City View Multicare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cicero, Illinois.
- Location
- 5825 West Cermak Road, Cicero, Illinois 60804
- CMS Provider Number
- 145850
- Inspections on file
- 63
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at City View Multicare Center during CMS and state inspections, most recent first.
A resident with bipolar disorder, anxiety, and intact cognition repeatedly refused prescribed psychotropic medications, as documented on the MAR and in nursing notes describing verbal refusal and resistant behavior. The resident reported telling an LPN she was allergic to an antipsychotic and that the LPN continued to offer it while documenting refusals. Despite multiple documented refusals and facility guidelines stating that declined treatments must be reflected in the comprehensive care plan, the interdisciplinary team did not develop a care plan problem, goal, or interventions for medication refusal, and the staff member responsible for such care plans acknowledged that no medication-refusal care plan had been created.
The facility failed to maintain an effective pest control program, as evidenced by visible dirt, spilled food, and numerous mice droppings observed on the floor of the kitchen dry storage area, which staff identified as mouse waste. A regional operations leader acknowledged ongoing mouse problems related to the building’s proximity to an alley, despite regular pest control visits. During a resident council meeting, residents unanimously reported ongoing issues with rodents and roaches, and a resident reported rats and mice running through their room several times a week, with a recent sighting reported. The Dietary Manager stated that the kitchen floor is supposed to be cleaned daily by staff but had not been, and the facility’s pest policy requires an effective pest control program and staff vigilance to keep the environment free of pests and rodents.
The facility failed to create and implement individualized, measurable fall care plans for four residents with documented fall risks and prior falls. One resident with dementia, a high fall risk score, and a wrist fracture from a fall had only a generic, system-generated goal stating that a safe environment would be maintained, with no resident-specific, measurable outcomes. Another resident with a history of falls, epilepsy, bilateral lower extremity amputations, and dementia had the same broad fall goal without customization. A third resident with dementia, schizoaffective disorder, a right femur fracture, and documented episodes of throwing himself from a chair and leaping to the floor was monitored but not provided enhanced supervision before the fall, and his fall care plan also contained only the generic safe-environment goal. A fourth resident with arthritis, chronic pain, syncope, weakness, a high fall risk score, and a prior fall while attempting to transfer to a chair had a longstanding fall care plan with the same non-specific goal, and staff interviews confirmed that this broad goal was routinely used for all residents instead of person-centered, measurable fall goals.
Surveyors identified multiple unsecured and loose handrails in 3rd-floor hallways, including those near a bathroom and outside several rooms, which could be displaced several inches and in one case had a screw protruding from the bracket. An LPN twice observed and confirmed the looseness of the handrails and acknowledged they are used for safety and to assist residents with gait abnormalities, while the Maintenance Director confirmed the expectation that handrails in common areas be secured and promptly repaired. Despite these acknowledgments and a written preventative maintenance policy requiring inspection of all handrails for loosened fasteners and immediate repair, the same handrails remained loose on subsequent observations.
Two residents at high risk for falls did not receive adequate accident prevention measures. One resident with motor coordination issues and a history of falls had a care-planned self-releasing seat-belt alarm that was not functioning when tested, and staff acknowledged it was not working and had not ensured it was repaired or replaced. Another resident with dementia, schizoaffective disorder, high fall-risk score, and a right hip fracture repeatedly attempted to get out of a wheelchair and throw himself from a chair in the dining room while only routine supervision was provided. Staff were positioned at a distance, responsible for monitoring multiple residents, and were unable to intervene before the resident leaped from the chair and fell. Despite documented behavioral symptoms, impaired mobility, and repeated attempts to exit the wheelchair, no enhanced or 1:1 supervision was implemented, and facility policies on fall prevention, individualized interventions, and incident reporting were not effectively followed.
Surveyors found that the facility exceeded the acceptable 5% medication error rate when an LPN prepared incorrect medications for a resident during a routine med pass. The resident’s POS specified Folic Acid 400 mcg once daily and Aspirin 81 mg once daily at 9 a.m., but the LPN prepared chewable Aspirin 81 mg, which was not prescribed, and Folic Acid 1,000 mcg instead of the ordered 400 mcg. Upon questioning, the LPN confirmed both the incorrect formulation of Aspirin and the incorrect Folic Acid dose, contrary to the facility’s policy requiring medications to be administered exactly as ordered by the physician.
A resident with a history of bipolar disorder and recent traumatic fall resulting in multiple fractures did not have their falls care plan updated with new interventions. Despite increased fall risk and functional decline, the care plan remained unchanged, and staff failed to document the recent fall or implement additional fall prevention measures as required by facility policy.
A resident with psychiatric and neurological conditions, requiring supervision for ambulation, was left unsupervised in the dining room. The lack of staff presence led to an altercation with another resident over spilled coffee, resulting in a fall and serious injuries, including a fractured humerus and nasal bone. Staff interviews confirmed no supervision was provided, and documentation showed discrepancies in staffing assignments.
Several residents were not served lunch at the same time as their tablemates, with some not having their names called and their trays left on the cart until later. Two residents also did not have diet tickets with their trays. Facility policy requires that all trays be served in order at each table to ensure a dignified dining experience.
Several cognitively intact and moderately impaired residents received Descovy for HIV pre-exposure prophylaxis without being informed or providing consent. Medical records lacked documentation of consent, education, or individualized care plans, and staff confirmed that written consent was not obtained prior to administering the medication.
The facility did not consistently hold quarterly care plan meetings with residents and their representatives, nor did it ensure residents were involved in the development and review of their care plans. Several residents lacked documentation of care plan meetings or discharge planning, and one resident who smoked was not identified as such in their care plan, despite having a smoking assessment and being observed smoking. The DON confirmed that smoking should be care planned, but this was not done.
