Bella Terra Bloomingdale
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomingdale, Illinois.
- Location
- 165 South Bloomingdale Road, Bloomingdale, Illinois 60108
- CMS Provider Number
- 145638
- Inspections on file
- 31
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Bella Terra Bloomingdale during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including venous insufficiency and CHF, had a right lower extremity duplex ordered, but the contracted radiology provider did not perform the exam within the 24-hour timeframe required by contract and did not communicate the delay to the facility. The imaging was completed several days after the order, and the results were not read or transmitted until days after the exam, despite the provider’s usual 6–8 hour turnaround. Facility leadership confirmed they did not receive results until days later and only contacted the radiology company after the family asked about the test, and there was no documentation of communication between the facility and the provider regarding the delays.
A nursing home area was not kept free from accident hazards, and staff did not provide adequate supervision to prevent accidents. This resulted in a deficiency related to the facility's failure to ensure a safe environment and proper oversight for residents.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
Several residents did not receive their prescribed medications at the scheduled times due to a gap in nursing coverage, resulting in medications such as Velphoro, Coreg, Gabapentin, and Budesonide-Formoterol Fumarate inhaler being administered hours late. Residents with complex medical needs, including those on dialysis and with chronic conditions, were affected, and facility policies requiring timely medication administration and documentation were not followed.
Four residents with diabetes did not receive their scheduled insulin doses on time due to a gap in nursing coverage, resulting in insulin being administered several hours late. The facility's failure to follow physician orders and its own medication administration policies led to significant medication errors, as confirmed by EMR review and resident interviews.
Due to a lack of administrative oversight and failure to revise nursing assignments when an agency RN arrived late, multiple residents did not receive their scheduled medications, including insulin and cardiac medications, at the prescribed times. Staff interviews and medical records confirmed that medications were administered several hours late, and no direction was given to other staff to cover the absent nurse's assignment, resulting in delayed nursing care for all affected residents.
During a COVID-19 outbreak, a facility failed to follow its respiratory testing policy by not testing symptomatic residents for both COVID-19 and influenza. Staff also neglected proper infection control practices, such as wearing required PPE and disinfecting glucometers correctly. These lapses affected multiple residents, including those with confirmed COVID-19 cases and those requiring regular blood glucose monitoring.
The facility failed to follow the posted menu, affecting residents on mechanical soft and puree diets. Residents were served different meals than indicated, such as beef instead of pork and ham instead of sausage patties, without prior approval from the dietician. The dietary manager made substitutions due to perceived poor quality, but the registered dietician was not informed, leading to confusion and non-compliance with facility policies.
A resident's bed remained unrepaired despite being reported as broken, with the footboard's plastic cover detached and exposing an electric connector. The facility's policy requires staff to report such issues, but no maintenance work order was found, indicating a failure to maintain a safe environment.
The facility failed to provide adequate grooming and hygiene care for residents requiring assistance with ADLs. A resident with cognitive impairment had untrimmed, dirty fingernails, while another was found with a urine-soaked brief, indicating a lack of timely incontinence care. Additionally, a female resident was observed with facial hair over several days, despite needing assistance with grooming. The facility lacked a specific policy for facial hair grooming, and staff noted that agency staff might overlook such details.
The facility failed to ensure accurate blood glucose testing for residents with diabetes, as nurses used alcohol pads improperly, affecting readings. Additionally, a resident's urinary concerns were not promptly addressed, with delayed sample collection and inadequate communication with the physician. These actions violated the facility's diabetes management and urinary catheter care policies.
The facility failed to implement fall prevention measures for two residents at high risk for falls. One resident, with multiple diagnoses including impaired cognition, lacked a wing mattress and properly positioned alarm pad, leading to recent falls. Another resident with severe cognitive impairment had a call light on the floor and missing floor padding, contrary to care plan requirements. Both residents had documented falls, highlighting a failure to adhere to prescribed interventions.
The facility failed to properly position urinary catheter tubing and drainage bags for three residents, leading to potential infection risks. One resident's catheter tubing was over his pants, and the drainage bag was placed on his bed. Another resident's tubing was looped under his leg, and a third resident's tubing was unsecured, with the drainage bag containing sediment. Facility policy requires securement and proper positioning of catheter equipment, which was not followed.
