Center Home Hispanic Elderly
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 1401 North California, Chicago, Illinois 60622
- CMS Provider Number
- 146062
- Inspections on file
- 41
- Latest survey
- December 26, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Center Home Hispanic Elderly during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a sacral pressure ulcer did not receive daily wound care as ordered, with missed treatments documented on multiple dates. Staff interviews and record review confirmed that wound care was not performed or documented according to facility policy, resulting in a deficiency related to wound care management.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents.
A resident with a history of falls, cognitive impairment, and lack of coordination sustained serious facial injuries requiring sutures after falling during a shower when left briefly unattended by CNAs. Additional lapses in supervision were observed, including a CNA inattentive to resident calls for help and two high fall risk residents left unsupervised in an activity room, all contrary to facility policy.
A facility-wide deficiency occurred when mechanical equipment, specifically the hot water mixing valve and boiler, failed, resulting in the loss of hot water for all residents. Multiple sinks and showers were found with water temperatures below regulatory standards or with no water supply. The Maintenance Director and Corporate Project Manager identified equipment failure and difficulties in obtaining the correct replacement parts, while the Administrator instructed staff to provide alternative hygiene care. The facility lacked a preventative maintenance program for plumbing, and temperature logs confirmed prolonged inadequate hot water.
A facility failed to provide adequate supervision for three high-risk residents, resulting in multiple unwitnessed falls and injuries. Despite being identified as high risk, the residents were not closely monitored, leading to falls during times when staff were on break or not present. The facility's lack of sufficient staff coverage and failure to implement necessary safety measures contributed to the incidents.
The facility failed to ensure call lights were within reach for nine residents, as observed during a survey. Residents were found in various positions, such as in bed or in a wheelchair, with call lights placed out of reach. Staff members acknowledged that call lights should be within reach, especially for those at risk for falls. The facility's policy on call light placement and fall prevention was not adhered to, as evidenced by the observations.
A former CNA at an LTC facility took inappropriate photos of a resident with severe cognitive impairment and shared them with a group of CNAs via text. The resident was found in a vulnerable state, and the CNA claimed she was unaware of the prohibition against sharing such images due to a lack of training and language barriers. The incident was reported, and the CNA was terminated for HIPAA and resident rights violations.
A facility failed to conduct a thorough investigation into an alleged verbal abuse incident involving a resident. The investigation, led by the Former Administrator, lacked essential details and did not involve social services or interviews with additional staff and residents who interacted with the accused CNA. The facility's policy requires comprehensive interviews to determine any prior incidents, which was not adhered to, resulting in a deficiency.
A facility failed to follow a care plan and address a dietician's recommendations for a resident with complex medical conditions, including severe cognitive impairment and chronic kidney disease. Despite repeated requests for follow-up labs to monitor hydration status, the nursing department did not act on these recommendations. The lack of communication and follow-up resulted in inadequate care for the resident.
The facility failed to provide adequate restorative care for residents due to staffing shortages, resulting in unmet needs for range of motion exercises. A resident with hemiplegia was not receiving necessary therapy, and another with mobility issues reported inconsistent care. Restorative aides were frequently reassigned, leaving CNAs to perform exercises, which were not consistently documented.
A facility failed to provide adequate nursing staff, resulting in care deficiencies for residents. On one floor, only three CNAs were available for 40 residents, leading to missed restorative care and improper monitoring of personal refrigerator temperatures. Several residents experienced issues such as unlabeled g-tube feeding bags, unchanged incontinence briefs, and medication administration errors. The facility did not utilize agency staff despite having a contract, and restorative staff were frequently pulled from their duties to cover shortages.
The facility failed to maintain food safety and hygiene standards, affecting 111 residents receiving oral nutrition. Staff did not perform hand hygiene upon entering the kitchen, and temperature logs for food storage were incomplete. A gallon of milk lacked an open date, and a dietary aide's hair was not fully covered. The kitchen drain was clogged, causing water backflow, and the ceiling paint was disintegrating. Sanitation logs were incomplete, indicating lapses in maintaining a safe environment.
The facility failed to properly dispose of garbage, resulting in an overflowing dumpster with an open lid. The Dietary Supervisor observed the issue, noting that the trash bags were from the Dietary department, while the Maintenance department was responsible for the dumpster. The Maintenance Director confirmed the importance of keeping the lid closed to prevent pest migration. Facility policies require the dumpster lid to be closed and all trash bags to be inside to prevent infection spread.
The facility failed to implement proper infection control measures, including inadequate isolation signage for a resident with ESBL and lapses in hand hygiene during dining services. A chaplain entered the resident's room without PPE due to improperly secured signs, and a CNA did not sanitize hands between tasks. These deficiencies could impact all residents, including those with severe cognitive impairments and various health conditions.
The facility failed to follow its policy on self-administration of medication, affecting three residents. Medications were found at residents' bedsides without proper labeling or documentation, and there were no physician orders or care plans for self-administration. The Director of Nursing acknowledged the importance of assessments, which were not conducted as required.
The facility failed to administer and document medications on time for several residents, with medications being dispensed hours after their scheduled times. An LPN acknowledged inefficiency, and the EMAR system highlighted these delays. The DON was present but did not assist, and a nurse reported a resident's consistent refusal of medications without timely documentation.
The facility failed to ensure a safe environment for residents, as observed by surveyors. A resident's room contained a cup with an unidentified gold liquid, suspected to be soap, posing a risk if ingested. Another resident had razors on their nightstand, with staff unaware of proper disposal policies. The DON confirmed that residents should be supervised while shaving, and razors should be discarded in a sharps container. These oversights could affect all residents on the unit.
The facility failed to securely store controlled medications and properly label insulin and eye medications. Controlled drugs for two residents were found in an unlocked refrigerator, and insulin and eye medications for four residents lacked open and expiration dates. An expired insulin pen was also found on a medication cart. The facility lacked a policy for controlled substance storage, contributing to these issues.
The facility failed to properly monitor and maintain residents' personal refrigerators, leading to unsafe storage conditions. Several refrigerators lacked daily temperature logs, had temperatures outside the safe range, and showed ice build-up. Staff were unclear about their responsibilities and the required temperature range, affecting residents with chronic conditions like COPD and asthma.
A facility failed to provide a homelike environment by not replacing missing window coverings for a resident, affecting their comfort and privacy. The resident, who has moderate cognitive impairment and other health conditions, was exposed to direct sunlight due to missing vertical blinds on one window. The Maintenance Director acknowledged the issue but had not replaced the blinds despite conducting regular rounds. Facility policies emphasize maintaining a safe and comfortable environment, which was compromised in this instance.
The facility failed to provide necessary ADL assistance to three residents with self-care deficits. One resident with dementia and hemiplegia was observed with poor personal hygiene, while another with dementia had a soiled brief and an untouched meal tray out of reach. A third resident was left in bed in a nightgown, with no clear indication of recent care. These observations indicate a lack of adequate personal care and feeding assistance for residents requiring support.
The facility failed to ensure proper pressure ulcer care and equipment management for three residents. A resident's low air loss mattress was found unplugged, risking exacerbation of an unstageable wound. Another resident lacked PRN wound care orders, and their dressing was improperly maintained. A third resident's wound care orders were not transcribed, leading to inadequate management of stage 2 wounds on both buttocks.
A facility failed to follow its gastrostomy feeding policy by not labeling a g-tube feeding bag with the required information, such as the resident's name, type of feeding, date, and time. A nurse admitted to hanging the bag without labeling it, contrary to the facility's policy.
The facility failed to properly label, date, and contain oxygen equipment for two residents, leading to potential infection control issues. A resident with COPD and another with cardiac arrhythmia were observed with oxygen tubing touching the floor and not stored in bags, contrary to facility policy. Staff acknowledged the importance of proper storage to prevent contamination.
A facility failed to obtain a physician's order for a resident requiring dialysis, despite the resident being admitted with diagnoses necessitating such care. The resident, who was cognitively intact, received dialysis without documented orders, which the DON acknowledged as a missed responsibility of the admitting nurse. This oversight could lead to the resident missing necessary dialysis treatments.
The facility failed to provide prescribed medications for two residents due to not following the medication ordering policy. An LPN confirmed the absence of Cetirizine for one resident and the unavailability of Fenofibrate and Trulicity for another, as the pharmacy had not sent them. The facility's policy requires medications to be ordered 72 hours before the last dose, which was not adhered to.
A facility failed to maintain a medication error rate below 5%, resulting in a 46.15% error rate. An LPN administered medications late and some were unavailable, affecting two residents. The errors included late administration and unavailability of prescribed medications, contrary to the facility's medication administration policy.
