Balmoral Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 2055 West Balmoral Avenue, Chicago, Illinois 60625
- CMS Provider Number
- 145796
- Inspections on file
- 27
- Latest survey
- March 22, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Balmoral Home during CMS and state inspections, most recent first.
The facility failed to protect multiple residents from resident-to-resident physical abuse despite known histories of aggression and care plans identifying risk for violence. One cognitively intact resident with schizoaffective disorder and a documented history of aggressive behavior physically attacked a peer, including hitting and pushing the peer out of a wheelchair. Another resident with quadriplegia and schizophrenia, care planned for risk of violence, was involved in more than one physical altercation, including hitting a cognitively intact roommate in the face in a hallway. A separate resident with schizophrenia, hallucinations, delusions, and a documented progression from moderate to significant aggressive behavior struck a roommate with Alzheimer’s disease while the roommate was in bed, causing facial redness and a scratch. CNAs and an LPN reported that these aggressive residents frequently attempted to hit others, screamed, cursed, and verbally threatened residents and staff, particularly female staff. The facility’s own investigations substantiated these altercations, and its policies state residents have the right to be free from abuse, yet multiple episodes of physical assault occurred.
A cognitively intact, ambulatory resident with schizophrenia repeatedly told a social worker on admission that she did not want to be in the facility, but this was not communicated to the Social Services Director and was not reflected on the elopement risk assessment or care plan, which documented no verbalized desire to leave. Later, during a night shift, alarms from stairwell and exit doors sounded, and a CNA ultimately observed the resident at an exit door, followed her outside, then briefly left her unsupervised to retrieve a coat, hat, and phone. When the CNA returned, the resident was gone, and staff and police were unable to locate her immediately; she was later found offsite and taken to a hospital after reporting possible frostbite.
A resident with Parkinson's disease and muscle weakness experienced worsening of a sacral pressure ulcer due to the facility's failure to consistently implement and document physician-ordered preventive measures, including regular turning, use of heel protectors, and appropriate mattress support. Clinical records and staff interviews confirmed that required interventions were not reliably performed or recorded, resulting in the ulcer progressing from stage 2 to stage 3.
A resident with multiple medical conditions, including a pressure ulcer, did not have accurate or complete treatment administration records. The resident reported missed dressing changes and lack of regular repositioning, and was observed without heel protectors. Two versions of the resident's TARs were provided on different days, with the initial version missing multiple required signatures for treatments, and the later version having these areas filled in. The DON acknowledged the discrepancies, and clinical notes showed the resident's pressure ulcer was worsening.
A cognitively impaired resident with a history of ingesting non-edible items was inadequately supervised, leading to access to potentially harmful items like baby powder and liquid soap. Despite the resident's known behaviors and medical history, staff were not consistently aware of the risks, resulting in a failure to provide a safe environment as per facility policy.
A resident with moderate cognitive impairment was found with medications left on their nightstand without an assessment or doctor's order for self-administration. The facility's policies require such assessments and orders, which were not conducted, posing a risk due to the resident's dementia and impaired judgment.
An LPN in a facility failed to sign out medications after administering them to four residents, as observed by a surveyor. The facility's policy requires immediate documentation to prevent double dosing, which was not followed. The residents, who were cognitively intact, had various diagnoses, and the oversight was confirmed through a review of their Medication Administration Records.
The facility failed to enforce its smoking and sharps disposal policies, leading to safety risks. A resident was found smoking in their bathroom, contrary to the designated smoking area policy. Additionally, several residents had razors in their rooms, which is against the facility's policy due to safety concerns. Staff acknowledged these violations, highlighting a lack of supervision and adherence to established guidelines.
The facility did not follow its policy of reconciling controlled substances at the end of each shift, affecting four residents on the first floor. During rounds, it was found that the Controlled Substance Check Form lacked signatures for a shift-to-shift count. An LPN admitted to not counting narcotics with the night nurse. The DON confirmed that nurses must count narcotics between shifts, and any failure would require an investigation.
