Avantara Palos Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Palos Heights, Illinois.
- Location
- 7850 West College Drive, Palos Heights, Illinois 60463
- CMS Provider Number
- 145607
- Inspections on file
- 42
- Latest survey
- March 15, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Avantara Palos Heights during CMS and state inspections, most recent first.
Staff failed to follow established care plan interventions for two residents with pressure ulcers and complex medical conditions, including COPD, MS, atrial fibrillation, major depressive disorder, paraplegia, and a stage 4 sacral ulcer. Despite care plans requiring incontinence care and skin checks every two hours, staff did not provide these services over a period exceeding four hours, leaving the residents in soiled conditions and not maintaining clean, dry dressings. A CNA acknowledged knowing the required care but did not perform it, stating she was waiting for the wound team.
Two residents with multiple pressure ulcers, including a stage 4 sacral ulcer, were not checked or changed for incontinence for approximately 4 hours and 45 minutes, leaving large amounts of dark, crusty dried feces on their skin and wound dressings. A CNA assigned to their care stated she did not change them because the wound team was scheduled to see them later. When the wound nurse and wound CNA arrived for treatments, they observed the dried fecal matter on the residents and their dressings. The wound nurse confirmed that fecal contamination of wound dressings poses a significant risk for bacterial contamination and potential setback in wound healing. Review of the facility’s wound and skin care policy showed it requires timely incontinence care to maintain skin integrity and prevent wound contamination, but this was not followed, resulting in a breakdown of standard hygiene protocols and compromised dignity and quality of care.
A resident with multiple chronic conditions and a documented full code status was found unresponsive and without a pulse. The assigned nurse left the room to verify code status and did not immediately begin CPR, stating she did not know how to overhead page a code blue. Another nurse later arrived to find no staff in the room, confirmed the absence of a pulse, and then started chest compressions. Staff on the unit and from another floor questioned whether 911 had been called, and one nurse ultimately called 911 herself after seeing an agency nurse on the phone, possibly with another ambulance service. The facility’s policy and statements from the MD and DON indicated that immediate CPR and prompt activation of emergency response were expected for a full code resident in cardiac arrest.
Surveyors found that medications were left unsecured at a resident's bedside, medication carts were left unattended with drugs accessible, and multi-dose medications were not properly dated when opened. Insulin requiring refrigeration was stored improperly, and the medication refrigerator was found at freezing temperatures with significant ice buildup, affecting the storage of multiple medications. Staff acknowledged these practices did not follow facility policy.
Surveyors observed multiple failures in food storage and sanitation, including uncovered and undated food items in cold storage, soiled scoops left uncontained in the pantry, personal items stored with residents' food, and the use of expired sanitizing test strips. The Food Service Director confirmed these practices were not in line with facility policy, potentially affecting all residents.
Surveyors observed that the facility's outside dumpster was left open and contained garbage, a situation acknowledged by the Food Service Director as improper and contrary to sanitation expectations. The facility did not have a garbage disposal policy in place, despite job descriptions and policies requiring staff to maintain sanitary and pest-free conditions for all residents.
Staff failed to administer prescribed medications as ordered, including giving a resident a different medication due to lack of stock and not informing residents when medications were missed. There was confusion among staff regarding the regulatory time window for medication administration, resulting in late or missed doses for several residents, and facility policy regarding medication administration was not consistently followed.
Multiple residents did not receive proper pressure ulcer prevention and care, including incorrect low air loss mattress (LALM) settings, excessive linen layers on LALMs, unclean mattress surfaces, and lack of required pressure-reducing wheelchair cushions. Staff were observed to be unaware of correct LALM settings and failed to ensure timely dressing changes and wound coverage, despite facility policies and care plans requiring these interventions.
Four residents with respiratory conditions did not receive care in accordance with facility policy and physician orders, as oxygen equipment was found undated, uncontained, and not changed within required timeframes. Staff confirmed that equipment should be dated, changed weekly, and stored in bags when not in use, but these practices were not followed.
Staff failed to perform hand hygiene between serving meal trays to multiple residents, making direct contact with each while assisting with meal setup and food preparation. This occurred despite facility policies and CDC guidelines requiring hand hygiene before and after direct resident contact and meal assistance.
A resident with severely contracted hands and a documented need for a splint program did not have the use of splints or restorative devices included in their comprehensive care plan as required. Although the resident and restorative nurse confirmed the use of a palm protector, the care plan was not updated to reflect this until much later, contrary to facility policy that mandates timely and periodic review of care plans after assessment.
A resident with severe hand contractures did not receive appropriate restorative care due to staff being unaware of required devices, missing documentation in care plans and facility logs, and lack of application of splints as directed. Staff interviews revealed that the need for restorative devices was not included in the EMR tasks, and the care plan was only updated after surveyor inquiry, despite facility policy requiring assessment and documentation upon admission.
Three residents at high risk for falls did not receive care plan interventions such as bed/chair alarms and adequate supervision. One resident with dementia suffered multiple fractures after an unwitnessed fall when left alone, and another was found with a non-functioning bed alarm. Staff were not consistently aware of or following care plan interventions, and there was no documentation of required education for family members involved in supervision.
A resident with severe protein-calorie malnutrition and a gastrostomy was not provided the prescribed amount of enteral nutrition due to a malfunctioning feeding pump. The pump repeatedly failed, resulting in the resident receiving significantly less formula than ordered, and staff did not follow physician orders for feeding rate and volume. This led to ongoing weight loss for the resident, despite an NPO order and no oral intake.
A resident did not receive prescribed doses of Benzonatate and Guaifenesin-DM because the medications were unavailable at the time of administration. A nurse attempted to use another resident's Benzonatate due to the delay in pharmacy delivery, and the facility's house stock list did not include Guaifenesin-DM, leading to the use of an incorrect substitute. Facility policy prohibits sharing medications between residents.
