Bethany Rehab & Hcc
Inspection history, citations, penalties and survey trends for this long-term care facility in Dekalb, Illinois.
- Location
- 3298 Resource Parkway, Dekalb, Illinois 60115
- CMS Provider Number
- 145958
- Inspections on file
- 57
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Bethany Rehab & Hcc during CMS and state inspections, most recent first.
A resident with impaired balance and multiple comorbidities, including COPD, type 2 DM, HTN, low back pain, osteoarthritis, and psychiatric disorders, reported that CNAs on night shift lifted her under the arms during a transfer instead of using a gait belt as required by her care plan and the facility’s gait belt policy. The resident’s grievance indicated she was upset by the incident, though she had no injuries. In interviews, a PTA confirmed that a gait belt should be used for one-person or two-person assists because a resident could lose balance, and the administrator acknowledged that a CNA had transferred the resident by holding her under the arms rather than using a gait belt, contrary to policy, resulting in a cited deficiency for not ensuring the area was free from accident hazards and that adequate supervision and assistive devices were used to prevent accidents.
Surveyors found that nursing staff did not consistently administer medications as ordered or within the facility’s required time frames for several residents. One resident with seizure disorder and HTN did not receive scheduled morning meds on time, and an antihypertensive was inappropriately held despite ordered parameters. Another resident with neurologic conditions received scheduled meds late. A resident with diabetic retinopathy lacked the ordered eye vitamin because it was not available. A resident with polycythemia vera and cardiac conditions received multiple meds over an hour late, with incorrect doses of cyanocobalamin, hydroxyurea, and Mucinex, an ordered beta-blocker was held without parameters, and ordered eye drops were unavailable. Another resident with DM, GERD, and HTN received morning meds significantly late. The regional nurse consultant confirmed that meds are to be given within one hour of the scheduled time and only held per MD parameters.
The facility failed to provide care-planned ADL assistance with personal hygiene and grooming for three residents who required staff help. One resident with multiple chronic conditions and an ADL self-care deficit was observed with long chin hair and stated she needed and preferred shaving, despite a care plan directing staff to assist with this task. Another resident with significant physical and mental health issues and a hand contracture was seen with facial hair and reported having asked staff to shave her chin. A third resident with neurologic and cognitive conditions, wearing a hand splint, had long, untrimmed fingernails with visible debris and expressed a desire for shorter nails. A regional nurse consultant stated CNAs are responsible for shaving and nail care (with nurses trimming nails for diabetic residents), and the facility’s ADL policy requires care to be provided according to individualized care plans, which did not occur in these cases.
Surveyors observed a med pass in which two residents did not receive medications as ordered, resulting in a 28% med error rate. For one resident with complex cardiac, hematologic, and neurologic conditions, an RN administered multiple morning meds more than one hour late, gave significantly reduced doses of cyanocobalamin and hydroxyurea, held metoprolol without any MD-ordered parameters, gave a lower dose of Mucinex than ordered, administered diltiazem late, and reported that ordered eye drops were not available. For another resident with DM and diabetic retinopathy, an RN reported that ordered Preservision eye vitamins were not available. The Regional Nurse Consultant stated that meds should be given within one hour of the scheduled time, only held per MD parameters or after MD contact, and that artificial tears and eye vitamins were believed to be stock items or should be ordered from the pharmacy, while facility policy requires meds to be administered per established schedules.
Two residents experienced significant medication errors when an RN failed to follow physician orders and established administration times. One resident with epilepsy and hypertension had an ordered antihypertensive held even though BP parameters to hold the drug were not met, and the morning medications were delayed. Another resident with polycythemia vera, HF, AFib, and HTN received a chemotherapy agent at a reduced dose, had a beta-blocker inappropriately held despite no hold parameters, and received a calcium channel blocker more than an hour late. Facility policy required medications to be given according to established schedules, and leadership confirmed that medications should only be held per MD parameters and that late doses should be reported.
A resident with a history of falls and prior femur fracture fell in the bathroom while being assisted by a CNA, and staff documented notifying the ADON and a practitioner, but did not clearly identify or document timely notification of the primary MD or the practitioner’s response. The MD later learned of the fall directly from the resident during a routine visit and reported that he had not been notified by the facility of either the fall or the subsequent hospital transfer after imaging revealed a fracture. Record review confirmed a hospital transfer form listing the MD as primary, but no progress note showed that he was informed of the transfer, contrary to the facility’s own condition change and notification policy.
A resident with a history of left femur fracture, weakness, and prior falls fell in the bathroom while being assisted by a CNA, landing on the left side. An RN initially assessed the resident and documented no apparent injury, but the next day another RN found the resident moaning with facial grimacing, left knee pain, and a bruise, and left an urgent message for the physician without receiving a timely response. During a subsequent routine visit, the MD learned of the fall, noted ongoing left lower extremity pain with no imaging completed, and ordered STAT x‑rays of the left hip, femur, and knee, which nursing documented as processed through a mobile diagnostic provider. Staff reported that the STAT imaging was not performed until the following day, when x‑rays revealed an acute subcapital left femoral neck fracture, demonstrating a delay in obtaining ordered diagnostic testing and timely evaluation after the fall.
Two residents experienced deficiencies in care: one with CHF did not have daily weights obtained as ordered, resulting in significant weight gain and hospitalization, while another who fell and fractured a clavicle did not receive timely X-ray or immobilization, leading to delayed pain management and intervention. Staff interviews confirmed missed documentation, lack of follow-up, and absence of required policies.
The facility did not consistently provide enough nursing staff to meet resident care needs, resulting in repeated staffing shortages across multiple shifts. Residents reported long waits for call light responses, missed hygiene care, and delayed meals, with some experiencing incontinence episodes due to delayed assistance. Staff interviews and documentation confirmed that care was often delayed or missed when the facility was short staffed, and there was no formal policy for call light response times.
The facility did not provide palatable meals, as evidenced by a meal that lacked required ingredients and flavor, resulting in resident complaints about taste and food quality. Staff confirmed missing ingredients and restrictions on adding flavor, while multiple residents reported ongoing dissatisfaction with meal options and taste.
The facility did not fully complete infection surveillance reports, failed to implement physician-ordered contact isolation for a resident with a multidrug-resistant infection, and allowed unsanitary wound care practices, including lack of hand hygiene and use of unclean instruments during dressing changes. These deficiencies were confirmed by facility leadership and observed during care.
Three dependent residents did not receive scheduled showers or bed baths as ordered, with documentation and resident interviews confirming missed care events and lack of follow-up after refusals. Residents were observed with poor hygiene, and multiple grievances had been filed regarding missed ADL care. Staff acknowledged the importance of regular hygiene and ADL assistance, but records showed these were not consistently provided.
A resident with dementia and other medical conditions attempted to elope from the facility and was returned after activating the front door alarm. The LPN on duty redirected the resident but did not notify the DON or update the care plan to reflect the new elopement risk. The care plan was not revised until after a subsequent elopement, despite facility policy requiring immediate documentation and intervention for behavioral changes.
A resident with dementia and other medical conditions, who was known to self-propel in a wheelchair and actively seek exits, was able to elope from the facility through the front door. Staff returned the resident quickly, but did not immediately notify the DON or update the care plan, resulting in delayed interventions and a second elopement. Facility policies for elopement response and documentation were not followed, and supervision was inadequate to prevent repeated incidents.
A resident requiring assistance with activities of daily living, including incontinence care, was left without timely care after a bowel movement, waiting several hours before being cleaned. Staff interviews confirmed delays due to staffing issues and workload, resulting in the resident remaining soiled for an extended period.
Multiple residents with significant care needs, including those with hemiplegia and quadriplegia, experienced long delays in call light response and personal care due to insufficient staffing. Staff and DON interviews confirmed that call-ins and staffing shortages led to delays in care, with residents reporting inconsistent staff presence and extended wait times. Resident Council Minutes also documented ongoing dissatisfaction with call light response times and staff rounding.
Two residents did not receive wound care and assessments as ordered, resulting in missed dressing changes, lack of documentation, and failure to identify new or worsening wounds. One resident was hospitalized with wound infections after repeated missed dressing changes and lack of assessment, while another was found with an uncovered back wound and an unreported deep tissue injury on the toe. Facility staff did not consistently follow protocols for wound care, assessment, and documentation.
Surveyors found that the facility did not label or date multiple prepared food items, including bread, containers of food in the refrigerator, and a dialysis lunch bag. A cook confirmed these items should have been labeled, and an administrator at the dialysis facility reported finding a moldy sandwich in a resident's bag, which was the only sandwich present.