The facility failed to maintain proper storage and security of medications, including controlled substances, in medication refrigerators on the first and third floors. The refrigerators were not at the correct temperature and had frost accumulation, indicating inadequate defrosting. Additionally, controlled drugs were not stored in a separately locked compartment, as required, and were accessible to residents and staff. Staff interviews revealed a lack of awareness and adherence to facility policies regarding medication storage.
A facility failed to refer a resident for a PASRR Level 2 screening despite the resident having diagnoses of bipolar disorder and schizophrenia. The initial PASRR Level 1 screening did not identify any serious mental illness, which was an oversight. The Assistant Administrator acknowledged the requirement for Level 2 screenings for such diagnoses, as per the facility's policy, but the facility did not update the PASRR Level 1 to reflect the resident's mental health conditions.
The facility failed to label and date oxygen equipment for two residents, contrary to its policy. One resident with multiple health issues was found with an undated nasal cannula, while another resident with intact cognition had an undated nebulizer mask. LPNs confirmed the equipment should have been dated, and the DON stated that dating is necessary to prevent infection.
An LPN in a long-term care facility administered a Divalproex Sodium DR 500 mg tablet to a resident after it fell on the floor, violating infection control protocols. The LPN admitted the mistake, acknowledging that the medication should have been discarded to prevent contamination. The facility's DON confirmed that the policy requires discarding dropped medications to maintain infection control standards.
A resident experienced discomfort due to a cold room temperature, which was reported to staff but not addressed until a surveyor's visit. The room temperature was found to be 61°F, below the facility's standard of 68°F, due to a crack in the window. The resident, who has multiple medical conditions, had been complaining about the cold since the previous week.
The facility failed to post complete Daily Nursing Staffing information, missing total nursing hours for RNs, LPNs, and CNAs, potentially affecting all 159 residents. The scheduler and administrator were unaware of the requirement to include total hours, and the posted information was incomplete for evening and night shifts.
Failure to Protect Residents From Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from abuse and physical assault, specifically resident-to-resident abuse. One resident with right heart failure, schizoaffective disorder, hypertension, and type 2 diabetes, and with intact cognition (BIMS 14), had a documented history of aggressive and maladaptive behavior, including conflicts and verbal or physical aggression toward staff and loud, intimidating behavior toward a roommate. Progress notes state that this resident physically attacked a peer unprovoked, and was observed hitting and pushing another resident out of his wheelchair. The facility’s internal investigation later substantiated that this resident was physically aggressive toward the peer. Another resident involved in multiple incidents had quadriplegia, schizophrenia, traumatic brain injury, and moderately impaired cognition (BIMS 11). This resident’s care plan identified a risk for violence related to schizophrenia, with goals that the resident would maintain safe behavior and do no harm to self or others, and that staff would closely monitor behavior. Despite this, progress notes document that this resident was involved in an altercation with a peer that became physical, and in a separate incident, another cognitively intact resident reported being hit twice in the face by this resident without provocation while sitting in the hallway. A nurse documented being called to the scene of the fight between the two roommates and another staff member stated that this resident “tries to hit people all the time,” noting that staff usually intervened but were unable to do so before both residents hit each other during the incident. Additional incidents involved a resident with schizophrenia, heart failure, insomnia, pulmonary hypertension, and moderate cognitive impairment (BIMS 11), who had documented hallucinations and delusions and a history of aggressive or agitated behavior and abuse/neglect as either recipient or perpetrator. Screening assessments showed this resident’s aggressive behavior and abuse history progressed from a moderate to a significant problem. Progress notes document that this resident hit a roommate, resulting in redness to the roommate’s face and a scratch on the nose, and that the roommate, who had Alzheimer’s disease, atrial fibrillation, diabetes, hypertension, osteoarthritis, and moderate cognitive impairment (BIMS 8), indicated that this resident had hit him in the arm and face while he was in bed. CNAs reported that the aggressive resident had a pattern of aggressive behavior toward other residents, including getting in their faces, screaming, cursing, verbally threatening them, and being particularly aggressive toward female staff. The facility’s internal investigation substantiated the altercation between these two residents. The facility’s own policies state that residents have the right to be free from abuse, neglect, and mistreatment and that the facility aims to prevent abuse by establishing a resident-sensitive and secure environment, yet multiple substantiated incidents of resident-to-resident physical abuse occurred. The administrator, who serves as the abuse coordinator, stated that regulatory requirements for abuse include immediately separating residents involved, notifying the administrator, physician, and family, and reporting to the state agency, and also stated that screaming and yelling is a form of abuse. Staff interviews confirmed that residents and staff were aware of ongoing aggressive behaviors, including frequent attempts by one resident to hit others and another resident’s repeated verbal aggression and threats toward peers and staff. Despite care plans and risk assessments identifying aggression and risk for violence, and staff awareness of ongoing aggressive behaviors, multiple residents experienced physical assaults by peers, with injuries such as redness and scratches documented, demonstrating that residents were not consistently protected from abuse as required by facility policy and resident rights.