Staff failed to follow medication administration policies, resulting in a 12% medication error rate. Two residents were affected: one received Hydrocodone without meeting the prescribed pain threshold, and another did not receive the correct cough medication due to unavailability and incorrect dispensing by an RN.
A resident was given Hydrocodone by an RN for pain levels below the severity specified in the prescriber's order, with the medication administered multiple times for pain rated less than 7, contrary to facility policy and physician instructions.
A resident with severe cognitive impairment and high fall risk experienced multiple falls, including one resulting in a significant bruise, due to staff failing to ensure a functioning bed alarm was in place and not following manufacturer safety guidelines for transporting the resident in a reclining chair. Staff did not consistently check alarm functionality or provide adequate supervision during transport, leading to unwitnessed falls and injury.
A resident with severe cognitive impairment and total dependence for care was not checked or changed for incontinence for several hours, despite being always incontinent. Staff failed to follow facility policy requiring checks every two hours, resulting in the resident developing incontinence-associated dermatitis (IAD) on the scrotal area due to prolonged exposure to urine and feces.
A facility failed to provide adequate fall prevention measures, resulting in a resident's fall and injury. The resident, at high risk for falls, was not given the required two-person assistance during care, leading to a fall and subsequent hospital visit. Observations also revealed that other high-risk residents lacked necessary fall prevention measures, such as low bed positions and bed alarms.
A resident's dignity was compromised when their urinary catheter was observed exposed and unsecured at a dining table. The unit manager and DON confirmed that the catheter should have been secured inside the pants. The resident had a urinary tract infection and obstructive uropathy, requiring a 22 French catheter, with a care plan specifying proper catheter placement and securing.
A resident at high risk for falls was not provided with the required two-person assist during incontinence care, resulting in significant bruising and swelling. The resident alleged being pushed out of bed by a CNA, but the incident was not immediately reported or documented by the LPN on duty. The facility's policy on abuse and neglect was not followed, as the allegation was not investigated until physical symptoms were observed.
A resident experienced inadequate pain management during sacral wound care due to the failure of staff to apply prescribed lidocaine gel before treatment. Despite receiving pain medication, the resident showed signs of pain, and the wound care nurse was unaware of the gel application protocol. The facility's pain management policy requires assessment and medication before, during, and after treatment, but this was not followed, leading to the deficiency.
A Hospice CNA was observed placing soiled linens on the floor during morning care for a resident, contrary to infection control practices. The CNA believed it was acceptable due to the linens being soiled. A Restorative Nurse corrected the CNA, stating that soiled items should be placed in a plastic bag. The Infection Preventionist Nurse confirmed the error, and the facility could not provide a relevant policy.
The facility did not maintain current daily nurse staffing information, with postings at the front desk being outdated by four days. The scheduler, responsible for updates, admitted to forgetting to update the information, and the facility lacked a policy on this requirement.
A resident with a history of Parkinson's Disease and Dementia sustained multiple fractures after attempting to self-transfer without adequate supervision. Despite known mobility limitations and a high risk for falls, the resident was left unsupervised, leading to significant injuries. Staff failed to investigate or document the incident, and suspicions of elder abuse were raised due to the lack of reported falls.
A resident with a complex medical history was found in an abnormal position in bed, but staff failed to assess for injuries or document the incident. Later, the resident was found with significant bruising and fractures, leading to a hospital visit and concerns of elder abuse. The facility did not follow its policy for immediate notification of the physician and family.
The facility failed to provide timely incontinence care for four residents, leaving them soiled for extended periods. A resident was left in urine for over fifteen hours, resulting in skin issues, while another experienced chills from being wet for eight hours. Two residents with cognitive impairments were found with saturated briefs, violating the facility's policy against double diapering.
A facility failed to document and obtain a physician order for a high-risk resident's skin breakdown, resulting in two small pink opened areas on the resident's thigh. The treatment nurse was unaware of the skin alterations, indicating a lack of communication and documentation. The facility's policy requires prompt identification and documentation of skin breakdown, which was not followed.
A facility failed to follow treatment orders for a resident with high-risk pressure wounds by not using Medihoney as ordered and not providing a low air loss mattress. The wound care nurse was unaware of the practitioner's orders, leading to improper wound care and mattress provision, contrary to the resident's care plan.
The facility failed to adequately monitor and educate staff on fall prevention, leading to unsupervised falls for five residents. These incidents resulted in injuries such as fractures and lacerations. The lack of adherence to fall prevention protocols and insufficient staff awareness of residents' fall risks contributed to these events.
The facility failed to treat residents with dignity and respect, as evidenced by reports of dismissive and rough behavior by some staff, particularly during evening shifts. Residents expressed concerns about inadequate communication and assistance, especially at night, and felt that reporting issues would be ineffective due to staff shortages. These incidents highlight a discrepancy between the facility's policy on dignity and the actual experiences of residents.
A resident, who is cognitively intact and dependent on staff for ADLs, reported rough handling by a CNA during care. The resident described the CNA as moving too quickly and being unpleasant, resulting in bruising on her arm. Although the initial assessment found no injuries, the resident later expressed that the handling was rough and likened it to being treated like a 'piece of meat.' The facility's policy defines rough handling as physical abuse, indicating a failure to protect the resident from such treatment.
Failure to Implement Scheduled Incontinence and Skin Care per Care Plans
Penalty
Summary
Facility staff failed to implement the comprehensive, person-centered care plans for two residents requiring skin and wound care, resulting in prolonged periods without incontinence care and skin monitoring. One resident, an older adult with COPD, multiple pressure ulcers to the left and right hips, back, and sacral areas, and atrial fibrillation, had a care plan last reviewed on 2/13/26 that required incontinence care every two hours and as needed, and maintenance of clean, dry dressings for pressure ulcers. Another resident, an older adult with multiple sclerosis, a stage 4 sacral pressure ulcer, major depressive disorder, and paraplegia, had a care plan last reviewed on 2/2/26 that required keeping the skin clean and dry with checks and changes every two hours to prevent skin breakdown and wound infection. On 3/13/26, between 7:00 AM and 11:45 AM, staff did not perform the scheduled incontinence care or skin monitoring for these two residents, leaving them in soiled conditions for over four hours despite the documented care plan interventions. During an interview at 12:10 PM the same day, a CNA acknowledged awareness of the residents’ care needs and the care plan requirements but stated that she did not provide the required incontinence care because she was waiting for the wound team. This failure to carry out the specific check-and-change and hygiene interventions as written in the residents’ comprehensive care plans constituted noncompliance with implementing care according to the residents’ person-centered goals and clinical needs.