During a lunch meal service, all residents on one unit were served food items that were below the required minimum temperature, with some items as low as 90 degrees Fahrenheit. Dietary staff measured and documented these temperatures but did not reheat the food before serving, contrary to facility policy.
A dependent resident was left without an accessible call light cord for an extended period, requiring her to use her pillow to activate the wall switch behind her bed. Despite full cognitive function, the resident's need for assistance was not promptly addressed, and maintenance was not made aware of the issue until the day of the survey, contrary to facility policy requiring daily checks and immediate reporting of call light defects.
A resident alleged to a RN that CNAs had hit her after an incident of agitation, but the RN did not notify administration or report the allegation to the state agency as required by facility policy. The administrator confirmed that no abuse report was filed, and record review showed the incident was not reported.
Staff failed to accurately code MDS assessments for three residents, including incorrect documentation of anticoagulant use, omission of dialysis status for a resident with chronic kidney disease, and misclassification of a resident's absence as a hospitalization instead of a pass. These errors were identified through record review and staff interviews.
A resident who was identified as a smoker and observed participating in smoking activities did not have smoking addressed in their care plan. Although a smoking assessment was completed and staff confirmed the resident's smoking status, the resident was not included on the facility's smoking list, and the care plan failed to address this behavior, contrary to the DON's expectations.
A resident with a history of wandering and hoarding was observed entering other residents' rooms and taking their belongings without staff supervision. Interviews confirmed this was a recurring issue, and while the care plan addressed hoarding, it did not specifically address wandering or ensure adequate monitoring.
A resident with multiple psychiatric diagnoses and documented malnutrition experienced significant unplanned weight loss after staff failed to provide double portions at meals as ordered by the RD. Despite clear recommendations and documentation, dietary tickets did not reflect the intervention, and the resident continued to lose weight over several months.
A resident was administered heparin injections for VTE prophylaxis without a documented diagnosis to support its use. Despite being ambulatory and having no recorded VTE or related condition, the resident continued to receive the anticoagulant, as confirmed by physician orders and medication records. Review of medical records and interviews with staff verified the absence of a clinical indication for the medication.
A resident with a documented mushroom allergy was served beef stroganoff containing mushrooms, as their allergy was not indicated on the diet ticket used by dietary staff. The Dietary Manager confirmed the omission, and facility policy requires that food allergies be clearly documented and not liberalized.
Staff failed to follow infection control protocols by using the same gloves to access a multi-use petroleum jelly container during incontinence care and then placing the contaminated jar with clean linens. Additionally, a CNA shared a drink with two residents in the dining area, contrary to facility policy and standard precautions, increasing the risk of cross-contamination.
Surveyors found that the facility did not consistently post up-to-date nurse staffing data in a location accessible to residents and visitors. On several checks, the required information was either missing or outdated, potentially impacting all residents.
A resident with multiple medical and behavioral diagnoses alleged being physically assaulted by another resident in the presence of two LPNs. The incident was reported to several staff members, but no immediate action was taken, and the administrator delayed filing an abuse report for eight days, contrary to facility policy requiring prompt reporting of abuse allegations.
A resident with multiple medical and behavioral conditions alleged being physically assaulted by another resident with a history of violent behavior. The incident, witnessed by two LPNs and reported to clinical staff, was not promptly investigated, as the administrator did not interview the resident, contact police, or file an incident report until eight days later, contrary to facility policy requiring thorough investigation of abuse allegations.
A resident with brittle diabetes reported symptoms of low blood sugar and requested a blood glucose check from an LPN, who did not perform the test, stating she was busy. The resident called 911, and paramedics found his blood sugar to be dangerously low. Staff interviews confirmed that glucometers were available and that the resident was able to communicate his needs, but the blood glucose check was not performed as ordered.
A cognitively impaired resident on a pureed diet at an LTC facility accessed a regular sandwich, leading to a fatal choking incident. Despite staff and EMS efforts, the resident died from asphyxiation. The resident had severe cognitive impairment and required supervision while eating, but was able to ambulate independently. The facility failed to prevent the resident from accessing non-pureed food, contributing to the incident.
A resident with a rash did not receive prescribed treatments from an infectious disease practitioner and a dermatologist. The resident's MAR showed no administration of recommended antifungal and antiparasitic medications. The ADON acknowledged that orders were not communicated to staff, and the facility's policy for verifying and documenting new orders was not followed, resulting in a deficiency in care.
A resident with diabetes was not served the correct therapeutic diet as ordered by their physician. Instead of receiving mandarin oranges, the resident was served mandarin orange fluff, which contained excessive sugar, contrary to the facility's dietary guidelines for a Consistent Carbohydrate, Limited Concentrated Sweets (CCHO LCS) diet. The Dietary Manager acknowledged the error, noting that the dessert served was inappropriate for the resident's dietary needs.
The facility's kitchen was found to have significant sanitation and food safety deficiencies, including sticky floors, uncovered food exposed to contamination, and appliances laden with grease and food debris. Expired and unlabeled food items were discovered in the refrigerator, and the cook reported being overworked and short-staffed, with the administration aware of these issues.
A resident with a history of bipolar disorder and substance abuse had his pass privileges revoked after an incident but was not reassessed for reinstatement despite compliance with medication and lack of recent behavioral issues. Facility staff provided inconsistent information, and there was no recent documentation to justify the continued restriction. The facility's policy on pass privileges was not followed, resulting in a deficiency in honoring the resident's rights.
A facility failed to refund a discharged resident's personal funds, totaling $518.39, due to uncertainty about where to send the money. The resident was admitted under Medicaid/social security and had a balance that included a $20 check from the family. Despite being the designated representative payee, the facility did not take action to refund the money, and no inquiries were made by the family.
