Clark Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 7433 North Clark Street, Chicago, Illinois 60626
- CMS Provider Number
- 145507
- Inspections on file
- 32
- Latest survey
- December 24, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Clark Manor during CMS and state inspections, most recent first.
A resident with intact cognition alleged that a CNA struck him on the forehead with a bed remote after becoming upset, resulting in a laceration requiring stitches. Although the resident reported the incident to nursing staff and the nurse practitioner documented the allegation, none of the staff reported it to facility administration as required by abuse policy.
Multiple residents reported frequent sightings of mice in their rooms, and direct observations confirmed the presence of mouse droppings in several areas, including behind furniture and near heating units. Despite a facility policy requiring an effective pest control process, the ongoing rodent issue was evident on three of four resident floors.
A resident was physically struck in the face by a roommate during an argument over television volume, with staff intervening only after the incident occurred. Both residents were cognitively intact, and the altercation resulted in the aggressor being separated and sent for psychiatric evaluation. The facility failed to ensure protection from abuse as required by policy.
A resident with a history of mental health issues sustained a minor scratch during an altercation with another resident on the smoking patio. The incident involved inappropriate behavior by one resident, leading to a physical confrontation. Staff intervened by separating the residents, notifying the police, and sending both to the hospital for evaluation. The facility reported the incident to the State Agency and initiated an investigation.
A resident with a Quick Release Seat Belt in a wheelchair was unable to release it independently due to improper securing, and the facility failed to assess the need for the restraint or document it correctly in the MDS. The resident, with a history of conditions increasing fall risk, was not shown how to release the belt, and the MDS was incorrectly coded, indicating no restraints were in use.
The facility failed to accurately document and treat wounds for three residents, leading to deficiencies in wound care management. One resident's wound was observed without a dressing, contrary to physician orders, and another resident's wound assessment lacked measurements. Additionally, a treatment was documented for a resident who was hospitalized, indicating a false entry. These issues highlight lapses in documentation and adherence to care plans.
The facility failed to maintain sufficient staffing levels on weekends, affecting all 245 residents. Payroll-Based Journal (PBJ) data showed discrepancies in staffing levels compared to the facility's Daily Nursing Staff Report. Interviews confirmed that the facility did not meet its staffing plan, leading to insufficient staffing on weekends.
The facility failed to ensure proper labeling and dating of food items, maintain cleanliness in food storage areas, conduct appropriate hand hygiene, and correctly thaw frozen meat. Mold was found on food items and refrigerator seals, and improper handwashing and thawing practices were observed, potentially affecting all 242 residents.
The facility failed to ensure that dumpster lids were properly closed, leading to potential pest issues. Surveyors observed multiple instances where dumpster lids were left wide open or propped open with garbage, despite empty sections being available. Both the Visiting Food Service Manager and the Housekeeping Director acknowledged the importance of keeping the lids closed to prevent pests and disease.
The facility failed to ensure residents were treated with respect and dignity by not serving meals simultaneously to all residents at the same table. Several residents were observed watching others eat for up to 20 minutes before receiving their own meals. Staff acknowledged the issue, citing meal tray organization by room as the cause.
The facility failed to prevent the development and worsening of pressure ulcers by not following provider orders, adding multiple layers on low air loss mattresses, and not providing adequate supervision for low air loss devices. Observations revealed residents using multiple layers on mattresses, an unplugged mattress, and a resident not using ordered heel protectors, increasing the risk of skin breakdown.
A resident with moderate cognitive impairment and limited mobility was unable to access their call light, which was clipped to an unreachable position on their pillow. Staff members acknowledged the issue and adjusted the call light, but the initial placement compromised the resident's ability to call for help.
A facility failed to protect a resident's confidential information when an LPN left a computer screen displaying the resident's personal and medical details visible in a main hallway. The LPN admitted the oversight, and the ADON and administrators confirmed the importance of following privacy protocols.
The facility failed to initiate a new Level I PASARR screen for a resident with Schizoaffective Disorder Bipolar Type before the expiration of the short-term approval. The Social Services Director was unaware of the specific requirements and timeframes, leading to a delay in obtaining the necessary Level II PASARR screening.