Failure to Provide Timely Incontinence Care and Maintain Wound Hygiene
Penalty
Summary
The facility failed to provide timely incontinence care and maintain hygiene for two residents with pressure ulcers, resulting in dried fecal matter remaining on their skin and wound dressings for over four hours. One resident was an older adult with COPD, multiple pressure ulcers to the hips, back, and sacral areas, and atrial fibrillation. The second resident was an older adult with multiple sclerosis, a stage 4 sacral pressure ulcer, major depressive disorder, and paraplegia. During wound observations conducted by the wound nurse and wound CNA late in the morning, both residents were found with large amounts of dark, crusty dried feces from a previous bowel movement on their skin and saturated onto their wound dressings, indicating the fecal matter had been present for an extended period. In an interview, the CNA assigned to both residents confirmed she had been responsible for their care since 7:00 AM and acknowledged that she had not checked or changed either resident for incontinence because she knew the wound team was going to see them later. She admitted that neither resident had been checked or changed since at least 7:00 AM, a period of approximately 4 hours and 45 minutes. The wound nurse confirmed that although the residents’ wounds were showing signs of improvement, the presence of fecal matter on a wound dressing poses a significant risk for bacterial contamination and potential setback in wound healing. Review of the facility’s Wound Prevention and Skin Care Policy showed that staff are directed to provide timely incontinence care to maintain skin integrity and prevent contamination of existing wound sites, but this policy was not followed, resulting in a breakdown of standard hygiene protocols and compromised dignity and quality of care for the residents.
Failure to Immediately Initiate CPR and Call 911 for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to immediately initiate CPR and promptly call 911 for a resident with a documented full code status who was found unresponsive and pulseless. The resident had multiple medical diagnoses, including type II diabetes, bradycardia, cerebral infarction, pulmonary hypertension, anemia, chronic respiratory failure, congestive heart failure, obstructive pulmonary disease, and sleep apnea, and had physician orders indicating full code. A CNA reported attempting to wake the resident around 4:30 a.m. and, when the resident did not respond, called a nurse. The nurse checked for a pulse, could not find one, and then left the room to verify the resident’s code status. After confirming the resident was full code, the nurse did not immediately initiate chest compressions and stated she did not know how to overhead page a code blue, prompting the CNA to get another nurse. Another nurse on the unit reported hearing the code blue page, seeing the agency nurse on the phone, and hearing other nurses question whether 911 had been called. One nurse stated she overhead paged the code and, upon arriving in the resident’s room, found no staff present, confirmed the absence of a pulse, and then started chest compressions. Another nurse from a different floor reported calling 911 herself because she was unsure if anyone else had done so and recalled that the agency nurse might have been calling another ambulance company instead of 911. The facility’s code blue policy requires the assigned nurse to initiate emergency interventions for full code residents after evaluating for cardiac arrest and to ensure 911 is called, and both the medical director and DON stated they expected immediate initiation of chest compressions for an unresponsive, pulseless full code resident. The American Heart Association guidance cited in the report emphasizes immediate high-quality CPR and prompt activation of emergency response as critical components of basic life support.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple failures in medication management and storage practices within the facility. Medications, including Fluticasone Propionate nasal spray, were found left at a resident's bedside rather than being secured on the medication cart as required. An LPN confirmed that the nasal spray should not have been left at the bedside. Additionally, a bottle of Aspirin EC was observed unattended on a medication cart, and a yellow gel capsule of benzonatate was found dispensed in a cup on the cart, with the RN stating it was being considered for another patient. Insulin (Lantus) that required refrigeration was found stored in a medication cart instead of a refrigerator, and multiple opened multi-dose medications, such as Acetaminophen suspension, Multivite suspension, and Timolol ophthalmic solution, were not dated as required by policy. Further deficiencies were observed in the storage conditions of refrigerated medications. The medication room refrigerator on the third floor was found to have a temperature of 15°F, which is within the freezing range, and significant ice buildup was noted. Numerous medications, including insulins and suspensions, were stored in this refrigerator. Additionally, ophthalmic solutions for a resident were found to be opened and dated beyond the 30-day discard period, with staff acknowledging that these should have been discarded. Facility policies require medications to be stored securely, labeled with open dates, and refrigerated within specified temperature ranges, but these procedures were not consistently followed.
Deficient Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to comply with proper food storage and sanitation protocols, as evidenced by multiple observations in the kitchen and food storage areas. During an inspection of the walk-in freezer and refrigerator, surveyors observed an uncovered food cart with individual serving containers of applesauce that were not covered, an opened and undated bag containing beef patties with visible freezer burn, an undated blue bag of sausage crumble with a tear in the packaging, and an undated, partially cut tomato wrapped in clear plastic. The Food Service Director confirmed that food should be covered and dated to maintain freshness and prevent spoilage. In the dry food storage and pantry area, surveyors found soiled bulk scoops resting uncontained on shelves and on top of bulk item containers, as well as an employee's backpack stored among residents' food items. The Food Service Director acknowledged that scoops should not be left out due to contamination risks and that personal items should not be stored with residents' food, as they may be dirty. Additionally, expired sanitizing test strips were found at the three-compartment sink, and the Food Service Director admitted that expired strips could provide inaccurate readings. Facility policies and job descriptions reviewed by surveyors require that food be covered, dated, and stored properly, that equipment and supplies be maintained in a sanitary manner, and that personal items not be stored with residents' food. The observed failures to follow these protocols have the potential to impact the health and safety of all 144 residents residing at the facility, as documented in the facility census.
