Bella Terra Schaumburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Schaumburg, Illinois.
- Location
- 675 South Roselle Road, Schaumburg, Illinois 60193
- CMS Provider Number
- 145678
- Inspections on file
- 27
- Latest survey
- December 10, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bella Terra Schaumburg during CMS and state inspections, most recent first.
The facility failed to monitor and assess a resident who lost 21 lbs in 14 days without re-weighing or assessment. Another resident under hospice care did not receive physician-ordered supplements, risking further weight loss. The facility lacked a weight loss/prevention policy, contributing to these deficiencies.
The facility failed to ensure residents and their representatives understood the Health Care Arbitration Agreement (HCAA) they signed, affecting four residents. A resident and a POA signed the HCAA without clear explanations of its implications, such as waiving legal rights. Staff responsible for presenting the HCAA were not formally educated on how to explain the agreement, and the facility lacked a policy on the arbitration agreement.
The facility failed to prevent resident-to-resident abuse involving two residents, where one resident verbally and physically assaulted another by grabbing his wrist, causing skin breakage. The incident was reported to the administrator and documented by an LPN, who found the residents in a heated exchange. The facility's policy mandates an abuse-free environment, which was not maintained.
The facility failed to provide written notices of hospital transfers to two residents or their representatives. Staff communicated verbally but did not send written notices, and the facility lacked a policy for such notifications.
The facility failed to notify residents or their representatives of the bed hold policy in writing during hospital transfers. In three cases, staff gave paperwork to EMTs but did not inform families, and there was no documentation of written notices. Interviews revealed a consistent practice of not informing families, despite the facility's policy requiring written notification.
A resident was diagnosed with schizophrenia without proper assessment, as required by professional standards. The diagnosis appeared on her face sheet two years after admission, despite not being listed in her admission hospital records. Interviews with facility staff revealed a lack of clarity and testing regarding the diagnosis, with the primary care physician and psych nurse practitioner both acknowledging the absence of a full psychiatric evaluation.
The facility failed to provide adequate ADL care for three residents requiring extensive assistance. A resident was found in the same clothes for four days with a saturated diaper, despite needing substantial assistance due to chronic conditions. Two other residents were left in reclining wheelchairs for extended periods without being toileted, contrary to their care plans and facility policy requiring regular incontinence checks.
A facility failed to implement a resident's skin preventive treatment as ordered by the physician. During a bed bath, a CNA found the resident's diaper saturated with urine and the coccyx red with a small open area, noting the absence of a usual dressing. Wound care nurses later confirmed the condition as MASD, with preventive treatment orders in place to prevent skin breakdown. The resident, on hospice care and bedridden, had orders for calamine-zinc oxide lotion, duraseptine with xeroform, and xeroform oil emulsion gauze to be applied every shift.
Two residents developed significant pressure injuries due to the facility's failure to report and identify skin alterations in a timely manner. One resident developed an unstageable pressure injury on the coccyx, while another developed a stage 2 ulcer on the heel, despite having protective measures in place. Both residents required assistance with personal care and had care plans indicating potential skin integrity issues.
A resident with a high fall risk was left unattended on the toilet, leading to a deficiency in safety supervision. The resident, not alert and oriented, was heard calling for help with no staff present. An agency CNA admitted to leaving the resident alone, and both a CNA and an LPN confirmed that the resident should not be left unattended due to her fall risk. The resident's fall risk score was 15, indicating a high risk according to the facility's evaluation.
A resident with a history of UTI did not receive prescribed catheter care, including Betadine application and catheter flush, as documented in their Treatment Administration Record. The DON confirmed these interventions were necessary to prevent infection, but documentation was missing for specific dates, indicating a lapse in care.
A discrepancy was found in the inventory of controlled medications for a resident, where 22 doses of methadone were available instead of the 23 documented. A nurse incorrectly documented the administration, skipping an entry. The facility's policy requires accurate counts and immediate reporting of discrepancies, which was not followed.
A facility failed to implement pharmacy recommendations for a resident's psychotropic medications after the physician agreed to a gradual dose reduction. Despite the consultant pharmacist's recommendation and the physician's agreement, the resident's medication orders were not adjusted. The psychotropic nurse admitted that clarification on the specific dose was needed but not obtained.
A facility failed to implement a gradual dose reduction (GDR) for a resident's psychotropic medications, despite a consultant pharmacist's recommendation and physician agreement. The resident continued receiving the same dosages of sertraline and quetiapine for several months, contrary to federal regulations and the facility's policy. The psychotropic nurse admitted that the necessary dosage adjustments were not clarified or implemented in a timely manner.