A facility failed to follow a physician's order for a resident's gastrostomy tube feeding rate, administering 55 ml/hr instead of the prescribed 75 ml/hr. This error persisted despite the resident's significant weight loss and reliance on tube feeding for nutrition, as confirmed by the registered nurse, Director of Nursing, and registered dietitian.
The facility failed to follow its policy on controlled drug count by not accurately counting and reconciling controlled medication records/logs for three residents. Medications were not signed off immediately after administration, leading to discrepancies in counts. Additionally, a resident's Morphine Sulfate was found without proper logging, and the nurse on duty was unaware of its administration or prescription status.
The facility failed to prevent and protect residents from resident-to-resident physical abuse, resulting in one resident sustaining a facial laceration and another reporting being struck on the ear. Both incidents involved residents with documented histories of aggressive behavior.
Failure to Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse policy and procedure when staff did not report an allegation of physical abuse made by a resident. The resident, who was cognitively intact, reported that a CNA became angry after the resident pressed the call light multiple times, took the bed control remote, and hit the resident on the forehead. The resident stated that after the incident, he called the nurse for help but was not believed. The resident was subsequently sent to the emergency room and received stitches for a forehead laceration. The incident was not reported to the facility's abuse coordinator or administration as required by policy. Interviews with the CNA and RN involved revealed that the resident was resistant to care and that the injury occurred when the resident pulled the bed remote from the CNA, causing it to hit his forehead. Both staff members acknowledged that the resident accused the CNA of hitting him, but neither reported the allegation to facility administration. The nurse practitioner also documented the resident's report of being hit by staff but did not report the allegation to the administrator. The facility's policy requires immediate reporting of all abuse allegations to the administrator and to the state within two hours, which did not occur in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice and mouse droppings on three of four resident floors. Multiple residents reported seeing mice in their rooms, both during the day and at night, and described repeated encounters with rodents even after being moved to different rooms. Observations confirmed the presence of mouse droppings in several resident rooms, including behind bedside cabinets, under heating/air conditioning units, next to beds, and near windows. In one instance, a hole was observed next to a heating/air register at the baseboard, which could serve as a potential entry point for rodents. Residents expressed discomfort and dissatisfaction with the ongoing rodent issue, with some specifically noting their dislike of mouse traps in their rooms. The facility's own pest control policy, revised in August 2024, states that there should be an effective pest control process in place to ensure the building is free of pests. Despite this policy, the documented observations and resident interviews indicate that the facility did not effectively prevent or address the rodent infestation.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A resident reported being physically struck in the face by a roommate during a disagreement over television volume. The incident occurred while both residents were in their shared room, with the aggressor standing close to the other resident and making contact with his fist to the left cheek and part of the nose. The resident who was struck also reported being threatened by the roommate as he was escorted out of the room. The incident was witnessed by staff who responded to the altercation after hearing noise and attempted to separate the residents. Initial assessments found no visible injuries on the resident who was struck. The involved residents both had cognitive assessments indicating they were cognitively intact. The resident who was struck had a history of chronic medical and psychiatric conditions, including heart failure, bipolar disorder, and major depressive disorder with psychotic symptoms. The aggressor had a history of hemiplegia, alcohol abuse, and liver disease. Staff interviews and documentation indicated that the altercation was preceded by an argument about television volume, and that staff intervened after the incident had already occurred. There was no indication that staff were aware of escalating tension prior to the physical contact. Facility records and staff statements confirmed that the residents were separated following the incident, and the aggressor was sent for psychiatric evaluation. The facility's abuse and neglect policy defines abuse as the willful infliction of mistreatment or injury, including actions that result in harm even if not intended. The deficiency was identified due to the facility's failure to ensure that residents were protected from abuse by another resident, as required by policy and regulation.