A resident with a history of right hip fracture and chronic pain was subjected to rough handling by two CNAs during morning dressing for dialysis, despite repeatedly expressing pain and asking staff to be careful. The CNAs continued care without stopping or seeking a nurse's assessment, and the incident was witnessed by the resident's roommate and later reported to the dialysis center. The facility's DON confirmed that staff should have stopped care when pain was reported, and the administrator did not fully interview the roommate witness.
A resident with multiple risk factors for pressure ulcers did not receive timely wound assessments or consistent wound treatments, and staff failed to ensure the pressure-relieving mattress was set according to the resident's weight. Documentation of wound care and monitoring was incomplete, and facility policy for immediate assessment and provider notification was not followed.
A resident with COVID-19, dementia, and anxiety was not provided with adequate ADL care before being transferred to the hospital. The LPN focused on the resident's low oxygen saturation and arranged for hospital transfer, assuming CNAs would ensure the resident was clean and dry. However, the CNA did not change the resident's incontinent pad from 2 PM until after 6 PM, leading to the resident being transferred in a soaked state. The ADON confirmed residents should be toileted every two hours and be clean before hospital transfers.
A resident with a documented full code status experienced cardiac arrest after possible aspiration, but facility staff, including an LPN, RN, and CNA, failed to initiate CPR prior to EMS arrival. Staff either did not recognize the resident's code status or assumed a DNR, resulting in a delay in life-saving interventions. Paramedics initiated CPR upon arrival, but it was discontinued after family request and physician approval. The delay led to the resident's death.
A resident with severe cognitive impairment, facial burns, and documented swallowing difficulties was left to be fed by untrained family members without staff supervision, despite clear care plan and therapy recommendations requiring staff assistance and specific swallow precautions. The resident aspirated during the meal, became unresponsive, and died in the facility after emergency intervention.
A resident with a history of falls and weakness was injured during a transfer from a wheelchair to a bed. The CNA did not properly assist the resident, resulting in a fall and a distal femur fracture. The facility lacked a specific policy for gait belt transfers, relying on best practices that were not followed.
A resident with a history of pain management issues reported missing doses of Norco, a narcotic pain medication. The facility's records showed discrepancies between the Individual Resident Controlled Substance Record and the medication administration record, with missing documentation on several dates. The DON confirmed the expectation for accurate documentation, as per the facility's controlled substance policy.
The facility failed to maintain the emergency supply cart for 52 residents, with an empty oxygen tank found during a check. Additionally, a resident with CHF did not have physician-ordered daily weights consistently recorded, leading to a significant weight gain without timely notification to the physician. Staff confirmed the oversight, and the facility's policies were not followed.
A resident, admitted after a fall with a facial fracture, did not receive adequate hygiene care during her stay, receiving only one shower despite being cognitively intact and requiring assistance. Her family repeatedly requested showers, but staff failed to comply, leading to threats of leaving against medical advice. The facility's resident council noted similar concerns about CNAs lacking time for showers, and the DON was unaware of the issue.
A resident's catheter bag was not emptied in a timely manner, leading to discomfort. The resident, who drinks a lot of water, required more frequent emptying of the catheter bag than once per shift. Despite this need, the bag was found full on multiple occasions, including during rounds by the administrator. The DON stated that catheter bags should be emptied at least once per shift or as needed.
A resident with recent fractures did not receive prescribed oxycodone until late in the evening due to medication access issues, despite high pain scores. The LPN administered alternative pain medications while waiting for the oxycodone, which was eventually accessed by another nurse. The DON acknowledged the need for timely administration of pain medication.
A resident with a positive TB test and abnormal chest X-ray was transferred to a hospital without proper documentation or communication. The facility failed to document the necessity of the transfer and did not send essential paperwork with the resident. Staff interviews revealed a lack of communication with the hospital and no policy for facility-initiated discharges.
A resident was transferred to a hospital without receiving a bed hold notice, as required by the facility's policy. Despite the facility's Bed Hold Policy mandating notification and agreement for each hospital or therapeutic leave, staff interviews confirmed that no notice was given to the resident or their representative.
A resident's store credit card and debit card were stolen from her room, leading to unauthorized charges totaling approximately $1,200. The resident, who required assistance for daily activities, was very distraught upon discovering the theft. The facility's records did not document the incident, and staff were unaware of the resident having these cards. An investigation confirmed the abuse, substantiated by fraudulent charges.
The facility failed to properly identify, assess, and treat pressure injuries for several residents, leading to the development and worsening of ulcers. One resident developed multiple pressure injuries due to inadequate preventive measures, while another experienced a reopening of a stage 3 ulcer without timely assessment or treatment. Additional deficiencies included improper wound care and equipment failures, highlighting systemic issues in pressure ulcer management.
The facility failed to manage pain effectively for two residents. One resident with metastatic breast cancer experienced severe pain due to a delay in receiving oxycodone, caused by miscommunication and access issues. Another resident did not receive a scheduled Lidoderm patch on time, resulting in unmanaged pain. The facility lacked a specific pain management policy, contributing to these deficiencies.
A dietary aide failed to follow proper food handling practices, leading to potential cross-contamination during meal service. The aide touched various surfaces without changing gloves and used her gloved fingers to wipe coleslaw from a scoop before serving it to residents. This was against the facility's policy, and four residents were served the potentially contaminated coleslaw.
The facility failed to properly cohort Covid-19 positive and negative residents, with positive residents sharing rooms with negative ones, contrary to guidelines. Additionally, an LPN did not adhere to PPE protocols, wearing only a surgical mask instead of the required N95 mask and face shield when entering isolation rooms.
A resident's dignity was compromised following a room transfer, as observed by a surveyor. The resident's bed was positioned against the wall, obstructing access to their nightstand and digital clock. They lacked a television remote and their breakfast trash was not removed despite requests. The resident also reported being denied a blanket when cold. The ADON confirmed the room transfer was a group effort by CNAs, and the resident's care plan preferences were not accommodated.
A resident with Spina Bifida and a left below-knee amputation did not receive adequate ADL care, including incontinence care and showers. The resident was found with stool and urine on her body and bed linens, and CNAs were unsure when care was last provided. An LPN noted complaints about the night CNA, and the facility lacked an ADL policy.
A resident with psoriasis did not receive her prescribed Ketoconazole shampoo treatment due to a broken shower chair, resulting in only two out of six treatments being administered. The resident reported not having her hair washed in three weeks, and staff confirmed the lack of proper hair washing due to the equipment issue.
A facility failed to implement fall interventions for a high-risk resident with dementia and mobility issues. The resident was observed without a required floor mat next to his bed, contrary to his care plan. Staff confirmed the resident's fall risk and the need for the mat, but it was not in place, violating the facility's Falls Policy.
A resident with significant weight loss was not provided fortified potatoes during a noon meal, despite a history of hemiplegia, dysphagia, and chronic kidney disease. The dietitian confirmed the resident should receive fortified foods, but they were not listed in the physician order sheets. The resident's weight records showed a significant weight loss, classifying him as underweight.
The facility failed to label insulin with an opened date for three residents, as observed during a survey. Insulin vials and pens were found opened but not dated, contrary to the facility's policy requiring labeling per manufacturer's guidance. An LPN confirmed the oversight, which involved specific insulin regimens for diabetes management.
Two residents experienced significant issues due to improper catheter management in an LTC facility. One resident suffered from bleeding and pain due to a malfunctioning catheter that was not adequately assessed or managed by the nursing staff, leading to hospital admission. Another resident's suprapubic catheter was dislodged during care, requiring hospital intervention for replacement. These incidents highlight deficiencies in catheter care and response to resident complaints.
Failure to Use Gait Belt During Assisted Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a gait belt during a transfer for one resident who required assistance with activities of daily living due to impaired balance. The resident’s care plan, dated 12/24/25, specified that she required one staff member to assist with transfers using a gait belt. The facility’s gait belt policy directed staff to always use a gait belt for one- and two-person transfers and to never lift a resident under the arms (“chicken wing”). A grievance form dated 2/10/26 documented that the resident reported being upset that CNAs on the third shift lifted her by her arms instead of using a gait belt, although she did not sustain any injuries. During interviews, the physical therapy assistant confirmed that a gait belt should be used for one- or two-person assists because a resident could lose their balance, and the administrator acknowledged that a third-shift CNA had held the resident under her arms rather than using a gait belt, stating that the CNA should have used the gait belt for the safety of the resident and staff. The resident’s diagnoses included influenza, COPD, type 2 DM, asthma, HTN, low back pain, hyperlipidemia, obstructive sleep apnea, weakness, acute bronchitis, schizoaffective disorder, hypo-osmolality and hyponatremia, osteoarthritis, bipolar disorder, anxiety disorder, and depression. This combination of a documented care plan requirement, a facility policy mandating gait belt use, and staff acknowledgment that the transfer was performed by lifting under the resident’s arms instead of using a gait belt formed the basis of the cited deficiency related to accident hazards and inadequate supervision to prevent accidents.