The facility did not serve spiced peaches as planned in the noon meal, affecting residents' nutritional intake. Observations and interviews confirmed that residents received chicken and noodles, green beans, and ice cream, but no spiced peaches, despite being on the menu. Dietary staff acknowledged the oversight, and the facility's policy requires adherence to the planned menu unless unavoidable circumstances arise.
Failure to Care Plan Repeated Psychotropic Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan addressing a cognitively intact resident’s repeated refusal of prescribed psychotropic medications. The resident had diagnoses including bipolar disorder, restlessness and agitation, and anxiety disorder, and a recent MDS BIMS score of 15 indicating intact cognition. Medication Administration Records for February documented multiple instances of drug refusal for two psychotropic medications, with code "2 - Drug refused" recorded on several dates. Nursing documentation also described the resident cursing at the nurse and refusing morning medications, and a nurse’s note recorded that the resident refused medication despite education, stating, "I don't care to take medication from you or anyone." The resident reported that an LPN continued to offer an antipsychotic medication despite the resident stating she was allergic, and that the LPN said she would document the refusal. Despite these repeated refusals and associated behavioral documentation, the resident’s care plan, as reviewed on March 2, did not include a problem, goal, or interventions related to refusal of medications. The Assistant Social Services Director, who was responsible for completing care plans for behaviors and refusal of medications, confirmed that there was no care plan addressing medication refusal and acknowledged that a resident with three or more refusals should be care planned so interventions could be put in place. She also stated she did not review the MAR but instead relied on the 24-hour report to identify behaviors. Facility policy on comprehensive care plans required that the comprehensive care plan include problems/needs identified in the comprehensive assessment and that care plans be reviewed and updated at least quarterly and more often with changes in condition or newly developed issues. Facility guidelines for resident refusal of treatment/services/medications stated that declined services must be documented in the medical record and included in the resident’s comprehensive care plan, but this was not done for this resident’s repeated medication refusals.
Failure to Maintain Effective Pest Control in Kitchen and Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent and eliminate rodents in the kitchen dry storage area, with the potential to affect all 266 residents. During an observation of the dry storage area with the Dietary Manager, surveyors noted visible dirt, spilled dried grits, and approximately 22 pieces of mice droppings on the floor by the wall under the bottom shelf. When asked, the Dietary Manager identified the droppings as mice droppings. The Regional Director of Operations also observed the area and acknowledged that the facility has problems with mice, attributing this to the kitchen’s proximity to an alley. The Regional Director stated that the pest control company comes regularly to the building. In a resident council meeting, residents unanimously reported that pest control, including rodents and roaches, is an ongoing concern throughout the facility. One resident stated that their room has rats and mice running through it a few days a week and reported last seeing rodents in the facility the previous day. When the Dietary Manager was later asked why there were so many mice droppings and why staff who accessed food items for breakfast did not clean the dirty floor and droppings, she stated she had been off work for several days and had just returned, and that the kitchen floor should be cleaned every day by staff. The facility’s undated Pest Policy states that an effective pest control program must be in place and that maintenance staff and all staff are responsible for maintaining a clean, safe, and comfortable environment free of pests or rodents.
Failure to Develop Individualized, Measurable Fall Care Plans for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered, and individualized fall care plans for multiple residents with known fall risks and/or fall histories. For one resident with dementia, a high fall risk score, and a documented fall resulting in right distal radial and ulna fractures, the fall care plan contained only a generic goal that the resident would have a safe environment maintained through the next review. This goal was system-generated, not customized, and did not include measurable, resident-specific outcomes despite the resident’s recent fall and injury. Another resident with a history of falling, epilepsy, bilateral lower extremity amputations, dementia, and altered mental status also had a fall care plan with the same broad, non-individualized goal, without specific, measurable objectives tailored to that resident’s complex conditions and fall risk. A third resident with dementia, schizoaffective disorder, low back pain, and a nondisplaced intertrochanteric fracture of the right femur had progress notes documenting repeated attempts to throw himself out of a chair in the dining area and then leaping onto the floor. Staff documented monitoring the area and assisting the resident back to a chair, but no enhanced or one-to-one supervision was implemented prior to the fall. Despite these behaviors and the fall event, this resident’s fall care plan also contained only the generic goal that a safe environment would be maintained through the next review, without individualized, measurable goals addressing his specific behavioral and fall risks. A fourth resident with generalized arthritis, chronic pain, left knee pain, syncope and collapse, weakness, and an unspecified fall had a high fall risk score and a documented incident in which the resident was found lying on the floor after stating they had tried to get into a chair and fell. This resident’s fall care plan, in place for several years, likewise contained only the broad goal of maintaining a safe environment through the next review, without measurable, person-centered outcomes related to the resident’s identified fall risks and prior fall. Interviews with the MDS Coordinator and Restorative Nurse Consultant confirmed that the facility routinely used this system-generated fall goal for all residents, acknowledged that it was broad and general, and that goals should be measurable, person-centered, and tailored to each resident’s specific needs, but the care plans reviewed did not reflect such individualized, measurable fall-related goals.
Unsecured Hallway Handrails Not Repaired per Preventative Maintenance Policy
Penalty
Summary
The facility failed to ensure that hallway handrails on the 3rd floor were firmly secured as required by its own preventative maintenance policy. On a floor with 32 residents, surveyors observed that the handrail next to the bathroom and across from a resident room was unsecured, loose, and able to be displaced approximately 3 inches up or down. An LPN observed the loose handrail, confirmed it was loose, and stated it needed to be tightened, acknowledging that handrails are used for safety and to assist residents with gait abnormalities. The Maintenance Director later affirmed that the facility’s expectation is that handrails in common areas are secured and promptly repaired when needed, and that they are installed for resident safety and assistance. Subsequent observation showed that the same handrail next to the bathroom and across from a resident room remained unsecured and loose with approximately 3 inches of movement, and additional handrails across from and outside other resident rooms were also unsecured, loose, and able to be displaced approximately 3 to 5 inches, including one bracket with a screw protruding about 1.5 inches. Another LPN confirmed these observations and affirmed that handrails are for resident safety. The facility’s preventative maintenance policy directed staff to inspect all handrails throughout the facility for loosened fasteners or connectors and to make any needed repairs immediately. This deficiency arose from the presence of multiple unsecured and loose handrails in resident-accessible hallways, repeated observations of the same unresolved condition over several days, and the facility’s failure to adhere to its written preventative maintenance policy requiring immediate repair of loosened handrails.