A facility failed to report a resident fall caused by improper transfer methods, including not using a sit-to-stand machine as required. Additionally, staff did not consistently use gait belts during transfers, and resident transfer statuses were not accurately documented, leading to unsafe practices.
The facility failed to provide showers as scheduled for five residents who required assistance with bathing. Documentation showed significant gaps between showers, contrary to the policy of providing showers twice weekly. The residents had various medical conditions necessitating assistance with ADLs, and the facility did not adhere to its hygiene care procedures.
The facility failed to follow its urinary catheter care policy, resulting in inadequate documentation and assessment of symptoms for three residents with indwelling catheters who developed UTIs. A resident was sent to the hospital with a UTI, but the nurse did not document urine appearance or output. Another resident had a UTI diagnosed without documented symptoms, and antibiotics were prescribed without assessment. A third resident had a change in antibiotic treatment without documented symptoms or lab results. The DON confirmed the expectation for staff to monitor and document urinary output, which was not met.
A resident with dysphagia requiring 1:1 feeding assistance was left unattended with a meal tray, despite needing help from qualified staff. The Activity Director present was not qualified to assist, and a CNA left the tray after the resident refused lunch. The DON confirmed the need for staff assistance, as per the resident's medical records.
A resident was observed receiving thickened water despite an agreement to allow thin liquids and ice chips between meals to prevent dehydration. The speech therapist had recommended this change after evaluating the resident, but the facility failed to implement the updated dietary orders.
The facility failed to ensure a resident's legal representative was fully informed about the use of psychotropic medications. The resident was administered several psychotropic medications without proper consent documentation, and the legal representative expressed concerns about the lack of information and potential side effects. Facility staff confirmed that consent forms were incomplete, failing to provide necessary details.
Failure to Ensure Timely Diagnostic Imaging and Results
Penalty
Summary
The deficiency involves the facility’s failure to obtain and/or ensure timely diagnostic imaging and results for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including hydronephrosis, hypertension, type 2 diabetes mellitus, diabetic foot ulcer, venous insufficiency, and congestive heart failure. An order was placed on February 6, 2026, for a right duplex venous scan related to venous insufficiency, and the order indicated the imaging was sent that same day. The radiology company reported that the exam was not actually performed until February 9, 2026, three days after the order, despite a contract requirement that services be provided within 24 business hours or a time be scheduled with notification to the facility if that timeframe could not be met. The radiology company further stated that results are usually available within six to eight hours after imaging, but in this case the exam was not read by a radiologist and the results were not sent to the facility until February 13, 2026. The DON confirmed the facility did not receive the diagnostic imaging results until February 13, 2026, and that she only contacted the radiology company after the resident’s family inquired about the results during a care plan meeting that same day. The radiology company liaison and territory manager acknowledged the delays in both performing the duplex and in resulting the exam, and indicated there was no communication with the facility about these delays, contrary to the contractual obligation to promptly notify the facility if the 24-hour service time could not be met. The facility did not have documentation showing any communication with the radiology company regarding the delayed exam or delayed receipt of results.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in which a nursing home area was not maintained free from accident hazards, and adequate supervision was not provided to prevent accidents. The report notes that the facility failed to ensure the environment was safe and that appropriate oversight was in place to minimize the risk of accidents for residents. This lack of supervision and failure to address potential hazards directly contributed to the deficiency cited by surveyors.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Administer Medications as Ordered and Scheduled
Penalty
Summary
The facility failed to administer medications as ordered by physicians and as scheduled in the electronic medical record (EMR) for five residents. On a specific date, a nurse was late for her shift, resulting in a gap between the departure of the day shift nurse and the arrival of the evening shift nurse. During this period, residents did not receive their scheduled medications on time. One resident, who requires Velphoro to be taken with meals due to dialysis, did not receive the medication with dinner, and both Velphoro and Coreg were administered more than four hours after the scheduled time. The resident expressed frustration, noting that management was aware of the nurse's tardiness but did not arrange alternative coverage to ensure timely medication administration. Other residents were similarly affected by the delay. One resident had to approach the nurse to request a blood sugar check and pain medication, receiving Gabapentin almost two hours late. Another resident with moderate cognitive impairment received Gabapentin over four hours late. Additional residents with complex medical histories, including COPD, diabetes, and heart disease, also experienced delays in receiving scheduled medications such as Gabapentin and Budesonide-Formoterol Fumarate inhaler, with administration occurring up to four hours after the scheduled time. The facility's policies require that medications be administered according to physician orders and documented immediately after administration. The pharmacist confirmed that certain medications, such as Velphoro, must be given with meals for effectiveness, and significant delays in administering medications like Coreg could result in symptomatic changes. The documentation and interviews confirm that the facility did not adhere to its own policies or physician orders regarding medication administration times for multiple residents.
Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to administer insulin as ordered by physicians for four residents with diabetes, resulting in significant medication errors. On May 17, 2025, there was a gap in nursing coverage when the day shift nurse left at approximately 3:00 PM and the evening shift nurse did not arrive until 5:45 PM. During this period, no other staff were assigned to administer medications, leading to delays in scheduled insulin administration. Residents reported not receiving their medications on time, and electronic medical records confirmed that insulin doses scheduled for the evening meal were administered several hours late. For example, one resident with multiple chronic conditions, including diabetes and heart failure, received their scheduled 5:00 PM insulin dose at 9:14 PM, more than four hours after dinner. Another resident, also with diabetes and other comorbidities, received their 5:00 PM insulin at 6:50 PM and their 4:00 PM sliding scale insulin at 6:50 PM, both significantly delayed. A third resident with moderate cognitive impairment received their 5:00 PM insulin at 9:09 PM, and a fourth resident received their 5:00 PM insulin at 8:42 PM. In all cases, the insulin was ordered to be given with meals or at specific times, but was not administered as scheduled. The facility's own policies require medications and treatments to be administered according to physician orders and federal and state regulations. The pharmacist confirmed that the types of insulin involved are intended to be given with meals or at specific times to maintain stable blood glucose levels, and that significant delays can cause blood sugar fluctuations. The failure to follow physician orders and facility policy resulted in significant medication errors for multiple residents.
Failure to Revise Nursing Assignments Resulting in Delayed Medication Administration
Penalty
Summary
The administration failed to provide adequate oversight and leadership to ensure that nursing care assignments were revised in response to a change in staffing, resulting in residents not receiving nursing care and medications as ordered by their physicians. On a specific day, an agency RN who was scheduled to work the evening shift arrived late, and no arrangements were made to cover her assignment or ensure that her residents received timely care. The staffing coordinator confirmed that the nurse was assigned to care for a group of residents but was not present for the start of her shift, and no other staff were directed to absorb her responsibilities during her absence. Multiple residents reported and records confirmed that scheduled medications, including critical medications for conditions such as diabetes, hypertension, and pain management, were administered several hours late. For example, one resident did not receive his prescribed Velphoro, carvedilol, and insulin at the scheduled time with his meal, which he stated was necessary for the medications to be effective. The electronic medical records showed that these medications were administered more than four hours after the scheduled time. Other residents also experienced delays in receiving their medications, with documentation showing administration times ranging from nearly two to over four hours late. Interviews with staff and residents corroborated that there was a lack of communication and direction from management regarding coverage for the absent nurse. The administrator acknowledged awareness of the nurse's anticipated late arrival but did not provide a reason for the failure to revise assignments or instruct available staff to cover the affected residents. As a result, all residents assigned to the absent nurse experienced delays in receiving necessary nursing care and medications as ordered.
Infection Control and Testing Failures During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to its respiratory testing policy during a COVID-19 outbreak, as evidenced by the improper testing of residents for both COVID-19 and influenza. Despite the facility's policy and guidance from the local health department, symptomatic residents were only tested for COVID-19, not influenza, which was necessary given the co-circulation of both viruses. This oversight affected multiple residents, including those who tested positive for COVID-19, and led to a delay in appropriate testing and management of the outbreak. In addition to testing failures, the facility did not consistently follow infection control practices for residents on transmission-based and enhanced-barrier precautions. Staff members were observed not wearing the required personal protective equipment (PPE), such as N95 masks and face shields, when entering rooms of residents with confirmed COVID-19 cases. Furthermore, staff failed to don gowns when providing care to residents under enhanced-barrier precautions, increasing the risk of spreading infections. The facility also did not properly disinfect glucometers between uses. Staff members were observed wrapping glucometers in bleach wipes without first wiping down the surfaces, contrary to the facility's policy and CDC guidelines. This improper disinfection practice was noted across multiple instances, involving several residents with diabetes who required regular blood glucose monitoring. These deficiencies highlight significant lapses in the facility's infection prevention and control program.