Resident Altercation Results in Minor Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in a physical altercation between two residents. One resident, a male with a history of Parkinsonism, COPD, Schizoaffective Disorder, Diabetes 2, and Alcohol Abuse, sustained a superficial scratch near his eye after an incident on the smoking patio. The altercation occurred when another resident, diagnosed with Bipolar Disorder and other conditions, urinated on the first resident's leg, leading to a physical confrontation. The affected resident reported the incident to the staff, who then called the police and separated the residents. Both residents were sent to the hospital for evaluation, and the incident was reported to the State Agency. The facility's policy on abuse and neglect emphasizes providing care in an environment free from abuse and neglect. However, the incident highlights a failure to ensure this policy was upheld. The resident who sustained the scratch expressed that he felt safe and did not wish to press charges, acknowledging the other resident's illness. Despite the lack of significant injury, the incident was documented, and the facility initiated an investigation. The staff responded by providing one-on-one monitoring and notifying relevant parties, including the police and the residents' families.
Improper Use and Documentation of Restraints
Penalty
Summary
The facility failed to ensure that a resident's self-releasing seat belt was secured in a manner that allowed the resident to freely release the belt. The resident, identified as R1, was provided with a Quick Release Seat Belt to prevent falls due to poor posture while sitting in a wheelchair. However, the belt was connected in a way that was out of the resident's view and reach, making it difficult for the resident to release it independently. The resident expressed that they were not shown how to release the belt and found it tight and unyielding. Additionally, the facility did not complete an assessment for the need for a restraint for R1. The report indicates that the restorative nurse was unaware of the requirement for a physical restraint assessment. The MDS Section P, which should document the use of restraints, was incorrectly coded as indicating no restraints were in use, despite the presence of the Quick Release Belt. The MDS Coordinator acknowledged the error and the lack of proper assessment or evaluation for the restraint. The facility's policy on restraints requires an assessment to determine the appropriateness of a restraint device, a physician's order, and regular evaluation of the restraint's necessity. However, these procedures were not followed, as evidenced by the lack of a proper assessment and incorrect documentation in the MDS. The resident's medical history includes conditions such as Chronic Kidney Disease, Diabetes Insipidus, and Schizoaffective Disorder, which contribute to their high fall risk and need for careful management of mobility aids.
Deficiencies in Wound Care Management and Documentation
Penalty
Summary
The facility failed to ensure accurate documentation and treatment of wounds for three residents, leading to deficiencies in wound care management. For one resident with dementia and xerosis cutis, the facility did not accurately document the location of a wound on the right posterior knee, and the wound was observed without a dressing, contrary to physician orders. The wound care coordinator acknowledged that the dressing should have been reapplied, but the CNA did not notify them when it came off. Additionally, the treatment administration record showed the last dressing change was documented three days prior, with no PRN entries recorded. Another resident with dementia and xerosis cutis had a laceration on the right 5th finger, but the initial wound assessment lacked measurements and a detailed description. The wound care coordinator admitted that the assessment should have included measurements, indicating a lapse in thorough documentation. This oversight in documentation could potentially affect the quality of care provided to the resident. A third resident with morbid obesity, xerosis cutis, and cellulitis of the left lower limb had a documented treatment administration for a wound on the left calf while the resident was hospitalized, indicating a false entry in the treatment administration record. The wound care coordinator acknowledged this as a mistake. These deficiencies highlight the facility's failure to adhere to its wound care policy, which mandates accurate documentation and implementation of care plans in compliance with regulatory standards.
