Complete Care At The Boulevard
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5905 West Washington, Chicago, Illinois 60644
- CMS Provider Number
- 145885
- Inspections on file
- 46
- Latest survey
- March 29, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Complete Care At The Boulevard during CMS and state inspections, most recent first.
The facility failed to ensure sufficient qualified dietary staff to prepare meals, as multiple dietary aides without cook certification were observed and reported to be cooking and baking for residents. Staff described being assigned to bake desserts and cook breakfast and lunch despite only holding food handler certificates, and one aide reported feeling scared to use the large oven. The Dietary Manager acknowledged that only she and one aide were qualified cooks, yet the schedule listed several food handlers as cooks, and these staff were actively preparing food and operating the tray line for residents receiving meals.
Surveyors found that dietary staff failed to follow hand hygiene protocols while working in the dish room. A dietary aide repeatedly handled soiled dish racks, pushed them into the dishwasher, and then removed clean trays and domes, changing gloves but not washing hands between dirty and clean tasks, despite a handwashing station being available. Another dietary aide reported that dishwashing was often done with fewer staff than intended, and the dietary manager confirmed that facility procedures and policies required handwashing between handling dirty and clean items. This failure had the potential to affect over one hundred residents who received meals from the kitchen.
A resident with multiple comorbidities and intact cognition, who had a care plan addressing a history or risk of abuse, reported that a former dietary manager aggressively approached and verbally confronted them in the dining room after misinterpreting a remark made during a conversation with a CNA. The resident stated they reported the incident to the administrator, completed a written report and statement, and that the event was witnessed by others and captured on camera; a former dietary aide confirmed that the confrontation occurred in front of others and was reported to administration. The administrator acknowledged that the event was initially treated only as a customer service issue, without initiating an abuse investigation or timely reporting as required by the facility’s abuse policy, and the facility could not produce an abuse investigation report when requested by surveyors, only later deciding to treat the incident as reportable abuse after further questioning.
A resident with multiple comorbidities and high risk for skin breakdown developed a severe, unstageable sacral pressure ulcer after staff failed to consistently implement and update individualized care interventions, including regular turning and repositioning. Despite clear physician orders and facility policies, the care plan was not revised after the wound developed, and the resident was left in a chair for extended periods without repositioning, leading to wound deterioration, infection, and hospitalization.
A resident with moderate cognitive impairment and high fall risk was allowed to use a wheelchair with a broken brake for at least two days. Staff were either unaware of the issue or did not act promptly to repair or remove the unsafe equipment, and required notifications to social services were not made when the resident refused to relinquish the chair. Facility policy requiring immediate removal and repair of malfunctioning equipment was not followed.
A resident with severe cognitive impairment and significant care needs experienced a fall resulting in a contusion and bruising around the right eye. The facility staff failed to notify the physician or follow protocol, delaying the resident's transfer to the hospital for necessary evaluation. Multiple staff members were involved in the incident and were terminated for not adhering to the facility's policies.
The facility failed to maintain adequate nursing staff, resulting in delayed call light responses. Residents reported insufficient CNA coverage during 2nd and 3rd shifts, with staffing data confirming low weekend staffing. The staffing coordinator acknowledged the shortfall, and records showed fewer CNAs than required, placing 104 residents at risk of inadequate care.
The facility failed to follow its food safety and sanitation protocols, affecting 101 residents on an oral diet. The dishwasher did not reach required temperatures for proper sanitization, and expired chlorine test strips were used in the three-compartment sink. Additionally, staff did not fully cover their hair, and open food items were not properly labeled, increasing the risk of contamination and foodborne illnesses.
The facility failed to ensure that the designated Infection Preventionist (IP), an LPN, completed the required specialized training for infection prevention and control in nursing homes. The IP, responsible for managing various infection control activities, had not completed the necessary training modules and test to demonstrate competency until after the survey began. This deficiency potentially affects the 104 residents in the facility.
The facility failed to complete required PASRR screenings for several residents before admission, impacting their placement and care. Residents with serious mental health conditions were admitted without necessary evaluations, contrary to facility policy. This deficiency highlights a lapse in the admission process, affecting the residents' access to appropriate care.
The facility failed to administer medications timely and maintain accurate narcotic counts for four residents. Discrepancies in medication counts were observed, and medications were not administered as scheduled due to unavailability. Nurses failed to document administration accurately and did not notify physicians of missed doses, violating facility policy.
The facility failed to manage medications and enteral feedings properly, with expired medications found in medication carts and storage rooms, and some medications lacking proper pharmacy labels. Expired enteral feeding containers were also found with visible spoilage. These deficiencies could affect 68 residents, including those with gastrostomy tubes.
The facility failed to properly document and administer influenza and COVID-19 vaccinations for several residents. Some residents were not offered or documented for influenza vaccinations, and others did not receive necessary education. One resident's consent form lacked a witness signature, and another resident did not receive the vaccines despite consenting, due to insurance issues and lack of follow-up. The IP nurse admitted to inconsistent documentation, contrary to facility policy.
A facility failed to maintain resident dignity and confidentiality for three residents. A CNA fed a resident while standing, against recommended practices, risking aspiration and compromising dignity. Additionally, dietary information for two residents was visibly posted, violating confidentiality. The residents had specific medical and dietary needs, and the facility's actions compromised their rights.
A resident was observed self-administering Fluticasone Propionate without a physician order or assessment, as required by facility policy. An LPN allowed the self-administration because the resident did not trust staff to administer it correctly. The facility's policy mandates assessment and a physician order for self-administration, which was not followed.
