Briar Place Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Indian Head Park, Illinois.
- Location
- 6800 West Joliet, Indian Head Park, Illinois 60525
- CMS Provider Number
- 145784
- Inspections on file
- 49
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 30 (1 serious)
Citation history
Health deficiencies cited at Briar Place Nursing during CMS and state inspections, most recent first.
A resident with multiple psychiatric and medical diagnoses, who was cognitively intact and had a physician order for independent community pass, had their pass privileges restricted for 30 days after an unsubstantiated allegation of drug possession. Staff found no contraband during a search, and there were no clinical signs of intoxication. The restriction was imposed despite the facility's policy requiring evidence of intoxication or overnight absence, neither of which were present.
A resident's bank card was left unsecured in her room while she was hospitalized, leading to its theft and unauthorized use by a CNA, resulting in financial exploitation and distress for the resident. Facility staff failed to follow proper procedures for handling resident mail and protecting personal property, in violation of abuse prevention policies.
A resident's mail was left under their pillow by activity staff while the resident was hospitalized, contrary to facility policy requiring secure storage when residents are unavailable. The mail was subsequently stolen and used, indicating a breach of privacy and confidentiality procedures.
A resident's care plan incorrectly listed them as Full Code despite both the POLST and physician order sheet indicating DNR status. The DON confirmed the care plan was inaccurate and did not match the resident's documented advance directives, contrary to facility policy.
A resident's care plan was not reviewed quarterly and failed to reflect the current DNR status, despite both the POLST and physician orders indicating Do Not Resuscitate. The care plan inaccurately listed the resident as 'Full Code' and had a goal target date set beyond the required 90-day interval. The DON confirmed the care plan was not accurate and overdue for review, in violation of facility policy.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report does not specify further details about the individuals involved or the exact nature of the hazards.
The facility did not maintain proper functioning of hallway air conditioning units, resulting in hallway temperatures exceeding recommended levels while resident rooms remained adequately cooled. Staff and a resident reported significant discomfort in the hallways, and portable AC units failed to resolve the issue. The deficiency affected all residents, including those with significant medical conditions, and was not consistent with facility policies requiring a comfortable and homelike environment.
The facility did not maintain hallway temperatures below 81°F, resulting in excessively hot hallways while resident rooms remained adequately cooled. A resident with multiple medical conditions reported discomfort in the hallways, and staff confirmed the issue, noting that portable AC units were not effective. The malfunctioning hallway air conditioning system persisted for about two weeks despite repair attempts, leading to an environment that was not comfortable for residents, staff, or visitors.
The facility did not document that the bed hold policy was provided to two residents upon transfer to a hospital, despite facility policy requiring this notification. Both residents, with complex medical and psychiatric histories, were transferred for emergency services, and staff interviews confirmed that the required documentation and notification were not completed.
A resident experienced severe pain following neck surgery due to the facility's failure to provide timely pain management. Despite reporting pain levels of 9/10, the resident only received acetaminophen as the facility did not have a prescription for Oxycodone. The resident endured three days of severe pain before receiving the correct medication, and another lapse occurred when the prescription ran out. The facility's Pain Management Program was not followed, with inaccurate pain assessments and delayed physician contact.
A resident with epilepsy was left unsupervised during a shower, resulting in a seizure and a fractured humerus. Despite her care plan requiring supervision due to her seizure history, she was allowed to shower alone. The incident went unnoticed for about 20 minutes until a nurse responded to her cries for help. The facility's policy on supervision was not followed, leading to this preventable accident.
The facility failed to follow its hand hygiene policy, affecting all 216 residents. Surveyors observed staff, including CNAs and a Wound Care Nurse, not performing hand hygiene after resident care or between tasks. Staff cited the absence of hand sanitizers in hallways and rooms due to residents' cognitive conditions, and some did not carry personal hand sanitizers as required. The Infection Preventionist confirmed the policy but noted the lack of sanitizers in common areas.
The facility failed to maintain a clean and sanitary environment for 143 residents on the first and second floors. Surveyors noted strong odors and unsanitary conditions, including a urine puddle and sticky floors. Interviews revealed confusion among staff regarding cleaning responsibilities, with housekeepers and nursing staff not effectively coordinating to address body fluid spills, leading to inadequate sanitation.
The facility failed to date two opened insulin vials, as required by its pharmacy policy, potentially affecting two residents. An LPN confirmed that insulin must be dated upon opening to track its 28-day expiration. The DON acknowledged the need for dating medications to ensure effectiveness. The facility's policy mandates dating opened vials to maintain medication purity and potency.
A resident with schizoaffective disorder was physically abused by a CNA, resulting in a head injury and contusions. An LPN witnessed the CNA hitting the resident and intervened. The resident was hospitalized, and the CNA was terminated. The facility's records showed no history of aggression from the resident, and the CNA's account of the incident was inconsistent.
A resident was discharged from an LTC facility without proper written notice after being allowed to leave on a community pass. The resident, with a history of cerebral infarction, diabetes, asthma, hypertension, and substance abuse, was accused of drinking alcohol and was asked to go for a psychiatric evaluation, which he refused. Despite a low alcohol level and no documented aggressive behavior, the facility considered him discharged AMA. Upon return, he was denied access and medications, leading to health issues while waiting for a new primary care physician.
A resident with schizoaffective disorder and a history of medication refusal was allowed unsupervised community access, resulting in her being found by police in a state of psychosis days later. Despite known delusional behaviors and medication refusals, the facility reinstated her independent pass without addressing these issues. The facility's policy considered her discharged AMA when she did not return, but her absence was not noticed until the next day.
The facility improperly discharged two residents against medical advice (AMA) while they were on approved community passes. The facility's policy automatically classified residents as AMA if they did not return from a pass, regardless of their intentions or medical advice. This affected residents with independent community access, potentially impacting 37 residents. Specific cases involved two residents who were considered discharged AMA despite not expressing a desire to leave AMA, highlighting a conflict between the facility's policies and proper discharge procedures.