Insufficient Weekend Staffing
Penalty
Summary
The facility failed to have sufficient staffing on weekends, affecting all 245 residents. The Payroll-Based Journal (PBJ) data revealed that weekend staffing was excessively low. Specific dates reviewed included 10/15/2023, 11/04/2023, 11/05/2023, and 12/17/2023, showing discrepancies between the PBJ report and the facility's Daily Nursing Staff Report. For instance, on 10/15/2023, the PBJ report documented 23 licensed nurses with total hours of 182.25, while the Daily Nursing Staff Report documented 24 nurses with total hours of 186. Similar discrepancies were noted on other reviewed dates. Interviews with the Assistant Administrator and Staffing Coordinator confirmed that the facility was not meeting its staffing plan. The Staffing Coordinator stated that there should be nine nurses on the 7am-3pm shift, nine nurses on the 3pm-11pm shift, and five nurses on the 11pm-7am shift, totaling 23 nurses in a 24-hour period. However, the PBJ data indicated that the actual staffing levels were lower than required, leading to insufficient staffing on weekends.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items, maintain cleanliness in food storage areas, conduct appropriate hand hygiene, and correctly thaw frozen meat. During an initial kitchen tour, it was observed that an opened gallon of coleslaw dressing had mold around the lid despite being within the use-by date. Additionally, a 5-pound bag of shredded mozzarella cheese was found without any labeling or dating, making it impossible to determine its safety for use. Mold was also found in the folds of the refrigerator door seal, and an opened container of Worcestershire sauce in the dry storage area lacked an opened date, leading to its disposal due to potential bacterial growth. In the dish machine area, a dietary aide was observed handling both dirty and clean items without performing hand hygiene in between, which was confirmed by the Culinary Development Specialist as a breach of protocol. The dish machine area was understaffed, with only two people working instead of the required three, leading to improper handwashing practices. The Regional Director of Operations confirmed that handwashing is necessary to prevent cross-contamination when handling both dirty and clean items. Additionally, improper thawing practices were observed when a large plastic bag containing meat was left in a sink filled with water without running cold water over it. The Kitchen Supervisor acknowledged that the meat should be defrosted under cold running water to prevent it from reaching the danger zone temperature. These deficiencies in food handling, storage, and hygiene practices have the potential to affect all 242 residents receiving food prepared in the facility's kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that the dumpster lids were properly closed to prevent the harborage and feeding of pests, insects, and rodents. On multiple occasions, surveyors observed that the lids of the dumpsters were left wide open. Specifically, on one occasion, one of the four lids of the north-facing dumpster was observed to be wide open. On another occasion, one of the four lids of the south-facing dumpster was also found to be wide open. Additionally, the south-facing dumpster had one of its lids propped open with garbage and boxes, despite the rest of the dumpster being completely empty. This indicated that the staff did not properly distribute the trash to allow the lids to be fully closed. Both the Visiting Food Service Manager and the Housekeeping Director acknowledged that the lids should be closed to prevent pests from accessing the garbage and potentially spreading disease. The Housekeeping Director also noted that the staff should have used the empty sections of the dumpster to ensure the lids could be closed properly. The facility's kitchen policy also mandates that all trash should be properly disposed of in external receptacles, which was not adhered to in this case.
Failure to Serve Meals Simultaneously to Residents at the Same Table
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. This deficiency was observed during a dining period where several residents were left without food while others at the same table were eating. Specifically, residents were seen watching their tablemates eat for several minutes before receiving their own meals. This affected six residents who were part of a sample of 35 residents reviewed during dining observations. On the day of the observation, residents were seated at tables in the dining room, and meals were not distributed simultaneously to all residents at the same table. For instance, one resident began eating at 12:35 PM, while others at the same table did not receive their meals until up to 20 minutes later. Staff members, including an Activity Aide and Certified Nursing Assistants, acknowledged that meals are typically served table by table but noted that the trays were organized by room, not dining location, which led to the delay. The Regional Director of Operations and the Registered Dietitian both confirmed that this practice was a dignity issue, as it is inappropriate for residents to watch others eat while they wait for their own meals. The affected residents had various medical conditions, including Parkinson's Disease, Schizoaffective Disorder, Dementia, and Chronic Obstructive Pulmonary Disease, among others. Their cognitive statuses ranged from intact to severely impaired, as indicated by their BIMS scores. Despite these conditions, the residents were capable of feeding themselves unassisted. The facility's Resident Admission Packet emphasizes the importance of treating each resident with respect and dignity, which was not upheld in this instance, as confirmed by the facility's staff and documented policies.