Failure to Follow Posted Menus and Ensure Nutritional Needs
Penalty
Summary
The facility failed to adhere to the posted menu for residents, impacting all 18 residents on non-vegetarian mechanical soft and puree regular diets, and one resident on a vegetarian pureed diet. On the specified date, the menu indicated that roasted pork loin was to be served for lunch, but residents on mechanical soft diets were served beef instead. The dietary server was unsure why beef was prepared instead of pork, despite the pork loin being suitable for mechanical soft diets. Additionally, the dietary department was not provided with an updated list of residents receiving mechanical soft diets, which affected meal preparation. Further discrepancies were observed during breakfast service, where the menu listed sausage patties, but residents were served mechanical soft ham instead. The dietary server was uncertain about the substitution, suggesting it might have been due to a shortage of sausage patties. An unidentified puree item served during breakfast was also not labeled, leading to confusion about its contents. The dietary manager admitted to making substitutions without prior approval from the dietician, citing poor quality and appearance of the original items as reasons for the changes. The registered dietician confirmed that menu substitutions should be approved in advance to ensure nutritional equivalence. However, the dietician was not informed of the changes and was unsure about the items served. The facility's policy mandates that menus be followed as written unless changes are necessary due to preferences, unavailability, or special meals, and that any changes should be approved by the dietician. The failure to follow these protocols resulted in residents not receiving the meals indicated on their meal tickets, highlighting a breakdown in communication and adherence to dietary guidelines.
Failure to Repair Resident's Bed
Penalty
Summary
The facility failed to repair a resident's bed, which was identified as broken by the resident herself. The resident reported that the footboard's plastic cover was detached and broken, and an unidentified male staff member assessed the bed but did not provide a timeline for repair. A Certified Nurse Assistant (CNA) later assessed the issue and stated she would complete a maintenance work order request. However, the resident continued to report that the bed was not fixed, and the plastic cover eventually fell off completely, exposing an electric connector. The facility's administrator reviewed the maintenance work orders and found no record of a request for the resident's broken bed. The facility's policy requires staff to report malfunctioning equipment to the maintenance department, but this procedure was not followed in this case. The lack of a maintenance work order and the continued disrepair of the bed indicate a failure to maintain a safe and comfortable environment for the resident.
Deficiencies in Grooming and Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate grooming and hygiene care for residents who require assistance with Activities of Daily Living (ADLs). One resident, a male with severe cognitive impairment, was observed with long, dirty fingernails and a broken nail, despite the facility's policy that nursing staff should regularly check and trim residents' nails. Another resident, a male with mild cognitive impairment, was found with a urine-soaked incontinent brief and a strong odor of urine, indicating a failure to provide timely incontinence care as per the facility's policy of checking for incontinence every two hours. Additionally, a female resident was observed with noticeable facial hair over several days, despite the expectation that CNAs should address grooming needs during shower times. The resident's care plan indicated a need for assistance with ADLs, including grooming, but there was no documentation of refusal to be groomed. The facility lacked a specific policy for facial hair grooming, and staff acknowledged that agency staff might overlook such details.