Failure to Maintain Functional Alarms and Provide Adequate Supervision for High Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that adequate supervision and fall-prevention interventions were provided for residents at risk for falls. For one resident with autistic disorder, developmental motor disorder, and lack of coordination, the care plan identified a history of actual falls and included a self-releasing seat alarm belt as an intervention. The resident’s functional assessment showed a need for partial to moderate assistance with sit-to-stand and transfer activities, and the BIMS score indicated intact cognition. During observation, the resident was seated in a wheelchair with an alarm box behind the seat. When an LPN asked the resident to stand, the chair alarm did not sound. The LPN acknowledged the alarm was not working and appeared to be in the seatbelt, and there was no indication that defective equipment had been reported as required by the CNA job description and the facility’s fall prevention program, which identifies missing or broken equipment as a fall risk factor. The facility also failed to implement appropriate fall-prevention interventions and supervision for another resident with dementia, schizoaffective disorder, a high fall risk score, and a nondisplaced intertrochanteric fracture of the right femur. Progress notes documented that this resident repeatedly attempted to throw himself out of a chair in the dining area while staff were monitoring the area. Later the same day, another note recorded that the resident leaped from the chair to the floor, after which he was assisted back to the chair and staff continued monitoring the dining area without initiating enhanced or one-to-one supervision. Subsequent notes described the resident being kept near the nurses’ station and requiring constant redirection due to restlessness and attempts to propel himself to his room, as well as repeated attempts to get out of his wheelchair in the dining room despite redirection. The resident’s care plans documented a history of actual falls, high fall risk related to cognitive impairment and mental illness with behavioral symptoms, and a need for extensive assistance with ADLs and one-person support for transfers. Staff interviews confirmed that, at the time of the dining room fall, the resident was known to be impulsive, confused, and frequently attempting to stand or put himself on the floor. The CNA and LPN present in the dining room stated they were aware the resident was repeatedly trying to get out of the wheelchair but were positioned near the dining room doors rather than directly next to him. Both reported that by the time they reached the resident, he had already fallen, and the CNA acknowledged that if staff had been positioned directly next to the resident, the fall could have been prevented. The DON stated that when monitoring is increased, staff are expected to directly observe the resident, but also confirmed that a single staff member was responsible for monitoring several residents in the dining room and that the resident was not provided direct or constant one-to-one supervision despite his repeated attempts to exit the wheelchair. Facility policies on fall prevention and incidents/accidents/falls emphasized identifying fall risk factors, implementing individualized interventions, visually checking residents for safety, and reporting significant incidents and injuries, but the documented practices and staff accounts showed that these measures were not effectively implemented for the residents involved. Additional documentation related to the second resident showed ongoing pain complaints and subsequent hospital evaluation revealing an age-indeterminate mildly displaced periprosthetic fracture of the right greater trochanter and displaced rib fractures, along with soft tissue swelling of the left humerus. Facility leadership and the attending physician acknowledged uncertainty about when the fractures occurred and whether they predated admission or were related to the documented fall, and the DON and Chief Nursing Officer indicated that no reportable incident was filed because the fracture was considered not acute and records from prior facilities were incomplete. The facility’s fall prevention and residents’ rights documents stated a commitment to safety, individualized fall risk assessment, appropriate interventions, and care that promotes quality of life, but the failures to ensure a functioning alarm for one resident and to provide adequate, individualized supervision and fall-prevention interventions for the other resident led to the cited deficiency.
Medication Administration Errors Exceed Acceptable Error Rate
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were administered as prescribed, resulting in a medication error rate of 8% (2 errors out of 25 opportunities), which exceeded the 5% threshold. For one resident (R245), the Physician Order Sheets documented an order for Folic Acid 400 mcg once daily and Aspirin 81 mg once daily, scheduled for 9:00 a.m. During a medication pass observation at 9:12 a.m., an LPN (V27) prepared and was ready to administer chewable Aspirin 81 mg and Folic Acid 1,000 mcg to this resident. When questioned, the LPN confirmed that chewable Aspirin had not been prescribed for the resident and acknowledged that the Folic Acid dose in hand was 1,000 mcg instead of the ordered 400 mcg. The facility’s undated drug administration policy requires that medications be administered as prescribed, in accordance with written physician orders and good nursing principles and practices, and within 60 minutes of the scheduled time. These observations, interviews, and record reviews demonstrated that the nurse did not follow the resident’s current physician orders or the facility’s medication administration policy when preparing the incorrect formulation of Aspirin and the incorrect dose of Folic Acid for administration.
Failure to Update Falls Care Plan After Resident Injury
Penalty
Summary
The facility failed to update a resident's falls care plan with new interventions following a significant fall event. The resident, who had a history of bipolar disorder with mood and behavioral disturbances, was initially not identified as being at risk for falls, and the only intervention listed was for nursing staff to complete a fall risk assessment per facility protocol. Despite the resident experiencing a traumatic fall resulting in multiple fractures and requiring maximum staff assistance with activities of daily living, the care plan was not revised to reflect the increased fall risk or to include additional interventions. The fall risk review completed after the incident did not acknowledge the recent fall or the resident's new health conditions that predisposed them to further falls. Staff interviews revealed confusion regarding the documentation of fall history and risk status, with the DON indicating that the fall risk review did not consider the most recent fall. The facility's policies require care plans to be reviewed and updated with any significant change in condition and mandate additional interventions after a fall, but these procedures were not followed for this resident. The lack of timely and appropriate updates to the care plan contributed to the deficiency identified during the survey.