The facility failed to display information about the [NAME] program, affecting 12 residents' ability to make informed decisions about community transition. The Social Service Director confirmed the absence of educational materials and posters, which were not provided until after a surveyor's visit.
A resident at the facility was found wearing a hospital wristband displaying personal information, which should have been removed upon admission to protect privacy. The wristband, visible to others, contained the resident's full name, date of birth, and medical record number, violating HIPAA regulations. Staff acknowledged the oversight and confirmed that such wristbands should not be worn in the facility.
A resident with a history of paraplegia and polyneuropathy did not receive consistent restorative therapy, including leg exercises and splint application, as required by their care plan. The resident reported that these interventions were not regularly provided, and documentation was missing for several days. The Restorative Aide confirmed that CNAs should provide therapy on weekends, but there was a lack of documentation. This failure placed the resident at risk of not maintaining their highest practical level of function.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. Two residents did not receive their scheduled medications due to an LPN's failure to check available resources and notify physicians of the missed doses. The facility's policy on medication administration and physician notification was not followed.
A resident reported not consistently receiving nighttime snacks, as required by the facility's policy. The Dietary Manager confirmed that snacks are distributed to CNAs for residents, but acknowledged reports of missed distributions. The DON was aware of the issue but did not provide staff training. The resident, who is cognitively intact, was not offered snacks on several occasions, despite the facility's policy.
A facility failed to accurately classify a resident's psychotropic medication on the consent form, potentially affecting the resident's understanding of the medication's side effects. The resident, with severe cognitive impairment and a history of mental health disorders, had their medication Remeron misclassified as an antipsychotic instead of an antidepressant on a previous form. This error led to consent being given under the wrong classification, which could result in misunderstanding the side effects associated with the medication.
A resident in an LTC facility experienced two incidents of verbal abuse by CNAs, both of which were substantiated by facility investigations. The resident, who requires maximum assistance and uses a wheelchair, reported being cursed at by one CNA and receiving derogatory remarks about her hygiene from another. Witnesses corroborated the resident's accounts, leading to the termination of both CNAs. The facility's policy prohibits such abuse, but these incidents demonstrated a failure to protect the resident.
A cognitively impaired resident was tied to their bed with pillowcases by an RN due to staffing shortages, leading to physical and mental anguish. The incident was witnessed by a CNA who reported it as abuse, although the facility's administrator initially disagreed. The facility's policy defines such actions as abuse, but the incident was not immediately reported to the Illinois Department of Public Health.
A resident in an LTC facility was improperly restrained by a nurse using a pillowcase, without a physician's order or consent, due to staffing shortages. The resident, who had multiple medical conditions and a history of falls, was tied to the bed to prevent falling, which was against the facility's restraint-free policy. The incident was reported by another staff member and identified as an immediate jeopardy situation.
A resident's inhaler was left unattended and not properly labeled, with no physician order for self-administration. Additionally, a treatment cart was found unlocked and unattended, contrary to facility policy. The DON confirmed these actions posed safety issues.
A staffing shortage in an LTC facility led to a resident being improperly restrained by a nurse using a pillowcase to prevent falls. The facility was short one CNA on a weekend shift, leaving only two CNAs to care for 41 residents on the second floor. The nurse, overwhelmed with duties, resorted to tying the resident's hands to the bed rail, acknowledging the action was wrong but felt necessary due to insufficient staffing.
A facility failed to immediately report an alleged abuse incident where a resident was tied to the bedside rails with a pillowcase by a nurse. The incident was reported internally, but not to the Illinois Department of Public Health (IDPH) as required by the facility's policy. The initial report to IDPH was made 32 days after the incident, violating the policy that mandates immediate reporting or within 24 hours if no serious injury occurred.
The facility failed to conduct timely PASRR Level I and II assessments for five residents with serious mental disorders, due to a transition period in the social services department and lack of communication with the screening agency. This oversight left residents without necessary specialized programs and treatment goals.
Two residents in the facility did not receive proper wound care, leading to significant health issues. One resident was hospitalized due to a surgical wound dehiscence, while another did not have daily wound dressings changed as ordered. Staff interviews revealed a lack of documentation and awareness of wound care needs, and facility policies were not adhered to.
Two residents experienced abuse in a facility, one physically and the other verbally. A resident with Alzheimer's was slapped by a CNA during care, confirmed by witnesses. Another resident with COPD was verbally abused by a CNA using profanity, recorded on social media. Both CNAs were terminated for their actions, which violated the facility's Abuse Prevention Program.
Unqualified Dietary Staff Used as Cooks and Bakers
Penalty
Summary
The facility failed to ensure there were sufficient qualified dietary staff available to cook meals for 127 residents who received meals from the kitchen. During interviews, multiple dietary aides reported that they were functioning as cooks or being required to perform cooking and baking tasks despite lacking cook certification. One former dietary aide stated that several individuals working as cooks did not have certification and that she was pressured to bake despite being a dietary aide and feeling scared to use the large, hot oven. During a kitchen tour, three dietary aides were observed performing meal preparation and tray line duties, including one aide who was cooking and plating breakfast while the others assembled and transported trays. The Dietary Manager reported that only she and one dietary aide were considered qualified cooks and that the remaining staff were food handlers, who she acknowledged were not supposed to prepare food because they had not taken the required classes. Despite this, the schedule listed several dietary aides as cooks, and staff interviews confirmed that food handlers were cooking breakfast and lunch and baking desserts. Documentation showed that most of these staff held only food handler certificates rather than cook certification, while the facility’s job description and safe food handling policy required appropriate procedures for preparing and cooking food in accordance with the FDA Food Code. The census showed 131 residents, with 127 receiving meals from the kitchen affected by these staffing and qualification issues.