Two residents experienced significant medication administration errors due to delays and unavailability of prescribed medications. One resident with convulsions and Parkinson's disease received their medications 1.75 hours late, while another resident with diabetes and hypertension had their medications administered 2.75 hours late, with one medication unavailable. The facility's policy requires timely administration, which was not followed.
A resident experienced severe pain due to the facility's failure to manage pain medication effectively. The resident's Norco prescription was not reordered in a timely manner, leading to a 24-hour period without the medication. The medication convenience box was not stocked, and the nurse was unable to access it, resulting in the resident receiving only Tylenol for pain relief. The pharmacy confirmed the delay in restocking, which contributed to the deficiency.
The facility failed to provide adequate pressure ulcer care for three residents, resulting in facility-acquired pressure ulcers. Insufficient Wound Care Nurses led to delayed incontinence care and missed treatments. Staff were unaware of the correct Low Air Loss Mattress (LALM) settings, leading to incorrect settings for the residents. One resident developed a stage 4 ulcer with tailbone exposure, while two others had stage 3 ulcers. The facility's LALM policy lacked specific settings, contributing to the issue.
A facility failed to maintain adequate staffing levels, resulting in insufficient care for residents. Multiple CNAs and a nurse called off or arrived late, leaving only two CNAs to care for 38 residents on one floor. This led to residents being found with soiled briefs, untrimmed nails, and unmet basic needs. The facility did not utilize agency staff despite having an emergency staffing policy.
The facility failed to provide restorative care to maintain or improve the range of motion for three residents due to inadequate staffing and failure to follow policy procedures. On the second floor, only two CNAs were available for 38 residents, and one was pulled from restorative duties to perform general CNA tasks. This resulted in missed Active and Passive Range of Motion exercises for the residents on specified dates, as documented in their care plans and nursing rehab documentation.
The facility failed to provide adequate ADL care for two dependent residents. One resident, with moderate cognitive impairment, was found with unkempt facial hair, long fingernails, and a soiled incontinence brief. Another resident, with severe cognitive impairment, was found extremely thirsty and with a soiled brief, despite the facility's policy for regular checks. The care plans requiring assistance with ADLs were not followed.
A resident with Multiple Sclerosis missed a Neurology appointment due to being hungry, and the facility failed to reschedule it. The resident's daughter raised concerns about the missed appointments, which were communicated to the DON, but no action was taken. The facility lacked a policy for scheduling or rescheduling appointments, leading to unresolved care concerns.
A facility failed to follow its catheter care protocols for a resident with neuromuscular dysfunction of the bladder. The resident's care plan required monitoring for UTI signs, but necessary catheter treatments were not transcribed onto the TAR or MAR. Observations showed the resident's catheter tubing had a purulent substance, and urine was cloudy, yet these issues were not reported to a physician. Staff interviews revealed confusion about catheter care procedures, and the facility's policy guidelines were not adhered to.
The facility failed to investigate multiple allegations of abuse and neglect involving residents with various medical conditions. Incidents included a resident being physically assaulted by another resident, a CNA allegedly yelling and handling a resident roughly, a nurse refusing to assist with ostomy care, and a charge nurse being disrespectful during a fire drill. Despite the facility's policy requiring thorough investigations, these incidents were not properly addressed, potentially exposing residents to further harm.
The facility failed to report four separate allegations of abuse and neglect involving residents with various health conditions. Incidents included physical altercations, verbal abuse by staff, and neglect of care needs. Despite the facility's policy requiring prompt investigation and reporting, these incidents were not reported to the state survey agency as required.
A resident with a history of epilepsy and restlessness fell and sustained a head laceration due to staff's failure to report and document her behavior of repositioning herself in bed. The resident was part of the falling star program, but specific behaviors were not communicated, leading to inadequate interventions and a subsequent fall.
The facility failed to report an unwitnessed fall resulting in a serious injury within the mandated 24-hour timeframe and lacked adequate policies for such reporting. The incident involved a resident who required six staples for a laceration on the forehead. The report was delayed due to an unspoken rule about reporting on the next business day if incidents occurred on weekends or holidays.
A resident with depressive disorder and impaired cognition was involuntarily transferred to a hospital after attempting self-harm. The facility failed to provide the required bed hold notification, as they did not intend for the resident to return. The decision not to accept the resident back was made after the transfer, violating the facility's policy and the Nursing Home Care Act.
The facility failed to assess a resident's current status before denying re-admission after hospitalization. The resident, with a history of depressive disorder and impaired cognition, was not allowed to return due to behavioral issues during transfer. The facility did not coordinate with the hospital or address the resident's behavioral concerns in the care plan.
A resident with depressive disorder and impaired cognition exhibited multiple self-harm behaviors, including setting clothes on fire and expressing suicidal ideation. The facility's care plan only addressed medication refusal and failed to include interventions for self-harm, despite the resident's documented behavioral incidents and history of expressing a desire to harm himself.
A resident with multiple medical conditions was not properly monitored for vital signs, leading to a failure to identify a change in condition. The resident was later diagnosed with septic shock after being transferred to the hospital. The facility lacked documentation of vital sign monitoring, with the last recorded vital signs being over a month old.
A facility failed to provide emergency treatment for a resident with low oxygen levels, citing the resident's DNR status. The resident did not receive timely care, resulting in hospitalization and subsequent death. Staff misunderstood the DNR status, leading to a lack of necessary interventions and delayed emergency response.
The facility failed to provide sufficient nursing staff with appropriate competencies, leading to a delay in care for a resident with respiratory distress. The resident, with a history of chronic conditions, was not promptly sent to the hospital, resulting in hospitalization and subsequent death. Inadequate documentation, incomplete orientation, and lack of proper training contributed to the deficiency.
A resident with multiple diagnoses experienced a critical drop in oxygen levels, but the LPN on duty did not administer oxygen immediately, misunderstanding the DNR status. Another LPN later provided oxygen, but the resident's condition continued to fluctuate. The facility failed to follow protocols for immediate medical intervention and proper documentation, contributing to the resident's deteriorating condition and eventual death.
The facility failed to follow their policy on involuntary transfer by not sending the appropriate paperwork with a resident who required transfer to the hospital. The resident exhibited unusual behaviors, and although advised by doctors to send the resident to the hospital, the necessary petition paperwork was not sent initially, resulting in the resident returning without treatment and needing to be sent back with the correct paperwork.
The facility failed to send the required paperwork with a resident who needed involuntary transfer to the hospital and did not notify the resident's POA about the discontinuation of psychotropic medication. This affected three residents reviewed for the facility's policy and procedures, revealing gaps in staff training and communication.
Failure to Provide and Document Ordered Wound Care for Resident with Sacral Ulcer
Penalty
Summary
The facility failed to follow its policy to ensure appropriate wound care treatment for a resident with a sacral pressure ulcer. The resident, who is moderately cognitively impaired and has a history of wounds, developed a sacral wound while in the facility and was later diagnosed with MRSA of the sacral bone after a hospital visit. The wound care nurse confirmed that the resident requires daily wound care with Santyl ointment as ordered, and that wound care is to be documented on the Treatment Administration Record (TAR). However, review of the TAR revealed that wound care was not documented or performed on several specific dates. Interviews with staff, including the wound nurse, DON, and infection preventionist, confirmed that the resident did not receive wound care on the identified dates, and that lack of documentation on the TAR indicates the treatment was not done. The facility's policy requires wounds to be assessed and measured at least every seven days and for treatments to be recorded. The failure to provide and document daily wound care as ordered constitutes a deficiency in following the facility's wound care policy.
Failure to Maintain Safe 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, and supervision was insufficient to prevent potential or actual accidents from occurring in the specified area. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Failure to Provide Adequate Supervision and Monitoring Resulting in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for residents, resulting in a significant incident where a resident with a high risk for falls sustained serious injuries during a shower. The resident, who had a history of falls, cognitive impairment, lack of coordination, and required maximal assistance with bathing, was being showered by a CNA who left the resident momentarily to retrieve towels. During this time, another CNA was present but was occupied putting on gloves and not in direct contact with the resident. The resident became agitated, attempted to ambulate, and fell, sustaining complex facial lacerations that required 12 sutures. The incident was witnessed by staff who reported that the resident should not have been left unattended, even briefly, given his known fall risk and behavioral tendencies. Additional observations during the survey revealed lapses in supervision and monitoring in other areas of the facility. On the second floor, a CNA was found using her phone in an empty resident room while a resident was calling for assistance, indicating inattentiveness to resident needs. On the third floor, two residents assessed as high risk for falls were observed sitting unsupervised in the activity room, contrary to facility policy that requires continuous monitoring in such settings. The CNA responsible for monitoring these residents was not present at the time but later stated she was assigned to supervise the area during that period. Facility policies reviewed by the surveyor specify that residents requiring staff assistance should not be left alone during bathing or showering and that supervision is a core component of resident safety. Despite these policies, staff actions did not align with established protocols, as evidenced by the incident in the shower room and the lack of supervision in other areas. The failure to maintain adequate supervision and monitoring directly affected multiple residents identified as high risk for falls, resulting in preventable harm.
