Beecher Manor Nrsg & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Beecher, Illinois.
- Location
- 1201 Dixie Highway, Beecher, Illinois 60401
- CMS Provider Number
- 145538
- Inspections on file
- 33
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Beecher Manor Nrsg & Rehab Ctr during CMS and state inspections, most recent first.
Surveyors found that two residents with dementia, histories of repeated falls, and other significant conditions such as Parkinson’s disease, fractures, and bone disorders were not provided with ordered low-bed fall precautions. Both residents had a leaf symbol posted by their room names indicating fall risk, and care documentation specified use of a low bed, yet each was repeatedly observed in bed with the bed raised about two feet from the floor rather than in the lowest position. A CNA reported being unaware of specific fall precautions for one resident, while the ADON/RN stated that when low-bed precautions are in place, beds should be lowered as close to the floor as possible when residents are in bed.
A resident with Parkinson's disease, a fractured femur, and a history of repeated falls was being assisted by a CNA who, despite observing heavy jerking movements and recognizing the need for a second staff member, attempted to position the resident on the side of the bed alone. The CNA did not request help from her available partner, and the resident subsequently fell, sustaining a scalp laceration that required staples. Facility policy and staff interviews confirmed that two staff were required for such transfers, and this protocol was not followed.
Two residents with dementia and cognitive impairment were involved in a physical altercation, resulting in one resident sustaining abrasions and scratches to the face and neck. The aggressive resident had exhibited prior exit-seeking and aggressive behaviors, including an attempt to choke an LPN, but remained in the facility after being started on new medications. The altercation was not directly witnessed by staff, and both residents were assessed and separated following the incident.
The facility failed to maintain kitchen hygiene and food safety, affecting 112 residents. Observations included sticky floors, improperly labeled and stored food items, inadequate sanitization levels, and inconsistent monitoring of food temperatures. The Dietary Consultant was seen without proper facial hair covering, and water was dripping from the ceiling, causing a wet kitchen floor. These issues indicate non-compliance with the facility's policies on sanitization, food storage, and personnel health.
The facility failed to provide adequate hygiene care for several residents, including a cognitively impaired resident with saturated incontinence briefs and reddened skin, a resident left in a wet undergarment for hours, a female resident with unwanted facial hair, and a resident with long, curled fingernails. These deficiencies highlight a lack of adherence to care policies and timely interventions.
The facility failed to implement proper fall precautions for four residents at risk for falls. A resident was found with her bed in a high position, contrary to her care plan. Another resident had a floor mat only on one side of the bed, despite needing mats on both sides. Two other residents were similarly observed with inadequate mat placement, despite their care plans indicating the need for mats on both sides due to their fall risk and medical conditions. The DON confirmed the expectation for high fall risk residents to have beds in low positions with mats on both sides.
The facility failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene protocols, as staff did not wear gowns during care for residents with catheters and wounds, and did not perform proper hand hygiene after handling potentially contaminated equipment. Additionally, improper perineal care was observed, with a CNA using the same cloth multiple times, risking cross-contamination.
A facility failed to provide a portable oxygen tank holder for a resident requiring continuous oxygen, leading to the resident experiencing shortness of breath while using the bathroom without oxygen. The resident, with chronic respiratory conditions, could not bring her oxygen due to her bariatric wheelchair's size. The LPN and DON acknowledged the oversight, noting the facility had portable holders but did not use them, despite the resident's need.
The facility failed to maintain consistent advance directives for two residents, leading to discrepancies between electronic health records and the Advance Directive book. For one resident, the electronic record showed a Full Code Status while the book had a DNR form, and for another, the electronic record had a DNR form while the book showed a Full Code form. The DON acknowledged the need for consistency to ensure correct life-sustaining measures are provided.
A resident with moderate cognitive impairment was improperly restrained in bed using interconnected bolsters and side rails without a physician's order or care plan. The facility's policy requires physician review before restraint use, which was not followed.
A facility failed to provide a resident or their representative with written notice of the bed hold policy before the resident was transferred to the hospital. The resident was sent to the hospital due to labored breathing, low oxygen saturation, low blood pressure, and a high heart rate. The DON confirmed the lack of documentation and stated that staff are expected to provide the bed hold policy during hospital transfers.
A resident with mild cognitive impairment did not receive wound care as per the physician's order. The wound care nurse failed to apply Hydrofera Blue to the resident's right hip wound, citing a discussion about changing the dressing. However, the wound care physician clarified that the updated order was for Calcium Alginate with form dressing, which was not reflected in the system, leading to the deficiency.