Deficiencies in Blood Glucose Testing and Urinary Output Monitoring
Penalty
Summary
The facility failed to ensure accurate blood glucose testing for four residents with diabetes. Observations revealed that agency nurses used alcohol pads to wipe away the first drop of blood without allowing the alcohol to dry, which can affect glucose readings. This practice was observed in multiple instances, leading to potentially inaccurate blood glucose readings for residents with orders to monitor their blood sugar levels closely due to their diabetes diagnoses. Additionally, the facility did not adequately address a resident's concerns regarding urinary output. The resident reported pain and discomfort during urination, which was not promptly addressed by the staff. The resident's urinary output was significantly decreased, and the urine was cloudy, foul-smelling, and contained blood. Despite these symptoms, there was a delay in collecting urine and nephrostomy drainage samples for analysis, and the resident's physician was not immediately informed of the situation. The facility's policies on diabetes management and urinary catheter care were not followed, contributing to these deficiencies. The diabetes management policy required allowing alcohol to dry before testing blood glucose, and the urinary catheter care policy required monitoring and reporting unusual urine appearances and resident complaints. These lapses in following established procedures led to the deficiencies identified in the report.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement care plan interventions to prevent falls for two residents with recent histories of falls. Resident R100, who was admitted with multiple diagnoses including nontraumatic intracerebral hemorrhage and impaired cognition, was identified as being at high risk for falls. Despite this, the care plan interventions such as a bed/chair alarm and a wing mattress were not properly implemented. On observation, R100 was found in bed without the wing mattress, and the sensory fall alarm pad was not positioned correctly. R100's wife expressed concern for his safety due to recent falls, and the Director of Nursing acknowledged the expectation for these interventions to be in place. Resident R14, who has severe cognitive impairment, was also identified as being at high risk for falls. However, during observation, the call light was found on the floor, and the floor padding was not in place as required by the care plan. Additionally, the resident's name tag did not have the yellow star indicating a high fall risk. The Director of Nursing confirmed that these interventions should have been implemented according to the facility's fall occurrence policy. Both residents had documented falls prior to these observations, indicating a failure to adhere to the prescribed fall prevention measures.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure proper positioning of urinary catheter tubing and drainage bags to prevent infection for three residents. One resident's catheter tubing was improperly positioned over his pants, and the drainage bag was placed on top of his bed, above the level of his bladder. The securement device for the tubing was ripped and detached, leaving the tubing unsecured. Another resident's catheter tubing was looped underneath his leg and was not secured because the securement device was wrapped around the tubing instead of being attached to his leg. The third resident also had unsecured catheter tubing, as the securement device was not attached to her leg, and her drainage bag contained urine with sediment. The facility's policy on urinary catheter care requires that catheter tubing be secured with a leg strap and that drainage bags be positioned below the bladder to prevent backflow. The Director of Nursing confirmed that catheter tubing should not be positioned over a resident's pants and that drainage bags should be placed below the bladder. The care plans for the residents involved indicated the need for catheter care every shift and proper positioning of the catheter bag and tubing, which was not adhered to in these instances.
Improper Transfer Practices and Inadequate Reporting of Falls
Penalty
Summary
The facility failed to ensure proper reporting and handling of a resident fall incident, which was caused by an improper transfer. A resident with a history of lumbar spinal fusion surgery and mobility issues was improperly transferred by a CNA, who did not use the recommended sit-to-stand machine with a 2-person assist. The CNA did not report the fall to the licensed staff, and the resident was assisted off the floor without a proper assessment. The resident later experienced increased pain and was transferred to the hospital for further evaluation. Additionally, the facility did not consistently use gait belts during resident transfers, as observed with multiple residents. One resident was assisted off the toilet without a gait belt, despite having a care plan indicating the need for such a device due to high fall risk. Another resident self-transferred to the toilet without supervision, and the CNA assisting did not use a gait belt, contrary to the resident's care profile requirements. The facility also failed to ensure that resident transfer statuses were accurately communicated and documented. Several residents had discrepancies between their care profiles and the actual transfer methods used by staff. For instance, two residents were transferred using a sit-to-stand machine, although their care profiles did not reflect this requirement. The lack of accurate documentation and communication regarding transfer statuses contributed to unsafe transfer practices.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers in accordance with its schedule and policy for residents who required assistance with bathing. This deficiency was identified for five residents who were reviewed for showers and baths. The facility's documentation showed that these residents did not receive showers as scheduled, with significant gaps between the showers provided. For instance, one resident did not receive a shower from September 16 to September 26, and another did not receive any shower or complete bed bath during their entire stay from September 21 to October 8. These lapses exceeded the facility's policy of providing showers at least once weekly. The residents involved had various medical conditions, including chronic heart failure, kidney disease, diabetes, dementia, and other health issues, which necessitated assistance with activities of daily living, including bathing. The facility's policy required that residents receive showers twice per week, and any refusals should be documented. However, the documentation provided did not align with this policy, indicating a failure to adhere to the established schedule and procedures for resident hygiene care.