Failure to Supervise Resident in Dining Room Leads to Serious Injury
Penalty
Summary
The facility failed to provide adequate supervision in the dining room, resulting in an avoidable accident involving a resident with multiple psychiatric and neurological diagnoses, including generalized anxiety disorder, paranoid schizophrenia, drug-induced secondary Parkinsonism, and moderate cognitive impairment. The resident required supervision or assistance with ambulation, as documented in their functional abilities assessment. Despite these needs, the resident was left unsupervised in the dining room, where an altercation occurred after the resident took another resident's coffee, leading to a fall. Staff interviews revealed that on the day of the incident, there was no CNA assigned to the unit, and both nurses present stated that no staff were supervising the dining room. Multiple staff members described the resident as delusional, disoriented, and prone to pacing and talking to himself, with a baseline of confusion. The fall resulted in significant injuries, including a comminuted fracture of the right humerus and a nasal bone fracture, requiring surgical intervention. The incident was not witnessed by staff, and there was uncertainty among staff about which residents were present in the dining room at the time. Documentation and interviews further indicated that staff on the unit considered the residents to be independent and did not monitor them in the dining room. The facility's fall prevention policy required additional interventions after a fall, but the lack of supervision and failure to recognize the resident's need for monitoring directly contributed to the incident. The staffing assignment sheet also showed discrepancies between staff assignments and actual coverage, with a CNA denying working on the unit despite being listed as assigned.
Failure to Serve Lunch Simultaneously to All Tablemates
Penalty
Summary
The facility failed to provide a dignified dining experience by not serving lunch to all residents seated at the same tables at the same time. During lunch service in the 8th floor common dining room, four residents were not given their lunch trays when other residents at their tables received theirs. Staff did not call the names of two residents who were present in the dining room, and their trays were left on the cart until staff later provided them. Two other residents were also served late and did not have diet tickets with their trays. The facility's dignity policy requires that trays be served in order at each individual table so that residents are not left waiting while others at the same table are eating.
Failure to Obtain and Document Consent for HIV Prophylaxis Medication
Penalty
Summary
The facility failed to obtain and document consent for participation in a pharmacy program involving the administration of Descovy for HIV pre-exposure prophylaxis for four residents. These residents, who had varying diagnoses including hypertension, kidney disease, schizoaffective disorder, epilepsy, diabetes, and depression, were all found to have received Descovy as per physician orders. Despite being cognitively intact or only moderately impaired, none of the residents were aware they were taking this medication, nor had they received any information or education about it. Interviews with the residents confirmed their lack of awareness and consent, with some explicitly stating they would not have agreed to take the medication if informed. Record reviews revealed that there was no documentation of consent, education, or individualized care plans related to the pharmacy program or the administration of Descovy in any of the residents' medical records. The Certified Nurse Consultant acknowledged that written consent was not obtained and that there was no documentation of resident agreement in the medical records. Additionally, there were no separate assessments documenting risk factors for each resident, and individualized care plans were still in development. The facility's Medical Doctor stated that consent, education, and explanation of risks and benefits should have been provided prior to administering the medication, which was not done.
Failure to Conduct Timely Care Plan Meetings and Address Smoking in Care Plans
Penalty
Summary
The facility failed to conduct care plan meetings with residents and/or their representatives on a quarterly basis and did not provide residents with the opportunity to participate in the development, review, and revision of their care plans. This deficiency affected six out of seven residents reviewed for care planning. Interviews with social services staff revealed that while care plan meetings are scheduled quarterly and annually, there were lapses in communication and documentation, including not inviting or updating residents and their families about care plan meetings or discharge planning. Medical record reviews showed that several residents did not have documented care plan meetings with their families in the past twelve months, and in some cases, there was no evidence of a discharge care plan or updates provided to families regarding referrals to other facilities. Additionally, the facility failed to develop a comprehensive care plan for a resident identified as a smoker. Despite the resident having a documented smoking assessment and being observed smoking on the patio, the resident was not included on the facility's smoking list, and their care plan did not address smoking. The DON confirmed that smoking should be included in care plans, but this was not done for the resident in question.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve lunch meals at the required safe and appetizing temperature to all 10 residents on the eighth floor nursing unit. During observation, dietary staff measured food temperatures on the steam table and found that several items, including chuckwagon beef stroganoff, noodles, buttered cabbage, and hamburgers, were below the facility's minimum required serving temperature of 125 degrees Fahrenheit, with some items as low as 90 degrees. Despite these findings, the dietary staff proceeded to serve the food without reheating it to the appropriate temperature. The facility's policy requires hot foods to be held at a minimum of 135 degrees during tray assembly and not served below 125 degrees, but this protocol was not followed during the observed meal service.
Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
A dependent resident was found in bed without a call light cord attached to the call light switch on the wall, making it difficult for her to summon assistance. The resident reported having to raise her bed and use her pillow to repeatedly hit the wall switch behind her head to activate the call light, a situation that had persisted for one month. The resident was assessed as having full cognitive function with a BIMS score of 15 out of 15. Nursing staff indicated that maintenance requests are documented in a binder at the nurse's station, but the last recorded maintenance report was from the previous year. Although the nurse stated that maintenance had been notified about the missing call light cord, maintenance staff reported only being informed of the issue on the day of the survey. The facility's policy requires daily checks of call lights, immediate reporting of defects, and ensuring residents have access to a functional call light at all times.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency as required by its abuse policy. A registered nurse (RN) was informed by certified nursing assistants (CNAs) that a resident was spitting and swearing at them, and when the RN assessed the resident, the resident stated that the CNAs had hit her. The RN questioned the CNAs, who dismissed the allegation as a recurring behavior from the resident, and the RN did not notify administration of the allegation, later stating it slipped his mind despite knowing the reporting requirement. The administrator confirmed that no abuse report was filed for the incident, and a review of facility records showed no report for the resident on the relevant date. The facility's policy requires all alleged violations involving abuse to be reported to the state agency immediately, or within 24 hours if there is no serious bodily injury, and to ensure thorough investigation of all allegations.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS indicated the use of high-risk anticoagulant medications, but a review of the physician order sheet showed no such medications were ordered. Another resident, diagnosed with chronic kidney disease and dependent on renal dialysis, was not marked as receiving dialysis on the MDS, despite care plan documentation and staff interviews confirming regular dialysis treatments. A third resident, who was out on pass in the care of a family member, was incorrectly coded on the MDS as having been hospitalized, contrary to progress notes documenting the actual situation. These inaccuracies were identified through record review and staff interviews, revealing errors in the completion of MDS assessments for all three residents reviewed in this sample.
Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as a smoker. Observations showed that the resident participated in smoking activities, and staff confirmed the resident's smoking status and possession of cigarettes. Despite a completed smoking assessment indicating the resident smokes, the resident's name was not included on the facility's smoking list, and the care plan did not address smoking. The DON stated that smoking should be included in care planning, along with other health conditions and behaviors, but this was not done for the resident in question. This deficiency was identified through observation, staff and resident interviews, and record review, which confirmed the lack of a care plan addressing the resident's smoking behavior.
Failure to Supervise Resident with Wandering and Hoarding Behaviors
Penalty
Summary
A resident with a known history of wandering and hoarding behavior was observed entering other residents' rooms without staff supervision. The resident took personal belongings, including a pair of blue sweat pants and an orange tee shirt, from two different residents and added them to her own possessions. No staff were present to monitor or redirect the resident during these incidents. Interviews confirmed that this behavior was ongoing, with one resident stating that the wandering resident frequently entered her room and took belongings. The Director of Nursing acknowledged that the resident's care plan addressed hoarding but did not specifically address wandering behavior. The care plan included interventions such as familiarizing staff with the resident's patterns, providing tasks to redirect her, and checking her room for hoarded items, but did not ensure adequate supervision to prevent the resident from entering other residents' rooms.
Failure to Provide Prescribed Double Portions for Resident with Significant Weight Loss
Penalty
Summary
A resident with a history of major depressive disorder, schizophrenia, autism, anxiety, delusional disorder, and paranoid disorder experienced significant unplanned weight loss over a six-month period. Despite a registered dietician's assessment identifying a 7.5% weight loss in three months and recommending double portions at all meals, the facility failed to implement this intervention. Review of dietary tickets and direct observation confirmed that double portions were not provided, and the resident continued to lose weight, totaling a 12.5% loss in six months. The resident's nutritional assessment documented malnutrition, and progress notes indicated that the plan included double portions, staff supervision at meals, and monitoring of intake and weights. However, the dietary manager confirmed that the resident's meal tickets did not reflect the double portion order, and the dietician stated that she expected her recommendations to be followed. The facility's policy required assessment and intervention for significant weight changes, but the recommended intervention was not carried out, resulting in continued unplanned weight loss for the resident.
Failure to Ensure Unnecessary Drug Use Was Avoided for Anticoagulant Therapy
Penalty
Summary
A resident with multiple diagnoses, including unspecified dementia, bipolar disorder, schizoaffective disorder, and other chronic conditions, was found to be receiving heparin injections for VTE (venous thromboembolism) prophylaxis. The physician order sheet indicated that the resident was to receive heparin 5000 units subcutaneously every eight hours, and the medication administration record confirmed that the resident received this medication multiple times in June. However, a review of the resident's medical diagnoses and the Minimum Data Set (MDS) revealed no documented diagnosis of VTE or any other condition justifying the use of heparin. During interviews, the medical doctor stated that the resident was on heparin because it was started in the hospital and to prevent blood clots, particularly in non-ambulatory patients. However, the resident was observed to be ambulatory and able to transfer independently. The administrator confirmed that there was no current diagnosis supporting the use of heparin for this resident, and documentation from a nurse practitioner visit also did not provide a diagnosis for the continued use of the anticoagulant.
Failure to Prevent Serving Allergen-Containing Food to Resident with Documented Allergy
Penalty
Summary
A resident with documented allergies to mushrooms was served beef stroganoff containing mushrooms during lunch. The resident noticed mushrooms in the sauce and informed staff of his allergy. Review of the resident's diet ticket for the following day showed that the mushroom allergy was not listed, and the facility's recipe for the dish confirmed the inclusion of mushrooms. The Dietary Manager confirmed that the resident's food allergy was not indicated on the diet ticket, which is the facility's process for alerting staff to dietary concerns. The facility's policy states that food allergies and intolerances will not be liberalized.
Failure to Maintain Infection Control Practices and Prevent Cross-Contamination
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices, resulting in cross-contamination risks. In one instance, a CNA provided incontinence care to a resident who was frequently incontinent of bowel and bladder. The CNA, while wearing the same gloves used for incontinence care, inserted her fingers into a multi-use container of petroleum jelly, applied it to the resident's buttocks, and then replaced the lid on the jar. The same jar was then placed in the clean linen cart with briefs and clean linen, despite facility policy stating that such containers should not be used for multiple residents to prevent cross-contamination. Additionally, a CNA was observed in the dining room supervising residents while drinking a slushee. The CNA shared her drink with two residents, which was confirmed by both an LPN and the DON as being against facility policy and inappropriate. The facility's infection prevention policy requires standard precautions for all residents to prevent the spread of infection, considering all body fluids, excretions, and secretions as potentially infectious.
