Bella Terra Lombard
Inspection history, citations, penalties and survey trends for this long-term care facility in Lombard, Illinois.
- Location
- 2100 South Finley Road, Lombard, Illinois 60148
- CMS Provider Number
- 145511
- Inspections on file
- 34
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Bella Terra Lombard during CMS and state inspections, most recent first.
A resident was admitted with multiple pressure-related skin injuries, including deep tissue injuries and unstageable pressure ulcers to the sacral and bilateral buttock areas, and had a care plan directing staff to monitor and document the location, size, and treatment of these wounds. The wound nurse completed an admission skin/wound evaluation but did not obtain or document measurements of the bilateral buttock pressure injuries, stating she sometimes avoids measuring when unsure how to do so or concerned about overestimating size, and may wait for the wound NP. The DON reported that pressure injuries should be measured at assessment and acknowledged that without initial measurements it is not possible to determine changes in wound size. This practice did not comply with the facility’s Wound Care Guidelines, which require wound assessments to include wound type, etiology, location, stage, and measurements of length, width, and depth, among other elements.
A resident with impaired mobility, pain, and multiple chronic conditions, including pressure ulcers, required staff assistance with transfers. After a shower and transfer back to bed by a CNA, redness and later a skin tear were noted on the resident’s left lower leg. The CNA’s inspection revealed that square sections in the middle of the bed frame were missing plastic protective covers, leaving exposed metal. The resident’s daughter reported that the resident had scratched her leg on the bed due to these missing pieces, and facility staff, including maintenance and administration, confirmed that the bed frame lacked required plastic protective components needed for safe use.
A resident with cognitive impairment and recent surgery alleged that a CNA held her wrist during care and did not release it when asked, causing discomfort. The allegation was reported to a nurse, who did not notify the abuse coordinator as required, leading to a delay in reporting to both facility leadership and authorities. Interviews confirmed the resident's complaints were not promptly reported by staff, contrary to facility policy.
The facility failed to provide timely incontinent care to two residents dependent on staff for toilet hygiene. One resident was found with a urine-soaked brief, while another was found with a urine and feces-soaked brief. Both residents' care plans required checks every two hours, which were not adhered to, leading to prolonged exposure to moisture.
A resident with severe cognitive impairment and a stage 4 sacral pressure ulcer did not receive wound care as per physician orders. The wound care nurse failed to irrigate the wound with normal saline and used hydrogel-moistened gauze instead of calcium alginate, despite recommendations from the wound care nurse practitioner. The nurse cited a lack of supplies as the reason for not following the prescribed treatment plan.
The facility failed to provide timely incontinent care to three residents dependent on assistance for toilet hygiene. One resident with mild cognitive impairment was found with a urine-soaked diaper hours after being changed, despite a care plan for two-hour checks. Another resident with similar impairment was also found with a soaked brief, and a third resident with severely impaired cognition was found with a double diaper soaked in urine. Staff acknowledged the requirement for two-hour checks, highlighting a failure to adhere to care plans and facility policy.
A resident's Norco medication was misappropriated in an LTC facility. The resident, with severe cognitive impairment, was prescribed Norco for pain management. During a shift change, it was discovered that the medication and narcotic count sheet were missing. An RN from agency staffing, who had access to the narcotic box, signed off on taking tablets at unusual times. Despite being the only one with access, the RN denied knowledge of the missing items. The incident was reported to authorities.
The facility failed to sanitize food preparation equipment before use, potentially affecting 138 residents. A chef used a rag with only soap and water to wash food processor components and a spatula, which were not sanitized or air-dried before preparing pureed meals. The Food Service Director confirmed the need for proper sanitization procedures.
The facility failed to assess and notify the wound nurse practitioner of a new wound for a high-risk resident, leading to its deterioration into a stage 2 to 3 pressure ulcer. Additionally, several residents at risk for pressure ulcers did not receive proper pressure-relieving interventions, such as heel elevation, as outlined in their care plans. These deficiencies highlight lapses in following the facility's Wound Care Guidelines Policy.