Failure to Perform Hand Hygiene Between Handling Soiled and Clean Dishes in Dish Room
Penalty
Summary
Surveyors identified a deficiency in kitchen infection control practices when a dietary aide working in the dish room failed to perform required hand hygiene between handling soiled and clean dishes. One dietary aide was observed scraping and dumping trays, placing utensils, plates, and cups into sanitizer, and explained that with two people present, one would run dishes through the dishwasher while the second person would handle the clean dishes. A second dietary aide then entered the dish room and was observed repeatedly pushing racks of dirty dishes into the dishwasher and then removing clean trays and dishes without changing gloves or performing hand hygiene, despite a handwashing station being present in the dish room. The same dietary aide continued to alternate between handling dirty dish racks and removing clean domes, trays, and dishes from the dishwasher, changing gloves multiple times but never washing hands between tasks. Another dietary aide reported by telephone that dishwashing was supposed to be done by three staff, but they often only had two, and described scraping, loading the dishwasher, and pulling carts with an emphasis on changing gloves as much as possible. The dietary manager stated that the facility’s process required two people in the dish room, with one scraping and setting up dishes and the other pushing dishes through the dishwasher and pulling them out, and confirmed that hand hygiene should be performed after pushing dishes through, followed by glove changes before handling clean dishes to prevent cross contamination. Facility policies and training documents on cleaning, sanitizing, ware washing, and handwashing required staff to wash hands prior to donning gloves and between glove changes, including after touching waste or contaminated surfaces and after leaving the dish area. This failure had the potential to affect 127 residents who received meals from the kitchen, out of a census of 131 residents, with four residents NPO.
Failure to Immediately Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy by not immediately investigating and reporting an allegation of verbal abuse involving one cognitively intact resident. The resident, who had multiple medical diagnoses including Type 2 diabetes mellitus with complications, end stage renal disease, peripheral vascular disease, gangrene, acquired absence of foot, hypertension, dependence on renal dialysis, cataracts, obesity, and primary insomnia, had a BIMS score of 15 indicating intact cognition and had a care plan focus for history of abuse or factors increasing susceptibility to abuse. The care plan interventions included reviewing assessment information and emphasizing treatment of causal factors and mental health issues. Despite this, when the resident reported an incident in which a staff member allegedly verbally abused and threatened them, the facility did not treat it as an abuse allegation at the time. The resident reported that one morning in January, during breakfast in the first-floor dining room before going to dialysis, the former dietary manager approached them from behind, got in their face, and accused them of calling her a derogatory name after overhearing the resident’s conversation with a CNA about something seen on television. The resident stated they clarified they were not speaking to the dietary manager, reported the incident to the administrator, wrote a report, and provided a written statement. The resident also stated their family called the state and that the incident was captured on camera. A former dietary aide corroborated that everyone in the dining room witnessed the incident, that the dietary manager approached the resident and backed the resident up while accusing the resident of calling her a derogatory name, and that it was reported to administration and the resident’s family reported it. Another dietary aide stated the former dietary manager had multiple run-ins with the resident and that these were reported to administration. When interviewed, the administrator stated that when the interaction between the resident and the former dietary manager was initially reported, it was handled as a customer service concern rather than an abuse allegation. The administrator described the interaction as a verbal misunderstanding and reported providing verbal counseling to the staff member, but did not provide documentation of an abuse investigation or names of individuals interviewed at that time. The surveyor requested the abuse reportable/investigation multiple times and the facility was unable to produce it, with the assistant DON/HR stating they were trying to get a key to retrieve the reportable while the administrator was unavailable. Only after the surveyor’s request and a subsequent re-interview of the resident did the facility decide to treat the incident as reportable abuse and initiate an abuse investigation, contrary to the facility’s written policy requiring an immediate investigation and timely reporting of all alleged violations of abuse.
Failure to Prevent and Manage Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to develop and update an individualized care plan and did not ensure that a resident at high risk for skin breakdown received appropriate treatment and services to prevent the development and worsening of a pressure ulcer. The resident, who had multiple medical diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, cognitive communication deficit, depression, and hypertension, was admitted with intact skin but was identified as high risk for skin breakdown based on a Braden scale score of 12. Despite this, the care plan was not updated with new interventions after a skin impairment was reported, and preventive measures such as turning and repositioning every two hours were not consistently implemented, especially when the resident was in a wheelchair. Staff interviews and record reviews revealed that the resident was dependent on staff for repositioning and hygiene, requiring two staff members for transfers and repositioning. Multiple staff members, including CNAs and LPNs, acknowledged that the resident was not always repositioned every two hours while in the chair, sometimes remaining seated for more than four hours. There was no documentation of the resident refusing care, and social services were not notified of any refusals. The wound care nurse and other staff were aware of the resident's high risk and the need for frequent repositioning, but the interventions remained unchanged even after the development of a new wound. The wound was noted to have an odor for about a week before the resident was sent to the hospital, and the care plan was not individualized or updated to address the new wound. The resident's condition deteriorated, with the sacral wound progressing from a small opening to an unstageable pressure ulcer with necrotic tissue, ultimately requiring hospitalization for sepsis and necrotizing fasciitis. Hospital records documented a stage 4 sacral decubitus ulcer with extensive tissue destruction and infection, necessitating surgical debridement. Facility policies required turning and repositioning as part of pressure injury prevention and evidence-based wound treatment, but these were not consistently followed or documented. The lack of timely and individualized interventions, failure to update the care plan, and inconsistent implementation of preventive measures directly contributed to the resident's development and worsening of a severe pressure ulcer.