Failure to Identify Elopement Risk and Provide Adequate Supervision Leading to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to identify and supervise a resident at risk for elopement, resulting in the resident leaving the building unsupervised. The resident was admitted from the hospital with a diagnosis of schizophrenia, was cognitively intact with a BIMS score of 15/15, ambulatory without assistive devices, and required supervision with ADLs and mobility. On the day of admission, a social worker documented that the resident repeatedly stated she did not want to be in the facility and refused a mental status exam, but was able to state the correct date. Despite this, the resident’s elopement assessment later documented that the resident did not verbalize a strong desire to leave, and the care plan stated that the resident voiced no interest in community re-entry. On the night of the elopement, nursing staff documented that the resident had been lying quietly in bed during rounds before a stairwell alarm sounded. Staff responded to the alarm, and a CNA went to the third-floor stairwell door, entered the code to silence the alarm, and did not see anyone in the stairwell. Shortly afterward, another alarm sounded from the first floor. The CNA went to the first floor and observed the resident standing near an outside exit door. The resident remained at the door for about two minutes and then pushed through the exit door. The CNA followed the resident outside and stayed approximately 5–6 feet away, observing that the resident was calm and staying in place initially. The CNA then left the resident outside to re-enter the facility to obtain his coat, hat, and phone because of the cold weather, leaving the resident unsupervised. When he returned less than two minutes later, the resident was no longer in the area. Staff searched around the building and checked exit doors but were unable to locate the resident. Police were called, and the resident was later found offsite and taken to the hospital after stating she might have frostbite and requesting to go to the hospital. The Social Services Director later stated that residents are considered at risk for elopement if they verbalize wanting to leave the facility and that, had she been informed of the resident’s statements about not wanting to be there, the elopement assessment should have reflected that and the team would have addressed it. She also stated that the social worker who documented the resident’s desire not to be in the facility did not inform her of this information.
Failure to Implement and Document Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement and document physician-ordered preventive measures for a resident with a sacral pressure ulcer, resulting in the deterioration of the wound from stage 2 to stage 3. The resident, who has Parkinson's disease and muscle weakness, reported that dressing changes were not performed daily and that staff did not consistently turn or reposition him as ordered. Observations confirmed the resident was lying on his back without heel protectors, and the Treatment Administration Records (TARs) for March and April showed multiple unsigned shifts for required turning and repositioning. Additionally, discrepancies were found in the TARs, with records being modified after the fact to indicate compliance that was not originally documented. Clinical notes from the wound nurse practitioner documented a significant increase in the size of the sacral pressure ulcer over time, and staff interviews confirmed the importance of regular turning and repositioning to prevent pressure injuries. Despite physician orders for repositioning every two hours, continuous use of heel protectors, and a low air loss mattress, these interventions were not consistently established or documented. The resident's care plan included these interventions, but failure to follow and document them led to the worsening of the pressure ulcer.