The facility failed to consistently provide and document restorative services, including ROM exercises and splint applications, for several residents. A resident with declining mobility did not receive prescribed exercises, while another resident with hemiplegia reported missing daily ROM sessions. Additionally, a resident with contractures had incomplete documentation for ROM and splint application, indicating a lack of adherence to care plans.
A resident with multiple sclerosis, who is incontinent, experienced a two-hour delay in receiving assistance after soiling himself, despite being alert and oriented. His care plan required staff checks every two hours, but there was no documentation on the day of the incident. The facility's policy mandates respect for residents' privacy and dignity, which was not upheld.
The facility failed to maintain fall interventions for two residents with a history of falls. One resident's bed was not consistently in the lowest position, and the call light was often out of reach, despite previous fall-related injuries. Another resident's bed alarm was improperly set up, with the sensor pad unplugged and not under the resident, contrary to the care plan. The facility's guidelines required safety interventions for at-risk residents.
The facility failed to properly store nebulizer equipment for three residents, leading to potential cross-contamination. Observations showed nebulizer masks and tubing stored in open plastic bags with outdated dates or touching surfaces, contrary to facility policy requiring weekly changes and proper storage. A nurse confirmed the need for dated and bagged storage to prevent contamination.
A resident's morphine prescription was not reordered due to a pharmacy requirement for an actual signature, resulting in only 6 tablets being sent instead of the prescribed 60. The resident's MAR showed the medication was unavailable for two days, during which oxycodone was administered for pain management. The DON explained the issue with the electronic signature, and the NP confirmed the prescription could have been refilled over the weekend.
The facility failed to ensure staff wore appropriate PPE for two residents on enhanced barrier precautions (EBP). A CNA provided care to a resident with a gastrostomy tube and another with a Foley catheter and surgical wound without donning a gown, despite the care plans and facility policy requiring gowns and gloves during high-contact activities. The infection preventionist confirmed the need for both gloves and gowns, highlighting a deficiency in infection control practices.
The facility failed to provide timely incontinent care to four dependent residents, as observed in multiple instances where residents were found with soaked briefs despite care plans requiring checks every two hours. The DON confirmed that staff are supposed to check and offer incontinent care every two hours, but this policy was not followed.
A resident with significant medical conditions reported not being changed by agency staff during a night shift, resulting in him being found soaked with urine and stool the next morning. Interviews with CNAs and the ADON confirmed the resident's account and highlighted issues with agency staff adherence to the facility's incontinence care policy.
Failure to Measure and Document Pressure Injury Size on Admission
Penalty
Summary
The deficiency involves the facility’s failure to follow its wound care policy requiring complete pressure injury assessments, including measurements, for a resident admitted with multiple pressure-related skin injuries. The resident’s EMR showed admission with diagnoses including rheumatoid arthritis, chronic kidney disease, congestive heart failure, pressure-induced deep tissue damage of the right buttock, and unstageable pressure ulcers of the sacral region and left buttock. The resident’s skin integrity care plan documented actual skin impairment related to sacral and bilateral buttock unstageable pressure ulcers and included an intervention to monitor and document the location, size, and treatment of skin injuries. Despite this, the admission/readmission nursing assessment and a Skin/Wound Evaluation completed within 24 hours of admission did not include measurements of the bilateral buttock pressure injuries. During interview, the wound nurse stated she assesses newly admitted residents for skin impairments within 24 hours of admission but acknowledged she did not measure this resident’s buttock pressure injuries and was unsure why. She further stated that sometimes she does not measure pressure injuries if she is unsure how to measure them or is concerned about measuring them as larger than they are, and may wait for the wound nurse practitioner to assess. The DON stated that the admitting nurse assesses and documents wounds and that the wound nurse then assesses within 24 hours, and she believed pressure injuries should be measured at the time of assessment. The DON also stated that without admission wound measurements, she could not determine if a wound had enlarged between admission and the wound nurse practitioner’s visit. The facility’s Wound Care Guidelines policy required wound assessment documentation to include, at a minimum, wound type, etiology, location, date, stage, and measurements (length, width, depth), along with wound bed, edges, exudate, undermining, tunneling, and wound-related pain, which was not followed for this resident’s bilateral buttock pressure injuries.