A resident with a history of drug abuse repeatedly brought contraband into the facility and tested positive for drugs, despite the facility's zero-tolerance policy. The facility's interventions were insufficient, and the resident ultimately died from combined drug toxicity involving fentanyl. The facility failed to adequately supervise and prevent the resident from obtaining and using illicit substances.
The facility failed to follow its wound policy and showering protocol, resulting in seven residents not receiving weekly showers and skin assessments as required. Observations and interviews revealed that staff did not monitor residents during showers or perform necessary skin assessments, and documentation was either incomplete or missing for several residents over two months.
The facility failed to ensure timely face-to-face physician visits for six residents, as required by their policy. Issues with documentation and technical problems with the facility's computer system contributed to the deficiency. The affected residents had serious medical conditions, and the lack of timely visits was not properly documented in their medical records.
The facility failed to assess a resident for the safety of self-administering hemorrhoid ointment, as required by their policy. The resident was allowed to self-administer without proper monitoring or documentation, and there was no physician's order or care plan in place.
The facility failed to determine how a resident sustained bruising to the left side, with staff either unaware of or not reporting the injuries. The resident, unable to communicate effectively, had multiple bruises that were not properly documented or investigated, contrary to the facility's abuse prevention policy.
A facility failed to follow its abuse policy and report injuries of unknown origin for a resident with aphasia. The resident was observed with a yellow discoloration on the left cheek and a purple discoloration on the left thigh, but these injuries were not documented or reported to the State Surveying Agency. Staff members were either unaware of the injuries or assumed they were old and did not report them. The facility's investigation was incomplete, and the required documentation and reporting were not followed.
The facility failed to follow its abuse policy and investigate injuries of unknown origin for a resident with aphasia. The resident had a yellow discoloration on the left cheek and a purple discoloration on the left thigh, which staff did not report or document properly. The attending physician confirmed the thigh bruise was new, contradicting the administrator's claim that it was old. The facility's abuse prevention policy was not followed, leading to a deficiency.
The facility failed to follow its presumed death policy, initiating CPR on two residents exhibiting clear signs of irreversible death, including rigor mortis and asystole. EMS confirmed the deaths upon arrival, noting the staff's inability to provide the last known time the residents were seen alive.
The facility failed to ensure medication was taken when administered and accounted for, affecting a resident with dementia. Medications were found on the resident's bedside table and on the floor, indicating a lapse in proper medication administration and monitoring by the nursing staff.
Failure to Follow Physician Orders and Community Pass Policy
Penalty
Summary
A resident with a history of alcohol abuse, anxiety disorder, major depressive disorder, PTSD, suicidal ideations, anemia, insomnia, psychoactive substance abuse, and schizophrenia was found to be cognitively intact and had an active physician order for independent community pass. Despite this, the facility restricted the resident's community pass for 30 days after another resident alleged that the individual had brought a marijuana pen into the facility. Staff searched the resident's room and found no contraband, and there was no documentation of symptoms indicating the resident was under the influence of any illicit substance. The resident refused to provide a urine sample and became agitated, but there was no evidence of intoxication or possession of drugs. The facility's community pass policy states that pass privileges may be revoked if a resident returns intoxicated or under the influence, and drug testing may be conducted if there is suspicion after an overnight pass. In this case, the resident had not been out overnight, and there was no credible evidence to support the restriction of the community pass. The decision to restrict the pass was based solely on an unsubstantiated allegation and the resident's refusal to provide a urine sample, without any documented clinical indications or policy-based justification.
Failure to Protect Resident from Financial Exploitation
Penalty
Summary
A cognitively intact female resident reported that her bank card was stolen and used for unauthorized purchases while she was admitted to the hospital. The resident stated she did not give her card to anyone and discovered unrecognized charges upon her return. The facility received her bank card through the mail and, instead of securing it, the mail was left under her pillow by the Activity Director, who was unaware that the resident was not present in the facility. This lapse in mail handling allowed the card to be accessed by unauthorized individuals. Subsequent investigation revealed that a Certified Nursing Assistant (CNA) was identified by police as the individual using the resident's card at a neighborhood store. The CNA denied taking the card but was suspended after the facility and police confirmed multiple unauthorized transactions. The Social Service Director and Human Resource Director both acknowledged that staff are not permitted to make purchases for residents, and the CNA's actions were outside the scope of their duties. The facility's abuse prevention policy states that residents have the right to be free from exploitation and misappropriation of property, which was not upheld in this instance.
Failure to Secure Resident Mail Results in Privacy Breach
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident's mail when staff left a card under the resident's pillow while the resident was admitted to the hospital. The resident later reported that the card was stolen and used at a neighborhood store. According to interviews, the activity staff are responsible for delivering mail directly to residents, and if a resident is not present, the mail should be given to social services for secure storage. In this instance, the activity staff did not follow the established procedure and left the mail in the resident's room, unaware that the resident was out of the facility. The facility's mail delivery policy requires mail to be handed directly to residents or securely stored if the resident is unavailable.
Failure to Accurately Reflect Advance Directives in Care Plan
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately reflected in the care plan, as required by policy. Record review showed that the resident's POLST form and physician order sheet both indicated Do Not Resuscitate (DNR) status, while the care plan incorrectly listed the resident as Full Code. During an interview, the Director of Nursing confirmed that the care plan was not accurate and acknowledged the discrepancy, stating that the resident was technically a DNR and that the care plan needed revision. The facility's policy requires that advance directives be addressed in the resident's plan of care, but this was not followed in this instance.