Failure to Consistently Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to consistently post daily nurse staffing data in an area accessible to residents and visitors. On multiple occasions, surveyors were unable to locate the required staffing data sheet at the front desk, and when it was eventually presented, it was not current. Specifically, the staffing data sheet was missing on one occasion and, on subsequent days, the posted information was outdated, with postings reflecting dates several days prior. This deficiency was observed through interviews and record reviews, and it has the potential to affect all 267 residents in the facility.
Failure to Timely Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a female resident with multiple diagnoses, including COPD, anxiety, PTSD, and insomnia. The resident alleged that she was physically assaulted by another resident in the elevator, with two LPNs present and aware of the incident. The resident reported that she informed a psychotherapist and a physician's assistant, but no action was taken, and she was not interviewed by the administrator or the director of nursing. No incident report was filed, and the police were not contacted following the allegation. The administrator acknowledged being informed of the allegation by an LPN, who reported that the resident claimed to have been beaten and had broken dentures. Despite this, the administrator did not file an abuse report immediately, citing the resident's unwillingness to discuss the incident and lack of physical marks. The initial facility-reported incident was not filed until eight days after the alleged event, which was not in accordance with the facility's abuse policy requiring immediate reporting of abuse allegations to the state agency.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse involving a female resident with multiple medical and behavioral diagnoses, including COPD, anxiety, PTSD, and insomnia. The resident reported being physically assaulted by another male resident, who also has a history of violent and psychotic behavior, while in the elevator. The incident was witnessed by two LPNs, and both a psychotherapist and a physician's assistant were informed. Despite the allegation, the resident stated that she was never interviewed by the administrator or the director of nursing, the police were not contacted, and no incident report was filed at the time. The administrator confirmed being notified of the allegation by an LPN, who reported that the resident was sobbing and claimed her dentures were broken. The administrator noted that the resident had no visible injuries and would not speak further about the incident. The initial facility-reported incident was not filed until eight days after the alleged event, and no documentation related to the investigation was provided for the period prior to the report. The facility's abuse policy requires thorough investigation of all alleged violations, but there was no evidence that this was done in this case.
Failure to Perform Blood Glucose Check for Symptomatic Diabetic Resident
Penalty
Summary
A diabetic resident with a history of brittle diabetes, bilateral above-the-knee amputations, and other medical conditions reported symptoms consistent with hypoglycemia, including feeling lightheaded and sweaty. The resident requested that his blood sugar be checked by the assigned LPN, but the nurse stated she was busy and did not immediately perform the blood glucose check. The resident, feeling unwell and concerned, returned to his room and called 911 for assistance. Paramedics arrived and found the resident exhibiting signs of hypoglycemia, such as pallor and sweating. The paramedics checked the resident's blood sugar, which was found to be dangerously low at 42 mg/dL. The LPN told the paramedics that she had not checked the resident's blood sugar and claimed she did not have an order to do so, despite the resident having physician orders for blood sugar monitoring as needed and specific instructions for hypoglycemia management. The resident was given a Glucerna drink and transported to the hospital, where his condition improved. Facility staff interviews confirmed that glucometers were available and that the resident was cognitively intact and able to communicate his needs. The Director of Nursing and other staff acknowledged that the resident's request for a blood sugar check should have been prioritized, especially given his symptoms and medical history. Documentation showed a gap in blood glucose monitoring during the relevant time period, and the facility was unable to provide a specific policy for diabetic management when requested.
Failure to Prevent Access to Non-Pureed Food Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a cognitively impaired resident, who was on an altered diet, did not have access to regular consistency food. This deficiency resulted in a tragic incident where the resident, who was on a pureed diet due to severe cognitive impairment and other medical conditions, was found choking on a regular sandwich. Despite efforts by the staff and emergency services to perform the Heimlich maneuver and provide emergency care, the resident was pronounced dead at the hospital due to asphyxiation from a food bolus. The resident, who was under hospice care with a diagnosis of frontotemporal neurocognitive disorder, dementia, and other conditions, had a BIMS score indicating severe cognitive impairment and required supervision while eating. On the day of the incident, the resident was observed by staff to be choking after reportedly consuming a turkey sandwich, which was not consistent with the prescribed pureed diet. The staff attempted to perform the Heimlich maneuver and called emergency services, but the resident ultimately succumbed to the choking episode. Interviews with staff revealed that the resident was ambulatory and had behaviors of pacing and wandering. The dietary manager confirmed that the resident was served a pureed diet during dinner, but regular sandwiches were available as bedtime snacks for other residents. The facility's failure to supervise and prevent the resident from accessing non-pureed food directly contributed to the choking incident and subsequent death.
Removal Plan
- Assessed the residents on a pureed diet and ensured that they cannot obtain food that is not on their pureed diet.
- Speech therapy is reevaluating all residents who are on a pureed diet to ensure that it is still the most appropriate diet for them.
- In-servicing has been initiated which included all Nursing, dietary and activity staff regarding residents on Pureed diets and supervision of the residents on pureed diets that they do not have access to other food. In servicing is on-going and will continue until all staff in serviced.
- Dietary staff must get a signature from nursing for the snacks that were delivered. All snacks delivered to the floors will be held in the locked Nutrition Room on each floor.
- An audit tool was created to supervise residents on pureed diets - auditing will be conducted.
- Policy and Procedure/System Revision: Food delivery and Care of residents on pureed diets.
- QAPI is held and the DON, ADON and Dietary Manager will be responsible for reporting on the on-going audit tools.
- In-servicing began and is on-going. The following staff are included in the in-servicing: Licensed nursing staff, certified staff, dietary staff, restorative staff, social services, and activity staff. In-servicing topics are as follows: New Policy and Procedures as it relates to providing Pureed diet to those residents that are on a Pureed diet and safeguarding that they do not have access to regular foods.
- The IDT Team have been educated on the IJ.
- New Policy Resident Access to food.
