous condition. Another resident, R133, was admitted to hospice care, as documented in the physician order set, but the MDS Section O for R133's annual comprehensive assessment failed to reflect the resident's hospice care status. The Clinical Care Coordinator emphasized the importance of accurate MDS assessments for reliable resident assessments and care planning, noting that care plans are reviewed at least a week after assessments are completed.
Failure to Conduct Required PASRR Level II Screenings
Penalty
Summary
The facility failed to refer three residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review, as required by the Preadmission Screening and Resident Review (PASRR) program. This deficiency affected three residents, identified as R73, R125, and R166, out of a sample of 35 residents. Resident R73 had new diagnoses of psychotic disorder with delusions, depression, and anxiety disorder, all with an onset date of November 7, 2023. Despite these diagnoses, the PASRR Level I form indicated no need for a Level II review, and no new screening was requested following the change in condition. Similarly, Resident R125 was diagnosed with major depressive disorder and depression, but the PASRR Level I form did not trigger a Level II review, and no new screening was conducted. Resident R166, who had a diagnosis of anxiety disorder and moderate cognitive impairment, also did not receive a necessary PASRR Level II screening. The Social Services Director acknowledged that conditions such as schizophrenia, bipolar disorder, major depressive disorder, and anxiety should trigger a PASRR Level II screening to ensure residents receive appropriate services. However, the facility did not initiate the required screenings for these residents, despite the presence of serious mental health conditions. The facility's policy mandates that residents with mental disorders or intellectual disabilities receive PASRR screenings within the allowed timeframe, but this was not adhered to in these cases.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately account for residents' narcotic medications on two out of six medication carts reviewed. Specifically, discrepancies were found in the documentation and actual count of Lorazepam and Clonazepam. For Lorazepam, the recorded doses did not match the actual remaining amount in the bottle, leading to a discrepancy of four to five milliliters. Similarly, for Clonazepam, there was a mismatch between the number of tablets recorded and the actual count in the bingo card. Additionally, the shift change accountability record for controlled substances was not signed on a particular shift, indicating a lapse in the required documentation process. The facility also failed to adhere to policies regarding the labeling and dating of insulin vials, storage of expired medications, and proper separation of topical and oral medications. Insulin vials were found without proper labeling, and expired tuberculin vials were stored in the refrigerator. Furthermore, expired house stock medications were found on medication carts, and topical medications were stored in proximity to oral supplements, posing a risk of contamination. These issues were observed in two out of three medication rooms and two out of six medication carts reviewed. The Director of Nursing acknowledged the deficiencies, emphasizing the need for accurate documentation and adherence to medication policies. The facility's policies require that all opened medication vials be labeled with the date of opening and discarded within specified timeframes. However, these procedures were not consistently followed, leading to potential risks for residents who rely on these medications for their care.
Medication Administration Errors
Penalty
Summary
The facility failed to administer the correct medication and dosage as ordered by the physician, resulting in a medication error rate of 10.71%. During an observation of medication administration, a Licensed Practical Nurse (LPN) administered Deep Sea Nostril Spray to the left nostril and Artificial Tears eye drops to the left eye of a resident, R118. However, the physician's order specified Sodium Chloride Nasal Spray to be applied in both nostrils and Artificial Tears eye drops to be administered as two drops in both eyes. In another instance, the same LPN was observed administering medication to resident R68, who requested eye drops for dry eyes. The LPN initially stated that the eye drops were not available in the medication cart and retrieved Artificial Tears from another floor, administering one drop to each eye. The physician's order for R68 specified Tetrahydrozoline HCl Ophthalmic Solution 0.05% as the as-needed eye drop, not Artificial Tears. These errors were brought to the attention of the Director of Nursing, who acknowledged the need for adherence to the five rights of medication administration.