The facility failed to provide adequate restorative care services for two residents, leading to deficiencies in their care. One resident did not receive consistent passive range of motion exercises or wrist splint application as per their care plan. Another resident reported not receiving the expected active range of motion exercises and assistance with bed mobility, which was confirmed by facility documentation. Staff prioritized residents with upcoming MDS assessments, resulting in inadequate restorative care for others.
The facility failed to label, date, and discard old food and beverages in two residents' personal refrigerators. One resident had old ice cream sandwiches, and another had cups with unknown liquids, both unlabeled and undated. The facility's policy requires labeling and discarding perishable items after three days. Both residents had multiple diagnoses, with one being cognitively intact and the other severely impaired.
The facility failed to maintain a pest-free environment, with house flies and gnats observed in resident rooms and common areas. A resident with moderate cognitive impairment reported flies in her room and on her person. The Assistant Director of Nursing acknowledged the issue, and the Maintenance Director stated that the facility is treated by a pest control company twice a month. The facility's pest control policy outlines measures to prevent and eradicate pests.
A resident with morbid obesity and hemiplegia suffered a femur and nasal fracture after a siderail broke during bed mobility assistance. The resident required two staff for assistance, but only one was present, contrary to the care plan. The incident highlighted a communication failure regarding the resident's care needs.
Failure to Maintain Low-Bed Fall Precautions for High-Risk Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to follow fall-prevention interventions for residents assessed as high risk for falls. One male resident with dementia, Parkinson’s disease, muscle wasting and atrophy, lack of coordination, and a history of repeat falls had a leaf symbol posted by his name outside his room, and his care card in the room closet listed “low bed” as a fall precaution. On multiple observations on January 23 and January 24, this resident was found lying in bed with the bed raised approximately two feet from the floor and not in the lowest position. The resident reported having had a fall at the facility. A CNA who had been assigned to this resident the previous day stated she was not aware of any specific fall precautions for him, despite the documented intervention of a low bed. A second resident, a female with dementia, non-pathological and pathological fractures, disorders of bone density and structure, and repeated falls, also had a leaf symbol posted by her name outside her room. She was observed lying in bed sleeping with the bed raised approximately two feet from the floor and not in the lowest position, while she stated she was trying to get some rest. The Assistant DON/RN explained that fall risk assessments are completed on admission, quarterly, annually, as needed, and after new falls, and that the facility reviews all falls and prior interventions. She further stated that when fall precautions include a low bed, the bed should be in the lowest position when the resident is in bed, and that the beds can be lowered very close to the floor. Despite these stated practices and documented precautions, both high-risk residents were observed with beds not maintained in the low position as ordered.
Failure to Provide Required Supervision During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to implement required safety measures to prevent a fall for a resident with a high risk for falls. The resident, who had diagnoses including a displaced fractured left femur, Parkinson's disease, and a history of repeated falls, was being assisted with personal hygiene and dressing by a Certified Nurse's Assistant (CNA) who had not previously cared for the resident and had not received a report from the off-going staff or nurse. During care, the resident's upper body was shaking and jerking heavily. Despite recognizing the need for a second staff member and a full body mechanical lift, the CNA proceeded to slide the resident to the side of the bed and placed her in a sitting position without assistance. While the CNA reached for a wipe, the resident jerked again and fell off the bed, resulting in a 3-centimeter laceration to the scalp that required staples for closure. Interviews with facility staff, including the LPN, DON, and the resident's primary care physician, confirmed that facility policy and standard practice required two staff members to be present when positioning a resident with such conditions on the side of the bed prior to transfer, especially when using a sit-to-stand mechanical lift. The CNA's partner was available but was not asked to assist. The resident's records indicated a high fall risk, and the facility's policy required staff to identify and implement interventions to minimize fall risks and complications. The failure to follow these protocols directly led to the resident's fall and injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between two residents, both of whom had diagnoses of dementia and compromised cognitive function. One resident, who had recently been admitted and assessed as having compromised mental status, exhibited exit-seeking and aggressive behaviors, including an incident where he attempted to choke a nurse. Despite these behaviors, the resident remained in the facility and was started on new medications following the initial aggression. The following day, the same resident became physically aggressive toward another resident, striking and scratching him in the face and neck area. The incident was not directly witnessed by staff, but was reported by the affected resident, who sustained abrasions and scratches. Both residents were separated after the incident, and assessments revealed injuries consistent with the reported altercation. The aggressive resident was unable to recall the event, and both residents had significant cognitive impairments that limited their ability to provide detailed accounts. Prior to the altercation, staff had observed the aggressive resident's exit-seeking and agitation, including a physical attack on a staff member. The facility's response to these behaviors included notifying the resident's power of attorney, consulting with a psychiatric nurse practitioner, and administering new medications. However, the resident remained in the facility and subsequently engaged in resident-to-resident physical abuse, resulting in injury.