Failure to Administer and Supply Medications as Ordered and Scheduled
Penalty
Summary
The deficiency involves the facility’s failure to provide medications as ordered and according to established schedules for multiple residents. One resident with epilepsy, morbid obesity, anxiety, depression, and hypertension had orders for buspirone, carbamazepine, and losartan. On the survey date, an RN took the resident’s blood pressure at 107/60, administered an anti-nausea medication, and stated she would return to give the scheduled morning medications. Over two hours later, she acknowledged that she had not yet administered those morning medications, and documentation showed she held the losartan even though the blood pressure was not below the physician-ordered parameter to hold the drug. Another resident with multiple sclerosis, dementia, central nervous system disorder, and other conditions had orders for propranolol three times daily and primidone five times daily. On the survey date, an RN administered the 9:00 AM scheduled medications at 10:30 AM, outside the facility’s stated one-hour before/after administration window. A third resident with diabetes, diabetic retinopathy with macular edema, and other eye-related diagnoses had an order for Preservision (a multivitamin with minerals) twice daily. On the survey date, the RN reported that the ordered eye vitamin was not available. A fourth resident with polycythemia vera, osteoarthritis, dysphagia, hypertension, atrial fibrillation, heart failure, dementia, and other conditions had multiple medications ordered at 9:00 AM, including cyanocobalamin 1000 mcg, hydroxyurea 500 mg two capsules, metoprolol, Mucinex 600 mg, diltiazem three times daily, and Systane eye drops three times daily. The RN administered these medications more than one hour late, gave cyanocobalamin 50 mcg instead of 1000 mcg, one capsule of hydroxyurea instead of two, held metoprolol without any ordered parameters to do so, administered Mucinex 400 mg instead of 600 mg, gave diltiazem late, and reported that the ordered eye drops were not available. A fifth resident with diabetes, weakness, dysphagia, anxiety, hypertension, heart disease, GERD, and osteoarthritis had orders for docusate, famotidine, and metoprolol twice daily at 9:00 AM and 5:00 PM, but the RN administered the 9:00 AM medications at 11:00 AM. The regional nurse consultant stated that medications should be given within one hour before or after the scheduled time, that late medications should be reported to the physician, and that medications should only be held if there are physician-ordered parameters.
Failure to Provide Care-Planned ADL Assistance With Personal Hygiene and Grooming
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with activities of daily living (ADLs), specifically personal hygiene and grooming, in accordance with residents’ care plans. One resident with diabetes mellitus, weakness, unsteadiness, dysphagia, anxiety disorder, hypertension, heart disease, GERD, and osteoarthritis had a care plan identifying an ADL self-care performance deficit and requiring one staff member to assist with bathing, personal hygiene, and oral care, including shaving and specific approaches if she resisted care. During observation, this resident was seen in her wheelchair with long gray hairs on her chin, stated she needed a shave, and indicated she liked her chin to be shaved, showing that the planned ADL assistance and grooming were not being carried out as care-planned. Another resident with epilepsy, weakness, morbid obesity, a contracture of the left hand, need for assistance with personal care, generalized anxiety disorder, major depressive disorder, and arthritis also had a care plan documenting an ADL self-care performance deficit and the need for one staff member to assist with bathing, personal hygiene, and oral care. This resident was observed lying in bed with small hairs on her chin and neck area and reported that she had asked to be shaved and wanted staff to shave her chin. A third resident with multiple sclerosis, cognitive communication deficit, dementia, central nervous system disorder, UTI, DVT, dysphagia, and major depressive disorder had a care plan requiring one staff member to assist with bathing, personal hygiene, and oral care. This resident was observed in a wheelchair with a splint on the right hand and long fingernails on the right hand, including a long pinky nail and a ring finger nail with a substance under it, and stated she wanted her nails shorter. The regional nurse consultant confirmed that CNAs are responsible for shaving and nail care (with nurses performing nail care for diabetic residents), and the facility’s ADL policy states that care, treatment, and services are to be provided according to individualized care plans, which was not done for these residents.
High Medication Error Rate and Untimely/Unavailable Medications During Med Pass
Penalty
Summary
Surveyors identified a medication administration deficiency when observing medication passes for two residents, resulting in 7 errors out of 25 opportunities, a 28% medication error rate. For one resident with multiple diagnoses including polycythemia vera, osteoarthritis, dysphagia, hypertension, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and history of falls, the Medication Administration Record (MAR) for February showed scheduled 9:00 AM doses of cyanocobalamin 1000 mcg, hydroxyurea 500 mg two capsules, metoprolol 25 mg 1/2 tablet at 9:00 AM and 9:00 PM, Mucinex ER 600 mg at 9:00 AM and 9:00 PM, diltiazem 30 mg three times daily at 9:00 AM, 1:00 PM, and 8:00 PM, and Systane eye drops three times daily at 9:00 AM, 1:00 PM, and 9:00 PM. On the survey date at 10:36 AM, more than one hour after the scheduled time, an RN administered these medications late, gave cyanocobalamin 50 mcg instead of the ordered 1000 mcg, administered only one capsule of hydroxyurea instead of the ordered two, held the metoprolol dose despite no physician-ordered parameters to do so, administered Mucinex 400 mg instead of 600 mg, gave diltiazem over one hour late, and reported that the ordered Systane eye drops were not available. For a second resident with diagnoses including diabetes mellitus with unspecified diabetic retinopathy with macular edema, history of falls, pain, weakness, age-related nuclear cataract, macular degeneration, dry eye syndrome, and major depressive disorder, the February MAR showed an order for Preservision (multiple vitamins with minerals) one tablet by mouth twice daily at 9:00 AM and 5:00 PM related to type 2 diabetes with diabetic retinopathy with macular edema. During the survey, an RN stated that the ordered eye vitamins were not available. The Regional Nurse Consultant later stated that medications should be administered within one hour before or after the scheduled time, that late medications should be reported to the physician for possible new orders, and that medications should only be held if there are physician-ordered parameters or after consulting the physician. The consultant also stated that artificial tears and eye vitamins were believed to be facility stock medications, and if not available as stock, staff should obtain them from the pharmacy. The facility’s Medication Administration Schedule policy, approved in November 2025, states that medications shall be administered according to established schedules.
Failure to Follow Physician Orders and Schedules Resulting in Significant Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents by not following physician orders and established medication administration schedules. One resident with epilepsy, morbid obesity, contractures, anxiety, major depressive disorder, and arthritis had orders for carbamazepine extended-release and losartan potassium, with instructions to hold losartan only if the systolic blood pressure was less than 100. On the survey date, an RN obtained a blood pressure of 107/60 and, after the resident complained of nausea, administered an antinausea medication and stated she would return to give the scheduled morning medications. Later, when asked, the RN acknowledged she had not yet given the morning medications, and the MAR showed that she held the losartan despite the blood pressure not meeting the ordered parameter to hold the medication. Another resident with polycythemia vera, osteoarthritis, dysphagia, hypertension, weakness, cognitive communication deficit, atrial fibrillation, hypothyroidism, heart failure, dementia, major depressive disorder, and a history of falls had orders for hydroxyurea 500 mg (two capsules daily at 9:00 AM), metoprolol 25 mg (½ tablet at 9:00 AM and 9:00 PM), and diltiazem 30 mg (three times daily at 9:00 AM, 1:00 PM, and 8:00 PM). On the survey date, the same RN administered these medications more than one hour after the scheduled time, gave only one capsule of hydroxyurea instead of the ordered two, held the metoprolol despite no physician-ordered parameters to do so, and administered diltiazem over an hour late. A regional nurse consultant stated that medications should be given within one hour before or after the scheduled time, that late medications should be reported to the physician for possible new orders, and that medications should only be held according to physician parameters. The facility’s policy required medications to be administered according to established schedules, and there was no facility policy specifically addressing significant medications.
Failure to Notify Physician of Fall and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident’s physician of a fall and subsequent hospital transfer as required by its Significant Condition Change and Notification policy. A male resident with a history of left femur fracture, weakness, history of falls, cognitive communication deficit, and adjustment disorder experienced a fall in the bathroom while being assisted by a CNA. The fall incident report documented that the ADON was notified, but did not show that the resident’s primary care physician was notified. A health status note described the circumstances of the fall and stated that the power of attorney and a nurse practitioner were notified, but did not specify which practitioner, the method or timing of notification, the number of attempts made, or the practitioner’s response. The RN who assessed the resident after the fall reported no apparent injuries and no complaints of pain at that time. The resident’s physician later documented that the resident reported a fall that had occurred approximately two days prior to the physician’s evaluation, and the physician stated he had not been notified by the facility of the fall on the day it occurred. The physician also reported he was not notified of the resident’s subsequent hospital transfer after x-rays revealed a fracture. Review of the medical record showed a hospital transfer form listing this physician as the primary care physician, but no progress note indicating that he was informed of the resident leaving the facility or being transferred to the hospital. The facility’s policy required that the medical practitioner be contacted for accidents or incidents with potential need for practitioner intervention, with each attempt charted, but the documentation and interviews showed that this did not occur for this resident’s fall and hospital transfer.