Failure to Keep Dumpster Closed and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to ensure that the outside dumpster was kept closed, as observed during a survey. On the date of observation, the dumpster was found open and containing garbage, with the Food Service Director present and acknowledging that the dumpster should be closed at all times to prevent rodent entry. The facility census documented 144 residents at the time of the observation. The Administrator later confirmed via email that the facility did not have a garbage disposal policy in place. Facility policies and job descriptions reviewed indicate expectations for maintaining sanitary conditions and effective pest control, including proper disposal of waste and keeping the environment clean and safe. The facility's pest control policy emphasizes the need for an effective pest control process, and job descriptions for dietary and housekeeping staff outline responsibilities for maintaining sanitation and infection control standards. Despite these documented expectations, the failure to keep the dumpster closed was observed and acknowledged by facility staff.
Medication Administration Policy and Timing Deficiencies
Penalty
Summary
The facility failed to follow its own medication administration policies and regulatory requirements for several residents. Staff were observed dispensing a different medication (Guaifenesin) than what was prescribed (Guaifenesin-DM) for a resident with a physician order for cough/congestion, as the prescribed medication was not available in the facility. The nurse confirmed that the correct medication was not in stock and the physician was later contacted to change the order, but the resident did not receive the prescribed medication as ordered. Additionally, staff were not aware of the requirement to notify residents when prescribed medications were not administered. Further deficiencies were observed in the timing of medication administration. Staff, including an LPN and a nurse supervisor, demonstrated confusion about the regulatory window for medication administration, with some medications being administered outside the required one-hour window before or after the scheduled time. Electronic Medication Administration Records (EMAR) showed that some residents had not received their scheduled medications on time, and residents were not informed when medications were missed. The facility's policies state that medications should be administered according to the prescriber's written orders and within the specified time frame, and that medications supplied for one resident should never be given to another. These procedures were not consistently followed.
Failure to Provide Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for five residents, as evidenced by multiple lapses in following established policies and care plan interventions. Staff did not ensure that low air loss mattress (LALM) settings matched residents' weights, did not maintain the cleanliness of LALM devices, and allowed excessive layers of linen beneath residents, contrary to facility policy. In one instance, a resident with an unstageable pressure injury to the sacrum was found lying on a LALM with five layers of linen, a soiled and partially uncovered wound dressing, and a visibly dirty mattress surface. Staff interviewed were unsure of the correct LALM settings and could not explain the significance of the settings in use. Additional deficiencies included the failure to provide pressure-reducing cushions for residents at risk of pressure ulcers while seated in wheelchairs, as required by their care plans and physician orders. Several residents were observed without the necessary gel chair cushions, and their LALM settings were not adjusted to reflect their current weights, as documented in their records. Staff acknowledged that the LALM settings should correspond to the resident's weight but were not consistently aware of or following this requirement. The facility's own policies specify the use of minimal linen layers on LALMs, prompt identification and treatment of skin breakdown, and the use of pressure redistribution devices for at-risk residents. Despite these policies, observations and interviews revealed that staff were not consistently implementing these interventions, resulting in residents being left without appropriate pressure ulcer prevention measures, incorrect mattress settings, and inadequate wound care.
Failure to Follow Respiratory Care and Infection Control Procedures
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents by not following policy procedures, physician orders, and infection control practices. Specifically, one resident with COPD was observed using oxygen at a higher flow rate than ordered, with an empty humidifier, and respiratory equipment such as a nebulizer mask and CPAP mask left uncontained and undated. The nebulizer mask was not discarded within the required seven-day period, and the humidifier had not been changed as needed. The resident confirmed the prescribed oxygen flow, but the equipment was not maintained according to policy, and staff acknowledged the lapses in equipment dating and containment. Additional deficiencies were observed for three other residents with conditions including morbid obesity, diabetes, heart failure, chronic kidney disease, COPD, and pneumonia. Their oxygen equipment, including face masks, nasal cannulas, and tubing, was found unlabeled, undated, and not properly contained when not in use. Staff interviews confirmed that oxygen equipment should be changed weekly, dated upon change, and kept in a bag when not in use to prevent cross-contamination, as per facility policy. These failures were observed during the survey and were not in compliance with the facility's own respiratory therapy and oxygen administration policies.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff prior to passing meal trays, as observed during meal service. An activity aide was seen preparing and arranging beverages, then retrieving and serving food trays to four residents without performing hand hygiene between each resident. The aide made direct contact with each resident while assisting with meal setup, including cutting food and placing residents' hands on their meals, and continued to serve multiple residents consecutively without washing hands or using hand sanitizer. The Director of Nursing confirmed that staff are required to perform hand hygiene between each resident when serving meals, in accordance with facility policy and CDC guidelines. Facility policies reviewed specify that hand hygiene must be performed before and after direct resident contact and before and after assisting with meals, using either hand washing or alcohol-based hand rub. The observed failure to follow these protocols was documented as a deficiency affecting four residents reviewed for infection control.
Failure to Timely Update Care Plan for Restorative Device Use
Penalty
Summary
The facility failed to follow its policy and procedures regarding the development and revision of a comprehensive care plan for a resident requiring restorative care. Specifically, a resident who had been admitted almost two years prior and was listed on the facility's splints/brace/prosthetic log did not have the use of splints, braces, or prosthetics included in their comprehensive care plan as of the care plan received on 9/16/25. Observations revealed the resident's hands were severely contracted and splints were not in use at the time. When questioned, the resident confirmed use of hand splints, and the restorative nurse later stated the resident had a left palm protector. However, review of the electronic medical record showed that the splint program was not added to the care plan until 9/16/25, despite the resident's ongoing need. The facility's policy requires that person-centered care plans, including restorative devices, be developed and periodically reviewed within 7 days of the comprehensive assessment, but this was not done for the resident in question.