A resident with multiple diagnoses, including Parkinson's disease and major depressive disorder, was found holding a medication cup with 7-10 pills and a pill on her bed, indicating improper medication administration and storage. The RN acknowledged the resident's habit of taking medications slowly and stated that staff should monitor until all medications are ingested, as per facility policy.
The facility failed to follow proper infection control practices during perineal care for two residents. CNAs did not change gloves or perform hand hygiene after cleaning soiled areas, violating the facility's policies. These actions were observed during care for a resident with a history of COVID-19 and another resident after a bowel movement.
A resident was prescribed Keflex for recurrent UTI prophylaxis without proper documentation or physician notes until several months after the medication was started. The Assistant DON confirmed the prescription, but the facility failed to provide documentation justifying the use of the antibiotic, despite having an infection surveillance checklist in place.
A resident with dementia and severe cognitive impairments sustained a laceration requiring 13 sutures during a transfer with a mechanical lift. The incident occurred when the resident kicked her leg, hitting the lift, while two CNAs were assisting. The resident's care plan required two staff for transfers due to poor safety awareness.
A resident with dementia and major depression disorder physically assaulted two other residents in the dining room. The incident, witnessed by a CNA, involved the resident slapping one resident multiple times and hitting another in the head with a fist. The facility's records confirmed the aggressive behavior, and the resident was sent to a hospital for increased aggression. The facility's policy mandates an environment free from abuse, but it failed to prevent this incident.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and assess a resident, identified as R137, who experienced significant weight loss. Upon admission, R137 weighed 145.6 lbs, but over a period of 14 days, she lost 21 lbs without being re-weighed or assessed. Despite having a history of weight loss and a diagnosis of dementia, depression, and other conditions, the facility did not conduct weekly weights as required for new admissions. The resident's food intake was inconsistent, and she was not seen by a dietitian until 20 days after admission, despite her poor intake and significant weight loss. Additionally, the facility failed to provide physician-ordered nutritional supplements to another resident, identified as R118, who was under hospice care and had experienced a significant weight loss of 10.5% over six months. The resident was supposed to receive a magic cup at lunch and dinner as part of their dietary plan, but this was not provided on two observed occasions. The lack of adherence to the dietary plan could potentially exacerbate the resident's weight loss. The facility did not have a weight loss/prevention policy in place, which contributed to the oversight in monitoring and addressing the nutritional needs of residents R137 and R118. The absence of such a policy likely led to the failure in providing necessary interventions and monitoring to prevent further weight loss in these residents.
Failure to Ensure Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents and/or their representatives understood the Health Care Arbitration Agreement (HCAA) they were signing, which affected four residents in a sample of 30. Resident R251, who was cognitively intact, signed the HCAA without a clear explanation of its implications, such as waiving the right to legal assistance. Similarly, R20's Power of Attorney (POA) signed the HCAA without understanding its significance due to a lack of explanation and time to review the document. R73, with moderate cognitive impairment, also signed the HCAA without a clear understanding of its terms, and R144, who was cognitively intact, misunderstood the nature of the arbitration agreement, thinking it involved a committee rather than waiving legal rights. The staff responsible for presenting the HCAA, including the Guest Services Director and Admissions Director, were not formally educated on how to properly explain the agreement to residents. The facility lacked a policy on the arbitration agreement, and the staff had not seen the educational materials provided by the facility. The education packet highlighted factors that could render the HCAA unconscionable, such as issues with age, literacy, or the manner in which the contract was presented, emphasizing the importance of ensuring the signer understands the terms without being rushed.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident verbal and physical abuse, specifically involving two residents. On the afternoon of November 19, 2024, one resident reported that another resident cursed at him, rolled over in his wheelchair, and grabbed his left wrist with a strong grip, causing skin breakage without bleeding. An X-ray was conducted, revealing no fractures. The two residents reportedly did not get along well, which may have contributed to the altercation. The incident was reported to the facility administrator by a nurse, who was informed of the yelling and wrist-grabbing incident. A Licensed Practical Nurse (LPN) was alerted by a CNA about the yelling and found the two residents in a heated exchange, with one resident holding the other's wrist. The LPN noted difficulty in understanding the aggressor's speech, but identified words related to the TV being loud. Progress notes for both residents documented the altercation, with one resident's care plan indicating a history of unclear speech and the other being alert and oriented. The facility's Abuse and Neglect Policy, revised in July 2024, mandates an environment free from abuse, which was not upheld in this instance.