Delay in STAT Diagnostic Imaging and Evaluation After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to promptly obtain diagnostic imaging and ensure timely evaluation and treatment after a fall. The resident was admitted with a history that included a prior left femur fracture, weakness, history of falls, cognitive communication deficit, and an adjustment disorder with mixed anxiety and depressed mood. On the evening of 12/30/2025, the resident fell in the bathroom while being assisted by a CNA. The CNA reported that the resident had been transferred to the toilet with a gait belt, then stood holding the handrail; when she reached for wipes on the counter, the resident let go of the handrail and fell onto his left side. An RN responded around 6:45 PM, found the resident on the bathroom floor lying on his left side, assessed him, and documented no apparent injuries and no complaints of pain at that time. On the morning of 12/31/2025, another RN assessed the resident in bed and found him moaning with facial grimacing, with his feet off the bed. When asked, the resident reported left knee pain, and the nurse noted a bruise on the left knee. The nurse stated she did not recall administering any pain medication beyond the resident’s existing order for acetaminophen 650 mg once daily for left lower extremity pain, which was documented as given that day. She reported calling the resident’s primary physician and leaving an urgent note with the medical assistant about the fall but did not receive a response before the end of her shift. No imaging had been obtained at that point, despite the resident’s ongoing pain and known history of falls and prior left femur fracture. Later on 12/31/2025, the physician saw the resident during a routine visit and was informed of the fall that had occurred approximately two days earlier. The physician observed the resident lying prone toward the left side and endorsing ongoing left lower extremity pain, with minimal relief from acetaminophen, and documented that no imaging studies had been completed to date. The physician ordered STAT x‑rays of the left hip, femur, and knee to evaluate for possible acute injury. A health status note that evening documented receipt of a telephone order for these STAT x‑rays and that the order was processed via a mobile diagnostic provider and entered into the electronic medical record. However, nursing staff reported that the STAT x‑rays were not performed until the following day, 01/01/2026. The diagnostic report from that date showed an acute subcapital left femoral neck fracture. The physician later stated that, had he been informed at the time of the fall, he would have ordered STAT x‑rays then, and he expressed surprise that the STAT imaging ordered on 12/31/2025 was not completed until the next day, resulting in a delay in diagnosis and evaluation of the fracture.
Failure to Obtain Daily Weights and Timely Follow-Up After Fall
Penalty
Summary
The facility failed to obtain daily weights as ordered for a resident with congestive heart failure (CHF), resulting in significant weight gain and hospitalization. The resident, who had a history of CHF, morbid obesity, respiratory failure, and other comorbidities, was observed to have gained over 60 pounds in one month. Despite a physician's order for daily weights, multiple days were missed without documentation of refusals or reasons for omission. Staff interviews confirmed that daily weights were not consistently obtained or recorded, and there was no evidence that the physician was notified of the significant weight gain as required by facility protocol. The Medication Administration Record did not reflect daily weights, and the facility lacked a policy for obtaining weights for CHF patients or for following physician orders related to weights. Additionally, the facility failed to ensure timely follow-up care after a resident experienced a fall resulting in a left clavicle fracture. The resident, who had multiple chronic conditions and was on hospice, fell while reaching for a TV remote and complained of shoulder pain. Although an X-ray was ordered, it was not completed until two days after the fall, and there was no documentation that staff followed up on the status of the X-ray or implemented a sling for immobilization until after the fracture was confirmed. Progress notes indicated the resident experienced pain and limited range of motion during this period, but interventions were delayed until the X-ray results were received. Interviews with facility staff, including the previous DON and nurse practitioner, confirmed that the delay in obtaining the X-ray and implementing appropriate interventions constituted a delay in care. The staff acknowledged that the X-ray should have been ordered and completed immediately, and that the resident should have received timely pain management and immobilization. The facility's failure to follow physician orders and ensure prompt follow-up after a significant change in condition contributed to the deficiencies identified in the care of both residents.
Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to consistently provide sufficient nursing staff to meet the care needs of its residents, as evidenced by multiple documented instances of staffing shortages across various shifts. Review of nursing schedules and daily work logs over a one-month period revealed repeated occasions where the number of aides and nurses who actually worked was less than the number scheduled. These shortages affected both day and night shifts, with some shifts missing up to three scheduled staff members. Resident council meeting minutes and grievance forms over several months documented ongoing concerns from residents and families regarding delayed call light responses, missed showers, late meal service, and inadequate incontinence care, particularly on weekends and holidays. Specific resident accounts highlighted the impact of these staffing shortages. One resident reported waiting 1.5 hours for assistance to use the restroom, resulting in an accident, and described infrequent bathing and long periods without staff contact overnight. Another resident stated that he waited 85 minutes for his call light to be answered, which led to soiling himself, and later had to use a bell for several days while his call light was being repaired, with response times averaging 50-60 minutes. Additional grievances included a resident left in feces for 50 minutes and call lights being turned off by staff without providing assistance. These accounts were corroborated by observations of residents with unmet hygiene needs and by staff interviews acknowledging the challenges of delivering timely care when short staffed. Interviews with facility staff and administration revealed a lack of a formal policy for call light response times and inconsistent awareness of staffing issues. The scheduler stated that all call-offs were covered and was unaware of any staffing problems, while a former CNA described days when staff struggled to deliver meals, answer call lights, and provide basic care. The Assistant DON stated that staff are expected to answer call lights within 3-5 minutes, but this expectation was not consistently met. The facility's own assessment indicated that residents required substantial to maximal assistance with bathing and toileting, yet the documented staffing levels and resident reports demonstrated that these needs were not reliably met.
Failure to Provide Palatable and Appetizing Meals
Penalty
Summary
The facility failed to provide residents with food that was palatable in flavor, as required. On the day of survey, a pork and rice casserole was served for lunch, but the preparation deviated from the recipe due to missing ingredients, specifically celery and lemon juice, which were not ordered and therefore omitted. The dietary staff member responsible for preparing the casserole acknowledged the lack of ingredients and stated that he was instructed by management not to add additional flavoring. The surveyor observed the casserole being prepared and later tasted it, noting that it lacked flavor, the meat was tough, and the rice was clumped together with no color. Residents reported ongoing dissatisfaction with the taste and quality of the food, expressing that their complaints were not being addressed. During a resident group meeting, several residents stated that the food often lacked flavor and that the alternate menu options were repetitive. Review of grievance logs and resident council meeting minutes over the past six months revealed multiple complaints regarding the palatability of meals, including specific negative feedback about the appearance and taste of the food served.
Infection Control Deficiencies: Incomplete Surveillance, Improper Isolation, and Unsanitary Wound Care
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program as evidenced by incomplete infection surveillance reports, improper implementation of contact isolation precautions, and unsanitary wound care practices. Infection surveillance reports for the past three months were found to be incomplete, missing critical information such as infection type, signs and symptoms, pharmacy orders, and comments. The Assistant Director of Nursing and Infection Preventionist acknowledged that the reports were not being fully utilized as intended, and the Regional Nurse Consultant confirmed that all necessary information should be documented to effectively track and trend infections. A resident with a history of congestive heart failure, type 2 diabetes mellitus, and an extended spectrum beta-lactamase resistant infection (ESBL) was not placed on contact isolation as ordered by the physician. Instead, the resident was on enhanced barrier precautions, and the appropriate signage for contact isolation was not present on the resident's door. The resident reported that staff did not consistently use personal protective equipment (PPE) during care, and the facility's list of residents on contact isolation did not include this individual, despite a physician's order and policy requirements for contact precautions in cases of multidrug-resistant organisms. Additionally, wound care for another resident with pressure ulcers was performed in an unsanitary manner. The wound care nurse failed to perform hand hygiene between glove changes and used scissors that were not sanitized, placing them on the resident's bed linens and using them to cut wound care materials. The presence of a fly in the resident's room during wound care was also observed, and the Assistant Director of Nursing and Infection Preventionist confirmed that these practices did not meet infection control standards and could contribute to wound infection.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to provide scheduled showers and assistance with activities of daily living (ADLs) for dependent residents, as evidenced by the experiences of three residents. One resident, admitted with multiple diagnoses including weakness, unsteadiness, and osteoarthritis, had physician orders for showers twice weekly. Documentation showed she received only three showers over a two-month period, with the last recorded shower occurring several weeks prior to the survey. There were no documented refusals, and multiple grievances had been filed regarding missed showers for this and other residents. Another resident, with significant medical conditions such as chronic kidney disease, heart failure, and muscle weakness, required substantial to maximum assistance for most cares and had orders for showers twice weekly. Observations revealed the resident was unkempt, with greasy hair, and reported not receiving showers for months due to issues with the shower room environment. Records confirmed only two showers were provided in the previous 30 days. A third resident, who was cognitively intact but required substantial to maximal assistance for bathing and was dependent for toilet hygiene, reported not receiving her preferred weekly bed baths for several weeks, except for one documented refusal. Her care plan indicated a need for frequent incontinence care and regular bed baths, but documentation showed missed care events and lack of follow-up after refusals. Staff interviews confirmed that residents should be checked every two hours and that ADL care is essential for hygiene and dignity, but the records and resident reports indicated these standards were not consistently met.