Failure to Provide and Document Restorative Devices for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate restorative care for a resident with severely contracted hands, resulting in a deficiency related to the maintenance and improvement of range of motion (ROM). Staff did not follow facility policy and procedures, as they were unaware of the resident's required restorative devices, such as hand splints or palm protectors. The resident's name was missing from both the splints/brace/prosthetic log and the nursing rehab assistance log, and the comprehensive care plan did not include any mention of splints, braces, or prosthetics. During observation, the resident was found not using splints despite severe hand contractures and reported being unable to move her fingers. The resident also indicated she had lost her hand splint and was considering ordering another one. Interviews with staff, including the assigned LPN, DON, and restorative nurse, revealed a lack of awareness regarding the resident's need for restorative devices. The restorative nurse stated that such information should be included in the electronic medical record (EMR) tasks, but upon review, the required device was not listed. The care plan was only updated to include the splint program after the surveyor's inquiry, nearly two years after the resident's admission. Facility policy requires assessment and documentation of restorative needs upon admission, with services reflected in individualized care plans and electronic logs, but these steps were not followed for this resident.
Failure to Implement Fall Prevention Measures and Supervision
Penalty
Summary
The facility failed to implement fall prevention measures as indicated in the care plans for three residents identified as high risk for falls. For one resident with dementia and a history of falls, the care plan required the use of bed/chair alarms and placement in the dining room during the day for supervision. However, the resident experienced an unwitnessed fall resulting in multiple fractures while left unsupervised in their room, despite the presence of a family member who was not educated on supervision requirements. Documentation did not show that the family member was instructed not to leave the resident alone or when to notify staff, and there was no record of staff providing such education. Another resident with cognitive impairment and a history of femur fracture was care planned for a bed alarm and increased supervision, including being up in the dining room in the morning. The resident was observed in bed with a bed alarm that was not functioning because it was turned off. Staff were unaware the alarm was not working, and the resident's care plan interventions were not consistently implemented, as the resident was not always monitored in the dining room as intended. The facility lacked a policy for bed alarms, and post-fall interventions were not clearly documented or followed. A third resident with dementia and multiple comorbidities, including a history of falls, sustained a significant injury after an unwitnessed fall. The resident's care plan included bed/chair alarms and supervision, but the fall occurred when the resident was left alone in the room. The facility's fall prevention policies required close supervision and reevaluation of interventions for high-risk residents, but these were not consistently applied. Staff interviews confirmed that care plan interventions were not always followed, and deviations were not documented as required.
Failure to Provide Prescribed Enteral Nutrition Due to Malfunctioning Feeding Pump
Penalty
Summary
The facility failed to ensure proper management of enteral feeding for a resident diagnosed with severe protein-calorie malnutrition and gastrostomy status. The resident was ordered to receive a specific amount of Jevity 1.2 via enteral feeding pump at a continuous rate of 75ml/hr to reach a total of 1,500ml per day, with an NPO (nothing by mouth) diet. Observations revealed that the enteral feeding pump was not functioning properly, as it was found idle and alarming, with no formula being infused for at least 10 minutes. The LPN on duty confirmed that the pump had ongoing errors, resulting in the resident receiving significantly less formula than prescribed—only 1,029ml over 20 hours instead of the required 1,500ml in 24 hours. Further review of the resident's weight records showed a consistent decline, with a 1.75% loss in one month and a 5.16% loss over approximately two months. The staff confirmed that the resident did not receive any oral nutrition due to the NPO order. The facility's enteral tube feeding policy requires nurses to follow physician orders regarding formula type, rate, and duration, but these were not adhered to in this case. The failure to ensure the feeding pump was functioning and to provide the prescribed amount of nutrition contributed to the resident's ongoing weight loss.
Failure to Provide and Administer Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered for a resident. The resident had physician orders for Benzonatate 100mg three times daily for five days and Guaifenesin-DM 100mg/10ml every six hours for two days. On the scheduled morning medication pass, the registered nurse was unable to locate the prescribed Benzonatate, stating it was a new order and needed to be called into the pharmacy. Additionally, the prescribed Guaifenesin-DM was not available in the medication cart, and only house stock Guaifenesin was dispensed, which did not match the physician's order. Further investigation revealed that the facility's central supply list, used to order house stock medications, did not include Guaifenesin-DM. During a medication cart inspection, a nurse admitted to considering administering Benzonatate from another resident's supply due to the unavailability of the ordered medication. Facility policy explicitly prohibits administering medications supplied for one resident to another. The failure to follow procedures for medication procurement and administration resulted in the resident not receiving prescribed medications as ordered.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to adhere to medication administration policies and procedures, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of 5%. Specifically, staff did not ensure that prescribed medications were available, dispensed the incorrect medication, and administered medication without proper authorization. In one instance, a registered nurse administered Hydrocodone to a resident who reported a pain level of 4, despite the medication being prescribed only for severe pain rated 7-10. The nurse acknowledged awareness of the order requirements but proceeded to give the medication regardless. In another case, a resident was prescribed Benzonatate and Guaifenesin-DM for cough and congestion. During medication administration, the nurse was unable to locate the prescribed Benzonatate and instead dispensed Guaifenesin, which was not the correct medication. The nurse confirmed the unavailability of the medication and did not follow the facility's policy to search for the medication or contact the pharmacy as required. These actions directly contributed to the identified medication errors.
Medication Administered Outside Prescriber Orders
Penalty
Summary
A deficiency occurred when a registered nurse (RN) administered Hydrocodone 7.5/325mg to a resident for pain levels below the threshold specified in the physician's order. The physician order required Hydrocodone to be given every 6 hours as needed for severe pain rated 7-10. On multiple occasions, including one observed instance, the RN dispensed the medication after confirming the resident's pain level was below 7, specifically at levels 4, 5, and 6. The medication administration record confirmed that Hydrocodone was administered at least five times for pain levels not meeting the prescribed criteria. Facility policy and medication administration guidelines require medications to be administered in accordance with prescriber orders, which was not followed in these instances.