Failure to Remove Unsafe Wheelchair with Broken Brake
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including moderate cognitive impairment and a high risk for falls, was observed using a wheelchair with a broken right brake. The resident, who is dependent for transfers and uses the wheelchair as a primary mode of locomotion, reported the broken brake to the surveyor. Staff, including a CNA and the Maintenance Director, were either unaware of the issue or had not addressed it despite being informed. The Maintenance Director acknowledged being aware of the broken brake but had not inspected or repaired it, citing competing priorities. The Maintenance Assistant also did not check the maintenance log, and the Restorative Director attempted to remove the unsafe wheelchair but did not notify social services when the resident refused. Facility policy requires that malfunctioning equipment be immediately removed from use and reported for repair, and that social services be notified in cases of resident refusal. Despite these policies, the resident continued to use the unsafe wheelchair for at least two days, and the broken brake was not repaired or removed from service. Multiple staff members confirmed the wheelchair was unsafe and could lead to incidents, but the necessary steps to ensure resident safety were not taken in a timely manner.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, resulting in a delay in transferring the resident to the hospital for further evaluation. The resident, who has severe cognitive impairment and requires significant assistance with activities of daily living, was found with a contusion and bruising around the right eye after a fall. Despite the visible injuries, the responsible staff did not report the incident or the change in condition to the physician or the Director of Nursing, as required by the facility's policies. The incident involved multiple staff members who failed to follow protocol. A Licensed Practical Nurse (LPN) observed the resident with bruising but did not notify the physician or the Director of Nursing. Additionally, two Certified Nursing Assistants (CNAs) were involved in the incident but did not report the fall to the nurse on duty. This lack of communication and failure to adhere to the facility's policies on reporting falls and changes in condition contributed to the delay in the resident receiving necessary medical attention. The facility's policies clearly state that any change in a resident's condition should be immediately assessed and reported to the physician, with emergency medical care provided if necessary. The failure to follow these procedures resulted in a delay in care for the resident, who was eventually transferred to the hospital with a head contusion and edema. The staff members involved were terminated for gross misconduct and failure to adhere to the facility's policies and procedures.
Inadequate Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to ensure adequate nursing staff to respond to call lights in a timely manner, as evidenced by resident council meeting minutes and staffing data. Residents reported that during the 2nd and 3rd shifts, there were instances where only one or two CNAs were available, leading to delays in answering call lights. The facility's staffing data, submitted via the PBJ system, indicated excessively low weekend staffing, which triggered concerns. The facility's staffing coordinator, V26, confirmed that the facility aims to staff nine CNAs for the morning and evening shifts and eight for the night shift, but there were occasions when these numbers were not met. The facility assessment document from March 2024 indicated that the nursing services staffing should include 12 CNAs for the day shift, nine for the evening shift, and eight for the night shift. However, records from July 2024 showed that the facility was operating with fewer CNAs than required, with instances of only eight CNAs working the morning shift and as few as five CNAs on the night shift. Additionally, resident council minutes from July 2024 noted complaints about CNAs using cell phones during work hours and not responding to call lights promptly. This staffing inadequacy placed all 104 residents at risk of receiving inappropriate care and services to meet their physical, mental, and psychosocial needs.
Deficiencies in Food Safety and Sanitation Protocols
Penalty
Summary
The facility failed to adhere to its policies on sanitation and food safety, which has the potential to affect 101 residents on an oral diet. Observations revealed that the dishwasher temperatures were not reaching the recommended levels necessary for proper sanitization. The dishwasher's wash cycle was observed to be below the required 150 degrees F, and the sanitation cycle was not reaching the necessary 180 degrees F. Testing strips used to verify the sanitization process did not change color as expected, indicating that the dishes were not being properly sanitized. Additionally, the dishwasher had recently been serviced, but issues with the testing strips and clogged sprays were noted, which contributed to the problem. The facility also failed to properly sanitize dishes in the three-compartment sink. The sanitizing compartment contained cloudy water with whitish particles, and the chlorine concentration was not reaching the required 100 PPM. The chlorine test strips used were expired, and the Dietary Manager was unaware of the expiration date, which further compromised the sanitization process. This oversight could lead to cross-contamination and potential foodborne illnesses among residents. Furthermore, staff in the kitchen were not following proper hair restraint protocols. A Dietary Aide was observed wearing a hair net that did not fully cover her hair, which could lead to contamination of food. Additionally, an open bag of peas and carrots in the freezer was not labeled with an open date or use-by date, increasing the risk of using expired food. These lapses in following established food safety protocols highlight significant deficiencies in the facility's food service operations.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), a Licensed Practical Nurse (LPN), completed the specialized training required for infection prevention and control in nursing homes. This deficiency was identified during a survey when the facility could not provide valid documentation or certification of the IP's completion of the necessary training program. The IP, who has been in the role since January 2024, is responsible for various infection control activities, including antibiotic surveillance, immunizations, and managing outbreaks of infections such as COVID-19, flu, and C. diff. Despite these responsibilities, the IP had not completed the required training modules and cumulative test to demonstrate competency in the role until after the survey began. The Director of Nursing (DON) emphasized the importance of having a certified IP to stay updated with CDC recommendations and to protect both staff and residents from infections. The facility's policy on the Infection Prevention Program states that the IP should serve as a resource for all staff and departments regarding infection prevention. However, the lack of completed training for the IP indicates a gap in ensuring that the individual in this critical role has the necessary knowledge and competence to effectively manage the infection prevention program, potentially affecting the 104 residents residing in the facility.