Failure to Update Care Plan After Elopement Attempt
Penalty
Summary
The facility failed to revise and update the comprehensive care plan for a resident at risk for elopement after an elopement attempt was documented. The resident, who had diagnoses including dementia without behavioral disturbance, diabetes mellitus, generalized anxiety disorder, and encephalopathy, was admitted to the facility and was known to self-propel in a wheelchair. On one occasion, the resident eloped from the facility through the front door, triggering the alarm, and was subsequently returned to the facility. The nurse on duty redirected the resident throughout the night and reported the incident during shift change but did not notify the Director of Nursing (DON) or update the care plan to reflect the new behavior and risk. There was no documentation in the resident's care plan regarding the elopement attempt, activation of the front door alarms, or the need for physical assistance to return the resident to the facility. The DON and the Care Plan Coordinator were not made aware of the incident until weeks later, and the care plan was not revised with new interventions until after a subsequent elopement occurred. Staff interviews confirmed that the resident had been actively exit-seeking, particularly during evening and night hours, and required frequent redirection. The resident exhibited increased confusion and fixation on leaving the facility for a specific purpose, which was a recent behavioral change. Facility policy required that any new onset or change in behavior, especially those increasing elopement risk, be documented and incorporated into the care plan with individualized safety interventions. Despite these policies, the care plan was not updated in a timely manner following the initial elopement attempt, and the required communication and documentation procedures were not followed. This lapse resulted in the resident's increased risk not being addressed promptly in the care plan.
Failure to Supervise and Address Elopement Risk
Penalty
Summary
The facility failed to provide adequate supervision and address elopement risks for a resident with a history of dementia, diabetes mellitus, generalized anxiety disorder, and encephalopathy. The resident, who was mobile in a wheelchair and known to self-propel quickly, was able to elope from the facility through the front door during the early morning hours. Although the alarm was triggered and staff returned the resident to the facility within 30 seconds, the incident was not immediately reported to the Director of Nursing (DON) or documented in detail, and no immediate interventions were implemented following the event. Subsequent interviews revealed that the DON and Care Plan Coordinator were unaware of the elopement attempt until weeks later, resulting in a delay in revising the resident's care plan and implementing new interventions. The care plan was not updated with additional safety measures until after a second elopement occurred. Staff on duty during the incidents reported that the resident was actively exit-seeking and required frequent redirection, but supervision and monitoring were insufficient to prevent the resident from leaving the facility undetected. Facility policies required immediate notification of administration and the DON in the event of an elopement or attempted elopement, as well as prompt implementation of increased monitoring and individualized safety interventions. These procedures were not followed after the initial elopement attempt, and documentation of the incident and subsequent monitoring was lacking. The failure to act according to policy and provide adequate supervision contributed to repeated elopement events for the resident.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and weakness, who was cognitively intact, did not receive timely incontinence care. The resident reported having a bowel movement around 4:00AM and was not cleaned up until almost 10:00AM, despite using the call light and waiting for staff assistance. A CNA confirmed that when she arrived for her shift, staff were behind in their duties, and upon assisting the resident, found stool present and noted that the resident continued to have a bowel movement during care. Facility policy requires care, treatment, and services for activities of daily living, and a registered nurse stated that residents should be rounded on at least every two hours.
Insufficient Staffing Resulting in Delayed Resident Care and Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents, as evidenced by multiple residents reporting long wait times for call light responses and delays in receiving personal care. One resident with hemiplegia and weakness reported waiting from 4:00AM until almost 10:00AM to be cleaned after a bowel movement, with staff confirming that they were behind in getting residents up and passing meal trays due to staffing shortages. Another resident dependent on assistive devices reported inconsistent staffing and waiting 30-45 minutes for call light responses. A third resident with quadriplegia and reduced mobility stated that call light wait times could reach up to 30 minutes, especially on weekends, and that staff did not round every two hours as expected. Staff interviews confirmed that there were multiple call-ins from CNAs, requiring agency staff and additional help to be called in, resulting in delays of 60-90 minutes to catch up with resident care. The DON acknowledged that call lights should be answered within 5 minutes and that residents should not be left in stool. Resident Council Minutes from several months documented ongoing concerns from residents about untimely call light responses and requests for more consistent rounding and communication from staff. The facility's policy on Activities of Daily Living states that care, treatment, and services should be provided to each resident, but the observed staffing levels did not meet these standards.
Failure to Provide Wound Care and Timely Assessment
Penalty
Summary
The facility failed to provide appropriate wound care and assessments as ordered for two residents, resulting in significant negative outcomes. For one resident with multiple comorbidities including end stage renal disease, diabetes with neuropathy, and peripheral vascular disease, dressing changes and wound assessments for bilateral leg wounds were not completed as ordered. Documentation showed missed dressing changes on several scheduled dates, and wound assessments were not performed or documented for an extended period. The resident's care plan required regular monitoring and documentation of wound status, but only sporadic wound assessments were found in the record. The resident and his family reported that requests for dressing changes were ignored, and observations by outside staff and family revealed dirty, unchanged dressings with foul odor. The resident was ultimately sent to the hospital and admitted with wound infections, where he required IV antibiotics and antifungal medications. Another resident with chronic wounds and a history of diabetes and kidney disease was found to have an open wound on the back without a dressing, despite physician orders for daily wound care and dressing application. The Assistant Director of Nursing was unaware that the dressing was missing and had not received any report from floor staff. During a facility-wide wound sweep, a deep tissue injury was also discovered on the resident's toe, which had not been previously identified or documented. The wound physician confirmed the need for continuous dressing on the back wound and emphasized the importance of early detection and treatment of wounds to prevent complications. Documentation for wound assessments and physician visits was incomplete or missing. Facility policy required weekly skin checks and wound assessments by licensed nurses, as well as daily observation by nursing assistants during care. However, the records showed that these protocols were not consistently followed, with gaps in documentation and lack of timely identification and reporting of new or worsening wounds. The failures in following physician orders, performing regular wound assessments, and ensuring proper wound care led to preventable wound deterioration and infection in both residents.
Failure to Label and Date Prepared Foods
Penalty
Summary
Surveyors observed that the facility failed to label prepared foods with dates and names as required by their own policy and professional standards. During an inspection of the refrigerator, bread rack, and dry goods storage, multiple food items, including containers of cream of wheat, tomato sauce, chicken noodle soup, and a brown sack lunch, were found without any labeling or expiration dates. The cook confirmed that bread delivered the previous day and food containers in the refrigerator should have been labeled but were not. Additionally, a dialysis lunch bag prepared for a resident was found unlabeled. The dialysis facility administrator reported seeing a sandwich with mold in a resident's bag, which was the only sandwich present, indicating that the lack of labeling may have contributed to the issue.
Failure to Prevent Rough Handling and Pain During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident was free from abuse during morning care. The resident, who had multiple complex medical diagnoses including end stage renal disease, chronic pain, and a history of a right hip fracture with ongoing pain, required assistance with dressing. On the morning in question, two CNAs were involved in getting the resident ready for dialysis. The resident repeatedly expressed pain and specifically instructed staff to be careful with his right hip. Despite these complaints, the CNAs continued with the dressing process, with one reportedly lifting the resident's leg in a manner that caused significant pain. The resident and his roommate both reported that the CNAs did not stop when the resident complained of pain, and the roommate described the staff as being rough and rushing the process. The incident was reported by the dialysis center staff after the resident disclosed feeling physically abused due to the rough handling. Interviews with the CNAs revealed that one was not familiar with the resident's care needs and that there was confusion and urgency due to the arrival of EMTs for dialysis transport. The CNAs acknowledged the resident's complaints about his hip but continued with care, with one CNA stating that there is no way to provide care without pain due to the resident's condition. The resident's daughter and the LPN also confirmed that the resident had ongoing pain and had reported rough treatment by staff. The facility's Director of Nursing stated that staff are expected to stop care and notify a nurse if a resident complains of pain during care, which did not occur in this instance. Additionally, the facility administrator did not conduct a complete interview with the roommate, who was a witness to the incident. The facility's abuse prevention policy prohibits any form of abuse, including the willful infliction of pain or mental anguish, which was not adhered to during this event.