Failure to Prevent Pressure Ulcers and Follow Care Protocols
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards to prevent the development and worsening of pressure ulcers. Specifically, the facility did not follow provider orders for the prevention of pressure injuries for one resident, did not adhere to policy and manufacturer directions when adding multiple layers on low air loss mattresses for two residents, and did not provide adequate supervision for low air loss devices to prevent accidents for one resident. Observations revealed that residents were using multiple layers on low air loss mattresses, which can cause bed sores or worsen existing wounds. Additionally, one resident's low air loss mattress was found unplugged, and another resident's heel protectors were not being used as ordered by the physician, increasing the risk of skin breakdown. One resident was observed with multiple layers on a low air loss mattress, contrary to the manufacturer's directions and facility policy, which state that only one or two layers should be used to prevent skin breakdown. Another resident was found with an unplugged low air loss mattress, and redness was observed in the sacral area during a skin check. The facility's wound care nurse confirmed that multiple layers on air mattresses could cause additional skin breakdown and emphasized the importance of ensuring that air mattresses are functioning properly. A third resident, who was at high risk for pressure ulcer development, was observed without the ordered heel protectors while in bed. The staffing coordinator and the resident confirmed that the heel boots were only used at night, despite the physician's order for them to be worn whenever the resident was in bed. The wound nurse reiterated that the heel protectors should be on when the resident is in bed to prevent skin breakdown. The facility's policy requires adherence to physician orders, but this was not followed in the case of the heel protectors for this resident.
Resident Unable to Access Call Light
Penalty
Summary
The facility failed to ensure that a resident had access to their call light, which is essential for requesting assistance. The resident, identified as having moderate cognitive impairment and limited mobility in all four extremities, was observed lying in bed with the call light clipped to the upper right corner of their pillow, making it unreachable. When asked, the resident was unaware of the call light's location and unable to reach it when informed. The call light system consisted of a string attached to a toggle switch on the wall, with the other end clipped to the pillow, which was not accessible to the resident due to their limited mobility. Staff members, including a Licensed Practical Nurse (LPN) and a Restorative Aide, were involved in assessing and attempting to reposition the call light. The LPN acknowledged that the call light placement is usually assessed by restorative staff, and the Restorative Aide added a longer string to make the call light reachable. The Director of Nursing confirmed that all residents should have reachable call lights. Despite these procedures, the initial placement of the call light rendered it unusable for the resident, compromising their ability to call for help in emergencies.
Failure to Protect Resident's Confidential Information
Penalty
Summary
The facility failed to protect a resident's personal and confidential information. During an inspection of the medication cart on the 5th floor, an LPN was observed leaving her computer on with the screen displaying a resident's picture, medical, and personal information. The computer screen was facing the main hallway, making the information visible to staff members and residents passing by. The LPN acknowledged that she should have closed or hidden the contents of the screen to prevent a HIPAA violation but did not do so because she was not going far. The Assistant Director of Nursing confirmed that the computer screen should be closed to protect residents' privacy, as displaying their pictures and medications is a violation of their privacy. The facility's Administrator and Assistant Administrator stated that staff are educated on privacy protocols, including covering sensitive information and ensuring computer screens are not visible when unattended. The facility's policy on resident rights emphasizes the right to personal privacy and confidentiality of personal and medical records.
Failure to Timely Initiate New PASARR Screening
Penalty
Summary
The facility failed to initiate a new Level I PASARR screen for a resident with a known mental illness, specifically Schizoaffective Disorder Bipolar Type. The resident's Level II PASARR outcome letter indicated a short-term approval without special services, which had an expiration date. The facility's Social Services Director (V19) admitted to being unaware of the specific requirements and timeframes for submitting new PASARR screenings. V19 stated that he reviews PASARR screenings at least once a month but was not aware of the need to submit a new Level I screen 10 days before the expiration of the short-term approval. Consequently, the resident's PASARR screening expired without a new Level I screen being submitted in a timely manner, leading to a delay in obtaining the necessary Level II PASARR screening for continued care. V19 only submitted the new PASARR screening after being made aware of the requirement on the day of the interview with surveyors. The facility's policy mandates that residents with mental disorders or intellectual disabilities receive PASARR screenings within the allowed timeframe, which was not adhered to in this case.