Failure to Review and Revise Care Plan to Reflect Accurate Advance Directive Status
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the development, review, and revision of comprehensive care plans. Specifically, the care plan for one resident was not reviewed quarterly as required, and the goal target date was set for approximately six months after the last revision, exceeding the 90-day interval mandated by facility policy. Additionally, the care plan was not updated to reflect the resident's current advance directive status, despite documentation in both the POLST and Physician Order Sheet indicating Do Not Resuscitate (DNR) status. Instead, the care plan continued to state 'Full Code,' which was inconsistent with the resident's documented wishes and physician orders. During interviews, the Director of Nursing confirmed that care plans should be reviewed quarterly or upon significant change, and acknowledged that the resident's care plan was inaccurate and overdue for review. The facility's policy requires care conferences for review and revision of care plans every 90 days or as needed, with the interdisciplinary team responsible for implementation. The failure to update and accurately reflect the resident's code status in the care plan represents a lapse in adherence to established procedures and documentation requirements.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions by staff or details about the residents involved are not provided in the report. No further information about the circumstances or individuals affected is included.
Failure to Maintain Safe Hallway Temperatures Due to Air Conditioning Malfunction
Penalty
Summary
The facility failed to ensure that essential equipment, specifically the chillers and air conditioning units serving the hallways, were maintained in proper working order. On the date of the survey, temperature checks revealed that while resident rooms were within an acceptable range (76.2°F to 80.0°F), the hallways on all floors were significantly above the recommended maximum, with temperatures ranging from 84.1°F to 89.1°F. Staff interviews confirmed that the air conditioning system for the hallways had been malfunctioning for approximately two weeks, with ongoing issues causing the units to lock out and overheat. Despite multiple visits from HVAC technicians and the use of portable air conditioning units, the hallways remained uncomfortably hot and did not reach adequate cooling levels. Residents and staff reported discomfort due to the high temperatures in the hallways. One resident, who is cognitively intact and has medical diagnoses including type 2 diabetes mellitus, morbid obesity, and hemiplegia, stated that the temperature outside their room was uncomfortable and that staff advised residents to stay in their rooms or other cooler areas. Staff confirmed that the hallways were too hot, particularly on the third floor, and that they were providing residents with cold water, ice, and popsicles to help manage the heat. Facility records and interviews indicated that the air conditioning system for the resident rooms was repaired, but the separate system for the hallways continued to malfunction. Maintenance staff described the building as old and noted that repairs to one unit often led to issues with another. The facility's preventative maintenance policy requires regular environmental tours and safety audits to ensure a pleasant temperature, and the resident rights policy emphasizes a safe, comfortable, and homelike environment. However, the persistent failure to maintain adequate hallway temperatures affected all 202 residents in the facility.
Failure to Maintain Safe and Comfortable Hallway Temperatures
Penalty
Summary
The facility failed to maintain hallway temperatures below 81 degrees Fahrenheit, resulting in excessively high temperatures in multiple hallways across all floors, with recorded temperatures ranging from 84.1 to 89.1 degrees Fahrenheit. While resident rooms were maintained at acceptable temperatures, the hallways remained uncomfortably hot due to a malfunction in the hallway air conditioning system. The issue was identified when staff and residents reported discomfort, and temperature checks confirmed the elevated temperatures in the hallways. A resident with diagnoses including type 2 diabetes mellitus, morbid obesity, and hemiplegia reported that while their room was comfortable, the hallways were uncomfortably hot, and staff advised residents to remain in their rooms or other cooler areas. Staff interviews corroborated that the hallways were too hot, particularly on the third floor, and that efforts were being made to keep residents hydrated and comfortable with water, ice, and popsicles. The maintenance director confirmed that the hallway air conditioning system had been malfunctioning for approximately two weeks, with repeated but unsuccessful repair attempts, and that portable air conditioning units brought in as a temporary measure were not sufficient to cool the hallways. Facility records and policies indicate that the expectation is for a safe, comfortable, and homelike environment, with regular environmental audits to ensure pleasant temperatures. Despite these policies, the failure to maintain adequate hallway temperatures created an environment that was not comfortable for residents, staff, or the public, potentially affecting all 202 residents in the facility.
Failure to Document Provision of Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to document that the bed hold policy was provided to a resident or their representative upon transfer to a local hospital. Specifically, for one resident with diagnoses including bipolar disorder and suicidal ideation, there was no documentation in the electronic medical record indicating that the bed hold notification was given when the resident was transferred to the hospital via 911 with an involuntary petition. Interviews with facility staff, including the administrator, DON, and Assistant DON, confirmed that the expectation is for the bed hold policy to be provided and documented at the time of transfer, but in this case, documentation was missing. Additionally, another resident with a history of bipolar disorder, diabetes type 2, alcohol dependence, and hypertension reported not receiving a copy of the bed hold policy or being informed about the 10-day bed hold policy when transferred to the hospital for emergency services. The facility's policy and resident handbook both state that residents are to be informed of the bed hold policy before and upon transfer to a hospital. Staff interviews acknowledged that the process was not followed consistently, and documentation was not completed as required.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R182, following his return from the hospital after neck surgery. R182, who had undergone a C3-C7 decompressive laminectomy and posterior cervical fusion, was in severe pain rated at 9/10 upon his return to the facility. Despite his condition, the facility did not have a prescription for his pain medication, Oxycodone, and instead administered acetaminophen, which was ineffective. The resident reported that the night shift nurse informed him that they could not obtain the stronger pain medication until the following morning, leading to a delay in receiving adequate pain relief. The resident continued to experience severe pain and anxiety over the weekend, as the facility staff failed to contact a physician to obtain the necessary prescription. The resident's pain was not managed effectively until the early hours of the third day after his return, when the Oxycodone prescription was finally filled. Additionally, there was a lapse in pain management when the resident's Oxycodone prescription ran out, resulting in another three days of severe pain before a new prescription was provided. The facility's Pain Management Program, which requires accurate documentation and timely physician notification for unrelieved pain, was not followed. The resident's pain assessments were inaccurately recorded as 0/10 during the periods of reported severe pain, and there was a lack of communication and action from the nursing staff to address the resident's pain in a timely manner. The Director of Nursing and Medical Director acknowledged that the facility's protocol was not adhered to, and the resident should not have endured such prolonged pain without appropriate intervention.