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to notify residents or their representatives in writing of transfers to the hospital, as required. This deficiency was identified in two cases. In the first case, a resident was transported to the emergency room, and their Power of Attorney was informed of the hospital admission only after the transfer occurred, with no written notice provided. In the second case, another resident was admitted to the hospital without any documentation of written notice being given to the resident or their representative. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing, revealed that while verbal communication with families occurred, written notices were not provided. The facility also lacked a policy addressing the requirement for written notification of transfers.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives of the bed hold policy in writing during transfers to the hospital or therapeutic leave. This deficiency was identified in three cases out of a sample of thirty residents. In the first case, a registered nurse (RN) caring for a resident who was transferred to the hospital in February admitted to giving the paperwork to the EMTs but could not recall notifying the family about the bed hold policy. The RN also could not find any documentation indicating that the family was informed. In the second case, a resident's progress notes indicated that the resident was transported to the emergency room, and the power of attorney was informed of the hospital admission, but there was no documentation of a written bed hold policy being provided. Similarly, in the third case, the facility was unable to provide documentation of a written notice regarding the resident's transfer to the hospital or the bed hold policy. Interviews with various nursing staff, including RNs and an LPN, revealed a consistent practice of giving bed hold policy paperwork to paramedics upon resident transfer, but not necessarily informing the family about the bed hold policy. The Director of Nursing confirmed that a hard copy of the transfer was not sent to the family, and the facility's policy, revised in July, stated that the resident or family must be informed of the bed hold duration in writing. This lack of documentation and communication with the residents' families regarding the bed hold policy constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Properly Assess Resident for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was properly assessed before being diagnosed with a serious mental illness, specifically schizophrenia, according to professional standards of practice. The resident, identified as R99, was admitted to the facility without a diagnosis of schizophrenia, as confirmed by her admission hospital records. However, two years after admission, schizophrenia was added to her face sheet as a diagnosis. Interviews with the psychotropic nurse and the primary care physician (PCP) revealed a lack of clarity on how this diagnosis was made. The psychotropic nurse, who began handling psychotropics in May of the current year, was unaware of the origin of the diagnosis. The PCP assumed the resident came with the diagnosis and admitted to not conducting any testing to confirm it. Further interviews with the psych nurse practitioner, who has been seeing the resident since February of the current year, indicated that the resident has a diagnosis of dementia, which could explain her behaviors. The nurse practitioner acknowledged that schizophrenia is a significant diagnosis that typically requires a full psychiatric evaluation and extensive testing, which had not been performed for this resident. The resident's face sheet also lists other diagnoses, including dementia, bipolar disorder, psychotic disorder with delusions, generalized anxiety disorder, delusional disorders, and major depressive disorder, none of which were confirmed to include schizophrenia upon her admission.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for residents requiring extensive assistance. Resident R59's family reported that he was not receiving timely care, including changing clothes and adult diapers. Observations confirmed that R59 was in the same clothes for four days, and his diaper was saturated with urine. His care plan indicated he required substantial assistance for dressing and toileting due to multiple chronic conditions, including cognitive impairment and mobility issues. Resident R118 was observed sitting in the same spot in a reclining wheelchair for extended periods without being toileted. His care plan required dependent assistance for toileting due to cognitive impairment and mobility limitations. Similarly, Resident R49 was left in a reclining wheelchair without being toileted, despite needing dependent assistance for toileting due to various chronic conditions. The facility's policy required rounds every two hours to check for incontinence, which was not adhered to, leading to these deficiencies.
Failure to Implement Skin Preventive Treatment as Ordered
Penalty
Summary
The facility failed to ensure that a resident's skin preventive treatment was in place according to physician orders. This deficiency was identified during an observation on November 18, 2024, when a hospice CNA was giving a bed bath to a resident whose adult diaper was saturated with urine, and the resident's coccyx was red with a small superficial open area. The CNA noted that there was usually a dressing on the coccyx, but it was absent that day. On the following day, two wound care nurses confirmed that the resident did not have any open pressure injuries on the coccyx, describing the condition as moisture-associated skin damage (MASD). The resident, who was on hospice care and bedridden, had preventive treatment orders to prevent skin breakdown or pressure injuries. The treatment administration record for November 2024 indicated orders for calamine-zinc oxide lotion, duraseptine with xeroform, and xeroform oil emulsion gauze to be applied to the coccyx/buttocks every shift for skin breakdown prevention.