Failure to Implement Fall Prevention Interventions and Safe Equipment Use
Penalty
Summary
The facility failed to implement and maintain effective interventions to prevent accidents for a cognitively impaired male resident with a high risk for falls. The resident, who had diagnoses including unspecified dementia with psychotic disturbance and was dependent on staff for mobility and personal care, was care planned to have a bed/chair alarm to alert staff when attempting to get up unassisted. However, on multiple occasions, the alarm was either not functioning, not in place, or not heard by staff, resulting in unwitnessed falls. Staff interviews and observations confirmed that the bed alarm was left in the reclining chair when the resident was put to bed, and at one point, the alarm was not working due to dead batteries. The resident was unable to use the call light and was known to become agitated when wet or soiled, increasing his risk of attempting to get up unassisted. Additionally, the facility failed to follow the manufacturer's safety recommendations for the use of the reclining chair during transport. The resident fell out of the reclining chair while being transported to the patio by a CNA, who was unable to see the resident while pulling the chair backwards over a door threshold. The manufacturer's manual specified that outdoor use of the chair should only occur under strict supervision and with a second caregiver when moving over uneven surfaces, which was not followed during the incident. Staff interviews indicated that only one CNA was present during the transport, and the resident made sudden movements that were not anticipated or prevented. As a result of these failures, the resident experienced at least two falls, one of which resulted in a large bruise on the left side of his neck and jaw. Documentation and interviews confirmed that the bruise was likely related to the fall, and the resident was found on the floor on more than one occasion. The facility's own fall policy required assessment, implementation, and reevaluation of interventions, but these were not consistently carried out, leading to the resident's injuries.
Failure to Provide Timely Incontinence Care Resulting in Skin Breakdown
Penalty
Summary
A male resident with severe cognitive impairment, total dependence for activities of daily living, and a history of dementia, anemia, acute kidney failure, benign prostatic hyperplasia, and cerebral infarction, was not provided with appropriate incontinence and perineal care as required by facility policy. The resident was observed sitting in a dining area for several hours without being checked or changed, despite being always incontinent of urine and frequently incontinent of bowel. Certified Nurse Aides (CNAs) attempted but failed to transfer the resident to the toilet and did not check or change his brief before returning him to the dining area. When questioned, staff reported the last change occurred early in the morning, several hours prior to the observation. Later in the day, the resident was finally checked and changed in bed, at which time his brief was found to be completely soaked with urine and feces, and a lesion was observed on the scrotal area. The resident’s family member reported that the resident was often found wet with double briefs during visits and had previously notified staff about the wound. Wound care staff and nurse practitioners confirmed the presence of moisture-associated skin damage (MASD) or incontinence-associated dermatitis (IAD) on the scrotum, attributed to repeated exposure to body fluids and inadequate incontinence care. Facility policy requires residents to be checked and changed at least every two hours, with perineal care provided as needed to maintain cleanliness and prevent skin irritation. Interviews with nursing staff and review of the care plan confirmed that these protocols were not followed for this resident, resulting in the development of IAD. Documentation and staff statements indicated that the resident was not checked or changed according to policy, leading to prolonged exposure to moisture and subsequent skin breakdown.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure resident safety by not providing the required two-person assistance during incontinence care, leading to a fall incident involving a resident. This resident, who was at high risk for falls due to multiple medical conditions including dementia and a history of falling, was observed with significant bruising and swelling on her face after reportedly being pushed out of bed by a CNA. The resident's care plan indicated that she required assistance from two or more helpers for personal hygiene tasks, but this was not adhered to, resulting in her fall and subsequent hospital evaluation. Additionally, the facility did not consistently implement fall preventive measures for other residents at high risk for falls. Observations revealed that several residents' beds were not in the low position as required, and some residents did not have the necessary bed alarms in place. These lapses in implementing fall prevention strategies affected multiple residents, as noted in the facility's high fall risk list. The facility's policies on fall occurrence and high-risk fall identification were not effectively followed, as evidenced by the lack of individualized care plan interventions and the absence of procedural guidelines for turning residents during incontinence care. The failure to investigate allegations of abuse promptly and the assumption that a resident's confusion negated the need for an incident report further contributed to the deficiency in ensuring resident safety.
Failure to Maintain Resident Dignity with Urinary Catheter
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring the proper placement and securing of a urinary catheter. During an observation, a resident was seen at a dining room table with their urinary catheter exposed, coming out of the top of their pants, and not secured. The unit manager confirmed that the catheter should have been inside the pants and secured down the leg into a privacy bag. The Director of Nursing also stated that all residents with urinary catheters are expected to have them properly secured and not exposed. The resident in question had a diagnosis of urinary tract infection and obstructive uropathy, requiring a 22 French urinary catheter. The care plan for this resident included ensuring the proper placement of the catheter, with a secure lock device, non-kinked tubing, and the drainage bag positioned below the bladder and off the floor.