Inaccurate Treatment Administration Records for Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain accurate and complete treatment administration records (TAR) for one resident with a history of Parkinson's disease, bipolar disorder, and muscle weakness, who was admitted in 2010. During an interview, the resident reported that his dressing for a pressure ulcer had not been changed the previous day or on the day of the interview, and that staff did not regularly reposition him or use heel protectors as ordered. Observation confirmed the resident was lying on his back without heel protectors, and he stated that repositioning only occurred during dressing changes, not daily as required. Upon review of the resident's TARs for March and April, two different versions were provided by the facility on consecutive days. The initial TARs showed multiple unsigned entries for required treatments, including application of an abdominal binder, heel protectors, and repositioning every two hours. The subsequent TARs had these previously blank areas filled in and signed. The Director of Nursing acknowledged the discrepancies and the presence of unsigned days in the original TARs. Clinical notes from the nurse practitioner indicated the resident's sacral pressure ulcer was deteriorating during this period. Facility policy requires that all treatments and services performed be documented objectively, completely, and accurately in the medical record.
Inadequate Supervision of Cognitively Impaired Resident
Penalty
Summary
The facility failed to adequately supervise and monitor a cognitively impaired resident, identified as R2, who has known behaviors of ingesting non-edible, toxic items. On multiple occasions, R2 was observed with potentially harmful items within reach, such as baby powder and liquid soap. Despite R2's history of pica and previous incidents where she ingested non-food items like baby powder and body lotion, staff members were not consistently aware of the risks or the need for supervision. For instance, a Certified Nursing Assistant (CNA) admitted to borrowing R2's overbed table and leaving baby powder within her reach, unaware of the potential for R2 to ingest it. R2's medical history includes paranoid schizophrenia, anxiety disorder, and moderate cognitive impairment, which contribute to her behaviors. The facility's Director of Nursing acknowledged the danger of R2 consuming non-edible items and emphasized the need for supervision. However, the lack of consistent awareness and supervision among staff members led to R2 having access to these items, posing a risk to her safety. The facility's policy on resident rights emphasizes the importance of a safe environment, which was not upheld in this instance.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the safe self-administration of medications, which was identified during a survey. The resident, identified as R148, has a history of dermatitis, atrial fibrillation, congestive heart failure, and dementia, with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Observations on multiple occasions revealed that medications, specifically Zinc oxide 20% ointment and triamcinolone acetonide 0.5% ointment, were left on R148's nightstand. This was contrary to the facility's policy, which requires an assessment and a doctor's order for self-administration of medications. The Director of Nursing (DON) confirmed that no assessment for self-administration had been conducted for R148, and there was no doctor's order permitting self-administration. The facility's policy mandates that medications should not be left at the bedside without proper assessment and authorization. The Registered Nurse (RN) acknowledged that the ointments should not have been at the bedside, as there was a risk of the resident mistaking them for something else, such as toothpaste. The facility's policies and job descriptions emphasize adherence to medical provider orders and compliance with regulations, which were not followed in this instance.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure that medications were signed out when administered for four residents, affecting a sample of 57 residents. On a specific date, a surveyor observed that an LPN had completed a medication pass but had not signed out the medications for four residents. The LPN admitted to administering the medications but had not yet documented it, intending to do so later. This oversight was confirmed through a review of the Medication Administration Records (MAR) for the residents, which showed that various medications were not signed out after being administered. The facility's policy requires medications to be signed out immediately after administration to prevent potential double dosing. The Director of Nursing confirmed this policy, emphasizing the risk of medications being misconstrued as not given if not signed out promptly. The residents involved were cognitively intact, with BIMS scores of 15, and had various diagnoses, including schizoaffective disorder, Parkinson's, and major depression. The failure to document medication administration as per policy could lead to significant medication errors, although the report does not specify any adverse outcomes resulting from this incident.