Inadequate Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to adhere to its policy for urinary catheter care, resulting in inadequate documentation and assessment of symptoms for residents with indwelling urinary catheters who developed urinary tract infections (UTIs). Three residents, identified as R1, R2, and R8, were affected by this deficiency. The facility's policy required staff to monitor and document urinary output, including color, clarity, and any unusual appearance, as well as to observe and report signs of UTIs. However, these requirements were not consistently met. Resident R2 was admitted with multiple diagnoses, including neuromuscular dysfunction of the bladder and dementia, and had an indwelling urinary catheter. R2 was sent to the hospital with symptoms of lethargy and altered mental status, where a UTI was diagnosed. The nurse, V14, did not document the appearance of R2's urine or the urinary output in the electronic medical record (EMR), despite the facility's policy. Similarly, Resident R8, who was severely cognitively impaired, had a UTI diagnosed based on lab results, but there was no documentation of symptoms or urine characteristics in the progress notes. The physician prescribed antibiotics without a documented assessment of symptoms or response to treatment. Resident R1, with a suprapubic indwelling urinary catheter, had a change in antibiotic treatment for a UTI without documented symptoms or lab results to justify the change. The progress notes lacked documentation of R1's response to the treatment. The Director of Nursing, V2, confirmed the expectation for staff to monitor and document urinary output and characteristics, which was not fulfilled in these cases. The facility's failure to follow its urinary catheter care policy led to inadequate monitoring and documentation, contributing to the deficiency.
Failure to Provide Required Feeding Assistance for Resident with Dysphagia
Penalty
Summary
The facility failed to provide adequate feeding assistance for a resident diagnosed with dysphagia, who required one-to-one feeding assistance. During an observation, the resident was seen at lunch with a mechanical soft tray and thickened liquids in front of him, attempting to drink the liquids without assistance. The Activity Director present at the table stated she was not qualified to feed residents. A Certified Nursing Assistant (CNA) mentioned that the resident had refused lunch and left the tray in front of him. The Director of Nursing confirmed that residents requiring one-to-one feeding assistance should be helped by a CNA, nurse, or speech therapist, and a tray should not be left unattended in front of such residents. The resident's medical records indicated a diagnosis of dysphagia and specified the need for one-to-one assistance with meals.
Failure to Follow Updated Dietary Orders for Resident
Penalty
Summary
The facility failed to follow dietary orders for a resident, identified as R1, who was on a special diet. On October 2, 2024, R1 was observed sitting near the nursing station with thickened water, which was consistent with his dietary orders. However, the speech therapist, V11, had evaluated R1 on September 24, 2024, and noted that although R1's hospital video swallow did not show aspiration, R1 was coughing on honey thick liquids during the evaluation. A care conference with R1's family on September 27, 2024, resulted in an agreement to allow thin liquids and ice chips between meals to promote hydration, as R1 was at risk for dehydration. Despite this agreement, the facility did not adhere to the updated dietary orders. On October 2, 2024, the Licensed Practical Nurse, V4, provided R1 with thickened water, contrary to the agreed-upon plan of allowing thin liquids and ice chips between meals. The Director of Nursing, V2, acknowledged that speech therapy recommendations should be followed, yet the facility failed to implement the updated dietary plan. The Order Summary Report dated October 2, 2024, confirmed the dietary orders for a regular diet with mechanical soft texture, nectar thick liquid consistency, and allowance for thin water and ice chips between meals, effective from September 27, 2024.
Failure to Inform Legal Representative About Psychotropic Medications
Penalty
Summary
The facility failed to ensure the legal representative of a cognitively impaired resident was fully informed regarding the use of psychotropic medications. The resident, who has a history of traumatic brain injury, major depressive disorder, and other significant health issues, was administered several psychotropic medications without proper consent documentation. The medications included Lorazepam, Aripiprazole, Escitalopram, and Trileptal. The consent forms for these medications were either incomplete or missing, failing to provide necessary information such as drug classification, targeted behaviors, side effects, and whether the legal representative agreed to the medication use. The resident's father, who is the designated Power of Attorney (POA), was not fully informed about the medications being administered. He expressed concerns about the use of these medications, particularly the mood stabilizer/antiepileptic medication Trileptal, which he believed could have detrimental side effects. The father also indicated that he was not notified about the administration of these medications and showed copies of incomplete consent forms provided by the facility. Interviews with facility staff, including the psychotropic nurse and the attending physician, confirmed that the consent forms should have included detailed information to ensure the POA was fully informed. The facility's policy on psychotropic medications, dated 5/30/2016, mandates adherence to federal regulations and obtaining consent for each psychotropic medication. However, the facility failed to comply with these requirements, leading to the deficiency identified in the report.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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