Failure to Prevent and Identify Pressure Injuries
Penalty
Summary
The facility failed to report and identify a pressure injury in a timely manner for two residents, leading to the development of significant pressure injuries. Resident R137, who had diagnoses including dementia and required assistance with personal care, developed an unstageable pressure injury on her coccyx. The initial wound assessment indicated that the injury was facility-acquired and unstageable, measuring 3 cm by 5 cm. It was noted that the resident was incontinent and should have been changed every shift, which could have prevented the injury from becoming unstageable. The care plan for R137 indicated a potential for skin integrity issues, but the injury was not identified until it was already severe. Resident R118, who also required assistance with personal care and had a history of depression and COPD, developed a stage 2 pressure ulcer on his left heel. The wound assessment showed that the injury was facility-acquired and resulted from the resident's heel resting on the footrest of his wheelchair. Despite having heel protector boots, the injury occurred, indicating a failure to properly offload pressure from the heel. The care plan for R118 included the use of boots to offload heel areas, but this intervention was not effectively implemented, leading to the development of the pressure ulcer.
Failure to Supervise High Fall Risk Resident on Toilet
Penalty
Summary
The facility failed to adequately supervise a resident with a known history of falls while she was on the toilet, leading to a deficiency in safety supervision. On November 17, 2024, at 2:20 PM, the resident was heard shouting for help while sitting on the bathroom toilet, holding the grab bar, with no staff present in the room, bathroom, or hallway. An agency CNA admitted to placing the resident on the toilet and acknowledged that the resident was not alert and oriented. Another CNA confirmed that staff should not leave the resident alone on the toilet due to her fall risk, and an LPN reiterated that the resident should not be left unattended because of her fall risk. The resident's Fall Risk Evaluation, dated April 1, 2024, indicated a high fall risk score of 15, where a score of 8 and above is considered high risk according to the facility's reference range.
Failure in Catheter Care for Resident with UTI History
Penalty
Summary
The facility failed to provide appropriate catheter care interventions for a resident with a history of urinary tract infection (UTI). The resident was observed with a urinary catheter in place, and the Director of Nursing (DON) confirmed that catheter care, including catheter flush and application of Betadine, should be performed every shift to prevent infection. However, the Treatment Administration Record (TAR) for the resident showed missing documentation for catheter care, Betadine application, and catheter flush on specific dates, indicating a lapse in the prescribed care routine.
Controlled Medication Discrepancy
Penalty
Summary
The facility failed to ensure accurate documentation and inventory of controlled medications for a resident. During a medication administration observation, it was noted that there were 22 physical doses of methadone available for a resident, while the Individual Controlled Substance Record indicated there should have been 23 doses. The discrepancy occurred when a registered nurse administered a dose of methadone and incorrectly documented the entry, skipping the 23rd dose and signing out the administered dose on the next line. The facility's policy requires a physical inventory of all controlled substances by two licensed personnel at each shift change or when keys are transferred, with any discrepancies reported immediately to the Director of Nursing. However, the discrepancy in the methadone count was not immediately addressed, indicating a lapse in adherence to the facility's Controlled Substance Storage Policy.
Failure to Implement Agreed Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed after being agreed upon by the physician for a resident reviewed for psychotropic medications. The consultant pharmacist recommended a gradual dose reduction (GDR) for the resident's psychotropic medications, quetiapine and sertraline, on August 2, 2024. The physician agreed with these recommendations on September 24, 2024. However, the resident's order summary report dated November 20, 2024, showed no orders for the medications at a reduced dose. The psychotropic nurse, responsible for addressing medication recommendations, acknowledged that she or the floor nurse should have clarified the specific dose the doctor intended to prescribe after agreeing to the GDR.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the gradual dose reduction (GDR) of psychotropic medications for a resident, identified as R94, who was part of a sample of 30 residents reviewed for unnecessary psychotropic medication use. The consultant pharmacist recommended a reevaluation and consideration for GDR of R94's medications, quetiapine and sertraline, due to potential side effects such as drowsiness, increased risk of falls, and hypotension. The physician agreed with these recommendations; however, the facility did not implement the GDR in a timely manner. R94 continued to receive the same dosages of sertraline and quetiapine from September through November, despite the physician's agreement to the pharmacist's recommendations. The psychotropic nurse acknowledged that they should have clarified the physician's intended dosage adjustments and implemented them promptly. The facility's policy on psychotropic medications, revised in August, mandates adherence to federal regulations, which was not followed in this instance.