Failure to Maintain Hot Water Supply Due to Mechanical Equipment Breakdown
Penalty
Summary
The facility failed to maintain all mechanical equipment in safe operating condition, resulting in the lack of hot water accessible to residents throughout the building. During a facility tour, multiple resident-accessible sinks and showers on all floors were found to have water temperatures significantly below the required range, with some fixtures having no water supply at all. The issue was traced to a malfunctioning hot water mixing valve, which was leaking and caused flooding in the boiler room. The leaking water extinguished the boiler's pilot light, further preventing the restoration of hot water. The Maintenance Director was aware of the issue but did not inform the surveyor during the initial tour. Facility records indicated that the hot water mixing valve had failed due to corrosion and age, and the correct replacement part was not immediately available. The Corporate Project Manager confirmed ongoing difficulties in sourcing the correct mixing valve and restarting the boiler. The Administrator was notified of the hot water outage and instructed staff to provide bed baths and use wipes for ADL care instead of showers. The facility did not have a preventative maintenance program for the plumbing system, and hot water logs confirmed that water temperatures remained below regulatory requirements for several days.
Inadequate Supervision Leads to Multiple Falls in High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate measures to prevent falls for three residents identified as high risk for falls. Resident 1, who was admitted with multiple health issues including alcoholic cirrhosis and dementia, experienced three unwitnessed falls in February, resulting in lacerations that required medical attention. Despite being identified as high risk for falls, Resident 1 was not under strict supervision, and staff failed to monitor the resident adequately, leading to falls that occurred without staff presence. Resident 2, admitted with chronic kidney disease and dementia, also experienced two unwitnessed falls in March, both resulting in injuries that required hospital visits. The facility's investigation revealed that the falls occurred during times when staff were on break, and there was insufficient staff to monitor residents adequately. The lack of supervision and failure to ensure staff coverage during breaks contributed to the incidents. Resident 3, with a history of hydrocephalus and cerebral infarction, had two falls, one in February and another in March, both resulting in injuries. The facility's investigation indicated that the falls occurred due to inadequate supervision and failure to assist the resident with repositioning. The physician confirmed that all three residents would benefit from close supervision to prevent falls, highlighting the facility's failure to implement necessary safety measures and supervision for high-risk residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for nine residents, as observed during a survey. Residents were found in various positions, such as in bed or in a wheelchair, with call lights placed out of reach. For instance, one resident was eating in their room with the call light not within reach, while another was in bed with the call light under the bed. A resident in a wheelchair was unable to reach the call light placed on the opposite side of the bed. Staff members, including a CNA and an RN, acknowledged that call lights should be within reach of residents, especially those at risk for falls. The facility's policy on call light placement and fall prevention was not adhered to, as evidenced by the observations. The policy states that call lights should always be accessible to residents, and the fall prevention program emphasizes the importance of keeping call lights within reach for residents at risk of falls. Despite these guidelines, multiple residents, including those identified as fall risks, were found without accessible call lights. This deficiency was noted by surveyors and confirmed by staff members, who admitted that they were aware of the requirement to keep call lights within reach.
Inappropriate Photos of Resident Shared by CNA
Penalty
Summary
The facility failed to protect a resident from mental abuse when a former CNA took inappropriate photos of the resident and shared them with a group of CNAs via text message. The resident, who had severely impaired cognition due to multiple medical conditions including cerebral infarction and hemiplegia, was photographed in a vulnerable state with her diaper open and soiled. The incident was reported on 12/30/2024, and the CNA responsible was terminated the following day for violations of HIPAA and resident rights. The former CNA claimed that she took the photos to highlight the neglect the resident was experiencing, as she found the resident in a distressing condition with no staff present to assist. The CNA stated she was unaware that sharing the photos was prohibited, citing a lack of abuse training and language barriers as contributing factors. The incident was reported to the Director of Nursing and Human Resources, and the resident's family was informed. The facility's policy strictly prohibits photographing or recording residents for non-medical purposes, and the sharing of such images is considered an allegation of abuse.
Incomplete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to adhere to its abuse policy by not conducting a thorough investigation into an alleged incident of verbal abuse involving a resident, identified as R4. The Human Resource Director, V11, reported that a CNA, V5, was accused of using profanity towards R4. However, the Former Administrator, V7, who was responsible for the investigation, did not involve social services or interview additional staff and residents who might have had relevant information. V7's investigation was incomplete, lacking essential details such as dates, times, and comprehensive statements from other staff and residents who regularly interacted with V5. The Director of Clinical Services, V17, noted that V7's investigation was missing critical information and instructed V7 to obtain a detailed account of the incident, which was not done. The facility's Abuse Prevention Program policy requires interviews with residents and staff who regularly interact with the accused to determine if there have been any prior incidents of abuse or neglect. This policy was not followed, as the investigation did not include statements from all relevant parties, leading to a deficiency in the facility's handling of the abuse allegation.
Failure to Follow Dietician's Recommendations for Resident's Hydration Status
Penalty
Summary
The facility failed to follow the care plan for a resident, identified as R2, to maintain adequate nutritional and hydration status. The facility also did not implement professional standards of practice by failing to address a Registered Dietician's recommendations for follow-up lab tests. R2, who is severely cognitively impaired and has multiple complex medical conditions, including severe sepsis, diabetes, chronic kidney disease, and pressure ulcers, was at risk due to this oversight. The dietician, V8, had repeatedly requested follow-up labs to monitor R2's hydration status, but these requests were not acted upon by the nursing department. The dietician, V8, noted that R2's lab results showed elevated sodium and blood urea nitrogen levels, indicating potential dehydration and other health concerns. Despite V8's multiple recommendations for follow-up labs, communicated via email to the nursing department, including the Director of Nursing (V2) and Assistant Director of Nursing (V10), no action was taken. V8 stated that she was informed by V10 that the doctor would be consulted, but there was no follow-up. The Nurse Practitioner, V19, emphasized the importance of following up on healthcare professionals' recommendations, noting that he was not informed of the dietician's requests. The Director of Nursing, V2, admitted to being unaware of the status of the lab requests and relied on V10, who was on vacation, to handle the follow-up. R2's attending physician, V21, stated that he was not informed of the dietician's recommendations but would have agreed to them if he had been. The lack of communication and follow-up on the dietician's recommendations resulted in a failure to provide appropriate care for R2, who was already in a vulnerable state due to his complex medical conditions.
Inadequate Restorative Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide appropriate restorative care to maintain or improve the range of motion and mobility for four residents, which could potentially affect 104 residents. The surveyor observed that the facility did not have sufficient staff available to provide the necessary restorative care, as restorative aides were frequently pulled to work on the floor due to staffing shortages. This resulted in the failure to deliver the prescribed restorative interventions, such as active and passive range of motion exercises, as documented in the residents' care plans and Kardex reports. One resident, who had hemiplegia and hemiparesis following a cerebral infarction, expressed the need for therapy as they were unable to move their right upper extremity. The resident's care plan included active range of motion exercises for the left extremities but omitted passive range of motion for the right extremities, which was not documented in the facility's records. Another resident, diagnosed with lack of coordination and gait abnormalities, reported receiving inconsistent physical therapy and expressed dissatisfaction with the lack of restorative care to prevent decline in daily living activities. Documentation for this resident showed gaps in the provision of active range of motion exercises. The facility's restorative nurse confirmed that both restorative aides were often reassigned to other duties, leaving the CNAs to perform range of motion exercises, though it was unclear if these were consistently carried out. The facility's restorative nursing policy requires individualized programs based on assessments, with documentation of interventions, but these were not consistently followed, leading to the deficiencies noted by the surveyor.