Resident Unsupervised During Shower Leads to Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident, identified as R85, during a shower, resulting in a serious accident. R85, a female resident with multiple diagnoses including epilepsy, experienced a seizure while showering independently. During the seizure, her arm became trapped between the shower rail and the wall, leading to a fracture of her right humerus. The incident was unwitnessed, and R85 was left unattended for approximately 20 minutes before a registered nurse, V11, responded to her cries for help. The resident's care plan indicated that she required supervision during showers due to her epilepsy and history of seizures, but this was not adhered to at the time of the incident. The facility's policy on resident supervision, which mandates adherence to individualized care plans, was not followed in this case. Despite R85's documented need for supervision due to her epilepsy and recent seizure history, she was allowed to shower alone. The incident report and interviews with staff confirmed that the shower room was locked, and staff were responsible for monitoring who accessed it. However, R85 was left unsupervised, contrary to her care plan's requirements. The medical director also confirmed that residents with uncontrolled seizures should be supervised for safety, underscoring the facility's failure to provide necessary supervision to prevent the accident.
Failure to Follow Hand Hygiene Policy
Penalty
Summary
The facility failed to adhere to its hand hygiene policy, which has the potential to affect all 216 residents. Surveyors observed multiple instances where staff did not perform hand hygiene after providing care or moving between resident rooms. On the third floor, a Certified Nurse Assistant (CNA) was seen exiting a resident's room without sanitizing hands, citing the absence of hand sanitizers in hallways and rooms due to residents' cognitive conditions. The CNA admitted to not having a personal hand sanitizer at the time. Similarly, on the second floor, another CNA was observed entering and exiting two residents' rooms without performing hand hygiene, and also did not have a personal hand sanitizer. Additionally, a Wound Care Nurse on the third floor was observed performing wound care without changing gloves or sanitizing hands between tasks, such as cleaning a wound and handling bowel movements. The Infection Preventionist confirmed that staff are instructed to carry personal hand sanitizers and perform hand hygiene at specific times, such as before and after resident care. However, the facility does not provide hand sanitizers in common areas or resident rooms due to the risk of residents ingesting them. The facility's hand hygiene policy emphasizes the necessity of hand hygiene after removing gloves and before and after resident care.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for 143 residents residing on the first and second floor units. During the survey, a strong odor was detected upon entering the first floor common area, and further observations on the second floor revealed an empty medicine cup, an empty milk carton on the elevator floor, and a wet, yellow puddle with a strong urine odor in the common area. The floors on the second floor were noted to be sticky, indicating inadequate cleaning practices. Interviews with staff revealed inconsistencies in cleaning responsibilities. A housekeeper assigned to the second floor mentioned that they were short-staffed on the day of the survey and expressed uncertainty about cleaning body fluids, stating it was the responsibility of certified nurse assistants. The Housekeeping Director confirmed that cleaning urine and feces was a shared responsibility between nursing staff and housekeepers, with nursing staff expected to remove the bulk of the soil before housekeepers sanitize the area. However, the facility's procedure for cleaning blood and body fluid spills was not effectively communicated or followed, contributing to the unsanitary conditions observed by the surveyors.
Failure to Date Opened Insulin Vials
Penalty
Summary
The facility failed to adhere to its pharmacy policy regarding the expiration dating of medications in vials, specifically insulin, which was observed during a survey. Two opened vials of insulin, one belonging to a resident receiving insulin Glargine and another to a resident receiving insulin Lispro, were found undated in the second-floor storage room refrigerator. This oversight was identified during an observation with an agency LPN, who acknowledged that insulin must be dated upon opening to track its expiration, as it remains effective for only 28 days after opening. The Director of Nursing confirmed that medications should be dated according to their recommended usage time to ensure effectiveness. The facility's Pharmacy Policies and Procedures Manual mandates that opened vials be dated to maintain medication purity and potency, with a specific requirement for a 'date opened' sticker and a new expiration date. The failure to date these insulin vials potentially affected the two residents, as their medication administration records indicated regular administration of these insulins for diabetes management.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a vulnerable resident from physical abuse by a staff member, resulting in multiple injuries. The resident, who has schizoaffective disorder and mild cognitive dysfunction, was involved in an altercation with a CNA during the evening shift. The incident was witnessed by an LPN who observed the CNA hitting the resident while in bed. The resident sustained a closed head injury and contusions on the right thumb and forearm and was subsequently transferred to the hospital for evaluation. The resident, upon interview, could not recall the details of the incident but mentioned being hit in the head and experiencing ongoing pain. The LPN who witnessed the event intervened by removing the CNA from the room and assessing the resident's injuries before calling 911. The CNA claimed that the resident became agitated and threw objects, leading to a physical altercation. However, the CNA's account was inconsistent, and they were unable to provide a clear explanation of their actions during the incident. The facility's records and staff statements indicated that the resident did not have a history of aggressive behavior. The CNA, who was terminated following the incident, denied receiving training on abuse prevention, although their personnel file showed completion of relevant training. The facility's abuse policy emphasizes the prevention of abuse and the creation of a secure environment for residents.