Inadequate Adherence to Infection Control Protocols
Penalty
Summary
The facility failed to ensure proper adherence to infection prevention and control protocols, specifically regarding the use of personal protective equipment (PPE) for residents under isolation precautions. Observations revealed that staff and family members did not consistently follow the recommended guidelines for wearing PPE when interacting with residents on enhanced barrier or contact isolation precautions. For instance, a therapist and another staff member were observed working with a resident with a wound vac without wearing PPE, despite the resident being on enhanced barrier precautions. Additionally, a family member was seen exiting a resident's room with contact isolation for C-Diff while still wearing PPE and subsequently interacting with others in the hallway, indicating a lack of proper education on isolation protocols. The report highlights specific cases where the facility's infection control measures were not followed. One resident with a history of a left foot wound and wound vac was not properly managed by staff who failed to wear PPE during care. Another resident with C-Diff was not isolated effectively, as evidenced by a family member's improper use of PPE. A third resident with a chronic Foley catheter and PEG tube was assisted by staff without PPE, despite the presence of wounds and indwelling medical devices. Interviews with staff revealed a lack of consistent education and understanding of the facility's infection control policies, contributing to these deficiencies.
Failure to Implement Effective Fall Precautions
Penalty
Summary
The facility failed to implement effective fall precautions for two residents identified as fall risks, leading to multiple falls and injuries. One resident, who has schizophrenia, bipolar disorder, and dementia, experienced four falls in May 2024 alone, resulting in knee abrasions and a cast on the left arm. The falls were attributed to inadequate supervision and improper placement of ambulatory equipment, such as a walker being out of reach. The fall coordinator acknowledged that the resident's behavior was a contributing factor, yet the care plan did not address behavioral interventions to prevent falls. Another resident was observed with their bed in a high position, contrary to the care plan's directive to keep the bed in the lowest position as a fall precaution. This resident, who has a history of falling and a healed traumatic fracture, expressed concern about falling again. The LPN and CNA responsible for the resident's care admitted to not ensuring the bed was in the correct position, which could have led to a fall and injury. The facility's policy mandates that residents identified as high risk for falls receive appropriate interventions, and that these interventions are reevaluated and revised as necessary. However, the fall coordinator noted discrepancies in the fall risk assessment for one resident, indicating a lack of accurate documentation and assessment. The facility's failure to adhere to its own policies and procedures contributed to the deficiencies observed by the surveyors.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident (R4) from physical abuse by another resident (R5). The incident occurred when R5, who has moderate cognitive impairment, hit R4 with a walker, resulting in a laceration on R4's forehead that required five sutures, a skin tear on the right hand, and an abrasion on the mid-back. R4, who has intact cognitive function, reported the incident to staff, and it was confirmed by multiple staff members who observed the injuries and provided immediate care. The facility's policy on abuse and neglect clearly states that physical contact between residents is not allowed and should be prevented by staff intervention. On the night of the incident, a Certified Nursing Assistant (CNA) and two Licensed Practical Nurses (LPNs) were involved in responding to the situation. The CNA was initially in another resident's room when she was called to assist with the altercation. Upon arrival, she found R4 bleeding from a gash on the forehead. The LPNs provided immediate care by cleaning the wound and applying pressure to stop the bleeding. The Assistant Director of Nursing (ADON) was also called to the scene and subsequently contacted emergency services, the physician, and the family. The Director of Nursing (DON) and the facility administrator were notified of the incident, and it was classified as physical abuse. The facility's investigation revealed that R5 was startled when R4 turned on the lights in their shared room, which led to the physical altercation. Staff interviews confirmed that residents are not supposed to hit each other and that such actions are considered abuse. The facility's policy emphasizes the importance of preventing abuse and ensuring a safe environment for all residents. Despite these policies, the incident occurred, indicating a failure in the facility's ability to protect residents from abuse.