Failure to Provide Adequate Assistance and Timely Reporting in Resident Care
Penalty
Summary
The facility failed to adhere to its policy and procedures for providing safety during incontinence care by not ensuring a two-person assist for a resident, identified as R61, who was at high risk for falls. Observations revealed that R61 had significant bruising and swelling on her face and neck, which she attributed to being pushed out of bed by a CNA during care. Despite the resident's high fall risk and care plan indicating the need for two-person assistance, the CNA provided care alone, leading to the incident. Additionally, the resident's bed was not maintained in the lowest position, contrary to the care plan requirements. The incident was not reported or documented immediately in the resident's medical record, as required by the facility's policy on abuse and neglect. The LPN on duty, V21, did not complete an incident report or notify the supervisor or DON about the resident's allegation of being pushed out of bed. Instead, the LPN assumed the resident was confused and only endorsed the situation to the next shift. It was not until the resident showed signs of bruising and swelling that the Unit Manager, V12, initiated an investigation. The facility's policy mandates immediate reporting and investigation of all abuse allegations, but this was not followed in R61's case. The DON acknowledged the lack of procedural guidelines for turning residents during incontinence care and confirmed that the resident should have been turned towards the CNA. The Administrator, who is the abuse coordinator, was not informed of the incident until after the resident exhibited physical symptoms, highlighting a delay in addressing the allegation and initiating an investigation.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to ensure comprehensive pain management for a resident, identified as R127, during surgical wound care. On the morning of 10/30/2024, R127 was observed flinching during sacral wound care treatment, indicating pain. Although R127 mentioned having received pain medication 15 minutes prior, the wound care nurse, V14, did not apply the prescribed lidocaine gel before starting the treatment. V14 was unaware if the gel had been applied, and the unit nurse, V15, confirmed she did not apply it, believing it was the responsibility of the treatment nurse. This lack of communication and adherence to the pain management protocol resulted in inadequate pain relief for R127. The facility's policy on pain management, revised on 8/16/2024, mandates that residents be assessed for pain and medicated appropriately before, during, and after treatments. R127's care plan, dated 9/18/2024, highlighted the risk for pain due to a sacral wound, rheumatoid arthritis, and osteoarthritis, with specific interventions to medicate prior to therapy and treatment. Despite these guidelines, the staff failed to administer the lidocaine gel as ordered by the physician, which was documented in an order summary dated 10/2/2024. This oversight in following the established pain management procedures led to the deficiency noted by the surveyors.
Infection Control Deficiency in Handling Soiled Linens
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during the handling of soiled linens and gowns. During an observation, a Hospice CNA was seen placing soiled linens and a gown on the floor while providing morning care to a resident. When questioned by the surveyor, the CNA stated that it was acceptable to place soiled items on the floor because they were already soiled. A Restorative Nurse corrected the CNA, indicating that soiled linens should be placed in a plastic bag for infection control purposes. The Infection Preventionist Nurse confirmed that the CNA should not have placed the soiled items on the floor and should have used a soiled hamper or plastic bag. The facility was unable to provide a policy regarding the proper handling of soiled linens.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to maintain an up-to-date daily nurse staffing information posting, which is required to be readily accessible to residents and visitors. On October 29, 2024, it was observed that the staffing information at the front desk was dated October 25, 2024, indicating it had not been updated for four days. The receptionist acknowledged the outdated posting and stated she would inform the responsible party. The administrator confirmed that the scheduler is responsible for updating the daily staffing information, but the scheduler admitted to forgetting to update it on October 28, 2024. Additionally, the facility was unable to provide a policy regarding the posting of daily staffing information.
Resident Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent an accident involving a resident, identified as R1, who sustained multiple fractures due to inadequate supervision. R1, a male resident with a complex medical history including Parkinson's Disease, Dementia, and a history of falls, was found with significant bruising and fractures after an incident where he attempted to self-transfer. Despite his known mobility limitations and high risk for falls, R1 was left unsupervised, leading to his injuries. On the evening of 09/21/2024, R1 was observed by staff with his legs hanging over the footboard of his bed, indicating an attempt to self-transfer. Staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, repositioned R1 but did not report any unusual findings or investigate how R1 got into that position. The following day, R1 was found guarding his arm, and upon further assessment, he was discovered to have multiple bruises and fractures, prompting a hospital visit where suspicions of elder abuse were raised due to the lack of reported falls or incidents. The facility's investigation revealed that R1's injuries were likely sustained during his attempt to self-transfer, a task he required assistance with due to his impaired mobility and cognitive status. Despite the presence of staff, there was a failure to adequately supervise R1 and ensure his safety, as evidenced by the lack of communication and documentation regarding his condition and the circumstances leading to his injuries. The facility's camera footage confirmed that R1 self-propelled to his room and attempted to transfer himself, highlighting the need for constant supervision given his high-risk status.
Failure to Assess and Document Resident Injury
Penalty
Summary
The facility failed to follow its policy and procedures for proper nursing care by not ensuring a resident who required assistance with transfers was immediately assessed for injury after being found in an abnormal position. The resident, an elderly male with a complex medical history including Parkinson's Disease, Dementia, and a history of falls, was found with his legs hanging over the footboard of his bed. Despite this unusual position, staff did not assess him for injuries or document the incident in his medical record, nor were the physician and family notified immediately. The resident was later observed with significant bruising and swelling on his right arm, which led to a hospital visit where he was found to have multiple fractures, including an impacted right humeral fracture and rib fractures. The family discovered these injuries during a visit and expressed concerns about potential elder abuse, as they were not informed of any falls or incidents by the facility. The facility's investigation revealed that the resident likely sustained these injuries while attempting to self-transfer, a task he was known to require assistance with. Interviews with staff indicated a lack of awareness and communication regarding the resident's condition and the incident. The facility's administrator reviewed camera footage, which showed the resident self-propelling to his room and being found in an abnormal position by staff, yet no immediate action was taken to assess or document the situation. The facility's policy requires immediate notification of the physician and family in the event of an accident involving injury, which was not adhered to in this case.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for residents who were dependent on staff assistance, affecting four residents. Resident R2, who was cognitively intact, was left soiled in urine for over fifteen hours, resulting in a strong smell of urine and skin alterations due to moisture. R2 reported feeling drenched and disgusted, and the staff confirmed that the amount of urine present indicated neglect in care. The facility's policy required checks every two hours, which was not adhered to. Resident R5, also cognitively intact, was left in a wet and cold state for over eight hours, leading to chills. The resident's bed sheets and comforter were wet, with brown urine rings indicating multiple voids. The staff member providing care noted the strong odor of urine and the saturated state of the resident's brief and bedding, suggesting a significant lapse in care. Residents R6 and R7, both with cognitive impairments, were found with saturated incontinence briefs and a strong smell of urine. R6 had two briefs on, with the inner one being heavily soiled, while R7's brief was saturated with a strong ammonia smell. The facility's policy against double diapering was violated, contributing to the risk of skin breakdown. The staff acknowledged that residents should be checked and changed every two hours, which was not done, leading to these deficiencies.