Failure to Provide Proper Discharge Notice and Medication
Penalty
Summary
The facility failed to provide a detailed written notice 30 days prior to the discharge of a resident, identified as R1, who was not allowed to return to the facility after being on a community pass. R1, a male resident with a history of cerebral infarction, diabetes, asthma, hypertension, and substance abuse, was admitted to the facility on December 22, 2023. On July 27, 2024, R1 was given a white pass for an overnight visit, signed by the necessary staff and his sister, allowing him to leave the facility. However, shortly after leaving, R1 was informed by the manager on duty and the administrator that he would be considered discharged against medical advice (AMA) and could not return. The facility's actions were based on an incident on July 26, 2024, when R1 was accused of drinking alcohol outside the facility. Despite a breathalyzer test showing a low alcohol level of 0.02, the staff requested R1 to go to the hospital for a psychiatric evaluation, which he refused. The facility then filled out an involuntary petition for inpatient hospitalization due to alleged belligerent and verbally aggressive behaviors, although these behaviors were not documented in R1's progress notes. The psychiatrist evaluated R1 and found no psychiatric difficulties requiring management, and the facility did not provide R1 with any written notice of discharge. Upon returning from his overnight pass on July 29, 2024, R1 was denied access to the facility and his room, and his belongings were brought to him via the side door. R1 was also refused medications, which included those for asthma, high blood pressure, and diabetes. It took R1 approximately four weeks to secure a new primary care physician, during which he experienced health issues due to a lack of medication. The facility's discharge report listed R1 as discharged AMA, despite the active discharge care plan indicating no plans for discharge. The facility's policy on AMA discharges was not followed, as R1 was not given a written notice or the opportunity to discuss his discharge with the attending physician.
Failure to Restrict Community Access for Resident with Psychiatric Needs
Penalty
Summary
The facility failed to restrict independent community access for a resident with a known history of refusing psychiatric and medically necessary medication, as well as exhibiting active delusions and hallucinations. This resident, who has diagnoses including schizoaffective disorder-bipolar type and generalized anxiety disorder, was allowed to leave the facility unsupervised despite these concerns. The resident did not return to the facility and was found three days later by local law enforcement, lying on the ground in the community, and was taken to the emergency room with active psychosis. The resident had a history of delusional behaviors and medication refusals, which were documented in progress notes. Despite these issues, the Social Service Director assessed the resident to be appropriate for independent community access and reinstated the green pass. The resident continued to experience hallucinations and delusional behaviors, and refused medications multiple times, including those for schizophrenia, hypertension, and diabetes, prior to being granted access to leave the facility. No interventions were documented to address these refusals. The facility's policy stated that residents who do not return from a community pass are considered discharged against medical advice (AMA). However, the facility failed to notice the resident's absence until the following day, and a missing person's report was filed. The resident was eventually located by police and admitted to a hospital's behavioral health unit. The facility's administrator acknowledged the oversight and the lack of communication regarding the resident's medication refusals.
Improper Discharge Procedures for Residents on Community Passes
Penalty
Summary
The facility failed to ensure that their policies related to independent community access were not in conflict with proper discharge procedures. This resulted in two residents being considered discharged against medical advice (AMA) while on approved day and overnight passes. The facility's policy automatically classified residents as AMA if they did not return from a pass, regardless of their intentions or medical advice, as a means to release liability. This policy affected residents who had been granted independent community access, potentially impacting 37 residents. The report highlights specific cases involving two residents, R1 and R3. R1 was considered discharged AMA after leaving on a supervised community pass, despite not expressing a desire to leave AMA. The facility had informed R1 that he would be considered AMA if he left, as he was supposed to go to the hospital. Similarly, R3 was considered discharged AMA after not returning by the facility's curfew time, even though she did not express a desire to leave AMA. The facility's policy dictated that residents who did not return on time from a pass were automatically considered AMA. The facility's policies, including the Community Pass Policy and the Outside Pass Policy, allowed for residents to be discharged AMA if they did not adhere to the standards set by the facility. The Discharge Against Medical Advice policy outlined procedures for staff to follow when a resident wished to leave AMA, including assessing the resident's competence and attempting to persuade them to stay. However, the automatic classification of residents as AMA when they did not return from a pass conflicted with these procedures, leading to the deficiency identified in the report.
Failure to Supervise Resident with Substance Abuse History
Penalty
Summary
The facility failed to effectively supervise a resident with a history of drug abuse, leading to multiple incidents of noncompliance and ultimately the resident's death due to combined drug toxicity. The resident, a [AGE] year old female, had a history of psychoactive substance abuse, including heroin and cocaine, and was noncompliant with her psychotropic medications. Despite being informed of the facility's zero-tolerance policy for alcohol and illicit drugs, the resident repeatedly brought contraband into the facility, including vapes and THC pens, and tested positive for THC and opioids during her stay. The facility's interventions, such as smoking restrictions and counseling, were insufficient to prevent the resident from obtaining and using illicit substances. The resident's noncompliance and continued drug use were documented in multiple social service notes, which detailed incidents of the resident being found with contraband and testing positive for drugs. Despite these documented incidents, the facility did not implement new specific interventions beyond the existing care plan. The resident's substance abuse issues were discussed with her mother and the Substance Abuse Coordinator, who recommended inpatient or residential treatment, but the resident refused. The facility's failure to adequately supervise and prevent the resident from obtaining contraband ultimately led to her death. On the day of the incident, the resident was found unresponsive in her bed and was pronounced dead after unsuccessful CPR attempts. The cause of death was confirmed as combined drug toxicity involving fentanyl and acetyl despropionyl fentanyl, substances for which there were no physician orders. The facility's policies and procedures for preventing contraband and supervising residents with substance abuse disorders were not effectively implemented, resulting in the resident's ability to obtain and use illicit drugs within the facility.
Removal Plan
- A system to ensure contraband does not enter the facility and is removed from the resident will be achieved through staff education.
- Education will be provided by the Administrator, to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager.
- This education will review the facility's contraband policy and will include that residents may be asked to voluntarily empty and show the contents of their pockets at any time if reasonable suspicion exists.
- Reasonable suspicion includes frequent leaves of absence with or without facility knowledge, odors, new needle marks, and changes in resident behavior such as unexplained drowsiness, slurred speech, lack of coordination, mood changes, particularly after interaction with visitors or absences from the facility.
- Residents may be asked to voluntarily reach into concealed clothing areas and remove any items and place these items on a horizontal surface.
- Staff are instructed to have the resident hand items to the staff members or place the items on the horizontal surface.