Failure to Recognize and Address Resident's Condition Leading to Acute Hip Fracture
Penalty
Summary
The facility failed to recognize, monitor, and provide needed services for a resident (R2) who had been noted with swelling of the right leg and a decline in activity. Despite the resident's daughter repeatedly informing the nursing staff about the swelling and the resident's complaints of pain, the staff attributed the symptoms to arthritis and did not take appropriate action. This inaction led to the resident continuing with a swollen leg for several days, ultimately resulting in an acute right hip fracture that required surgical intervention. The report documents that the facility reported an unwitnessed fall with injury on 03/18/2024, which led to the discovery of the acute right hip fracture. However, prior to this, there were multiple instances where the resident's condition was not adequately assessed or documented. For example, on 03/12/2024, the resident's daughter noticed discoloration on the resident's right lower face cheek, right arm, and hand, but there was no documentation of the provider being notified or any thorough assessment or treatment being done. Additionally, the resident's change in condition form dated 03/10/2024 indicated right knee pain starting on 03/08/2024, but no appropriate follow-up actions were taken. Interviews with various staff members, including CNAs, nurses, and the Director of Nursing, revealed inconsistencies and a lack of proper communication and documentation regarding the resident's condition. The resident's physical therapy notes also showed a decline in activity, with the resident refusing gait training and showing low tolerance for standing. Despite these clear signs of a deteriorating condition, the necessary medical evaluations and interventions were delayed, leading to the resident's acute right hip fracture and subsequent surgery.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to maintain the safety of residents by not identifying risks for fall prevention and not ensuring adequate supervision and assistance. Resident R6, who had a history of dementia and was at high risk for falls, experienced multiple falls resulting in severe injuries, including a right arm/shoulder fracture and subdural hematoma. Despite being identified as a high fall risk, the facility did not implement effective interventions such as bed alarms or increased supervision, especially during nighttime when the falls occurred. Staff interviews revealed that R6 was impulsive and forgetful due to dementia, which contributed to the falls, yet the only intervention noted was the use of a call light, which R6 often forgot to use. Resident R3, also diagnosed with dementia and at high risk for falls, experienced multiple falls within three days of admission to the facility. These falls resulted in a closed fracture of the right wrist. The facility failed to update R3's care plan or implement new interventions after each fall. The resident's Power of Attorney (POA) expressed concerns about the lack of communication from the facility regarding the falls and the inadequate measures taken to prevent further incidents. The facility's policy required fall risk assessments and the implementation of interventions, but these were not effectively carried out for R3. The facility's failure to adhere to its fall prevention policy and adequately supervise high-risk residents led to significant injuries for both R6 and R3. Staff interviews and documentation indicated a lack of consistent and effective interventions, such as bed alarms or increased supervision, which could have mitigated the risk of falls. The deficiencies in care and supervision directly contributed to the residents' injuries and highlighted the need for improved fall prevention strategies in the facility.
Failure to Follow Pain Management Regimen for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident's pain management regimen was followed in accordance with physician's orders. The resident, a [AGE] year-old female with a history of a nondisplaced intertrochanteric fracture of the right femur, muscle weakness, dementia, and pain in the right knee, was not consistently assessed for pain. Despite the resident's care plan and physician orders requiring pain assessments every shift, the March 2024 Medication Administration Record (MAR) showed no documentation of these assessments. Interviews with the resident's Power of Attorney and several Certified Nursing Assistants (CNAs) revealed that the resident frequently expressed pain, but the staff did not consistently document or address these complaints. The Director of Nursing confirmed the lack of pain assessments in the MAR, acknowledging that nurses are supposed to assess pain every shift. The resident's care plan, dated 02/29/2024, indicated that the resident was at risk for pain due to musculoskeletal issues and required regular pain assessments and appropriate pain management interventions. However, the facility's failure to adhere to these guidelines resulted in the resident's pain not being adequately monitored or managed. The facility's policy on pain management, which mandates pain assessments in situations where there is a potential for pain, was not followed, leading to a significant impact on the resident's well-being.
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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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