Staffing Shortages Lead to Care Deficiencies
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by the observations and interviews conducted by the surveyor. On the 2nd floor, there were only three CNAs available for 40 residents, which was deemed insufficient by the staff themselves. The restorative aide was pulled from her duties to work the floor, leaving no one to provide restorative care. This staffing shortage led to inadequate care for residents, including missed restorative care and improper monitoring of personal refrigerator temperatures. Several residents experienced deficiencies in care due to the staffing issues. For instance, R11 had an unlabeled g-tube feeding bag, and R37's incontinence brief was not changed in a timely manner, with his lunch tray left out of reach. R56 was found with open wounds on her buttocks that were not covered with dressings, and her wound care orders were not properly transcribed. Additionally, R48 and R57 experienced medication administration errors, with medications being administered late or unavailable. The facility's failure to implement its emergency staffing policy and utilize agency staff contributed to these deficiencies. The staffing coordinator confirmed that the facility does not use agency staff, despite having a contract with an external agency. The restorative nurse and aides were frequently pulled from their duties to cover staffing shortages, impacting the delivery of restorative care. The facility's timecard report showed that several staff members clocked in late, further exacerbating the staffing issues.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to several food safety and hygiene protocols, which could potentially affect all 111 residents receiving oral nutrition. Observations revealed that staff did not perform hand hygiene upon entering the kitchen, as evidenced by the Administrator in Training not knowing the location of the handwashing facility and admitting to not washing hands due to being in training. Additionally, the Dietary Supervisor confirmed that handwashing is expected upon kitchen entry to prevent pathogen transmission. Temperature logs for food storage were incomplete, with missing entries for both coolers and freezers on specific dates. This lapse in monitoring could compromise food safety, as maintaining appropriate storage temperatures is crucial. Furthermore, a gallon of milk was found without an open date, and a dietary aide's hair was not fully covered, which could lead to cross-contamination. The Dietary Supervisor acknowledged these oversights, emphasizing the importance of labeling and hair coverage to prevent contamination. The facility also exhibited maintenance issues, such as a clogged kitchen drain that had been problematic for three years, causing water backflow during dishwashing. The Dietary Supervisor and a dietary aide confirmed the ongoing issue, which poses a hazard to staff. Additionally, the kitchen ceiling paint was disintegrating, potentially affecting both staff and residents due to particle inhalation. The facility's sanitation practices were also lacking, with missing entries in the POTS and PANS Sanitization Log, indicating that the solution's potency was not consistently checked. These deficiencies highlight significant lapses in maintaining a safe and hygienic environment for food preparation and service.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by an overflowing dumpster with one of its lids open. This was observed on January 13, 2025, when the Dietary Supervisor noted that the dumpster was overflowing with black and white trash bags, and one of the three lids was open. The Dietary Supervisor confirmed that the black trash bags originated from the Dietary department, while the Maintenance department was responsible for managing the dumpster. On January 15, 2025, the Maintenance Director acknowledged that the dumpster lid should always be closed to prevent pests like rats and flies from entering and potentially migrating into the building. The facility's Waste Management Policy and Safe Food Handling - Dumpster Policy both emphasize the importance of keeping the dumpster lid closed and ensuring all trash bags are inside the dumpster to prevent the spread of infection.
Infection Control Deficiencies in Isolation and Hand Hygiene
Penalty
Summary
The facility failed to properly implement its infection prevention and control program, as evidenced by several deficiencies observed during a survey. A resident, identified as requiring contact isolation due to ESBL (Extended Spectrum Beta Lactamase) in the urine, did not have appropriate isolation signage posted on their door. The signs were improperly secured, causing them to dangle upside-down and display only the blank side. This led to a chaplain entering the resident's room without wearing the necessary personal protective equipment (PPE). Despite the resident being listed on the facility's isolation log, there was a lack of communication and awareness among staff and visitors regarding the resident's isolation status. Additionally, the facility failed to ensure proper hand hygiene practices during dining services. A Certified Nursing Assistant (CNA) was observed setting up meal trays for residents without performing hand hygiene between tasks, despite handling a resident's wheelchair. The Infection Preventionist confirmed that staff are expected to use hand sanitizer available in the dining room to prevent the spread of germs. The residents involved had severe cognitive impairments, with one diagnosed with heart failure, cardiac arrhythmia, and anxiety disorder, and another with anorexia, heart failure, and Type 2 Diabetes Mellitus. These lapses in infection control practices have the potential to affect all residents in the facility.
Failure to Follow Self-Administration Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the self-administration of medication by residents, affecting three residents and potentially impacting all residents on the second floor. The policy requires a self-administration review, a physician's order, and a care plan for residents who self-administer medication. However, these steps were not followed for residents R13, R66, and R84. Observations revealed that these residents had medications at their bedside without proper labeling or documentation, and there was no evidence of a physician's order or a care plan allowing them to self-administer. Resident R66 was found with an unlabeled inhaler on their bedside table, which they claimed to use independently without staff instruction. Similarly, resident R84 had an inhaler and a bottle of iron on their window ledge, which they used as needed. Both residents' order summaries did not include orders to self-administer medication, and their care plans lacked documentation for self-administration. Resident R13 was found with a nasal spray in their pocket, but there was no order or care plan for self-administration, and their cognitive status was noted as severely impaired. The facility's Director of Nursing acknowledged the importance of completing self-administration reviews, obtaining a doctor's order, and care planning for the safety of the residents. However, the facility failed to conduct the required assessments semi-annually, as evidenced by the lack of documentation for R13 between 2021 and 2025. The facility's policy and residents' rights documentation emphasize the need for cognitive, physical, and visual assessments to ensure safe self-administration, which were not adequately performed in these cases.
Medication Administration Delays and Documentation Issues
Penalty
Summary
The facility failed to administer and document medications within regulatory requirements for seven residents. On multiple occasions, medications were dispensed and prepared for administration well past their scheduled times. For instance, an LPN was observed dispensing medications for a resident that were scheduled for 8:00 am at 9:46 am, and another resident's medications scheduled for 9:00 am were dispensed at 11:44 am. The LPN acknowledged the delay and attributed it to inefficiency. Additionally, the EMAR system highlighted these delays by marking the medications in red, indicating late administration. The Director of Nursing was present but did not assist in the medication administration process. Another nurse reported that a resident consistently refused medications, yet the documentation of these refusals was not completed promptly. The facility's medication administration policy requires medications to be administered according to the physician's order, including the right time, which was not adhered to in these instances. This lack of adherence to the policy and regulatory requirements led to the deficiency noted by the surveyors.
Hazardous Environment Due to Inadequate Supervision and Unsafe Practices
Penalty
Summary
The facility failed to maintain a safe environment free from hazards for two residents, which could potentially affect all 39 residents on the third-floor unit. During a survey, a clear cup with a thick, gold liquid was observed on a resident's sink, visible from the hallway. The resident was unable to identify the substance, and a CNA speculated it might be soap from the shower room pumps. The CNA acknowledged that if another resident consumed the liquid, it could be harmful. Additionally, three razors were observed on another resident's nightstand, visible from the hallway. The resident stated that staff provided the razors for shaving and disposed of them in the garbage after use. The LPN was unaware of the facility's policy regarding razors and acknowledged the potential risk if another resident accessed them. The DON confirmed that residents should be supervised while shaving, and razors should be discarded in a sharps container after use. The presence of razors and chemicals in residents' rooms without proper supervision and disposal procedures highlights the facility's failure to ensure a hazard-free environment.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications, which was identified during a survey. Controlled medications for two residents were found unsecured in an unlocked medication refrigerator, contrary to the requirement that such medications be double-locked. This was observed during an audit of the third-floor medication room, where Lorazepam and Morphine sulfate were found with the names of two residents. The LPN acknowledged that the medication refrigerator should be locked, as well as the medication room door, to ensure safety. Additionally, the facility did not label insulin and eye medications with open and expiration dates for four residents, and expired insulin was found on a medication cart. During an audit of the first-floor medication cart, several insulin pens and eye medications were found without the necessary labeling, and an expired insulin pen was noted. The Director of Nursing confirmed that expired medications should be removed to prevent administration errors, and the purpose of labeling is to ensure patient safety by knowing when medications expire after opening. The facility lacked a policy regarding the storage of controlled substances, which contributed to these deficiencies.
Deficiencies in Monitoring Resident Refrigerators
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of personal refrigerators used by residents for storing perishable items. Observations revealed that several residents' refrigerators lacked daily temperature logs, had temperatures recorded outside the safe range, and exhibited significant ice build-up. For instance, R49's refrigerator had not been logged for six days, and R15's refrigerator was found to be at 76F, well above the safe temperature range. Staff members, including housekeeping and nursing personnel, were unclear about their responsibilities and the required temperature range for safe food storage. The facility's policy mandates that nursing staff are responsible for daily checks of residents' personal refrigerators for proper labeling, temperature recording, and storage. However, interviews with staff members such as V13 and V14 indicated a lack of awareness and adherence to these procedures. V13, responsible for monitoring refrigerator temperatures, was unsure of the correct temperature range and had not reported issues like ice build-up to the manager. Similarly, V14 was unable to confirm the required temperature range, highlighting a gap in staff training and communication. Residents affected by these deficiencies included those with chronic conditions such as COPD, asthma, and dementia, which could make them more vulnerable to foodborne illnesses. For example, R3's refrigerator lacked a thermometer, and the temperature log was pre-signed for future dates, indicating a failure in accurate monitoring. The Director of Nursing acknowledged that the responsibility for monitoring these refrigerators was shared between housekeeping and nursing staff, but the lack of consistent oversight and documentation posed a risk to resident safety.