Failure to Complete PASRR Screenings Before Admission
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were completed for five residents prior to their admission. The Social Services Director, V16, acknowledged that PASRR screenings are crucial for determining the appropriate placement of residents and should be completed before admission. However, it was found that PASRR Level 1 screenings for residents R9, R16, and R37 were only submitted on February 4, 2025, after their admission. Additionally, R15 and R33 had inaccurate Level I PASRR screenings, and V16 admitted that new screenings were necessary to determine if Level II evaluations were required. Resident R9, diagnosed with schizophrenia, schizoaffective disorder, and major depression, and Resident R37, with severe cognitive impairment and multiple mental health diagnoses, both required Level II evaluations according to their PASRR Level 1 screenings. However, these evaluations were not conducted prior to their admission. Resident R16, diagnosed with major depression and psychosis, did not require a Level II evaluation according to the PASRR Level 1 screening. The facility's policy mandates compliance with state and appointed screening agencies, but this was not adhered to in these cases. Furthermore, Resident R54, with a history of schizoaffective disorder and major depressive disorder, was admitted without a completed PASRR Level 1 screening from the hospital. The Social Services Director, V17, stated that the admissions office should have ensured the completion of the PASRR Level 1 screening before admission. The lack of a PASRR Level II evaluation for R54 meant that the resident was not receiving the specialized treatment required for their mental health conditions. The facility's failure to conduct timely and accurate PASRR screenings for these residents highlights a significant deficiency in their admission process.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer prescribed medications in a timely manner and maintain accurate narcotic medication counts for four residents. During a controlled substance count, discrepancies were observed in the medication bingo cards for a resident, where the actual pill count did not match the documented count. The registered nurse admitted to administering the medications but failing to document the administration. Additionally, a resident's liquid medication count was also inaccurate, with one less bottle than recorded. Furthermore, medications were not administered as scheduled for two residents due to unavailability. A licensed practical nurse failed to administer a resident's Gemtesa medication on two consecutive days and did not notify the physician of the missed doses. Similarly, another resident's Mupirocin medication was not administered on two days, and the nurse erroneously documented its administration without notifying the physician. The facility's policy requires medications to be given within one hour of the specified time and narcotics to be recorded accurately, which was not adhered to in these instances.
Medication and Enteral Feeding Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications and enteral feedings, leading to several deficiencies. During a survey, expired medications were found in three of six medication carts, including an open bottle of Morphine Sulfate with an expiration date of 05/17/2024, and Bisacodyl Enteric Coated tablets with expiration dates of 12/2024 and 09/2023. Additionally, a vial of Lispro insulin was found without a proper pharmacy label, and a nasal medication, Fluticasone Propionate, was also missing a pharmacy label. These medications were not discarded as required by the facility's policy, which states that expired medications should not be administered and that medications must have proper labeling. Furthermore, expired enteral feeding containers labeled Nepro 1.8 CAL were found in a medication storage room, with visible milk curdles at the bottom, indicating spoilage. These containers had an expiration date of 11/2024 and were not removed from storage, posing a risk to residents who rely on enteral feedings. The facility's policy mandates that medications and feedings should be discarded after their expiration date and that any unmarked or improperly labeled medications should be returned to the pharmacy for proper labeling. These oversights have the potential to affect 68 residents in the facility, including those with gastrostomy tubes for enteral feedings.
Deficiency in Vaccination Documentation and Administration
Penalty
Summary
The facility failed to minimize the risk of acquiring, transmitting, or experiencing complications from influenza and COVID-19 for six residents. The deficiency was identified through interviews and record reviews, revealing that several residents were not properly offered or documented for influenza vaccinations. For instance, one resident was offered and refused the influenza vaccine in August 2024, but there was no documentation of subsequent offers or refusals for the current flu season. Additionally, three residents did not receive immunization education prior to vaccine administration or refusal, and another resident's consent form for the influenza vaccine lacked a witness signature. Furthermore, one resident consented to receive the influenza vaccine, but it had not been administered by the time of the report. The same resident also consented to the COVID-19 vaccine, which had not been given due to insurance issues and lack of follow-up with the pharmacy. The Infection Preventionist (IP) nurse, responsible for managing immunizations, admitted to not documenting offers and education consistently. The facility's policy requires offering influenza and pneumococcal vaccinations to all residents, with proper documentation of education and vaccination status, which was not adhered to in these cases.
Violation of Resident Dignity and Confidentiality
Penalty
Summary
The facility failed to maintain resident rights pertaining to dignity and confidentiality for three residents. One resident was not fed with dignity, as a Certified Nursing Assistant (CNA) fed the resident while standing, which is against the recommended practice of feeding at eye level to ensure the resident's ability to chew and swallow safely. The CNA continued to feed the resident without ensuring that the resident had finished chewing, which could potentially lead to aspiration. The Director of Nursing and the Director of Rehabilitation both confirmed that feeding should be done at eye level to prevent such issues and to maintain the resident's dignity. Additionally, the facility failed to protect the confidentiality of medical information for two residents. Signs indicating the residents' names and dietary information were visibly posted above their beds, which could be seen by visitors. This practice was confirmed by the Director of Rehabilitation, who acknowledged that the information on the swallow precaution signs is part of the residents' medical records and should be kept confidential. The visible posting of such information violates the residents' rights to confidentiality as outlined in the facility's Resident Rights policy. The residents involved had various medical conditions that required specific dietary needs and assistance. One resident had severe cognitive impairment and required one-on-one assistance during meals, while another resident was cognitively intact but had specific dietary instructions. The facility's failure to adhere to proper feeding practices and to protect the confidentiality of medical information compromised the dignity and rights of these residents.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess and monitor a resident for self-administration of medication, which was observed during a medication pass. A Licensed Practical Nurse (LPN) provided a nasal medication, Fluticasone Propionate 50mcg, to the resident, who then self-administered two sprays into both nostrils. The LPN stated that the resident was allowed to self-administer because she did not trust the facility staff to administer it correctly. However, a review of the resident's Physician Order Sheet, Medication Administration Record, and Electronic Health Record revealed that there was no physician order or assessment for the resident to self-administer her medication. The facility's policy on medication administration and storage requires that self-administration of medications by residents is only permitted when the resident has been assessed and deemed capable, and a physician order has been written for self-administration. This policy was not followed in the case of the resident, leading to the deficiency.