- Care of residents on Pureed Diets.
Failure to Implement Treatment Plans for Resident with Rash
Penalty
Summary
The facility failed to implement treatment plans from an infectious disease practitioner and a dermatologist for a resident with a rash. The resident, identified as R3, was observed with multiple red spots on the upper body, which were reported to itch at times. The infectious disease practitioner recommended an oral antifungal medication, Fluconazole, and an antifungal cream, but these were not administered as per the resident's Medication Administration Record (MAR). Additionally, a dermatology consult recommended treatment with permethrin cream, which was also not administered according to the MAR. The Assistant Director of Nursing (ADON) and Infection Preventionist acknowledged that the infectious disease nurse practitioner enters her own orders into the system, and if not communicated to the staff, they remain unaware of the orders. Furthermore, it was noted that if a resident returns from a specialist without orders, the nurse should verify the orders with the specialist's office, which was not done in this case. The facility's Physician's Orders Policy outlines the process for receiving and documenting new orders, but it appears this process was not followed, leading to the deficiency in care for the resident.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to ensure a resident was served a no concentrated sweets diet as ordered by the physician. A resident with a diagnosis of diabetes mellitus with hyperglycemia had a physician's order for a No Concentrated Sweets diet dated 8/4/22. However, during a noon meal on 11/8/24, the resident was served and consumed a dessert of mandarin orange fluff, which was not in accordance with their dietary restrictions. The facility's Diet Spreadsheet for that day indicated that residents on a Consistent Carbohydrate, Limited Concentrated Sweets (CCHO LCS) diet should have received mandarin oranges instead of mandarin orange fluff. The Dietary Manager confirmed that the dessert served was incorrect for the resident's diet, as the fluff contained a lot of sugar. The facility's policy and guidelines for CCHO diets, which replaced the No Concentrated Sweets Diet, were not followed in this instance.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper sanitation practices in the kitchen, which could potentially lead to foodborne illnesses affecting all 239 residents receiving prepared foods. During the survey, the kitchen was observed to have sticky floors with a grease-like substance and food debris, creating trip hazards without any warning signs. A large industrial fan was used to dry wet floors, but it also blew towards uncovered food, potentially contaminating it. Kitchen appliances, including a large stove and dual deep fryers, were found to be covered in grease and food debris, with no record of when the fryer oil was last changed. The cook, V9, admitted to not having cleaned the fryers due to being overworked and short-staffed, and stated that the administration was aware of these issues. Additionally, the surveyor found several food items in the walk-in refrigerator that were either expired, unlabeled, or improperly stored. These included a block of Swiss cheese, cooked bacon, shredded carrots, mozzarella cheese, cooked pinto beans, and scrambled egg mix, some of which were past their expiration dates or lacked proper labeling. The kitchen also had a metal deli meat slicer with dried food remnants and ovens with baked-in grease. The dietary manager was not present during the survey, and the administrator later acknowledged that the kitchen had not been cleaned according to the established deep cleaning schedule.
Failure to Reassess Resident's Pass Privileges
Penalty
Summary
The facility failed to reassess a resident's right and privileges to go out on pass, which affected one of the nine residents reviewed for resident rights. The resident, identified as R3, is a male with a history of bipolar disorder, mood disorder, and psychoactive substance abuse. He was previously allowed to leave the facility independently with a green pass but was placed on a red pass, restricting his ability to leave, after an incident where he violated the rules. Despite his compliance with medication and lack of recent behavioral issues, his pass privileges were not reassessed in a timely manner. Interviews with facility staff revealed inconsistencies in the handling of R3's pass privileges. The Psychosocial Security Director and Licensed Practical Nurse both indicated that R3 had been on a red pass for some time, but there was no recent documentation of behaviors that would justify this restriction. The Psychiatric Rehabilitation Service Coordinator mentioned that assessments are conducted on admission, quarterly, and annually, and that R3's pass privileges were revoked due to a past incident of intoxication. However, there was no clear documentation or recent assessment to support the continued restriction of R3's pass privileges. The facility's policy on outside community pass privileges outlines specific procedures for revoking and reinstating pass privileges based on resident behavior. According to the policy, R3 should have been reassessed and potentially reinstated to a green pass after a specified restriction period, provided he complied with facility procedures. However, the facility failed to follow these procedures, as evidenced by the lack of documentation and reassessment of R3's pass privileges, leading to a deficiency in honoring the resident's rights to self-determination and communication.
Failure to Refund Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to refund a discharged resident's personal funds, resulting in a deficiency. The resident, who had been admitted under Medicaid/social security, was owed a balance of $518.39 in their account. Despite the resident's discharge, the Business Office Manager acknowledged that the funds remained in the account because there was uncertainty about where to send the money. The resident's family had contributed to this balance with a $20 check. The facility had been designated as the resident's representative payee by the Social Security Administration, yet no action was taken to refund the money, and no inquiries were made by the family regarding the funds.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to adhere to the planned menu, resulting in residents not receiving spiced peaches with their noon meal. On the specified date, a Diet Type Report indicated that 247 residents had diet orders, with one resident being NPO and another on enteral feeding. During lunch service on the 6th floor, observations revealed that residents, including two specific individuals, were served chicken and noodles, green beans, and ice cream, but no spiced peaches were present on their trays. A test tray provided to the survey team also lacked the spiced peaches, confirming the menu was not followed. Interviews with dietary staff, including a Dietary Aide and the Director of Dietary, confirmed that spiced peaches were not served, despite being listed on the menu. The Director of Dietary acknowledged the oversight after reviewing the menu. The Assistant Director of Nursing and the Registered Dietician both emphasized the importance of following the menu to meet residents' nutritional needs. The facility's policy mandates adherence to a cycle menu planned by a Registered Dietician, with changes only allowed under unavoidable circumstances, which were not documented in this instance.
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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