- It is the objective of this policy that the above steps occur in plain sight of multiple witnesses (if possible) to afford appropriate protection to both the resident and the involved staff member(s).
- These steps are necessary to assure that the resident is treated with respect and dignity throughout the procedure.
- It is appropriate to ask the resident to empty his/her pockets and display their contents or roll down his/her socks.
- It is not appropriate to bring a resident into a room for a more specific search unless there is strong suspicion that the individual is attempting to bring in objects/items that may cause serious harm.
- If a more specific search is required the staff are to follow guidelines as set forth by the administrator or the administrative representative.
- This may even involve requesting professional assistance from the local police.
- Only outerwear articles of clothing including, but not limited to, jackets, coats, scarves, hats, gloves, and vests, shall be removed in plain site of staff.
- This policy recognizes that residents have attempted to hide/conceal contraband articles in undergarments in the past.
- If this appears to be the case and staff assess and suspect that these items may cause harm, staff are directed to contact the administrator or the administrative representative for instructions on how to proceed.
- The facility emphasizes treatment with dignity at all times.
- The facility reserves the right to remove locks from drawers, cabinets, closets, lockers, or any other object if there is reason to suspect that the resident possesses any item or items that may potentially harm other persons.
- The facility may choose, at its discretion, to involve drug-sniffing dogs (e.g., from a K9 company) if residents are suspected to be trafficking drugs inside the facility.
- A root cause analysis will be completed upon identification of contraband.
- Upon completion of the training, staff will sign a record of continuing education sheet to confirm their knowledge and understanding of the topic presented.
- The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession.
- A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder.
- If agency nurses have any questions regarding the information presented in the staff education binder, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education.
- In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses.
- The facility has identified five staff members who are on a leave of absence/vacation.
- These staff members will be contacted by the Administrator to review staff education regarding the prevention of contraband from entering the facility and the removal of contraband from resident possession.
- The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work.
- The staff member will sign a record of education to validate their understanding of the information presented in the binder.
- If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education.
- In the Administrator's absence, the Director of Nursing will answer questions regarding the education.
- Additionally, this education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually.
- A system to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through staff education.
- Education will be provided by the Administrator to registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager.
- This education will review the facility's policy on Alcohol/Substance Use/Abuse.
- The education will review that Each resident (and/or representative) is informed that facility policy prohibits the use of alcohol without a doctor's order.
- Facility policy prohibits the use of illicit drugs.
- As a condition of residence, each person living in the facility acknowledges that he/she will not use alcohol or illicit drugs during residence in this building.
- Persons assessed with an active substance abuse problem are offered appropriate treatment and rehabilitative services.
- While this policy addresses illicit drugs and alcohol, the same standards and expectations are in place for persons with a prescription narcotic addiction.
- These individuals are also responsible for engaging in appropriate treatment to reduce/eliminate dependency on opioids.
- Persons returning from the community who present with signs and symptoms of intoxication will be evaluated by the nurse on duty or charge nurse.
- The nurse is responsible for assessing the person's physical condition and present behavior.
- The nurse will be responsible for contacting the attending physician (A.P.) if the resident is determined to be in need of medical attention and/or a decision is required regarding withholding prescribed medications.
- Documentation will be placed in the chart emphasizing signs/symptoms of intoxication/inebriation (such as smell of alcohol, behavior changes, balance/gait problems, appearance of the eyes, and change in speech pattern).
- Documentation should include the resident's own admission of alcohol/drug use.
- The facility reserves the right to have the person submit to blood/urine testing at any time if policy violation is suspected.
- Persons who are evaluated as medically unstable will be transferred for appropriate medical care.
- Follow-up interventions and treatment recommendations will be communicated to the resident/representative and documented in the medical record.
- Outside treatment sources will be utilized as appropriate.
- Residents with substance abuse disorders are expected to participate in acute/active treatment, sobriety counseling, or aftercare interventions, as appropriate to their personal situation.
- The facility has the right to implement money management interventions pursuant to federal law if substance abuse continues.
- Persons who continually jeopardize their health and the health and safety of others will be evaluated for involuntary discharge.
- Education will include instruction on how to identify which residents have a substance abuse disorder and how to locate resident-specific interventions to prevent them from obtaining contraband while in the facility.
- This information will be kept in binders at the nurse's stations.
- The binders will include a list of residents with substance abuse disorders and information on resident-centered interventions to prevent them from obtaining contraband while in the facility.
- These binders will be updated by social services weekly and with resident changes in condition.
- Upon completion of this education, staff will sign a record of continuing education to confirm their knowledge and understanding of the information presented.
- This education will be provided to new staff upon hire during orientation training and will be repeated to all staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and the business office manager annually.
- The Director of Nursing will contact agency staff before their scheduled shift to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility.
- A binder with staff education will be kept at the front desk and agency staff will be required to read and sign to validate their understanding of the information presented in the binder.
- If agency nurses have any questions regarding the information presented in the staff education binder, they will be instructed to contact the Director of Nursing for clarification prior to signing the record of education.
- In the absence of the Director of Nursing, the Assistant Director of Nursing will review the education requirements and answer any questions for agency nurses.
- The facility has identified five staff members who are on a leave of absence/vacation.
- These staff members will be contacted by the Administrator to review staff education regarding the prevention of residents with substance abuse disorders from introducing contraband into the facility or obtaining contraband in the facility.
- The staff education will be placed in a binder at the front desk and must be reviewed and signed by the staff member before returning to work.
- The staff member will sign a record of education to validate their understanding of the information presented in the binder.
- If the staff have any questions regarding the education, they will be instructed to contact the Administrator before signing the record of education.
- In the Administrator's absence, the Director of Nursing will answer questions regarding the education.