Failure to Maintain Homelike Environment Due to Missing Window Coverings
Penalty
Summary
The facility failed to provide a homelike environment by not replacing missing window coverings for a resident, identified as R51, which affected their comfort and privacy. During an observation, it was noted that R51 was sitting in a recliner near the windows, with sunlight directly hitting their eyes due to missing vertical blinds on one of the windows. The left window had approximately six-inch gaps between five vertical blind panels, and there was no roll-down curtain to block the sun. The right window, although missing some vertical blind panels, had a roll-down curtain that was closed, effectively blocking the sun. R51 expressed a desire for shades and questioned whether they would have to pay for them. The Maintenance Director, identified as V32, acknowledged that the blinds were pulled down by a former resident and admitted that they were supposed to replace them. Despite conducting rounds 2 to 3 times a day, V32 had not replaced the missing blinds or installed a roller blind for the left window. R51, who has a history of type 2 diabetes mellitus, seizures, dementia, anxiety disorders, and falls, was noted to have moderate cognitive impairment with a BIMS score of 8. The facility's policies emphasize the importance of maintaining a clean, safe, and comfortable environment, yet the failure to replace the window coverings compromised the resident's right to a dignified and homelike environment.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for three residents, each with significant self-care deficits. One resident, diagnosed with dementia and hemiplegia, was observed with unkempt hair, a long beard, and nails, indicating a lack of personal hygiene care. Despite the resident's confusion and inability to perform self-care, the necessary grooming assistance was not provided, as confirmed by a chaplain who translated the resident's responses. Another resident, also with dementia, was found with a soiled incontinence brief and an untouched meal tray placed out of reach, suggesting neglect in both personal care and feeding assistance. The staff's inconsistent acknowledgment of the resident's need for feeding assistance further highlights the deficiency. A third resident, diagnosed with dementia and generalized weakness, was left in bed in a nightgown, with no clear indication of when her incontinence brief was last changed. The resident's family member expressed concern over the lack of care, emphasizing the resident's usual routine of being up and dressed by the time of their visit.
Deficiencies in Pressure Ulcer Care and Equipment Management
Penalty
Summary
The facility failed to ensure proper functioning and use of pressure ulcer prevention and treatment measures for three residents. One resident's low air loss mattress was found unplugged, leading to deflation, which could exacerbate an existing unstageable wound on the sacrum. The Director of Nursing acknowledged that the mattress was sometimes mistakenly unplugged when the bed was moved, indicating a lapse in ensuring the equipment was consistently operational. Another resident did not have PRN wound care orders for a hydrocolloid dressing on the sacrum, which was observed to be falling off and adhered to itself. The resident's care plan noted a risk for skin impairment due to bladder incontinence, yet the dressing was not maintained properly, and the resident's incontinence brief was found moderately saturated with urine, suggesting inadequate monitoring and care. A third resident had treatment orders for a hydrocolloid dressing on the left buttock, but these orders were not transcribed onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR). The resident had open areas on both buttocks, but neither was covered with a dressing at the time of observation. The Wound Care Nurse confirmed the presence of stage 2 wounds on both buttocks and noted a change in treatment orders, yet the facility failed to ensure these orders were documented and followed, leading to inadequate wound care management.
Failure to Label G-Tube Feeding Bag
Penalty
Summary
The facility failed to adhere to its gastrostomy feeding policy, resulting in a deficiency related to the labeling of a gastrostomy tube (g-tube) feeding for a resident. During an observation, it was noted that the g-tube feeding bag for a resident was not labeled with the required information, including the resident's name, type of feeding, date, and time the infusion started. A registered nurse confirmed that they had hung the bag that morning but did not label it as per the facility's policy. The facility's policy, dated June 2014, mandates that the container be labeled with the resident's name, formula name, concentration flow rate, date, and time, which was not followed in this instance.
Failure to Properly Store and Label Oxygen Equipment
Penalty
Summary
The facility failed to properly label, date, and contain oxygen equipment for two residents, leading to potential infection control issues. Resident R3, diagnosed with chronic obstructive pulmonary disease (COPD) and asthma, was observed with oxygen tubing hanging across the bed and touching the floor, dated from several months prior and not contained in a bag. Similarly, Resident R109, with diagnoses including obesity and cardiac arrhythmia, had oxygen tubing hanging across the oxygen concentrator and touching the floor, also undated and uncontained. Both residents reported not having bags to store their oxygen tubing when not in use. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) acknowledged that the oxygen tubing should be stored in a bag to prevent contamination and potential infection. The facility's policy requires oxygen equipment to be changed and dated weekly and covered when not in use, which was not adhered to in these cases. The failure to follow these procedures was confirmed through observations and interviews, highlighting a lapse in maintaining infection control standards for oxygen equipment.
Failure to Obtain Physician's Order for Dialysis
Penalty
Summary
The facility failed to obtain a physician's order for a resident who requires dialysis, affecting one resident in a sample of 64. The resident, identified as R3, was admitted with diagnoses including dependence on renal dialysis, chronic kidney disease stage 5, and renal sclerosis. Despite being cognitively intact with a BIMS score of 13, R3's Active Physician Order Sheet did not include orders for hemodialysis. The Director of Nursing (DON) explained that it is the admitting nurse's responsibility to verify and carry out orders from the sending facility, including dialysis orders, upon a resident's admission. The facility's documentation showed that R3 received dialysis on specific days, but there was no physician's order to support these treatments. The DON acknowledged that the dialysis orders were missed, which could lead to the resident missing dialysis and deteriorating. The facility's procedure for dialysis care requires verifying a physician's order, which was not done in this case, leading to the deficiency.
Medication Unavailability for Two Residents
Penalty
Summary
The facility failed to adhere to its medication ordering policy, resulting in the unavailability of prescribed medications for two residents. For one resident, Cetirizine 5mg, scheduled for daily administration, was not dispensed on the morning of January 14, 2025, as the medication was not available. The LPN searched for the medication but confirmed its absence. For another resident, Fenofibrate 54mg and Trulicity 1.5mg/0.5ml, both scheduled for administration, were not dispensed as they were not available. The LPN acknowledged that the pharmacy had not sent these medications and confirmed that they would be sent later that day. The facility's policy requires medications to be ordered 72 hours before the last dose, which was not followed in these instances.
Medication Administration Errors Exceed 5% Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 46.15% error rate. This deficiency was observed during a survey where 12 medication errors occurred out of 26 opportunities. Two residents were directly affected by these errors. The errors included late administration of medications and unavailability of prescribed medications. Specifically, one resident's medications were administered 1.75 hours late, and one medication was unavailable. Another resident's medications were administered 2.75 hours late, with two medications unavailable due to the pharmacy not sending them. The Licensed Practical Nurse (LPN) involved acknowledged the errors and the reasons behind them, such as the pharmacy's failure to deliver certain medications and the late administration of others. The facility's medication administration policy requires medications to be administered according to the physician's order, including the right time, which was not adhered to in these instances. The surveyor's observations and interviews with the LPN highlighted these deficiencies in medication administration practices.
Medication Administration Errors in Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors due to improper medication administration practices. One resident, diagnosed with unspecified convulsions and Parkinson's disease, had physician orders for Divalproex and Levetiracetam to be administered twice daily. However, on a specific date, the medications were dispensed 1.75 hours after the scheduled time, which was outside the regulatory requirement of administering medications within one hour before or after the scheduled time. The LPN acknowledged the delay and the EMAR highlighted the late administration in red. Another resident, with diagnoses of type II diabetes mellitus and hypertension, had physician orders for Lisinopril, Metformin, Glipizide ER, and Trulicity. On the same date, the resident's blood sugar was recorded at 341, and the 9:00 am medications were dispensed approximately 2.75 hours late. Additionally, Trulicity was not available for administration, and the LPN had to contact the pharmacy to confirm its delivery. The facility's medication administration policy requires medications to be administered according to the physician's order, including the right time, which was not adhered to in these instances.