Medication Administration and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for a resident, identified as R123, who was part of a sample of 30 residents reviewed for medication storage. R123 was admitted with multiple diagnoses, including Parkinson's disease, major depressive disorder, and rheumatoid arthritis, among others. On November 18, 2024, it was observed that R123 was holding a medication cup with 7-10 pills and had a small yellow pill on her bed mattress. R123 reported that these were her morning medications, which she intended to take later with food. This indicates that the medications were not administered at the time they were prepared, as per the facility's policy. The Registered Nurse (RN), identified as V6, acknowledged that R123 often takes a long time to consume her medications, preferring to take them one at a time with food in between. V6 stated that staff should monitor the resident until all medications are ingested and that if a resident requests to take medications later, they should be taken away and re-administered at a later time. The facility's Medication Administration General Guidelines policy requires that medications be administered at the time they are prepared and that the resident is observed to ensure the dose is completely ingested. The failure to adhere to these guidelines resulted in the deficiency noted in the report.
Infection Control Lapses During Perineal Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during perineal care for two residents, R80 and R137. R80, who has a history of COVID-19, urinary tract infection, and is always incontinent of bowel and bladder, was observed receiving perineal care from CNAs V5 and V7. During the procedure, V7 did not change gloves or perform hand hygiene after wiping stool from R80's perineal area before assisting her to turn, which is against the facility's hand hygiene and perineal care policies. These policies require changing gloves and performing hand hygiene to prevent cross-contamination when moving from soiled to clean areas. Similarly, CNA V15 was observed changing R137's adult diaper after a bowel movement and failed to remove gloves or wash hands after cleaning the resident. Instead, V15 continued to adjust the resident's pillow, cover her, and lower the bed without performing hand hygiene. This action also violated the facility's hand hygiene policy, which mandates hand hygiene before and after assisting a resident with toileting and after contact with body fluids. These lapses in infection control practices were confirmed through interviews with the Infection Control Nurse and a review of the facility's policies.
Unnecessary Antibiotic Prescription for a Resident
Penalty
Summary
The facility failed to ensure that a resident was not prescribed an unnecessary antibiotic, specifically affecting one of the five residents reviewed for unnecessary medications in a sample of thirty. The resident, identified as R128, was prescribed Keflex Oral Capsule 250 MG for recurrent urinary tract infection (UTI) prophylaxis, starting on March 29, 2024. However, there were no physician notes or documentation regarding the initiation of this medication until November 20, 2024, when a progress note mentioned recurrent urinary tract issues and the use of Keflex. The Assistant Director of Nursing confirmed that the resident was on the medication for recurrent UTIs, but the facility did not provide any documentation prior to November 20, 2024, to justify the prescription. The facility's infection surveillance checklist, dated August 8, 2024, indicated the use of the McGreer Criteria Checklist for infection prevention and control, but this was not reflected in the documentation for R128.
Resident Injury During Transfer Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a significant injury. The resident, who was diagnosed with dementia, malnutrition, and peripheral venous insufficiency, had severe cognitive impairments and was dependent on staff for transfers. The care plan indicated that the resident required assistance from two staff members for transfers due to poor safety awareness and impulsiveness. During a transfer from a shower chair using a mechanical lift, the resident kicked her left leg, hitting the lift and sustaining a laceration that required 13 sutures. The incident occurred while two CNAs were assisting with the transfer; one was moving the lift, and the other was guiding the resident. The resident's medical history included a previous hematoma on the left leg, which was noted a day before the laceration incident. The hematoma was discovered during a transfer and was attributed to trivial trauma. On the day of the incident, the resident was not following directions and was known to become agitated during care. The wound care nurse confirmed the laceration and hematomas were sustained during the transfer, and the resident was subsequently sent to the emergency room for treatment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' right to be free from resident-to-resident physical abuse. On 3/16/24, a resident with dementia and major depression disorder, identified as R1, physically assaulted two other residents, R2 and R3, in the dining room. According to staff interviews, R1 slapped R2 in the head multiple times with an open hand and then hit R3 in the back of the head with a fist. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the contact was not accidental. R1 was subsequently sent to a local hospital for increased aggression. The facility's records, including progress notes and a Change in Condition Note, confirmed the aggressive behavior of R1. The facility's Abuse and Neglect policy, reviewed on 7/14/23, mandates an environment free from any type of abuse, including physical abuse such as hitting and slapping. Despite this policy, the facility failed to prevent the physical abuse incident involving R1, R2, and R3, thereby not ensuring a safe environment for its residents.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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