Failure to Maintain Bed Hardware Safely, Resulting in Resident Skin Tear
Penalty
Summary
The facility failed to ensure a resident’s bed was free from accident hazards when a bed was used without required plastic protective pieces on the metal frame. The resident involved had multiple diagnoses, including rheumatoid arthritis, chronic kidney disease, congestive heart failure, and several pressure ulcers, and had an ADL care plan indicating impaired mobility, pain, and a need for staff assistance with transfers. After providing a shower, a CNA transferred the resident back to bed and observed redness on the resident’s left lower leg. The CNA inspected both the shower chair and the bed and noted that square pieces in the middle of the bed frame were missing plastic protective covers. A subsequent Skin Alteration Nursing Evaluation documented a rear left lower leg skin tear for the resident later that same day. During a care plan meeting, the resident’s daughter reported that there were missing pieces on the bed and that the resident had scratched her leg on the bed. The Admissions Director acknowledged hearing from the Social Services Director that a resident’s bed needed to be replaced due to missing plastic protective pieces, and the Maintenance Assistant confirmed that two plastic protective pieces were missing from the center of the bed frame, leaving exposed metal squares. The Administrator stated that a resident’s bed should have all required pieces to ensure resident safety, confirming that the bed in use for this resident did not meet that standard at the time of the incident.
Failure to Promptly Report Allegation of Abuse
Penalty
Summary
Facility staff failed to promptly report a resident's allegation of abuse to the facility's abuse coordinator as required by facility policy. A resident with multiple medical conditions, including moderate cognitive impairment, blindness, and recent abdominal surgery, reported that during incontinence care, a CNA held her left wrist and would not let go when asked, causing her discomfort and prompting her to swat at the CNA. The resident recognized the CNA by her voice and reported the incident to her nurse the following morning, stating she felt rushed during care. The nurse who received the allegation did not report it directly to the abuse coordinator but instead relayed the information to her supervisor, the Assistant Director of Nursing (ADON). The ADON, in turn, discussed the matter with the Director of Nursing (DON) later in the day, after the resident's Power of Attorney also reported concerns. The Assistant Administrator only became aware of the allegation after the DON received a voicemail from the resident's Power of Attorney. The initial report to authorities and the start of the investigation were delayed until the Assistant Administrator interviewed the resident and determined an allegation of mental abuse had occurred. Interviews with the involved CNAs confirmed that the resident had complained of pain and asked for her wrist to be released during care, but the CNA continued to hold her wrist. Neither the CNA nor the assisting agency CNA reported the incident or the resident's complaints at the time. The facility's policy requires immediate reporting of all abuse allegations to the Administrator, but this protocol was not followed, resulting in a delay in both internal and external reporting of the suspected abuse.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to two residents, R4 and R5, who were dependent on staff for toilet hygiene. R4, an elderly female with intact cognition, was admitted on a specific date and was observed at 10:10 AM with a urine-soaked incontinent brief that had brownish discoloration. R4 reported that she had been changed at 4:30 AM and was waiting to be changed again. The CNA responsible for R4 stated that she started her shift at 6:00 AM and was delayed in providing care due to passing breakfast trays. R4's care plan required staff to check for incontinence every two hours and as needed. R5, another elderly female with severely impaired cognition, was observed at 10:15 AM with a urine and feces-soaked brief, also with dark brown discoloration. A CNA, who was not assigned to R5, was checking on her and noted the condition. R5's care plan similarly required checks every two hours and as needed. The Director of Nursing confirmed that the facility's policy was to provide incontinent care every two hours and as needed, and noted that prolonged exposure to moisture could lead to Moisture Associated Skin Dermatitis (MASD). The facility's policy on incontinent and perineal care, revised previously, mandated rounds every two hours to check for incontinence.