Failure to Provide Timely Pressure Ulcer Assessment and Care
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident with multiple risk factors, including left side hemiplegia, diabetes mellitus, obesity, and bowel incontinence. The resident was identified as high risk for wound development and had a stage 2 pressure ulcer on the sacral region. Despite these risks, the facility did not perform timely pressure ulcer assessments, as the initial assessment was delayed by a week after the wound was first identified. Wound treatments were not initiated until a week after identification, and there were multiple missed wound treatments and monitoring entries documented in the Treatment Administration Record (TAR). Additionally, the facility did not document treatment comments in the progress notes as required. Observation revealed that the resident's pressure-relieving air mattress was not set according to the resident's weight, which could compromise its effectiveness. Staff, including the newly assigned wound care nurse, were not fully aware of the resident's wound care history or current interventions. The facility's own policy required immediate assessment and notification of the healthcare provider for wound treatment, which was not followed. The lack of timely assessment, inconsistent wound care, and failure to implement appropriate pressure-relieving interventions contributed to the deficiency.
Failure to Provide ADL Care Before Hospital Transfer
Penalty
Summary
The facility failed to provide adequate ADL care for a resident prior to their transfer to the hospital. The resident, who had diagnoses including COVID-19, dementia, and anxiety, was frequently incontinent and required assistance with transfers and toileting. On the day of the incident, the resident's oxygen saturation was low, prompting the LPN to focus on their medical condition and arrange for hospital transfer. However, the LPN assumed that the CNAs would ensure the resident was clean and dry before the transfer, which did not occur. The CNA on duty did not change the resident's incontinent pad or provide incontinence care from 2 PM until the resident was sent to the hospital after 6 PM. The CNA observed the resident was visibly wet but mistakenly thought it was due to spilled water. The Assistant Director of Nursing confirmed that residents should be toileted every two hours and be clean and dry before hospital transfers. The resident's care plan indicated they required assistance with toileting every two hours, which was not adhered to, resulting in the resident being transferred to the hospital in a soaked and odorous state.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Facility staff failed to provide Cardiopulmonary Resuscitation (CPR) to a resident who was documented as a full code. The deficiency occurred when a Licensed Practical Nurse (LPN) was informed by a visitor that the resident was not breathing. The LPN entered the resident's room, found food in and around the resident's mouth, and noted gurgling sounds, indicating possible aspiration. The LPN then left the room to call 911, and during this time, the resident stopped breathing. Despite being aware of the resident's full code status, no CPR was initiated by facility staff prior to the arrival of emergency medical services (EMS). Multiple staff interviews confirmed that neither the LPN nor other staff present initiated CPR, as they either assumed the resident was a Do Not Resuscitate (DNR) or were unclear about the resident's code status. The Registered Nurse (RN) who was called to verify the resident's death also did not initiate CPR, believing the resident was a DNR. The Certified Nursing Assistant (CNA) present also did not start CPR, and could not specify the time elapsed between the resident being found unresponsive and EMS arrival. Documentation and interviews confirmed that the resident was a full code, and both the facility's medical director and the paramedics stated that CPR should have been started immediately upon recognition of cardiac arrest in a full code resident. EMS arrived several minutes after the initial call and found no CPR in progress. Upon confirming the resident's full code status and lack of a valid DNR, paramedics initiated CPR, but it was discontinued shortly after at the request of the family and with physician approval. The delay in initiating CPR resulted in the resident experiencing a delay in life-saving medical care and subsequent death. The deficiency was substantiated by interviews, record reviews, and direct observation.
Removal Plan
- Director of Nursing, Assistant Director of Nursing, Post Acute Nurse, MDS Nurses, Wound Care Nurse, Regional Director of Nursing, Charge Nurse or Designee educated clinical staff and new hires during the orientation process regarding CPR policy and procedure and Advanced Directive policy and procedure including identification of when CPR is needed.
- Current Resident orders reviewed by regional nurse to confirm resident preference aligned with code status.
- Mock codes conducted by Assistant Director of Nursing and Regional Nurse with clinical staff to ensure adherence with facility CPR policy and procedure.
- Ad Hoc QAPI meeting held with QAPI team members in person and medical director via phone. CPR policy reviewed and no changes are needed to the current policy. The Advance Directive policy was reviewed, and no changes are needed to the current policy.
- To ensure compliance is maintained the Director of Nursing or designee will conduct a mock code with clinical staff once per month on each shift and will interview staff to verify understanding of CPR policy and procedure and Advanced Directive policy and procedure, including identification of when CPR is needed.
- Audit results will be reviewed by the Quality Assurance Committee, and concerns will be addressed immediately.
Failure to Provide Required Feeding Assistance and Supervision Results in Resident Aspiration and Death
Penalty
Summary
A deficiency occurred when staff failed to provide required feeding assistance and supervision to a resident with severe cognitive impairment, facial and neck burns, and documented swallowing difficulties. The resident's care plan and speech therapy recommendations specified that she required one staff member to assist with eating, should be positioned upright, and needed to follow strict swallow precautions, including mechanical soft diet, nectar-thick liquids, and feeding on the right side of the mouth. Despite these documented needs, a CNA delivered the resident's meal tray to her room and left it with family members, who had not been educated or trained on the resident's specific feeding requirements or swallow precautions. During the meal, the resident's family attempted to feed her without staff supervision or assistance. Staff interviews revealed that the CNA was unaware of the resident's feeding status or special precautions, and the family had not received any education or return demonstration on safe feeding techniques. The LPN on duty was nearby but not present in the room, and only became aware of a problem when a family member reported that the resident was choking. Upon entering the room, the LPN found the resident in a semi-upright position with food in and around her mouth, and her family attempting to reposition her. The resident was then placed fully upright, and food was removed from her mouth, but she exhibited gurgling sounds suggestive of aspiration. The resident subsequently became unresponsive and stopped breathing. Emergency services were called, and CPR was initiated by paramedics upon arrival, but the resident expired in the facility. Documentation confirmed that the resident was not wearing her teeth during the meal, and that staff had not provided the required supervision or assistance as outlined in her care plan and therapy recommendations. The facility did not have a policy or procedure for feeding residents with swallow precautions at the time of the incident.
Removal Plan
- Identify all residents currently residing in the community that require assistance eating due to swallowing precautions, assess new admissions for swallow problems, and ensure any residents identified have a speech therapy evaluation to determine if swallow precautions need to be implemented, with physician notification as needed.
- Educate clinical staff regarding feeding assistance with return demonstration, how to identify residents with swallow precautions, and staff responsibility regarding feeding and monitoring of residents with swallow precautions. Educate new hires during orientation on feeding assistance and swallow precautions procedures.
- Conduct return demonstration by clinical leadership and designated staff.
- Hold Ad Hoc QAPI meeting with QAPI team members and medical director to review procedure for swallow precautions and feeding assistance, and make necessary changes to the procedure regarding speech therapy swallow precaution recommendations for residents.
- Director of Nursing or designee will conduct an audit on clinical staff's knowledge of feeding assistance via return demonstration and observe staff providing feeding assistance to ensure compliance with speech therapy recommendations. Audit results will be reviewed by the Quality Assurance Committee, and concerns will be addressed immediately.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in a distal femur fracture. The resident, who had a history of falls and weakness, was being transferred from a wheelchair to a bed by a CNA using a gait belt. During the transfer, the resident's knees gave out, and the CNA lowered the resident to the floor. The resident was alert and oriented at the time of the incident. The resident's admission assessment indicated a risk for falls and required maximal assistance for mobility, including sit-to-stand or Hoyer lift for transfers due to knee weakness. The CNA involved stated that she was advised to transfer the resident with a gait belt and that the resident was a one-person assist. However, the resident reported that the CNA did not assist her during the transfer and that she fell forward onto her knees. The Director of Nursing confirmed that the transfer occurred without proper assistance or the use of a gait belt, leading to the resident's fall and subsequent fracture. The facility did not have a specific policy for gait belt transfers, relying instead on best practices, which were not followed in this case.