Failure to Enforce Smoking and Sharps Policies
Penalty
Summary
The facility failed to ensure that a resident smoked in a designated smoking area and did not adequately prevent environmental hazards, specifically the presence of razors, for several residents. One resident was observed smoking in their bathroom, which is against the facility's smoking policy. The resident, who is cognitively intact, was found with smoking materials in their possession despite being assessed as unable to handle them safely. The facility's policy states that smoking is only allowed in designated areas, and residents requiring supervision should be monitored accordingly. Additionally, the facility did not prevent residents from having razors in their rooms, which poses a safety risk. One resident was observed holding three razors, which they stated were given by staff for personal grooming. The facility's policy prohibits residents from having razors due to safety concerns, and staff are responsible for monitoring residents who shave themselves. Another resident with moderate cognitive impairment was found with a razor on their nightstand, and staff confirmed that razors should not be in residents' rooms. The facility's policy on the disposal of sharps, including razors, requires that they be placed in approved containers after use. However, observations revealed that razors were left in residents' rooms, contrary to the policy. Staff members acknowledged that razors should not be accessible to residents due to the potential for injury. The facility's failure to adhere to its policies on smoking and sharps disposal has the potential to affect the safety of all residents on the first and second floors.
Failure to Reconcile Controlled Substances at Shift Change
Penalty
Summary
The facility failed to adhere to its policy of reconciling controlled substances at the end of each shift, which has the potential to affect all four residents receiving controlled substances on the first floor. During facility rounds, it was observed that the Controlled Substance Check Form lacked signatures for a narcotic shift-to-shift count on a specific date. An LPN admitted to not counting narcotics with the night nurse at the start of her shift. The Director of Nursing confirmed that nurses are required to count narcotic medications between incoming and outgoing nurses at the end of each shift, and any failure to do so would necessitate an investigation into discrepancies. The facility's undated policy on Controlled Substances mandates that controlled medications be counted at the end of each shift by both the nurse coming on duty and the nurse going off duty. Additionally, the policy states that procedures for monitoring controlled medications to prevent loss, diversion, or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications, including controlled substances, in two of three medication refrigerators. Observations revealed that the medication refrigerators on both the first and third floors were not maintaining the correct temperature, with readings of 42 and 48 degrees Fahrenheit, respectively. Additionally, the refrigerators were found to have frost accumulation, indicating a lack of regular defrosting. The facility's policy requires regular temperature monitoring and defrosting when necessary, but these procedures were not followed, leading to improper storage conditions for medications. Furthermore, the facility did not secure Schedule II controlled drugs in a separately locked compartment, as required. Controlled medications for two residents, who had expired, were found in unlocked refrigerators accessible to other residents and staff. The facility's policy mandates that controlled substances be stored in a locked container separate from non-controlled medications, but this was not adhered to. Interviews with staff revealed a lack of awareness and adherence to these policies, contributing to the deficiencies observed.
Failure to Conduct PASRR Level 2 Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for rescreening to the state agency for Preadmission Screening and Resident Review (PASRR). The resident, identified as R126, was admitted to the facility on October 11, 2024, with diagnoses including bipolar disorder and schizophrenia. Despite these diagnoses, the initial PASRR Level 1 screening conducted on August 29, 2024, indicated that no Level II screening was required, as it did not identify any serious mental illness (SMI). This oversight was noted during an interview and record review, where it was revealed that the facility did not update the PASRR Level 1 to include the resident's mental health diagnoses, which would have triggered a Level 2 PASRR. The Assistant Administrator (V10) acknowledged that Level 2 PASRRs are necessary when a resident has a mental health diagnosis such as schizophrenia or bipolar disorder. V10 stated that the facility's policy requires PASRR screenings to ensure residents are placed in appropriate facilities and that it is mandatory to conduct these screenings. The facility's policy, dated December 2023, mandates compliance with federal and state standards for PASRR assessments, expecting the appointed agency, Maximus, to complete Level 2 screenings if a PASRR condition exists. However, the facility failed to adhere to this policy, resulting in the deficiency affecting one resident in a sample size of 57 residents.