Failure to Follow Wound Care Orders for Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to adhere to physician orders for wound care management of a stage 4 sacral pressure ulcer in a resident with severe cognitive impairment. The resident was admitted with an unstageable sacral wound and additional wounds on both heels and the right knee. Upon observation, the wound care nurse did not follow the prescribed treatment plan, which included irrigating the wound with normal saline and using calcium alginate for packing. Instead, the nurse used saline-sprayed gauze for cleansing and hydrogel-moistened gauze for packing, deviating from the physician's orders. The wound care nurse practitioner had recommended the use of calcium alginate due to the moderate to heavy drainage observed in the wound, but the nurse did not implement this recommendation. The nurse cited a lack of individual saline vials and Cavilon spray as reasons for not following the prescribed wound care protocol. The Director of Nursing confirmed that the nurse should have followed the wound care orders as documented. The wound care nurse practitioner also noted that they could not enter orders into the system due to being from an outside agency, and the nurse was responsible for entering the orders under the physician's name.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to three residents who were dependent on assistance for activities of daily living, specifically toilet hygiene. Resident 2, a female with mild cognitive impairment, reported being changed at 5:00 AM and was found with a urine-soaked diaper at 10:05 AM, despite the care plan indicating checks every two hours. Similarly, Resident 3, also with mild cognitive impairment, was last changed at 4:30 AM and was found with a urine-soaked brief at 10:00 AM, with a care plan requiring checks every two hours. Resident 4, with severely impaired cognition, was found with a double diaper soaked in urine at 10:10 AM. The facility's policy, revised in June, mandates incontinent care rounds every two hours. Staff members acknowledged the requirement for two-hour checks and the need for more frequent care for residents on medications like Lasix or those who are heavy wetters. The observations and interviews indicate a failure to adhere to the established care plans and facility policy, resulting in inadequate care for the residents.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of prescribed narcotic medication, specifically Norco 5/325 mg. The resident, who has a history of dementia, alcohol dependence, bipolar disorder, and other medical conditions, was prescribed Norco for pain management. The medication was to be administered every six hours as needed. However, discrepancies were noted in the narcotic count sheet, indicating that more tablets were signed out than were actually administered to the resident. The incident was identified during a shift change narcotic count when it was discovered that both the Norco tablets and the narcotic count sheet were missing. The LPN on duty reported that the RN from agency staffing, who was responsible for the medication during the previous shift, had signed off on taking three tablets at specific times, which was unusual given the resident's routine of receiving the medication only once daily. The RN was the only staff member with access to the narcotic box during her shift, raising suspicions about her involvement in the misappropriation. Interviews with the staff involved revealed that the RN denied knowledge of the missing medication and count sheet, despite being the only one with access. The Assistant Director of Nursing was notified, and attempts to contact the RN were initially unsuccessful. The facility's incident report documented the misappropriation and the involvement of the local police and public health authorities, but the focus of the deficiency was on the failure to safeguard the resident's medication from wrongful use.
Failure to Sanitize Food Preparation Equipment
Penalty
Summary
The facility failed to ensure that food preparation equipment was properly sanitized before preparing food, which could potentially affect all 138 residents receiving food from the kitchen. During an observation, the chef was seen using a rag from a bucket containing only water with soap to wash food preparation items, including a food processor container, lid, blade, and spatula. These items were not sanitized or air-dried before being used to prepare pureed meals for the residents. The Food Service Director confirmed that the items should have been brought to the dish room for proper washing, rinsing, sanitizing, and air drying. The chef continued to use the un-sanitized equipment to prepare pureed broccoli and pasta, which were then served to the residents. The facility's Diet Type Report indicated that only one resident was NPO and did not receive food from the kitchen, meaning the unsanitized food preparation could potentially impact the remaining residents.
Failure to Implement Pressure Ulcer Prevention and Assessment
Penalty
Summary
The facility failed to ensure proper assessment and notification regarding a new wound for a resident, R98, who was at high risk for pressure ulcers. Despite having a history of severe pressure ulcers, R98's new sacral wound was not reported to the wound nurse practitioner, V13, who was unaware of the wound until much later. The wound, initially a skin tear, was not properly documented or assessed from 6/7/24 to 6/25/24, leading to its deterioration into a stage 2 to 3 pressure ulcer. The facility's Director of Nursing, V2, expected staff to report new wounds and ensure timely assessments, which did not occur in this case. Additionally, the facility did not implement pressure-relieving interventions for several residents at risk for pressure ulcers. R240 was observed with heels flat on the bed despite having an unstageable pressure injury and instructions to float heels with foam boots. Similarly, R105 and R121 were found with their heels resting directly on the mattress, contrary to their care plans that required heel elevation or the use of heel protector boots. These lapses in following care plans and facility guidelines contributed to the risk of pressure ulcer development or worsening. The facility's Wound Care Guidelines Policy, which mandates the elevation of heels and timely wound assessments, was not adhered to for the residents reviewed. The lack of consistent implementation of pressure-relieving measures and failure to notify the wound nurse practitioner of new wounds led to deficiencies in the care provided to residents at risk for pressure injuries.