Failure to Document Narcotic Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation of narcotic pain medication administration for a resident, leading to discrepancies in medication records. The resident, who was admitted with a history of hypertension, congestive heart failure, and other conditions, had an order for hydrocodone-acetaminophen (Norco) to be administered as needed for pain. However, the resident reported missing doses and maintained a personal log to track her medication, which showed inconsistencies with the facility's records. Specifically, the Individual Resident Controlled Substance Record indicated that Norco tablets were signed out on several occasions, but the medication administration record did not reflect these administrations on multiple dates. The Director of Nursing acknowledged the expectation for nursing staff to document medication administration accurately to ensure compliance with the resident's orders. The facility's controlled substance policy requires immediate documentation on both the controlled substance proof of use form and the medication administration record after administering the drug. Despite these requirements, the records for the resident showed missing documentation for several dates, leading to concerns about the administration and tracking of the narcotic medication.
Failure to Maintain Emergency Cart and Obtain Daily Weights
Penalty
Summary
The facility failed to maintain the emergency supply cart for 52 residents residing on the north hallway. On December 27, 2024, it was observed that the crash cart checklist, which should be checked daily, had not been updated since December 17, 2024. An LPN confirmed that the oxygen tank on the cart was empty, which could cause a delay in providing oxygen during a code blue situation. The Director of Nursing stated that the night shift is responsible for checking the cart every night to ensure all equipment, including a full oxygen tank, is present. The facility's policy requires the crash cart to be audited daily, and any missing items should be replaced immediately. The facility also failed to obtain physician-ordered daily weights for a resident with congestive heart failure (CHF). The resident's order summary indicated a daily weight order since November 15, 2024, with no stop date. However, the resident's weight records showed only sporadic entries, with significant weight gain noted between weigh-ins. An LPN and a CNA confirmed that the resident was on the daily weight list, but the weights were not consistently recorded or communicated. The Director of Nursing stated that daily weights should be completed and reported to the nurse, especially for residents with CHF, to monitor for fluid retention and notify the physician if necessary.
Failure to Provide Dignified Care for Resident
Penalty
Summary
The facility failed to ensure a resident was treated with dignity, as evidenced by the case of a resident who was admitted following a fall with a facial fracture. The resident, who was cognitively intact and required partial/moderate assistance with hygiene, was not provided with a shower during her stay, except for one instance. Despite multiple requests from the resident's family, the staff did not provide the necessary care, leading the family to threaten to take the resident home against medical advice. The resident's son reported that his mother, who was alert and oriented, began to question if something was wrong with her due to the lack of care. The facility's failure to provide showers was further corroborated by the resident council meeting minutes, which documented concerns from residents about CNAs stating they did not have time to give showers. The Director of Nursing was unaware of the incident and stated she would have followed up if she had known. The facility's pamphlet on resident rights emphasizes the right to dignity and respect, which was not upheld in this case.
Failure to Timely Empty Catheter Bag
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, identified as R2, by not emptying the urine collection bag before it became full. On the morning of November 6, 2024, R2 was observed in his room with a full catheter bag, which he reported as uncomfortable. R2 had used his call light to request assistance. A Licensed Practical Nurse (LPN) acknowledged that R2 drinks a lot of water, necessitating more frequent emptying of the catheter bag, more than once per shift. The Director of Nursing (DON) stated that catheter bags should be emptied in a timely manner, at least once per shift or as needed. The facility's administrator also noted finding R2's catheter bag full during rounds on October 31, 2024. Progress notes from October 29, 2024, indicated that 2000cc of urine was emptied from R2's catheter bag, suggesting a pattern of delayed care.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who was admitted following a hospitalization for a fall that resulted in pelvic and arm fractures. The resident, who was admitted in the afternoon, did not receive her prescribed oxycodone until late in the evening, despite having a pain score of 9/10 upon arrival. The delay in administering the prescribed pain medication was due to the unavailability of the medication in the facility's storage system, which the attending LPN could not access. The LPN attempted to obtain the medication by requesting a stat refill from the pharmacy but was unable to administer it until another nurse accessed the medication storage system later in the shift. During the interim, the resident was given alternative pain medications, including Gabapentin, Tylenol, and Ibuprofen, but continued to report high pain scores. The Medication Administration Record (MAR) confirmed the administration of these medications and the delayed administration of oxycodone. The Director of Nursing acknowledged that pain medication should be administered as ordered, highlighting the facility's failure to ensure the resident received timely pain management as prescribed.
Failure in Documentation and Communication During Resident Transfer
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer of a resident to a local hospital. The resident, who had a positive TB skin test and an abnormal chest X-ray, was transferred without a physician documenting the necessity of the transfer in the medical records. Additionally, there was no evidence of communication with the hospital staff, either verbally or in writing, prior to the transfer. The facility did not send essential documents such as advanced directives, care precautions, or medication lists with the resident, which are crucial for ensuring a safe and effective transition of care. Interviews with the facility staff, including the Director of Nursing, Assistant Director of Nursing, and Licensed Practical Nurses, revealed that none of them communicated with the hospital or ensured that the necessary paperwork accompanied the resident. The Medical Director confirmed that the facility lacked the appropriate isolation rooms for TB, which necessitated the transfer, but he had not documented this in the resident's records. The facility also did not have a policy in place for facility-initiated discharges, contributing to the oversight in documentation and communication.
Failure to Provide Bed Hold Notice Before Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative prior to the resident's transfer to a hospital. The resident, identified as R1, was transferred for evaluation due to a positive/reactive tuberculosis skin test and an abnormal chest X-ray. The facility's records from 9/29/24 to 10/2/24 showed no documentation that R1 or their power of attorney received a bed hold notice before the transfer on 9/30/24. Interviews with facility staff, including an LPN, the Director of Nursing, the Assistant Director of Nursing, and another LPN, revealed that none of them provided R1 with a bed hold notice at the time of transfer. The facility's Bed Hold Policy requires notifying the resident or their representative of the bed hold policy and obtaining a Bed Hold Agreement for each hospital or therapeutic leave occurrence. However, this procedure was not followed in R1's case, as confirmed by the facility administrator.
Failure to Protect Resident's Belongings Leads to Theft
Penalty
Summary
The facility failed to protect a resident from the wrongful use of her belongings, specifically her store credit card and debit card, which were stolen from her room. The resident, who was cognitively intact but required assistance for various activities of daily living, discovered her cards missing and was very distraught, crying, and needing consolation from the staff. The resident's daughter, who is also her Power of Attorney, reported the missing cards to the facility's insurance coordinator and the local police. The daughter later discovered unauthorized charges totaling approximately $1,200 on the cards, including transactions at local department stores, gas stations, and a rideshare company. The facility's initial report to the State Agency indicated that the resident noticed her debit card missing and that the last time she saw it was several days prior. An investigation was initiated by both the local police and the facility. However, the facility's records, including progress notes and care plans, did not document the missing cards or the incident. Interviews with staff revealed that they were unaware of the resident having credit or debit cards in her room, and the facility's inventory list did not include these items. The facility's final report to the State Agency confirmed the abuse towards the resident, substantiated by the fraudulent charges on her bank and store credit card statements.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to identify, assess, and treat pressure injuries in a timely manner for several residents, leading to the development and worsening of pressure ulcers. One resident, identified as R51, developed an unstageable pressure injury on the left heel, a stage 2 injury on the right heel, and a stage 3 injury on the right scapula. Despite being at very high risk for pressure injuries, as indicated by the Braden Scale, the necessary preventive measures, such as the use of heel boots and an air mattress, were not effectively implemented or monitored. The wounds were discovered only after they had progressed significantly, and the wound nurse acknowledged that they should have been identified sooner. Another resident, R224, experienced a reopening of a stage 3 pressure injury on the coccyx, which was not promptly assessed or treated. The resident's husband reported delays in care, including long wait times for assistance and a lack of follow-up after the wound was initially noticed. The wound nurse confirmed that the staff failed to notify the physician or obtain treatment orders in a timely manner, which contributed to the deterioration of the resident's condition. Additional deficiencies were observed with residents R3 and R62. R3 had a stage 3 pressure injury on the left thigh that was not properly dressed, and the wound was exposed to stool due to inadequate care. Weekly skin assessments were not conducted as required, partly due to staff absences. R62 was found lying on a deflated air mattress, which was not functioning due to a disconnected power cord, compromising the resident's pressure injury prevention. These incidents highlight a systemic failure in the facility's pressure ulcer prevention and management practices, as outlined in their policy.