Failure to Provide Timely Pain Management Due to Medication Stock Issues
Penalty
Summary
The facility failed to manage a resident's pain effectively due to the unavailability of the prescribed Norco medication. The resident, who has a history of peripheral vascular disease, leg pain, and a vascular wound, was left without his Norco pain medication for over 24 hours. This resulted in the resident experiencing severe pain, rated as 8 out of 10 on a numerical pain scale. The resident reported that the Norco medication, which was supposed to be administered every 6 hours as needed, was not given because the facility ran out of stock, and the nurses did not attempt to retrieve it from the medication convenience box. The investigation revealed that the facility's medication ordering policy was not followed, as the Norco was not reordered in a timely manner. The Director of Nursing (DON) confirmed that the last Norco tablet was administered at 11:50 AM on the previous day, and the medication was reordered only after the last pill was given. The facility's policy requires medications to be reordered before the last pill is used to prevent running out. Additionally, the medication convenience box, which serves as a temporary source for medications, was not stocked with Norco, and the nurse was unable to access it due to a lack of a correct password. The pharmacy was responsible for restocking the medication convenience box but failed to include Norco 10/325 MG tablets. The Director of Clinical Services and the pharmacy confirmed that the Norco supply was on its way to the facility, but the delay resulted in the resident not receiving the necessary pain management. The nurse practitioner emphasized the importance of timely medication administration to manage the resident's pain effectively, highlighting the facility's failure to adhere to its pain management policy.
Inadequate Pressure Ulcer Care and Incorrect LALM Settings
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for three residents. The facility did not have enough Wound Care Nurses to meet the needs of the residents, resulting in delayed incontinence care and failure to administer prescribed treatments. Additionally, staff were not aware of the required settings for Low Air Loss Mattresses (LALM), leading to incorrect settings for the residents reviewed. One resident, with a history of dementia, multiple sclerosis, and diabetes, developed a facility-acquired stage 4 pressure ulcer on the sacrum with tailbone exposure and a suggestion of osteomyelitis. The resident's care plan included the use of an air loss mattress, but the LALM was set incorrectly. The resident was found with a soiled incontinence brief and a bowel movement on the sacrum dressing, indicating a lack of timely incontinence care. The treatment administration record showed multiple days where wound care was not documented. Another resident, with dementia and chronic kidney disease, developed a stage 3 pressure ulcer. The LALM was set incorrectly for this resident as well, and the incontinence brief was found wet and soiled with urine. The treatment administration record for this resident also showed a missed documentation of wound care. A third resident, with diabetes, also had a stage 3 pressure ulcer and was found with an incorrectly set LALM and a soiled incontinence brief. The facility's policy on LALM did not include specific settings, contributing to the issue.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to ensure adequate nursing staff was available to meet the needs of residents, as evidenced by multiple call-offs and late arrivals of CNAs and nurses on both day and evening shifts. On the day in question, three CNAs called off for the day shift, and one nurse and two CNAs called off for the evening shift. Additionally, several CNAs arrived late for their shifts, further exacerbating the staffing shortage. This resulted in only two CNAs being available to care for 38 residents on the 2nd floor, with one of them being a restorative aide pulled from her usual duties. The staffing shortage led to inadequate care for residents, as observed by the surveyor. One resident was found with long, thick, discolored fingernails and a soiled incontinence brief, indicating a lack of personal hygiene care. Another resident was left in a wheelchair for approximately four hours with a soiled incontinence brief and a cloudy urinary catheter, suggesting insufficient monitoring and care. A third resident was found repeatedly requesting water, which was not available in the room, and had a wet incontinence brief, indicating neglect in basic care needs. The facility's staffing issues were compounded by the lack of a clear policy for addressing call-offs and the non-use of agency staff, despite the facility's emergency staffing policy allowing for such measures. The Director of Nursing and other staff members acknowledged the staffing challenges but did not provide a clear solution or explanation for not utilizing agency staff. The facility's failure to maintain adequate staffing levels and provide necessary care to residents was evident in the observations and interviews conducted by the surveyor.
Inadequate Staffing Leads to Missed Restorative Care
Penalty
Summary
The facility failed to provide appropriate restorative care to maintain or improve the range of motion for three residents, R1, R2, and R3, due to inadequate staffing and failure to follow policy procedures. On the second floor, there were only two CNAs available for 38 residents, and one of them, who was supposed to be a Restorative Aide, was pulled to perform general CNA duties due to staffing shortages. This resulted in the absence of restorative care for the residents on certain days, as documented in the care plans and nursing rehab documentation. Specifically, R1 and R2 did not receive their scheduled Active Range of Motion (AROM) exercises, and R3 did not receive Passive Range of Motion (PROM) exercises on specified dates. The facility's Restorative Nursing Program, which aims to promote the highest practicable physical, mental, and psychosocial well-being, was not adhered to as restorative care was not provided as scheduled. The Restorative Nurse confirmed that if documentation is blank, it indicates that the care was not provided. The failure to provide restorative care as directed has the potential to affect all 38 residents on the second floor, as the program is designed to preserve function and promote optimal improvement. The report highlights the facility's inability to ensure that staff were available to provide the necessary restorative care, leading to a deficiency in maintaining the residents' range of motion and mobility.
Failure to Provide Adequate ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADL) for two dependent residents, R2 and R3. R3, who has moderate cognitive impairment and is dependent on staff for personal hygiene and toileting, was observed with long, unkempt facial hair and excessively long, thick, discolored fingernails. Additionally, R3's incontinence brief was found to be soiled with urine, indicating a lack of timely incontinence care. The care plan for R3 required assistance with all ADLs, including personal hygiene and appropriate cleansing after each incontinent episode, which was not adhered to by the staff. R2, who has severe cognitive impairment and requires extensive assistance with ADLs, was found in bed repeatedly requesting water, which was not available in the room. Upon receiving water, R2 drank it immediately, suggesting extreme thirst. Furthermore, R2's incontinence brief was also found to be soiled with urine, despite the facility's policy requiring CNAs to check and change briefs every two hours. The facility's failure to implement care plan interventions and adhere to their ADL policy resulted in inadequate care for these residents.
Failure to Reschedule Neurology Appointment for Resident
Penalty
Summary
The facility failed to ensure they had a policy for scheduling and rescheduling appointments, which led to a missed Neurology appointment for a resident diagnosed with Multiple Sclerosis. The resident was scheduled for a Neurology clinic appointment on November 11, 2024, but did not attend because she was hungry. The Director of Nursing (DON) acknowledged the missed appointment but did not reschedule it. The resident's daughter expressed concerns about the missed Neurology appointments, which were communicated to the DON, but no action was taken to address these concerns. The facility's Social Service Director confirmed that the concerns were documented and shared with the nursing staff, but there was no follow-up from the DON. The Admissions Director, responsible for scheduling transportation for appointments, confirmed that there was no rescheduled Neurology appointment for the resident. Additionally, the facility administrator admitted via email that there was no policy in place for scheduling or rescheduling appointments, contributing to the unresolved status of the resident's care concerns.
Failure to Follow Catheter Care Protocols
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the care of residents with indwelling urinary catheters, leading to a deficiency in the care of a resident with neuromuscular dysfunction of the bladder. The resident's care plan required monitoring, recording, and reporting signs and symptoms of urinary tract infections (UTIs) to a physician. However, the facility did not transcribe physician orders for catheter care onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR), resulting in the exclusion of necessary catheter treatments and cleaning orders. Observations revealed that the resident's catheter tubing was coated with a white, purulent substance, and the urine was cloudy, indicating potential issues that were not reported to the physician as required. Interviews with facility staff, including registered nurses and certified nursing assistants, highlighted a lack of knowledge and adherence to the facility's urinary catheter care policy. Staff were unable to confirm when the resident's catheter bag was last changed, and there was confusion about the standard frequency for changing urinary drainage bags. The Director of Nursing and Medical Director provided inconsistent information regarding the standard practice for catheter and drainage bag changes. The facility's urinary catheter care policy outlined specific conditions under which catheters and tubing should be removed and reinserted, but these guidelines were not followed, contributing to the deficiency.