Deficiencies in Kitchen Hygiene and Food Safety Practices
Penalty
Summary
The facility failed to maintain the kitchen in a manner that would prevent foodborne illness, affecting 112 residents who receive meals from dietary services. During a kitchen tour, it was observed that the dry storage floors were sticky, and several food items, including vanilla wafers and spaghetti, were opened without proper labeling of open or use-by dates. In the walk-in cooler, a bag of mixed vegetables and a five-gallon bucket of pickles were found without proper labeling, and jars of marinara sauce had broken seals. Additionally, deli sandwiches were kept beyond the recommended 48 to 72 hours, and there were no logs for sanitization buckets. The walk-in freezer contained non-food items, and the sanitization bucket in use measured below the required 200 ppm. The facility's documentation revealed inconsistent monitoring of chemical sanitization levels and food temperatures. The Dietary Consultant, V25, was observed in the kitchen without proper facial hair covering, and water was dripping from the ceiling, causing the kitchen floor to be wet. The facility's policies on sanitization, food storage, and personnel health were not adhered to, as evidenced by the lack of proper labeling, inadequate sanitization levels, and improper storage of food items. These deficiencies indicate a failure to follow professional standards for food safety and hygiene, potentially leading to foodborne illness among residents.
Deficiencies in Hygiene and ADL Care
Penalty
Summary
The facility failed to provide adequate hygiene care and maintenance for several residents, leading to deficiencies in their care. Resident R65, who is cognitively impaired and dependent on staff for all care needs, was found with an overly saturated incontinence brief and reddened coccyx and perineum. Despite being assessed as high risk for skin breakdown, there was no order for zinc cream until after the issue was observed by staff. This indicates a lack of timely intervention to prevent skin irritation and potential breakdown. Resident R106, who is cognitively intact but dependent on staff for care, reported not receiving incontinence care since early morning, despite staff being aware of her needs. Her incontinence brief was found saturated with urine, and she expressed distress over being left in a wet undergarment. The facility's policy requires incontinence care every two hours, which was not adhered to, resulting in discomfort and potential risk for skin issues. Additional deficiencies were noted with residents R4 and R90. R4, who has moderate cognitive impairment, was observed with long chin hairs, which she expressed a desire to have removed. Staff acknowledged that facial hair on female residents is a dignity issue, yet it was not addressed. R90, with severe cognitive impairment, had long, curled fingernails despite being dependent on staff for personal hygiene. The facility's guidelines require regular nail care to prevent injury, which was not provided, posing a risk of self-injury and infection.
Failure to Implement Fall Precautions for At-Risk Residents
Penalty
Summary
The facility failed to implement proper fall precaution measures for four residents identified as being at risk for falls. Resident R33 was observed with her bed in a high position, contrary to her care plan which required the bed to be in the lowest position with brakes locked. This was noted by the Assistant Director of Nursing. Resident R14 was found with a floor mat only on the left side of her bed, despite her care plan indicating the need for mats on both sides due to her risk factors including a history of cerebral vascular accident and decreased mobility. Similarly, Resident R52 was observed with only one mat on the right side of his bed, while his care plan required mats on both sides due to his history of falls and conditions such as Parkinson's disease and dementia. Resident R69 was also observed with only one mat on the left side of his bed on two separate occasions, despite his care plan indicating the need for mats on both sides due to his history of falls and multiple medical conditions. The Director of Nursing confirmed that the expectation for high fall risk residents is to have beds in low positions with mats on both sides, which was not adhered to in these cases.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) Guidelines, as observed in the care of four residents. Staff did not wear gowns during incontinent care for residents with wounds, catheters, and other conditions requiring EBP. For instance, a Licensed Practical Nurse (LPN) and Certified Nursing Assistants (CNAs) provided care to a resident with a suprapubic catheter and nephrostomy tube without wearing gowns, despite the facility's guidelines requiring such precautions. Additionally, the facility did not provide trash cans inside resident rooms and near exits for proper disposal of personal protective equipment (PPE), further compromising infection control measures. In another instance, a CNA moved a Foley catheter bag with ungloved hands and then proceeded to handle a resident's meal tray without performing hand hygiene. This action was contrary to the facility's hand hygiene policy, which mandates hand cleaning after contact with potentially contaminated equipment and before handling food. The resident involved had a history of urinary tract infections, highlighting the importance of strict adherence to infection control practices. Furthermore, during perineal care for a resident, a CNA used the same cloth towel multiple times without folding or changing it, which could lead to cross-contamination. The CNA admitted to rushing the procedure, which compromised the quality of care. The facility's perineal care policy requires using a clean cloth for each wipe to prevent infections and skin irritations. These deficiencies indicate a lack of compliance with established infection prevention protocols, potentially affecting resident safety and care quality.