Failure to Display [NAME] Program Information
Penalty
Summary
The facility failed to display information about the [NAME] program in a public and accessible location, which is a requirement for informing residents of their rights regarding community transition. This deficiency was identified during a survey conducted on February 4, 2025, when it was observed that no posters or educational materials related to the [NAME] program were posted on any of the facility's floors, including the main dining room where residents frequently gather. The Social Service Director, identified as V16, was unaware of any postings and confirmed the absence of such materials after checking all floors. The deficiency affected 12 residents who were potential candidates for the [NAME] program, as they were not provided with the necessary information to make informed decisions about community transition. On February 5, 2025, V16 acknowledged that educational materials and information had not been distributed to residents until after the surveyor's visit. The lack of information potentially impacted the residents' ability to exercise their right to explore or decline community transition, as they were not informed of their rights or the contact information needed to participate in the program.
Failure to Remove Hospital Wristband Compromises Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal information, which is a violation of the Health Insurance Portability and Accountability Act (HIPAA). A resident, who was recently admitted to the facility, was observed wearing a hospital wristband that displayed his full name, date of birth, and medical record number. This wristband, which should have been removed upon admission, contained private information that was visible to other residents and visitors, thus compromising the resident's confidentiality. The resident, who has intact cognitive function as indicated by a BIMS score of 13/15, expressed a desire for his information to remain private. Despite this, the wristband remained on the resident until it was brought to the attention of the facility staff by a surveyor. The registered nurse acknowledged the oversight and identified it as a HIPAA violation. The unit manager and assistant director of nursing confirmed that hospital wristbands with identifying information should not be worn by residents in the facility, indicating a lapse in the facility's adherence to its policy on resident rights and confidentiality.
Inconsistent Restorative Therapy for Resident
Penalty
Summary
The facility failed to provide consistent restorative therapy to a resident, identified as R61, which compromised the resident's ability to maintain their highest practical level of function. R61, who is cognitively intact with a BIMS score of 15, has a medical history that includes rhabdomyolysis, paraplegia, and polyneuropathy. The resident reported that staff were supposed to assist with leg exercises and apply a splint, but these interventions were not consistently provided. During an observation, R61 mentioned that the splint was applied for the first time in a long period, coinciding with the presence of a state agency in the facility. The Restorative Aide, V12, confirmed that restorative aides document therapy in the resident's electronic medical record and that CNAs are responsible for providing therapy on weekends. However, there were multiple instances over the past 90 days where documentation of splint or brace assistance was missing. The Restorative Director, V24, acknowledged the importance of the restorative therapy program but was unsure why staff failed to document the interventions. The facility's failure to consistently provide and document restorative therapy placed residents at risk of receiving inappropriate care, potentially affecting their physical, mental, and psychosocial well-being.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.69% error rate during the survey period. This deficiency was identified through the observation, interview, and record review of two residents. One resident, diagnosed with Type 2 Diabetes and other conditions, did not receive their scheduled dose of Metformin due to the medication not being available in the facility. The LPN responsible did not check the emergency automated medication dispenser (AMD), which had the medication in stock, nor did they notify the resident's physician about the missed dose. Another resident, with diagnoses including Multiple Sclerosis and hypertension, did not receive their scheduled Lidocaine patch. The LPN did not retrieve the patch from the central supply stock room, where it was available as house stock. The LPN admitted to being nervous and not thinking to check the available resources. Additionally, the LPN failed to inform the resident's physician about the missed medication. The facility's policy requires that physicians be notified when medications are not administered as per orders, which was not followed in these instances.
Inconsistent Nighttime Snack Distribution
Penalty
Summary
The facility failed to consistently offer and serve nighttime snacks to a resident, as per the facility's policy. During a resident council meeting, a resident expressed that they were not consistently receiving nighttime snacks. The Dietary Manager confirmed that snacks are supposed to be offered to all residents, and they are distributed to the floor CNAs to be given to residents. However, the Dietary Manager acknowledged that there are instances when residents report not receiving their snacks. The Director of Nursing was aware of the issue but did not conduct any in-services or training to address the concern. The resident involved is cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15. The resident's medical history includes difficulty in walking, a non-pressure chronic ulcer, and low back pain. A review of the facility's records showed that the resident was not offered snacks on multiple occasions within a 30-day period. The facility's policy states that nourishments should be provided at bedtime and distributed by nursing staff, but this was not consistently followed.
Misclassification of Psychotropic Medication on Consent Form
Penalty
Summary
The facility failed to accurately classify a resident's psychotropic medication on the consent form, which could potentially affect the resident's understanding of the medication's side effects. The resident, who is severely cognitively impaired and unable to complete a mental status interview, has a medical history that includes dementia, anxiety disorder, major depression disorder, and psychotic disorder. The psychotropic medication form for this resident, dated 02/04/2025, incorrectly classified Remeron (Mirtazapine) as an antidepressant, whereas a previous form dated 03/03/2021 had incorrectly classified it as an antipsychotic. This misclassification led to consent being given under the wrong classification, which could result in misunderstanding the side effects associated with the medication. The Assistant Director of Nursing, who is responsible for updating psychotropic consents every 15 months, acknowledged the error in the classification of Remeron on the earlier form. According to the facility's policy, psychotropic medications should have appropriate indications for use and be monitored for side effects, with consents updated regularly. The FDA indicates that Remeron is used for treating major depressive disorder in adults, and the facility's consent form lists side effects for antidepressants that differ from those for antipsychotics. This discrepancy in classification and consent could lead to issues with informed consent regarding the medication's side effects.
Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to protect a resident from verbal abuse, affecting one of the four residents reviewed for abuse. The resident, a female with epilepsy, anxiety disorder, and chronic embolism, is alert and oriented, requiring maximum assistance with activities of daily living and using a manual wheelchair. The resident reported two incidents of verbal abuse by CNAs. In the first incident, a CNA allegedly cursed at the resident after she requested assistance for another resident. Witnesses corroborated the resident's account, and the CNA was terminated. In the second incident, another CNA allegedly made derogatory remarks about the resident's hygiene, which the resident found offensive. Despite the CNA's denial, the investigation substantiated the claim, and the CNA was also terminated. The facility's abuse investigations confirmed both incidents of verbal abuse, with statements from the resident, other residents, and staff supporting the allegations. The facility's policy affirms residents' rights to be free from abuse, and the incidents were found to violate this policy. The administrator, who also serves as the Abuse Prevention Coordinator, conducted the investigations and confirmed the substantiation of the allegations. The facility's policy prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents, yet these incidents demonstrated a failure to uphold these standards, resulting in the termination of the involved CNAs.
Resident Tied to Bed with Pillowcases by Nurse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse and mental anguish by staff, as evidenced by an incident involving a cognitively impaired resident, R2. R2, who has a history of restlessness, agitation, and repeated falls, was found with their wrists tied to the bed side rails using pillowcases by a registered nurse, V6. This action was taken by V6 due to a staffing shortage and the nurse's inability to supervise R2, who was known for climbing out of bed and falling. V6 admitted to tying R2's wrists to prevent falls while they were busy with medication rounds, acknowledging that there was no physician order for such a restraint and that it constituted abuse. The incident was witnessed by a CNA, V21, who found R2 tearful and in discomfort, with gestures indicating pain. V21 reported the incident to another nurse and the Director of Nursing, expressing that tying a resident to the bedrail with a pillowcase was a form of abuse. The facility's administrator, V1, initially did not consider the action as abuse, attributing it to the nurse being busy and short-staffed. However, other staff members, including a nurse consultant and a restorative director, recognized the action as abuse, emphasizing the psychological and physical harm it could cause. The facility's policy on abuse prevention defines abuse as the willful infliction of injury, unreasonable confinement, or causing pain and mental anguish. Despite this, the facility initially failed to report the incident to the Illinois Department of Public Health as required. The incident was later identified as immediate jeopardy, highlighting the facility's failure to protect the resident from abuse and appropriately identify and report the incident.
Removal Plan
- R2 screened, reassessed for risk for abuse with care plan interventions.
- All staff in-serviced training completed by V1, V2 and V29.
- Documentation showed that all residents were re-educated on abuse.
- R2, R14, R15, R16, R17, R18, R19 and R20 were screened for potential abuse with care plan reviewed and initiated.
- All staff will be responsible for monitoring residents for behavior that can make them vulnerable for abuse.
- All residents determined to be vulnerable or those that will be affected by this deficiency citation R2, R14, R15, R16, R17, R18, R19 and R20 were identified, and plan of care initiated, with ongoing, on admission, quarterly and annually.
- Review Quality Assurance audit tool started weekly ongoing to ensure compliance.
Improper Use of Physical Restraints on a Resident
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary physical restraints, as evidenced by an incident involving a resident, R2, whose wrists were tied to the bed with a pillowcase by a registered nurse, V6, without a physician's order, consent, or medical justification. R2, who was admitted with multiple medical conditions including restlessness, agitation, and a history of falls, was restrained due to staffing shortages and the nurse's inability to supervise R2 adequately. The nurse admitted to tying R2's hands to prevent falls, acknowledging that it was wrong and not part of the facility's fall prevention interventions. R2's medical records did not document any medical symptoms or behaviors justifying the use of restraints, nor was there any physician order, restraint assessment, or consent obtained. The facility's policy requires that any use of restraints must be medically justified, ordered by a physician, and consented to by the resident or their representative. The incident was reported by another staff member who found R2 restrained and described the resident as experiencing psychosocial distress, including crying and agitation. Interviews with various staff members, including the Director of Nursing and the Restorative Director, confirmed that the facility is a restraint-free environment and that the use of a pillowcase as a restraint was inappropriate and considered abusive. The facility's policies on restraint use and fall prevention were not followed, and the incident was identified as an immediate jeopardy situation, highlighting a significant lapse in adherence to regulatory standards and resident care protocols.
Removal Plan
- All staff were trained on what constitute proper training, unnecessary use of restraint, with ongoing training scheduled Quarterly.
- All residents have been assessed to ensure that none are restrained improperly or unnecessarily.
- Assessment will be ongoing and conducted at admission, quarterly and annually.
- Outside consultant and V2 and V29 conducted in-service training on behavior management.
- Documentation showed all the facility residents were in-service on abuse and restraints.
- R2, R14, R15, R16, R17, R18, R19 and R20 were care planned/interventions with potential for abuse and proper restraints related to their diagnoses.
- A system put in place for audit to be done weekly to ensure compliance with unnecessary use of restraint to be monitored by V1, V2 and V29.