Failure to Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents involving allegations of abuse and neglect, affecting several residents. In one incident, a resident with rheumatoid arthritis and hypertension reported that another resident entered their room, attempted to hit them, and grabbed their arms. Despite the resident's repeated complaints about feeling unsafe, the facility did not investigate the incident or notify the resident's representative or physician. The assistant administrator at the time was unaware of the incident, and no follow-up was conducted. Another incident involved a resident with dementia and diabetes who alleged that a CNA yelled at them and handled them roughly. The grievance form was signed by the administrator, but no investigation was conducted to identify the CNA involved. The Director of Nursing admitted to switching CNA assignments without identifying the perpetrator, potentially exposing other residents to abuse. The Social Services Assistant confirmed the resident's anxiety about the incident and reported it to the administration, but no formal investigation was completed. Additional incidents included a resident with diabetes and sepsis who reported that a nurse refused to assist with their ostomy care, resulting in a spill and the nurse yelling at them. The administrator acknowledged the grievance but did not investigate the potential mental abuse. Another resident with cognitive impairment reported that a charge nurse was disrespectful and neglectful during a fire drill. The administrator admitted to not conducting a thorough investigation, relying solely on a conversation with the Assistant Director of Nursing. The facility's policy requires thorough investigations of all abuse and neglect allegations, but these procedures were not followed in these cases.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report four separate allegations of abuse and neglect to the state survey agency, potentially affecting five residents. The incidents involved various forms of alleged mistreatment, including physical altercations between residents, verbal abuse by staff, and neglect of care needs. Despite the facility's policy requiring prompt investigation and reporting of such allegations, these incidents were not reported as required. One incident involved a resident with rheumatoid arthritis and other conditions who reported being physically grabbed by another resident. Another resident with cognitive impairment alleged that a CNA was rough and yelled at them. A third resident, who was dependent on staff for colostomy care, reported that a nurse refused to assist them and accused them of intentionally causing a mess. Lastly, a resident with cognitive impairment and other health issues was reportedly yelled at by a charge nurse, who also slammed a door in the face of a family member. The facility's administrator and assistant administrator acknowledged that these incidents contained potential allegations of abuse and neglect that should have been reported. However, no investigations were completed, and no reports were submitted to the state survey agency. The facility's abuse prevention policy mandates that such allegations be reported within two hours and a final investigation report be submitted within five working days, but these procedures were not followed.
Failure to Report and Document Resident's Behavior Leading to Fall
Penalty
Summary
The facility failed to ensure that staff reported new behaviors to the appropriate supervisor and department head for one resident, resulting in the resident being found on the floor with a laceration to the head. The resident, who had a history of epilepsy, restlessness, agitation, and failure to thrive, was sent to the hospital emergency department and treated with laceration repair (staples). The incident was reported to the Director of Nursing, and it was noted that the resident had an unwitnessed fall, which led to the injury. The resident was part of the facility's falling star program, which indicated a high risk for falls, but the specific behavior of the resident attempting to reposition herself was not communicated effectively among the staff or documented in the care plan. On the day of the incident, the resident was found on the floor mat next to her bed with a laceration on the right side of her head. The staff initiated emergency response procedures, and the resident was transported to the hospital. Upon return, the resident had six staples in her head. Interviews with various staff members revealed that the resident had a history of attempting to reposition herself in bed, which included arching her back and moving her legs over the wedge. However, this behavior was not consistently reported or documented, leading to a lack of appropriate interventions to prevent falls. The Director of Nursing and other staff members were unaware of the resident's specific behaviors that contributed to her falls. The LPN who observed the resident's unusual movements did not report these observations to the restorative nurse or the Director of Nursing. As a result, the care plan did not include interventions to address the resident's ability to reposition herself, which likely contributed to the fall and subsequent injury. The failure to communicate and document the resident's behaviors and the lack of appropriate interventions led to the deficiency in providing quality care for the resident.
Failure to Timely Report Serious Injury
Penalty
Summary
The facility failed to report an unusual occurrence resulting in a serious injury to the State Agency within the mandated time frame and did not have adequate policies and procedures for such reporting. This deficiency affected a resident who had an unwitnessed fall, resulting in a laceration on the right side of the forehead that required six staples. The incident occurred on May 11, 2024, but the report was not submitted until May 13, 2024, exceeding the 24-hour reporting requirement. The Director of Nursing and other staff were aware of the incident on the day it occurred, but the report was delayed due to an unspoken rule about reporting incidents on weekends or holidays on the next business day. This practice was not in compliance with the facility's policy, which mandates reporting within 24 hours, even on weekends and holidays if necessary. The facility's policy on incident and accident reporting was found to be inadequate as it did not specifically address the reporting of serious injuries. The Regional Director of Clinical Services/Corporate Nurse and the Director of Nursing acknowledged the reporting delay and the lack of a specific policy for serious injury reporting. The facility's failure to report the incident in a timely manner and the absence of a clear policy for serious injury reporting were identified as deficiencies during the survey.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide bed hold notification when transferring a resident to another facility. This deficiency affected a resident who was not informed about the option to return to the facility after being discharged. The resident, who is [AGE] years old and has a depressive disorder with impaired cognition, was involuntarily transferred to a hospital after attempting to set his clothes on fire. The transfer occurred on 4/13/2024, and the facility did not provide the required bed hold notice because they did not intend for the resident to return. The Director of Nursing (DON) and the Licensed Practical Nurse (LPN) involved confirmed that no decision was made about the resident's return at the time of transfer, and by the following Monday, the facility decided not to accept the resident back. The facility's policy requires that a Bed Reserve Policy Notification be given to the resident at the time of admission and each time they are transferred from the facility. However, this policy was not followed in the case of this resident. The Administrator later stated that the resident was accepted into another nursing home, and the decision not to take the resident back was due to the behavior that led to the hospital transfer. The facility's failure to provide the bed hold notification was a clear violation of their own policy and the Nursing Home Care Act, which mandates a bed hold for a period of ten days when a resident is hospitalized.
Failure to Assess Resident's Status Before Denial of Re-Admission
Penalty
Summary
The facility failed to determine the current status of a resident (R3) before denying re-admission after hospitalization. R3, who has a history of depressive disorder and impaired cognition, was initially admitted on [DATE] and discharged to the hospital on 4/13/2024 after attempting to set his clothes on fire. The facility did not provide a bed hold notice and had no intention of allowing R3 to return. The decision not to re-admit R3 was made without assessing his current status post-treatment or coordinating with the hospital. The Director of Nursing (V2) and the Administrator (V1) confirmed that the decision was based on R3's behavior during the transfer to the hospital, and no efforts were made to address R3's behavioral concerns in his care plan, as noted by the Social Service Director (V11). The care plan only addressed medication refusal and did not include measures for self-harm or other behavioral issues. R3 had multiple behavioral concerns, including fighting with other residents, taking off his clothes, sleeping in the hallway, and refusing medication. Despite these issues, the facility did not have a specific policy for permitting residents to return after hospitalization. The Social Service Director (V11) acknowledged that the care plan did not adequately address R3's self-harm tendencies or other behavioral concerns. The facility's failure to assess R3's current status and lack of coordination with the hospital led to the denial of re-admission, affecting R3's ability to receive services at the facility after discharge.
Failure to Address Behavioral Concerns in Resident Care Plan
Penalty
Summary
The facility failed to address behavioral concerns in the care plan for a resident (R3) who exhibited self-harm behaviors. R3, who has a depressive disorder and impaired cognition, was admitted to the facility and had multiple documented behavioral incidents, including trying to set his clothes on fire, fighting with other residents, taking off his clothes and sleeping in the hallway, and refusing medication. Despite these incidents, the care plan only addressed medication refusal and did not include interventions for self-harm or other behavioral concerns. Interviews with staff revealed that R3 had expressed suicidal ideation and had been involuntarily petitioned multiple times due to his behavior. The Social Service Director confirmed that the care plan did not address self-harm, even though R3 had a history of expressing a desire to harm himself and had engaged in dangerous behaviors. The facility's care plan policy requires comprehensive assessments and individualized plans of care, but this was not followed in R3's case, leading to a lack of intervention for his behavioral needs.
Failure to Monitor Vital Signs and Identify Change in Condition
Penalty
Summary
The facility failed to monitor vital signs and identify a change in condition for a resident (R2), who was later diagnosed with septic shock. R2, a resident with multiple medical diagnoses including diabetes, hypertension, and dementia, was found to be congested, hypotensive, and tachycardic with a blood pressure of 86/56, heart rate of 113, and oxygen saturation of 90% on room air. Despite these abnormal vital signs, there was no documentation of monitoring before the resident was sent to the hospital. The last recorded vital signs for R2 were from over a month prior, on 3/30/2024. The LPN on duty during the night shift reported that R2's condition had declined, but no vital signs were documented during her shift until the morning when R2 was transferred to the hospital. The Director of Nursing (V2) acknowledged that vital signs should be checked daily for residents with fluctuating blood pressure, especially those on medication. However, there was no order on the Medication Administration Record (MAR) for daily vital sign monitoring for R2. The lack of consistent monitoring and documentation of R2's vital signs led to a failure to identify the early signs of sepsis, resulting in the resident being transferred to the hospital in septic shock. The facility did not have adequate documentation to show that R2's condition was being properly monitored before the transfer.