Failure to Provide Portable Oxygen Tank Holder for Resident
Penalty
Summary
The facility failed to provide a portable oxygen tank holder for an ambulatory resident who requires continuous oxygen. The resident, who has chronic obstructive pulmonary disease, morbid obesity, and chronic respiratory failure, was observed lying in bed with 4 liters of oxygen per nasal cannula. The resident reported that she could walk to the bathroom independently but did not have a way to bring her oxygen with her due to her bariatric wheelchair being too wide to fit into the bathroom. As a result, she experienced shortness of breath while using the bathroom without her oxygen. The Licensed Practical Nurse (LPN) acknowledged that the facility had portable oxygen tank holders but did not use them because residents had oxygen tank holders on their wheelchairs. The LPN was aware of the resident's situation and that she went to the bathroom without her oxygen. The Director of Nursing (DON) confirmed that an ambulatory resident with a continuous oxygen order should be able to go to the bathroom with their oxygen on and that the resident should have been provided with a portable oxygen tank holder. The facility's policy on oxygen administration requires reviewing the resident's care plan for special needs and assembling necessary equipment, including a portable oxygen cylinder.
Inconsistent Advance Directives for Two Residents
Penalty
Summary
The facility failed to maintain current and accurate advance directives for two residents, R69 and R115, as identified during a record review conducted by a state surveyor and the Director of Nursing (DON). For R69, there was a discrepancy between the electronic health record, which showed a Full Code Status POLST Declaration form dated 6/21/24, and the Advance Directive book at the nurses' station, which contained a DNR form dated 2/23/21. Similarly, for R115, the electronic health record indicated a DNR form dated 5/11/24, while the Advance Directive book showed a Full Code form dated 2/16/24. The DON acknowledged that both the Advance Directive book and the electronic health record should be consistent to ensure the facility provides the correct life-sustaining measures as per the resident's wishes. The facility's Advance Directive policy, dated November 2016, mandates that copies of written advance directives be uploaded into the residents' clinical records. Additionally, for staff without access rights to these records, the residents' advance directives should be maintained on the nursing unit and be available for staff reference when rendering care and services. The inconsistency between the records and the Advance Directive book could lead to the facility not administering the appropriate life-sustaining measures desired by the residents.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility was found to have improperly used physical restraints on a resident, identified as R81, who is a [AGE] year-old female with moderate cognitive impairment. During an observation on 8/29/24, R81 was seen with a wedge to her right upper body, both upper side rails up, and two bolsters interconnected with a strap at the bottom of the bed, effectively confining her to the bed. The Assistant Director of Nursing acknowledged that these bolsters, without a physician's order, could be considered a restraint. The resident's care plan did not include the use of bed bolsters, and there was no physician order for their use in the physician order sheet for August 2024. The Director of Nursing confirmed that a physician order and care plan should have been in place for the use of bolsters. The facility's physical restraint policy, dated February 2014, states that restraints should not be used for punishment or staff convenience and requires physician review before ordering or reordering restraint use.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to a resident or their representative before the resident was transferred to the hospital. The deficiency was identified during a review of the resident's electronic health record, which showed that the resident was sent to the hospital due to labored breathing, low oxygen saturation, low blood pressure, and a high heart rate. There was no documentation indicating that the resident or their representative received a copy of the facility's bed hold policy. The Director of Nursing confirmed the absence of such documentation and stated that it is expected for the facility staff to provide the bed hold policy when a resident is transferred to the hospital.
Failure to Follow Updated Wound Care Orders
Penalty
Summary
The facility failed to follow the physician's order for wound care for a resident with mild cognitive impairment. During an observation, it was noted that the wound care nurse did not apply Hydrofera Blue to the resident's right hip wound as per the physician's order. The wound care nurse admitted to changing the dressing the previous day but could not explain why Hydrofera Blue was not used. The physician's order sheet specified cleansing the wound with saline, applying Hydrofera Blue, and covering it with a dry dressing. Further investigation revealed a communication breakdown regarding the wound care orders. The wound care nurse stated that there was a discussion about changing the dressing from Hydrofera Blue to Santyl, which led to the omission. However, the wound care physician clarified that the most updated order was for Calcium Alginate with form dressing, and the staff should have updated the system to reflect this new order. This miscommunication resulted in the failure to provide the correct wound care as per the physician's updated instructions.