Medication and Treatment Cart Safety Lapses
Penalty
Summary
The facility failed to ensure that a treatment cart and resident medication were not left unattended, posing a potential accident hazard. An inhaler belonging to a resident was observed on an over-bed table, visible from the hallway, and not in its manufacturer's container or with a pharmacy label. The resident stated they used the inhaler to help with breathing, but there was no physician order for the resident to self-administer the medication. The nurse confirmed that the resident was not part of a self-administration program and had not received the inhaler as scheduled, despite the medication administration record indicating otherwise. Additionally, a treatment cart was found unlocked and unattended in the hallway, not within the visual proximity of the nurses. The nurse acknowledged forgetting to lock the cart, which is against the facility's policy that requires treatment carts to be locked when not in use or under direct supervision. The Director of Nursing confirmed that only nurses should have access to the cart keys and that leaving it unlocked poses a safety issue. The facility's policies on medication administration and storage emphasize that medications should not be administered without a physician's order and that self-administration is only permitted with a proper assessment and physician order.
Staffing Shortage Leads to Resident Restraint
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of residents, particularly affecting a resident known for attempting to get out of bed without assistance. On a specific day, the facility was short-staffed, with only two CNAs available instead of the usual three for the second floor, which houses 41 residents. This shortage led to a situation where a registered nurse, overwhelmed with responsibilities, tied a resident's hands to the bed rail with a pillowcase to prevent falls, acknowledging the action was wrong but felt necessary due to the lack of staff. The facility's staffing policy requires adequate staffing levels and skills mix to deliver high-quality, person-centered care, with a designated nurse on-call for emergencies. However, on the day of the incident, a CNA called off, and the facility struggled to find a replacement, especially since it was a weekend. The Director of Nursing confirmed that the usual staffing for the second floor should include two nurses and three CNAs, but due to the call-off, only two CNAs were available, leading to the incident involving the resident being tied to the bed rail.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to immediately report an alleged abuse incident involving a resident who was tied to the bedside rails with a pillowcase by a nurse. This incident was reported to the facility's Administrator by the Director of Nursing, who sent the nurse home pending investigation. Despite the conclusion that the allegation was unfounded and there was no injury, the facility did not report the incident to the Illinois Department of Public Health (IDPH) as required by their policy. The facility's policy on abuse prevention mandates that any allegation of abuse should be reported to the Department of Public Health's regional office immediately, or within 24 hours if there is no serious bodily injury. However, the initial report to IDPH was made 32 days after the alleged incident. This delay in reporting was a violation of the facility's own policy, which requires timely reporting of such allegations to ensure proper investigation and response.
Failure to Conduct Timely PASRR Assessments for Residents with Serious Mental Disorders
Penalty
Summary
The facility failed to refer five residents for Preadmission Screening and Resident Review (PASRR) Level I and II assessments, which are necessary for residents with serious mental disorders. The Director of Social Services, identified as V4, acknowledged that these assessments were not completed for residents R2, R3, R4, R5, and R6. Each of these residents had diagnoses indicating serious mental illness, such as schizoaffective disorder, major depressive disorder, and bipolar disorder, which required timely PASRR evaluations to ensure they received appropriate care and services. The deficiency was partly due to a transition period in the facility's social services department, during which there was no Social Services Director to manage the PASRR process. V4, who was new to the facility, was unaware of the need for these assessments until the surveyor's interview. The facility's business office manager, V5, confirmed that the absence of a Social Services Director led to a lack of communication with the appointed screening agency, resulting in missed PASRR evaluations. The facility's policy requires that newly admitted residents with serious mental illness, intellectual disability, or developmental disability be assessed for PASRR Level II within a specified timeframe. However, due to the oversight, the necessary assessments were not conducted, leaving the residents without the specialized programs and treatment goals they needed. Notifications from the assessment tool and service letters from the screening agency were not acted upon, contributing to the deficiency.
Failure to Provide Adequate Wound Care for Residents
Penalty
Summary
The facility failed to provide appropriate wound care for two residents, leading to significant health issues. Resident 1, who was admitted with a surgical site on the left inner thigh, did not receive the necessary wound treatment and skin care plan interventions. The facility did not complete weekly wound skin assessments or Braden scale assessments as required. This lack of care resulted in the resident being admitted to the hospital for dehiscence of the wound in the groin area. Resident 4 also did not receive the prescribed wound treatment. The resident's wound dressings were not changed daily as ordered by the physician, and the treatment was not documented as provided on specific dates. This oversight in care was noted despite the resident having multiple pressure ulcers and being dependent on assistance for activities of daily living. Interviews with facility staff, including the wound care nurse and the Director of Nursing, revealed a lack of awareness and documentation regarding the residents' wound care needs. The facility's policies on surgical wound care and skin inspection were not followed, contributing to the deficiencies in care for both residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, affecting two residents. The first incident involved a female resident with Alzheimer's and other health conditions, who was reportedly slapped by a CNA during ADL care after she became combative and scratched the CNA. The incident was witnessed by another CNA and the resident's roommate, both confirming the slap. The facility's investigation led to the termination of the CNA involved, although the resident was unable to be interviewed due to her mental status. The second incident involved a female resident with COPD, paraplegia, and other health issues, who was involved in a verbal altercation with a CNA. The CNA used profanity during a conversation with the resident, which was recorded on social media. Despite the resident's claim that the CNA always spoke to her in such a manner, the facility determined the interaction to be verbal abuse. The CNA was terminated following the incident, as the use of profanity was deemed inappropriate and against facility policy. Both incidents highlight the facility's failure to ensure a safe environment free from abuse, as required by their Abuse Prevention Program. The facility's policy emphasizes the residents' right to be free from abuse and mistreatment, yet these incidents demonstrate lapses in adherence to this policy, resulting in the termination of the involved staff members.
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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