Failure in Pain Management for Two Residents
Penalty
Summary
The facility failed to ensure proper pain management for two residents, resulting in significant discomfort and distress. One resident, suffering from metastatic breast cancer with metastases to the bone and liver, experienced severe pain due to a delay in receiving prescribed oxycodone. The resident was admitted to the facility without her pain medications, which were not available until two days later. During this period, the resident reported pain levels of 6 to 8 out of 10 and expressed frustration over the lack of timely medication administration. The delay was attributed to a miscommunication regarding the continuation of the medication order and issues accessing the emergency medication box. Another resident, who required a Lidoderm patch for pain management due to lumbago with sciatica and lumbar vertebra fractures, did not receive the patch as scheduled. The patch was supposed to be applied at 6:00 AM, but it was not administered on time, and the night nurse had prematurely signed off on its application. This oversight resulted in the resident experiencing a pain level of 7 and having to wait for the patch to be applied later in the morning. The facility's lack of a specific pain management policy and the failure to adhere to medication administration protocols contributed to these deficiencies. The Director of Nursing and other staff acknowledged the lapses in communication and procedure, which led to the residents' unmanaged pain. The facility's existing policies did not adequately address the timely administration of pain medications, highlighting a gap in ensuring residents' comfort and well-being.
Improper Food Handling and Cross-Contamination
Penalty
Summary
The facility failed to ensure proper food handling practices to prevent cross-contamination during meal service. During the observation of the noon meal plating, a dietary aide, identified as V7, was seen handling diet cards and touching various surfaces, including a refrigerator handle and packages of hamburger buns, without changing gloves. V7 then used her gloved fingers to wipe coleslaw from inside a scoop to read its size marking and continued to use the same scoop to serve the coleslaw to residents. This action was contrary to the facility's hand washing and glove usage policy, which requires changing gloves after touching surfaces to prevent contamination. Four residents, identified as R61, R62, R67, and R71, who were on regular diets, were served the coleslaw that was potentially contaminated due to these improper handling practices.
Improper Cohorting and PPE Use in Covid-19 Isolation
Penalty
Summary
The facility failed to adhere to its Covid-19 policies and procedures by improperly cohorting Covid-19 positive and negative residents and not ensuring the use of required Personal Protective Equipment (PPE). On July 22, 2024, it was observed that residents who tested positive for Covid-19 were not isolated from those who tested negative. Specifically, residents R11 and R49, who were Covid-19 positive, were sharing rooms with Covid-19 negative residents R41 and R29. The Assistant Director of Nursing/Infection Preventionist (V3) stated that they were following guidance from the local health department, which was later clarified by health department personnel (V5 and V6) as not recommending the cohorting of positive and negative residents together. The facility's own Covid-19 action plan also indicated that positive and negative residents should not be cohorted together. Additionally, the facility did not ensure that staff adhered to PPE protocols when entering rooms of residents on Contact/Droplet isolation. On July 23, 2024, an LPN (V12) was observed entering the room of a Covid-19 positive resident wearing only a surgical mask instead of the required N95 mask and face shield. This was contrary to the facility's infection control policy, which mandates the use of an N95 mask, gown, gloves, and eye protection for healthcare personnel entering the rooms of residents with suspected or confirmed SARS-CoV-2 infection.
Resident Dignity Compromised After Room Transfer
Penalty
Summary
The facility failed to ensure a resident was treated with dignity following a room transfer. During an observation, a resident was found in a room with their bed positioned against the wall, making it difficult for them to access their nightstand and digital clock, which was not set correctly. The resident expressed a need for a television remote, which was not available, and their breakfast trash was not removed despite requests to the CNA present. The resident also recounted a previous incident where they were denied a blanket when they felt cold. The Assistant Director of Nursing confirmed that the resident was moved by CNAs as part of a group effort to rearrange room assignments. The resident's care plan indicated a preference for independent activities such as watching television and listening to music, which were not accommodated in the new room setup. The Illinois Department on Aging Pamphlet emphasizes the importance of treating residents with dignity and respect, which was not upheld in this instance.
Failure to Provide Adequate ADL Care for a Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, including incontinence care and showers, for a resident with a self-care performance deficit due to Spina Bifida and a left below-knee amputation. On the morning of July 22, 2024, the resident was found in bed with stool halfway down her thigh and up to her middle back, and her shirt was soaked with urine from her nephrostomy tube. The bed linens were soiled with dried rings of urine in various colors. Certified Nursing Assistants (CNAs) V21 and V22 were observed scrubbing dried stool from the resident's back, causing her to call out in pain. The CNAs admitted they were unsure when the night CNA last provided care. A Licensed Practical Nurse (LPN) noted complaints about the night CNA and confirmed the resident should have been checked and cleaned much sooner. The facility lacked a policy on ADLs, as stated by the Administrator on July 23, 2024.
Failure to Administer Prescribed Scalp Treatment
Penalty
Summary
The facility failed to provide a prescribed scalp treatment to a resident diagnosed with psoriasis. The resident, a female with multiple diagnoses including morbid obesity, epilepsy, major depressive disorder, seborrheic dermatitis, arthritis, and psoriasis vulgaris, was observed with a white scaly buildup on her scalp. She reported not having her hair washed in three weeks, despite being scheduled for showers twice a week. The resident's Treatment Administration Record indicated that the prescribed Ketoconazole shampoo was documented as administered only twice out of the six required treatments. The deficiency was attributed to the lack of a functional shower chair, which broke during transport, preventing the resident from receiving proper hair washing. The Certified Nursing Assistant confirmed that the resident was only receiving bed baths due to the broken chair, and the medicated shampoo was not being used. The facility administrator acknowledged the issue, stating that a new shower chair had been ordered but had not yet arrived. This oversight resulted in the resident not meeting her treatment goals for psoriasis management.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure fall interventions were in place for a resident identified as high risk for falls. The resident, a male with diagnoses including unspecified dementia, abnormalities of gait and mobility, osteoarthritis, history of falling, vascular dementia, and cognitive communication deficit, was observed in his room with a folded floor mat against the wall instead of on the floor next to his bed. This observation was made despite the resident's care plan indicating the need for a low bed and a floor mat as part of his fall prevention interventions. Interviews with facility staff, including an LPN and a CNA, confirmed that the resident is a fall risk and should have the floor mat in place when lying down. The facility's Falls Policy requires that high-risk residents have interventions implemented to meet their individual needs, which was not adhered to in this case.
Failure to Provide Fortified Foods for Resident with Weight Loss
Penalty
Summary
The facility failed to provide fortified potatoes during the noon meal for a resident experiencing significant weight loss. The resident, an elderly male with a history of hemiplegia, hemiparesis, dysphagia, chronic kidney disease, and a history of falling, was observed sitting in his wheelchair appearing thin. He reported being unaware of any nutritional supplements being provided. During a meal observation, the resident was served a ground pork sandwich and fries instead of the prescribed fortified potatoes. The dietitian confirmed that the resident had triggered for significant weight loss the previous month and should have been receiving fortified foods with breakfast and lunch. However, the dietitian did not have access to the resident's diet cards, and the physician order sheets did not list the fortified foods. The resident's weight records indicated a significant weight loss of 5.9% in one month, classifying him as underweight. The facility's unplanned weight loss policy states that a 5% weight loss in one month is significant, requiring consultation between the dietitian and physician to determine appropriate dietary supplementation strategies.
Failure to Label Insulin with Opened Date
Penalty
Summary
The facility failed to ensure that insulin medications were labeled with an opened date for three residents reviewed for medications. During an observation, it was found that a Lantus insulin vial and Lispro insulin pen for one resident, a Lantus insulin pen for another resident, and Glargine insulin for a third resident were opened but not dated. A Licensed Practical Nurse acknowledged that these insulin products should have been labeled with an open date to track their usability. The physician orders for these residents indicated specific insulin regimens for diabetes management, which required proper labeling to ensure safe administration. The facility's policy on the storage and return of drugs mandates that multi-dose vials and pens be stored and dated according to the manufacturer's guidance.
Deficiencies in Catheter Management and Resident Care
Penalty
Summary
The facility failed to thoroughly assess and manage a resident's malfunctioning catheter, leading to significant complications. Resident R3 experienced bleeding and catheter pain, which were not adequately addressed by the nursing staff. On the day of the incident, R3 complained of pain and burning at the tip of his penis, but the attending LPN did not flush the catheter, notify a physician, or take vital signs. Later, another LPN deflated the catheter balloon due to R3's severe pain, which resulted in immediate relief but also caused significant bleeding. R3 was subsequently sent to the hospital, where he was admitted for a urinary tract infection, displaced Foley catheter, and hypotension. Additionally, the facility failed to prevent the displacement of a suprapubic catheter during care for another resident, R1. A CNA inadvertently dislodged R1's catheter while assisting him in the bathroom. The LPN on duty attempted to reinsert the catheter but was unsuccessful, necessitating R1's transfer to the hospital for catheter replacement. The DON acknowledged that catheters should not be dislodged during care, indicating a lapse in proper handling and care procedures. Both incidents highlight the facility's deficiencies in catheter management and response to residents' complaints of pain and discomfort. The lack of immediate assessment and intervention for R3's catheter issues and the improper handling of R1's suprapubic catheter during care contributed to the adverse outcomes experienced by the residents. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors.
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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