- The procedure for developing resident-centered care plans to provide guidance to staff to prevent residents with a history of substance abuse from introducing contraband into the facility or obtaining contraband in the facility will be achieved through education provided by the Administrator to the Social Services department staff on the importance of identifying residents with substance abuse disorders and assessing their risk of introducing drugs/contraband and obtaining drugs/contraband while in the facility.
- This risk assessment is documented in the resident chart in the Social Service Initial Interview for SMI/Substance Abuse Disorder (SS) assessment.
- This risk assessment must be used by the social services staff to develop a resident-centered care plan to address the potential risks of the resident introducing drugs/contraband into the facility and obtaining contraband/drugs while in the facility.
- Care plan interventions will be based on the resident's personal risk factors and coping mechanisms and may include but are not limited to efforts outlined in the facility policy for Alcohol/Substance Use/Abuse such as outside treatment services, acute/active treatment, sobriety counseling, or aftercare interventions.
- The effectiveness of the care plan must be reviewed quarterly and with changes in condition and updated as indicated.
- A binder will be placed at each nurse's station with a list of residents with substance abuse disorders as well as information on the resident-centered interventions for preventing them from obtaining contraband while in the facility.
- These binders will be updated by the social services department weekly and with resident changes in condition.
- Upon completion of this education, social services staff will sign a record of continuing education to confirm their understanding and knowledge of the topics presented.
- This education will be presented to new hire social services staff upon hire and will be reviewed with all social services staff annually.
- Agency staff is not utilized in the social services department.
- There are currently no social services staff on leave of absence or vacation.
- There have been no updates to facility policies.
- A system to supervise residents from obtaining contraband and from having or obtaining illicit drugs in the facility will be achieved through staff education.
- The Administrator will educate staff including registered nurses, licensed practical nurses, CNAs, social workers, activity staff, security guards, housekeeping staff, dietary staff, maintenance staff, reception staff, human resources director, and business office manager on the facility standard for providing adequate supervision for residents with substance abuse disorders to prevent them from obtaining contraband/ drugs.
- This education includes a review of the facility policy for safety and supervision which focuses on ensuring a facility-oriented approach to safety to address risks for groups of residents including residents with substance abuse disorders/history.
- Education will discuss the importance of identifying safety risks and environmental hazards on an ongoing basis.
- Staff will be educated that resident supervision is a core component of resident safety and that the type and frequency of supervision are determined by the individual resident's needs.
- Staff must intervene immediately whenever an unfavorable event between residents, staff, or visitors is noticed.
- Staff must decrease safety hazards as much as possible and provide redirection when necessary.
Failure to Follow Showering and Skin Assessment Protocols
Penalty
Summary
The facility failed to follow its wound policy and showering protocol, resulting in seven residents not receiving weekly showers and skin assessments as required. Observations and interviews revealed that staff did not monitor residents during showers or perform necessary skin assessments. For instance, a resident was observed taking a shower without staff supervision or a subsequent skin assessment. Additionally, the Director of Nursing (DON) and other staff members confirmed that shower sheets and skin assessments were either incomplete or missing for several residents over two months. This included instances where residents received showers, but no documentation of skin assessments was found, and cases where residents did not receive showers at all. The facility's wound policy mandates weekly skin assessments by a licensed nurse, with findings documented and signed off. However, the review of shower sheets for August and September 2023 showed significant gaps in compliance. Several residents had no recorded showers or skin assessments for these months, and in cases where showers were documented, the required skin assessments were not completed. Staff interviews corroborated these findings, indicating a systemic failure to adhere to the facility's protocols for resident care and documentation.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to follow their physician visit policy and ensure that the attending physician conducted face-to-face visits within the first 30 days of admission and at least once every 60 days thereafter. This deficiency affected six residents, as documented through interviews and record reviews. The Nurse Practitioner (NP) and the Attending Physician both acknowledged issues with timely documentation and uploading of visit notes into the residents' electronic medical records. The NP admitted to being unable to find recent notes for several residents, and the Attending Physician cited technical issues with the facility's computer system as a reason for delayed documentation. Resident 7, who had multiple serious diagnoses including deep tissue injury, sepsis, and dementia, did not have documented face-to-face visits within 30 days of admission or re-admission. Similarly, Resident 15, with conditions such as anxiety disorder and dementia, lacked documentation of face-to-face visits within the required timeframes. The Administrator later presented documentation via email, but these documents lacked identifying information and were not found in the residents' medical records during the survey. Other residents, including Resident 16 with a history of stroke and diabetes, Resident 18 with a right femur fracture and dementia, Resident 19 with a right below-knee amputation and heart failure, and Resident 21 with diabetes and a history of falling, also had gaps in their documented face-to-face visits. The facility's physician visit policy mandates that each resident must be seen by a physician at least once every 30 days for the first 90 days after admission and then at least every 60 days thereafter. The failure to adhere to this policy was evident in the missing documentation and delayed uploading of visit notes.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to follow its self-administration of medications policy by not assessing a resident (R17) to determine if it was safe for them to self-administer medications. A nurse (V26) allowed R17 to self-administer hemorrhoid ointment without monitoring or ensuring the medication was administered as prescribed. The Director of Nursing (V2) stated that no resident at the facility could self-administer medications without an assessment and clearance from a physician, which R17 did not have. Additionally, another nurse (V10) confirmed that a physician's order is required for self-administration, but there was no documentation or care plan for R17 regarding self-administration of medications. R17's medical record lacked any assessment by the interdisciplinary team to determine the safety of self-administration of the hemorrhoid ointment. The facility's policy, dated 09/2020, requires that residents be assessed for cognitive, physical, and visual ability to self-administer medications safely, and an order must be obtained from the attending physician. The policy also mandates documentation of the resident's understanding and response to the medication, which was not done for R17.