Failure to Document and Obtain Physician Order for High-Risk Resident's Skin Breakdown
Penalty
Summary
The facility failed to adhere to its skin care regimen and treatment formulary by not documenting and obtaining a physician order for a resident identified as high risk for skin breakdown. The resident, who had a Braden scale score indicating high risk, was observed with two small pink opened circular areas on the inner right upper thigh and right posterior thigh. During incontinence care, a treatment nurse and a CNA discovered a dressing on the resident's leg, but the treatment nurse was unaware of any skin alterations, indicating a lack of communication and documentation. The nurse stated that an assessment should have been completed in the computer to generate an alert for new skin alterations. The skin/wound note and physician order sheet dated the same day documented new skin alterations classified as abrasions, with specific measurements and treatment orders for xeroform dry dressing. The facility's policy requires prompt identification, documentation, and obtaining appropriate treatment for residents with skin breakdown, which was not followed in this case. The charge nurses are responsible for documenting any skin breakdown in the electronic health record upon assessment and identification, which did not occur prior to the evaluation.
Failure to Follow Wound Care Orders and Mattress Protocol
Penalty
Summary
The facility failed to adhere to the treatment orders for a resident identified as high risk for skin breakdown, who had stage four and stage three pressure wounds. The resident, who was admitted with multiple diagnoses including pressure ulcer stage four, anemia, and dementia, had a Braden score indicating high risk for skin breakdown. Despite the wound practitioner's orders to use Medihoney for cleaning the wound, the facility did not follow these instructions. The wound care nurse was unaware of the order and did not input it into the electronic medical record, leading to a discrepancy between the practitioner's notes and the treatment being administered. Additionally, the facility did not ensure the resident was placed on a low air loss mattress as required for residents with stage three and stage four pressure injuries. The wound care nurse mistakenly believed the wounds were surgical and vascular, not pressure sores, and therefore did not provide the appropriate mattress. This oversight was contrary to the resident's plan of care, which specified the need for a low air loss mattress to prevent further skin breakdown.
Inadequate Fall Prevention and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide a safe environment by not adequately monitoring residents at risk for falls, resulting in five residents experiencing unsupervised falls. The facility did not follow its policy of ensuring all staff were educated on residents at risk for falls and the fall prevention program. This lack of supervision and education led to multiple incidents where residents fell and sustained injuries. One resident, with a history of falls and cognitive impairment, fell in the dining room after unlocking her wheelchair and moving away from the table. The fall resulted in a facial laceration that required emergency room treatment. Another resident, also with a history of falls and severe cognitive impairment, fell out of bed and sustained a rib fracture. The resident was on blood thinners, necessitating an emergency room visit. A third resident, with severe cognitive impairment and a history of falls, attempted to transfer herself to the toilet, resulting in a hip fracture that required surgical intervention. Additional incidents involved a resident with no cognitive impairment who fell while attempting to get out of bed, resulting in fractures to the left femur and pubis. Another resident, with severe cognitive impairment, fell out of bed and sustained a head injury requiring staples. The facility's failure to ensure staff were aware of and followed fall prevention protocols contributed to these incidents, as staff were not adequately informed about the residents' fall risks or the interventions in place to prevent such occurrences.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple observations and interviews with residents. One resident expressed that while daytime staff were generally kind, some evening staff were dismissive and rough, particularly towards her roommate. Another resident voiced concerns about not receiving medications due to staff shortages and noted that staff communication was often lacking, especially during the second and third shifts. This resident felt that reporting issues would be futile due to the staffing situation. A third resident reported that at night, assistance was often unavailable, leading to distress and unresponsiveness from staff despite her calls for help. Additional observations included a resident who noted that staff were abrupt and did not engage in meaningful communication, which made her feel uncared for. Another resident described an incident where a staff member was overly talkative and did not allow her roommate to communicate effectively. The facility's policy on privacy and dignity emphasizes the importance of respecting residents' preferences and ensuring respectful communication, yet these incidents indicate a failure to adhere to these standards. Interviews with facility leadership confirmed the expectation for staff to treat residents with dignity, but the reported experiences suggest inconsistencies in practice.
Resident Reports Rough Handling by CNA
Penalty
Summary
The facility failed to ensure a resident was free from abuse, as evidenced by an incident involving a cognitively intact resident, R2, who reported rough handling by a CNA during care. R2, who is dependent on staff for assistance with activities of daily living (ADLs) such as bed mobility and transfers, reported that the CNA was moving too quickly and was not pleasant or patient. Although R2 initially stated that the incident was 'no big deal' and that she felt safe in the facility, she later described the CNA's actions as shoving her side to side and being rough, which resulted in bruising on her arm. The incident was reported to the nursing supervisor, who conducted a full body assessment and found no injuries. The CNA involved was immediately sent home pending the outcome of the investigation. Despite the initial assessment showing no physical harm, R2 later expressed that the CNA's handling was rough and that she felt like she was being treated like a 'piece of meat.' The resident also mentioned that the CNA seemed to be in a hurry and expressed dissatisfaction with her job. Interviews with staff, including the nursing supervisor, registered nurse, and social service director, revealed that the facility's response included wellness checks and interviews with the resident. The facility's policy on abuse and neglect defines abuse as the willful infliction of mistreatment or injury, and rough handling is considered a form of physical abuse. Despite the resident's later statements minimizing the incident, the initial report and subsequent interviews indicate a failure to protect the resident from rough handling, which falls under the facility's definition of physical abuse.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