Failure to Provide Emergency Treatment for Resident with Low Oxygen Levels
Penalty
Summary
The facility failed to provide emergency treatment and care for a resident with a low oxygen level, in accordance with professional standards of care, and failed to immediately contact 911 for an acute change in condition based on the resident's Do Not Resuscitate (DNR) status. This resulted in the resident not receiving timely care and treatment until six hours after the change in condition, requiring hospitalization with a diagnosis of Acute Respiratory Failure with Hypoxia, Sepsis, Metabolic Encephalopathy, Severe Sepsis with Septic Shock, Urinary Tract Infection, Acidosis, and Coagulation Defect. The resident subsequently expired at the hospital. This deficiency affected one of four residents reviewed for change in condition on the total sample list of 23 residents. The resident's progress notes indicated that the resident had low oxygen saturation levels of 84% and 82% at different times, but the Licensed Practical Nurse (LPN) did not provide oxygen or contact 911, citing the resident's DNR status. The Physician Orders for Life Sustaining Treatment (POLST) for the resident specified that oxygen should be used as part of selective treatment, but this was not followed. The Director of Nursing (DON) and the physician were notified but did not ensure that the resident received the necessary emergency care. The facility's policies on respiratory distress and change in condition were not adhered to, leading to a delay in providing critical care. Interviews with staff revealed a misunderstanding of the DNR status, with some believing it meant no interventions should be provided. The DON and the physician clarified that care should still be provided, including the use of oxygen and contacting 911. The facility also lacked proper documentation and communication regarding the resident's condition and the actions taken. The Immediate Jeopardy was identified and later removed, but noncompliance remained due to the need for further evaluation of the facility's corrective actions and quality assurance monitoring.
Removal Plan
- Re-education began with Facility Nurses and CNAs with focus on: This will be ongoing until all Nurses and CNAs are re-educated. Facility roster of all Nurses and CNAs was printed and being used for Staff signage as they are educated on process to ensure all is educated. Facility will ensure new hires are educated during the first 3 days of orientation period for Understanding DNR and Understanding Change in Condition:
- Understanding DNR: Meaning no CPR or heroic measures in case of complete cardiac arrest Do not mean no treatment or hospitalization for acute symptoms
- Understanding Change in Condition: Vitals and thorough assessment must be done Must notify Physician/NP immediately or as soon as possible Must notify Family immediately or as soon as possible Must initiate nursing interventions based on assessment findings Closely monitor Resident until transported to ER Document, document, document May initiate oxygen as needed without Dr's order Call 911 and transfer to ER as warranted prior to Dr's order Solicit assistance from Co-Workers as needed If unable to contact Physician/NP, contact Medical Director Once Physician/NP is contacted, give thorough assessment findings and follow his/her instructions
- Nursing Management will evaluate the training by giving reminders and/or asking questions at Morning Standup Meetings with Nurses which is currently being held daily and by doing chart audits/reviews.
- Administrator will be responsible for overall compliance to plan of correction in conjunction with DON to ensure all Nursing Staff are re-educated on the process.
- The Quality Assurance Quality Improvement Team meets monthly. This event will also be brought to the next monthly QAQI meeting for discussion and re-evaluation of interventions. If further interventions are needed at that time, they will be implemented accordingly.
Inadequate Nursing Staff Competency and Response
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to ensure residents' safety and maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency resulted in a delay in care for a resident (R3) who experienced respiratory distress and was not promptly sent to the hospital. The resident had a history of orthopedic aftercare, chronic kidney disease, and other conditions, and was noted to be pale and lethargic with declining oxygen saturation levels. Despite these symptoms, appropriate interventions were not implemented in a timely manner, leading to the resident's eventual hospitalization and subsequent death due to sepsis and acute respiratory failure with hypoxia and septic shock. The report highlights several instances of inadequate documentation and response to the resident's condition. Progress notes for the shifts on the day of the incident were missing, and there was no documentation of oxygen being administered when the resident's oxygen levels were critically low. Additionally, the LPN who attended to the resident had only received four days of orientation and lacked a completed competency checklist. The Director of Nursing (DON) confirmed that care should still be provided to residents with a Do Not Resuscitate (DNR) order, including administering oxygen and calling 911 if necessary. However, these actions were not taken promptly in R3's case. Further investigation revealed that the facility's orientation and competency assessment processes were incomplete or inadequately documented for multiple staff members. The DON stated that new nurses should receive a minimum of five days of orientation, but records showed that this was not consistently followed. Additionally, there was no policy on training or orientation of nurses, and several staff members reported feeling unprepared and uncomfortable with their responsibilities. This lack of proper training and oversight contributed to the inadequate response to R3's medical emergency, ultimately affecting the resident's outcome.
Failure to Provide Timely Medical Intervention and Proper Documentation
Penalty
Summary
The facility failed to ensure that nurses provided care in accordance with professional standards for a resident experiencing a reduction in oxygenation and a delay in receiving emergency medical attention. The resident, who had multiple diagnoses including chronic kidney disease and osteoarthritis, showed signs of severe distress with oxygen saturation levels dropping to 84% and 82% at different times. Despite these critical levels, the LPN on duty did not administer oxygen immediately and misunderstood the DNR status, believing it meant no interventions should be provided. The LPN also failed to document the interventions and was unable to contact the doctor, nurse practitioner, or the Director of Nursing for guidance. When another LPN arrived, she found the resident in a deteriorated state and immediately administered oxygen, which improved the resident's oxygen levels to 87%. However, the resident's condition continued to fluctuate, and there was a lack of proper documentation and monitoring throughout the shifts. The Medical Doctor later confirmed that the resident should have been given oxygen and sent to the hospital, regardless of the DNR status, and expected the nurses to monitor the resident closely. The facility's policies and job descriptions clearly outlined the need for immediate medical intervention and proper documentation in cases of changes in resident status. However, these protocols were not followed, leading to a significant delay in emergency care for the resident. The lack of timely intervention and proper documentation contributed to the resident's deteriorating condition and eventual death at the hospital due to sepsis and acute respiratory failure.
Failure to Follow Involuntary Transfer Policy
Penalty
Summary
The facility failed to follow their policy on involuntary transfer by not sending the appropriate paperwork with a resident (R2) who required involuntary transfer to the hospital. On 3/26/2024, R2 exhibited unusual behaviors, including making cat-like noises and claiming that everyone had the devil in them. The LPN on duty, V11, contacted R2's psychiatrist and doctor, who advised sending R2 to the hospital for evaluation. However, when R2 returned from the hospital without treatment, V11 realized that the necessary involuntary petition paperwork had not been sent with R2. Consequently, R2 had to be sent back to the hospital with the correct paperwork completed by the Social Services Director, V17. The facility's staff, including the Administrator (V1), Director of Nursing (V3), and other nurses, acknowledged that the petition paperwork should have been completed and sent with R2 initially. The report highlights that there was a lack of understanding among some nurses about the process for completing the petition paperwork, which led to the oversight. The facility's policy and job descriptions for LPNs and RNs indicate that they are responsible for completing necessary medical forms, including those for transfers and discharges, but this was not adhered to in this instance.
Failure to Send Required Paperwork and Notify POA
Penalty
Summary
The facility failed to send the appropriate paperwork with a resident who required involuntary transfer to the hospital and did not notify the resident's power of attorney (POA) that a psychotropic medication was discontinued. This deficiency was identified during an interview and record review, affecting three residents reviewed for the facility's policy and procedures. Specifically, a Licensed Practical Nurse (LPN) sent a resident to the hospital for evaluation due to exhibiting unusual behaviors but did not send the required involuntary petition paperwork. The resident was returned to the facility without being admitted to the hospital, and the same emergency medical technicians had to take the resident back to the hospital after the petition was completed by the Social Services Director (SSD). The LPN admitted to not knowing that a petition was required and did not receive the hospital paperwork when the resident initially returned from the hospital. The Director of Nursing (DON) and the Administrator confirmed that the POA was not notified about the discontinuation of the resident's psychotropic medication. The DON stated that it is the social worker's responsibility to complete the petition paperwork when a resident needs to be sent to the hospital due to behaviors, and nurses are expected to complete the paperwork after hours or when the social worker is not available. However, it was revealed that some nurses were not familiar with the process of completing the petition paperwork. The SSD acknowledged that the POA should have been notified about the medication changes and that an in-service was requested to train nurses on completing the petition paperwork. The facility's policies and job descriptions for LPNs and RNs include responsibilities for completing medical forms, charting, and handling admissions, discharges, and transfers. Despite these policies, the failure to send the required paperwork and notify the POA about medication changes led to deficiencies in the facility's handling of residents' behavioral health needs and communication with their representatives.
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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