Failure to Provide Adequate Restorative Care Services
Penalty
Summary
The facility failed to provide adequate restorative care services for two residents, leading to deficiencies in their care. One resident, who is cognitively impaired and dependent on staff for all care needs, was supposed to receive passive range of motion (PROM) exercises and have a wrist splint applied regularly. However, documentation showed inconsistencies in the provision of these services, with the resident not having the splint on during observations and receiving PROM less frequently than planned. The resident's care plan was not followed as intended, indicating a lapse in the facility's restorative care services. Another resident, who is cognitively intact but dependent on staff for hygiene, dressing, and repositioning, was supposed to receive active range of motion (AROM) exercises and assistance with bed mobility. The resident reported not receiving the expected restorative visits and exercises as frequently as outlined in their care plan. The facility's documentation confirmed the resident's claims, showing a significant gap between the planned and actual delivery of restorative services. Staff interviews revealed that residents with upcoming MDS assessments were prioritized, leading to other residents, like this one, not receiving the necessary restorative care.
Failure to Label and Discard Old Food in Residents' Refrigerators
Penalty
Summary
The facility failed to properly label, date, and discard old food and beverages from residents' personal refrigerators, as observed in the cases of two residents. One resident had nine soft, old ice cream sandwiches in her personal refrigerator's freezer, which were not labeled or dated. Despite the resident stating that staff assists her with cleaning the refrigerator, the ice cream sandwiches remained in the freezer over multiple days. The housekeeper was unaware of the old ice cream sandwiches, and the Director of Nursing acknowledged that all residents' food should be labeled and dated to prevent potential illness. This resident had multiple diagnoses, including heart failure and dementia, but was cognitively intact according to her MDS. Another resident's personal refrigerator contained three cups with an unknown liquid, which were also not labeled or dated. The resident confirmed she consumes the drinks, and the cups remained in the refrigerator over several days. The housekeeper and Director of Nursing both stated that all liquids should be labeled and dated to avoid potential illness. The facility's policy requires that any food or beverage must be dated and labeled, and perishable items not consumed after three days should be discarded. This resident had severe cognitive impairment and multiple diagnoses, including chronic kidney disease and dementia.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain a pest-free environment for its 117 residents, as evidenced by the presence of house flies and gnats in resident rooms and common areas. A specific incident involved a female resident with moderate cognitive impairment who reported flies in her room and on her person. Observations by the surveyor confirmed the presence of house flies in the resident's room and around the food cart in front of the kitchen hallway. Additionally, flies and gnats were observed around the North and South Nurse's stations. The Assistant Director of Nursing acknowledged the widespread presence of flies. The Maintenance Director stated that the facility is treated by a pest control company twice a month, with the last treatment occurring on 8/16/24, and acknowledged the need for a pest-free environment for residents. The facility's pest control policy, dated 11/1/23, outlines ongoing measures to prevent and eradicate common household pests, including flies.
Failure to Provide Adequate Bed Mobility Assistance Results in Resident Injury
Penalty
Summary
The facility failed to provide safe bed mobility assistance for a resident, resulting in significant injuries. The resident, who had diagnoses including morbid obesity, hemiplegia, and contractures, required the assistance of two staff members for bed mobility. However, during an incident, a nursing assistant provided care alone, contrary to the resident's care plan. While the resident was being turned onto her side, she used the siderail for support, which broke, causing her to fall to the floor. This fall resulted in a right femur fracture, a nasal fracture, and a laceration requiring sutures. The incident was further compounded by a lack of awareness among staff regarding the resident's care needs. The Director of Nurses discovered that the care card used by staff incorrectly indicated that the resident required only one person for assistance, despite assessments and the care plan specifying a two-person assist. Interviews with other nursing assistants confirmed that the resident was known to require two staff members for safe bed mobility due to her size and limited mobility. The facility's failure to ensure accurate communication of the resident's care needs and to provide adequate supervision during care led to the accident. The siderail, although rated for high weight capacity, broke under the force exerted during the incident. The resident's cognitive status was intact, and she was dependent on staff for mobility, highlighting the importance of following the care plan to prevent such accidents.
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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