Failure to Determine Cause of Resident's Bruising
Penalty
Summary
The facility failed to determine how a resident sustained bruising to the left side, affecting one resident reviewed for injury of unknown origin. On multiple occasions, the resident was observed with yellow discoloration to the left cheek and purple discoloration extending from below the left hip to above the knee. The resident, who is unable to communicate effectively due to aphasia, could not provide details on how the injuries occurred. Staff members, including CNAs and a nurse, were either unaware of the bruising or assumed it was old and did not report it. The facility's administrator stated that the thigh bruise was due to a fall and had been investigated, but there was no response regarding the facial bruising. The medical record did not document the left facial bruising, and the attending physician confirmed that the purple discoloration indicated a new bruise, contradicting the administrator's statement that it was old. The facility's investigation into care-related concerns for the resident was incomplete and did not address all observed injuries. Staff interviews were undated and inconsistent, with some staff denying recent falls and others noting a slip in the shower weeks prior. The resident's medical record noted a fall on 2/9/24, resulting in bruising to the left buttocks and thigh, but there was no documentation of the left cheek discoloration. The facility's abuse prevention policy requires documentation and investigation of injuries of unknown source, but this protocol was not followed, leading to a failure in protecting the resident from potential abuse or neglect.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy and report an injury of unknown origin to the regulatory agency, affecting one resident reviewed for abuse reporting. The resident, who is unable to communicate effectively due to aphasia, was observed with a yellow discoloration on the left cheek and a purple discoloration extending from below the left hip to above the knee. Despite these observations, the facility did not document or report these injuries to the State Surveying Agency. Staff members, including CNAs and a nurse, were either unaware of the injuries or assumed they were old and did not report them. The facility's administrator claimed that the thigh bruise was due to a fall and had been investigated, but there was no response regarding the facial bruise. The resident's medical record indicated a fall on a previous date, but there was no documentation of the facial bruising. The attending physician confirmed that the purple discoloration indicated a new bruise, contradicting the staff's assumption that it was old. The facility's abuse prevention policy requires documentation and reporting of injuries of unknown origin, but this was not followed. The facility's investigation into the resident's care concerns was incomplete, with staff interviews not addressing the facial bruising and other injuries. The facility failed to provide documentation that the injuries were reported to the State Surveying Agency, as required by their policy.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse policy and investigate an injury of unknown origin for a resident (R21). The resident was observed with a yellow discoloration on the left cheek and a purple discoloration extending from below the left hip to above the knee. The resident, who is unable to communicate effectively due to aphasia, could not explain how these injuries occurred. Staff members, including CNAs and a nurse, were unaware of the injuries or assumed they were old and did not report them. The facility's administrator claimed that the thigh bruise was due to a fall and had been investigated, but there was no documentation regarding the facial bruise. The attending physician confirmed that the purple discoloration indicated a new bruise, contradicting the administrator's statement that it was old. The facility's abuse prevention policy requires documentation and investigation of injuries of unknown origin, but this was not followed in R21's case. R21's medical records showed a history of a fall on 2/9/24, resulting in bruising to the left buttocks and thigh, but there was no documentation of the facial bruise. The facility's investigation into care-related concerns for R21 was incomplete, with staff interviews not addressing the facial bruising or scratches on R21's arms. Skin alteration reviews also failed to document the left cheek and thigh discolorations. The facility's abuse prevention policy mandates that injuries of unknown origin be documented and investigated, but this was not done for R21's injuries, leading to a deficiency in following the abuse policy and ensuring resident safety.
Failure to Follow Presumed Death Policy
Penalty
Summary
The facility failed to follow its presumed death policy and initiated CPR on two residents exhibiting obvious signs of irreversible death. Resident 17 was found unresponsive with rigor mortis in the jaw, lividity in the back and legs, and no vital signs. Despite these clear indicators of death, a code blue was called, and CPR was initiated. EMS arrived and confirmed the presence of rigor mortis and asystole, determining that the resident had been deceased for several hours. The staff could not confirm the last time the resident was seen alive, and the EMS left without taking the resident. Resident 28 was found unresponsive in bed with full rigor mortis throughout the body and asystole. The resident had a history of post-traumatic stress disorder, psychoactive substance abuse, anxiety disorder, major depressive disorder, attention-deficit hyperactivity disorder, and suicidal ideation. Despite the presence of rigor mortis, CPR was initiated, and EMS was called. Upon arrival, EMS confirmed the resident's death and noted that the facility staff could not provide the last known time the resident was seen alive. The facility's presumed death policy states that resuscitation should not be performed if a resident is presumed and confirmed dead by two licensed nurses, based on specific criteria such as fixed and dilated pupils, no spontaneous respiration, mottled discoloration of the body, no spontaneous movement, and absence of vital signs. In both cases, the facility staff failed to adhere to this policy, leading to unnecessary CPR attempts on residents who were already deceased.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medication was taken when administered and accounted for, affecting one resident (R15) who was reviewed for medication. On 3/20/24, a white oval tablet was found on R15's bedside table, which the resident was unaware of. The tablet was identified as Topiramate, a medication given to R15 to prevent seizures. The nurse (V44) was unaware of when the medication was placed on the bedside table. Additionally, on 3/26/24, two pills were found on the floor in front of the nurses' station, identified as atorvastatin and taltz. The Director of Nursing (V2) confirmed that nurses are expected to stay with residents to ensure they take their medication and to check for any dropped medications to prevent other residents from taking them. The medical director (V54) emphasized that medications should not be left at a resident's bedside, especially if the resident has dementia, and that it is standard practice for nurses to remain with residents during medication administration. R15's medical record notes a diagnosis of dementia, and the physician order sheet dated 5/8/23 includes an order for Topiramate 25mg tablets, to be given three times a day for a total of 75mg. The medication administration record for March 2024 shows that Topiramate is scheduled to be administered at 6:00 AM and 9:00 PM daily. The facility's medication administration policy, dated 1/1/2020, states that medications should be administered only to the individual for whom they are prescribed, within one hour of the prescribed times, and with positive verification of the resident's identity. The policy also requires that medications be administered according to the physician's written orders, verifying the right medication, dose, route, and time.
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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