Failure to Follow Physician's Order for Tube Feeding Rate
Penalty
Summary
The facility failed to follow the physician's order for a prescribed gastrostomy tube feeding rate for a resident (R4). On multiple occasions, the tube feeding rate was set at 55 ml/hr instead of the ordered 75 ml/hr. This discrepancy was observed on 05/14/24, when the surveyor noted the incorrect rate and confirmed it with the registered nurse (V15) who was responsible for R4's care. The nurse acknowledged the error and stated that the rate should have been set at 75 ml/hr as per the physician's order updated on 05/10/24. The Director of Nursing (V3) also confirmed that the nurses are expected to follow the orders in the resident's electronic health record (EHR). The registered dietitian (V34) highlighted that the incorrect feeding rate could affect the resident's total calorie intake, which is critical since R4 had experienced significant weight loss over the past three months. R4 has a complex medical history, including conditions such as Gastro-Esophageal Reflux Disease, Schizoaffective Disorder, Dysphagia, and Chronic Obstructive Pulmonary Disease, among others. The resident is NPO (nothing by mouth) and relies entirely on tube feeding for nutrition. The physician's order to increase the feeding rate to 75 ml/hr was made to address R4's significant weight loss, which amounted to a 12.8-pound reduction over three months. Despite this, the facility's failure to adhere to the updated feeding rate order resulted in the resident receiving insufficient nutrition, as documented in the resident's care plans and medical records.
Failure to Accurately Count and Reconcile Controlled Medications
Penalty
Summary
The facility failed to follow its policy on controlled drug count by not accurately counting and reconciling controlled medication records/logs for three residents. During an inspection, it was observed that the medication narcotic count logbook was not signed off as given for several medications administered to a resident. The counts of Lyrica, clonazepam, and Adderall did not match the narcotic sheet, and the nurse admitted to not signing off the medications immediately after administration, which is against the facility's policy. Another resident's Pregabalin count also did not match the log, and the nurse again admitted to not signing off the medication immediately after administration. The Assistant Director of Nursing confirmed that all controlled medications should be signed off immediately to prevent misuse and maintain accurate counts. Additionally, a third resident's Morphine Sulfate was found in the medication fridge without proper logging, and the nurse on duty was unaware of the medication's administration or prescription status. The Assistant Director of Nursing stated that all controlled medications should be logged and discontinued medications should be discarded to prevent errors and misuse. The facility's policy on controlled medications count requires nurses to sign off the medication sheet immediately after administration and to have another nurse witness the wasting of controlled medications if needed.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent and protect residents from resident-to-resident physical abuse, affecting two residents. One incident involved a resident (R1) who was hit in the face with a shoe by another resident (R2), resulting in a facial laceration that required four sutures. R1, who is moderately cognitively impaired, reported that R2 had verbally threatened him before the physical assault. Despite the presence of staff, the altercation escalated, and R1 was subsequently sent to the hospital for treatment. R2, who is cognitively intact, was placed on 1:1 supervision and later sent to the hospital for a psychiatric evaluation. R2's history of aggressive behavior and verbal abuse towards staff and roommates was documented, but the facility's abuse assessment did not accurately reflect these behaviors, potentially contributing to the incident. Another incident involved a resident (R5) who reported being struck on the left ear by another resident (R4). R4, who has a history of violent behavior and severe mental illness, was verbally and physically aggressive towards staff and residents. R4 was placed on 1:1 monitoring and sent to the hospital for a psychiatric evaluation. R5, who is cognitively intact, reported the incident to the social worker and called the police. The facility's staff separated the residents and assessed R5 for injuries, finding no immediate harm. R4's history of aggression and criminal behavior was well-documented, and the facility had previously noted R4's risk factors for abuse and neglect. The facility's policy on abuse and neglect emphasizes the importance of providing care in an environment free from any type of abuse. However, the incidents involving R1 and R5 indicate a failure to adequately assess, care plan, and monitor residents with behaviors that might lead to conflicts. The facility's documentation and staff interviews reveal gaps in the identification and management of residents with aggressive behaviors, leading to physical altercations and harm to other residents.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