Failure to Label and Date Oxygen Equipment
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and dating of oxygen equipment, affecting two residents. Resident 54, who has multiple diagnoses including heart failure and chronic obstructive pulmonary disease, was observed with an undated nasal cannula. The resident's care plan and physician orders specify that oxygen equipment should be changed and dated weekly or as needed. However, the nasal cannula was not dated, and a Licensed Practical Nurse (LPN) confirmed that the tubing should have been dated, as it is typically changed weekly by the night shift. Similarly, Resident 126, who has intact cognition and multiple health issues such as atrial fibrillation and chronic heart failure, was observed with an undated nebulizer mask. The resident's physician orders also require the nebulization cup and tubing to be changed weekly or as needed. An LPN acknowledged the absence of a date on the nebulizer mask and discarded it. The Director of Nursing confirmed that oxygen tubing should be dated to prevent infection from prolonged use, as per the facility's policy on oxygen administration.
Medication Administration Error and Infection Control Breach
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices when a Licensed Practical Nurse (LPN) administered medication that had fallen on the floor to a resident. During a medication pass, the LPN dropped a Divalproex Sodium DR 500 mg tablet on the floor next to the resident's wheelchair and subsequently picked it up and administered it to the resident orally. This action was observed by a surveyor, and upon questioning, the LPN acknowledged the error, stating that the medication should have been discarded and replaced with a new one to prevent infection. The Director of Nursing (DON) confirmed the facility's policy that medications dropped on the floor should be discarded due to potential contamination and infection risk. The resident involved, identified as R55, had a physician's order for the medication to be administered three times a day. The facility's infection prevention and control program emphasizes maintaining a safe and sanitary environment to prevent the transmission of infections, which was not adhered to in this instance.
Failure to Maintain Comfortable Room Temperature for Resident
Penalty
Summary
The facility failed to provide a comfortable environment for a resident, identified as R162, due to a cold room temperature. On December 1st, a surveyor observed that R162's room was cold, and the resident confirmed that he had been complaining about the cold temperature since November 27th. A Licensed Practical Nurse (LPN) also noted that the room was as cold as the weather outside and considered it an immediate need. The Maintenance Director, V5, was unaware of the issue until the surveyor's visit and found the room temperature to be 61 degrees Fahrenheit, which was below the facility's standard of at least 68 degrees Fahrenheit. The cold temperature was attributed to a crack in the window. R162 has several medical conditions, including the presence of a right artificial hip joint, type 2 diabetes mellitus, hyperlipidemia, muscle wasting and atrophy, difficulty in walking, and unilateral primary osteoarthritis of the right hip. Despite these conditions, R162's cognitive status was intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The facility's policies emphasize the importance of maintaining a safe, clean, and comfortable environment for residents, yet the failure to address the cold temperature in R162's room was inconsistent with these policies.
Failure to Post Complete Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Nursing Staffing information was posted daily and completed appropriately, which could potentially affect all 159 residents. On December 1, 2024, a surveyor requested the Daily Staffing Posting from the scheduler, who was unable to locate it in the reception area. The scheduler then provided a document from a clipboard at the first-floor nurse's station, which lacked the current number of residents and did not include the total hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) for each shift. The scheduler admitted to not being informed about the requirement to include total nursing hours in the Daily Staffing Schedule. The administrator also confirmed that they were unaware of the need to include total nursing hours in the Daily Staffing Schedule. On the following day, the Director of Nursing acknowledged that the Daily Staffing Posting should include total nursing hours for each shift and be posted daily, as per regulations. However, the posted staffing information was incomplete, missing RN, LPN, and CNA hours for the evening and night shifts. The facility's Nursing Home Staffing Policy and the State Operations Manual require accurate daily staffing information to be posted, including the number of licensed nurses and CNAs, total resident census, and total nursing hours per shift.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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