Inconsistent Restorative Services and Documentation
Penalty
Summary
The facility failed to provide appropriate restorative services to residents, as evidenced by the lack of consistent range of motion (ROM) exercises and splint applications for several residents. Resident R28, who was previously able to ambulate with assistance, reported a decline in mobility and stated that he did not receive the prescribed exercises, such as standing with a walker or using an arm bike. The task history confirmed that these exercises were infrequently documented, indicating they were not regularly performed. Resident R14, who was supposed to receive active and active-assisted ROM exercises twice daily, also experienced inconsistencies in the provision of these services. The documentation for R14 showed multiple days without any recorded restorative services, suggesting a failure to adhere to the prescribed regimen. Similarly, Resident R79, diagnosed with hemiplegia, reported not receiving daily passive ROM exercises as ordered, with documentation missing for several days. Resident R5, who had contractures and required daily passive ROM and splint application, was found to have incomplete documentation for these services. The restorative aides were responsible for providing ROM and applying splints, but the records showed numerous days where these tasks were not documented. Interviews with staff confirmed that the restorative services were not consistently provided or recorded, contributing to the deficiency in care.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat a resident, identified as R9, in a dignified manner. On the morning of June 23, 2024, R9 activated his call light at approximately 6:20 AM, seeking assistance after soiling himself with stool and urine. Despite being alert and oriented, as confirmed by a Registered Nurse (RN), R9 did not receive help until after 8:20 AM, resulting in a two-hour delay. R9's Minimum Data Set indicated a BIMs score of 14, confirming cognitive intactness. His care plan, dated June 7, 2024, specified that he is always incontinent of bladder and bowel due to multiple sclerosis, with an intervention for staff to check him every two hours. However, there was no documentation of bowel charting on June 23, 2024. The facility's Privacy and Dignity policy, dated June 6, 2024, mandates that residents' privacy and dignity be respected at all times, which was not adhered to in this instance.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to ensure fall interventions were in place for two residents with a history of falls. For one resident, R108, observations revealed that the bed was not in the lowest position on multiple occasions, and the call light was either on the floor or not within reach. Despite the implementation of interventions such as a bed alarm, floor mats, and positioning the bed at the lowest level after a previous fall, these measures were not consistently maintained. The resident had previously fallen and sustained injuries, including a broken hip and leg. For another resident, R33, the bed alarm system was not properly set up. The sensor pad was found hanging behind the headboard and unplugged from the alarm box, contrary to the care plan that required a bed alarm to prevent falls. A Certified Nursing Assistant confirmed the improper setup of the bed alarm, which should have been placed under the resident and connected to the alarm box. The facility's Fall Prevention Program Guidelines emphasized the need for safety interventions for residents at risk of falls, including ensuring call devices are within reach and utilizing personal alarms when appropriate.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to ensure proper storage of nebulizer equipment to prevent cross-contamination for three residents. Observations revealed that one resident's nebulizer mask and tubing were stored in an open plastic bag dated over two months prior, indicating a lack of timely replacement. Another resident's nebulizer equipment was similarly stored in an open plastic bag with the same outdated date, and the resident confirmed occasional use of the nebulizer. A third resident's nebulizer mask was found touching a privacy curtain, without being stored in a plastic bag or dated, which further indicates improper storage practices. Interviews with a registered nurse confirmed that nebulizer tubing and masks should be dated and stored in plastic bags to prevent contamination, with orders typically requiring weekly changes. The facility's policy also mandates changing oxygen setups every seven days or as needed if heavily soiled. The failure to adhere to these protocols resulted in the improper storage and potential contamination of nebulizer equipment for the residents involved.
Failure to Reorder Resident's Morphine Prescription
Penalty
Summary
The facility failed to reorder a resident's medication, specifically morphine, which was necessary for pain management. The resident was observed waiting for the medication, and it was revealed that the pharmacy only sent 6 tablets instead of the prescribed 60 due to a requirement for an actual signature on the prescription. The Director of Nursing explained that the hospital's electronic signature was not sufficient for the pharmacy to fill the entire prescription. The resident's Medication Administration Record (MAR) indicated that the morphine was unavailable for two days, during which time the resident was given oxycodone for pain management. The Nurse Practitioner confirmed that the prescription could have been refilled over the weekend by a covering provider and eventually refilled the morphine prescription.
Inadequate PPE Use for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP). Specifically, two residents, one with a gastrostomy tube and another with an indwelling Foley catheter and a surgical wound, were not provided care with the required PPE. The care plans for both residents indicated that staff should use gowns and gloves during high-contact activities, such as dressing, bathing, and transferring. However, during observations, a certified nursing assistant (CNA) was seen providing incontinence care and repositioning one resident, and assisting another resident to a wheelchair, without donning a gown, although gloves were used. The facility's EBP policy, revised earlier in the month, mandates the use of gowns and gloves to reduce the transmission of resistant organisms during high-contact care activities for residents with medical devices or wounds. The infection preventionist confirmed that staff should wear both gloves and gowns when in contact with residents on EBP. Despite this policy, the CNA did not adhere to the guidelines, leading to a deficiency in infection control practices.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to dependent residents, as observed in four out of five residents reviewed for activities of daily living (ADL) care. Resident 1, a female with severely impaired cognition, was found with a soaked inner liner inside an incontinent brief at 9:22 AM, despite being checked at 6:20 AM and found dry. Resident 3, also with severely impaired cognition, was observed with a urine-soaked inner pad at 9:35 AM, even though her care plan required checks every two hours. Resident 4, with intact cognition, was found in bed with a double-layered incontinent brief soaked with urine at 9:42 AM, having last been changed at around 5:50 AM. Resident 5, with intact cognition, reported receiving personal care last at midnight and was found with a heavily soaked, blackish-colored incontinent brief at 9:52 AM, with urine and stool smeared all over her buttocks. The facility's policy requires incontinent care rounds every two hours, which was not adhered to in these cases. The Director of Nursing (DON) confirmed that staff are supposed to check and offer incontinent care every two hours and as needed. The facility's revised Perineal Care policy, dated 7/28/23, also mandates rounds at least every two hours to check for incontinence. Despite these policies, the observations and interviews indicate a failure to provide timely incontinent care, leading to residents being left in soiled briefs for extended periods. This deficiency highlights a significant lapse in adhering to the care plans and facility policies designed to ensure the well-being and hygiene of dependent residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who is dependent on staff received assistance with incontinence care. The resident, a [AGE] year-old male with diagnoses including hemiplegia and hemiparesis following cerebral infarction, morbid obesity, generalized anxiety, and major depression disorder, reported that on a specific night shift, he was not changed by the agency CNA from 10 PM to 6 AM. The resident pressed his call light multiple times in the morning, but it was not until after 6:00 AM that the day shift CNA responded and found him soaked with urine and stool, indicating he had not been changed since the night before around 8:30 PM. The resident's care plan requires staff to check for incontinence episodes every two hours, which was not adhered to by the agency staff on that night shift. Interviews with the facility's CNAs and the Assistant Director of Nursing (ADON) corroborated the resident's account. The day shift CNA confirmed finding the resident soaked and having to change the complete bed due to the extent of soiling. Another CNA mentioned that it was not uncommon to find residents not changed by agency staff when she started her morning shift. The ADON acknowledged that the resident had previously reported similar issues with agency staff and that the facility tries to assign regular staff to him due to his dissatisfaction with agency staff. The facility's policy mandates rounds at least every two hours to check for incontinence, which was not followed in this instance.
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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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