Continental Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chicago, Illinois.
- Location
- 5336 North Western Avenue, Chicago, Illinois 60625
- CMS Provider Number
- 145730
- Inspections on file
- 58
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Continental Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with impaired cognition and total dependence for mobility was found to have sustained fractures of unknown origin, which were only discovered after a hospital transfer. The facility did not report the injury within the required timeframe as outlined in its abuse prevention policy, submitting the report to authorities later than the 24-hour window allowed.
A resident with impaired cognition and multiple medical conditions was admitted with bilateral heel deep tissue injuries, but the facility failed to accurately assess and document these injuries or update the care plan to include necessary interventions such as heel protectors. Weekly skin assessments did not reflect the resident's true condition, and discrepancies existed between assessment tools and the care plan regarding the resident's mobility and needs.
A resident dependent on staff for transfers, with multiple medical conditions and moderate cognitive impairment, fell during a mechanical lift transfer when the lift tipped and caused the wheelchair to flip. Two staff members were present, but the lift's legs were not properly spread for stability, leading to the incident. The resident was evaluated and found to have no injuries.
A resident's personal refrigerator was not consistently monitored according to facility policy, as daily temperature checks were not documented on several dates. Although the refrigerator was observed to be clean and within the appropriate temperature range, staff interviews confirmed that required documentation was not completed each day, resulting in a failure to follow established food safety procedures.
Surveyors found that the facility did not enforce its no-smoking policy, as evidenced by the smell of cigarette smoke and cigarette butts found in a resident's room. Staff interviews confirmed that smoking is prohibited indoors, but a resident admitted to past non-compliance and was known to have violated the policy. The facility's failure to supervise and enforce smoking restrictions created an accident hazard for residents and staff.
Two residents with behavioral histories had escalating altercations, culminating in one spraying a substance in the other's face, causing a fall and head laceration requiring staples. Despite prior care planning and increased monitoring after an earlier argument, staff did not prevent the physical assault and resulting injury.
A resident admitted for IV antibiotic treatment for osteomyelitis and wound infection did not receive IV Vancomycin as ordered by the physician, missing four doses over the first two days after admission. The medication was available in the facility's automated system, but was not administered or obtained via STAT order, as confirmed by the DON and review of the MAR and care plan.
Smoking was observed in non-designated areas such as resident rooms and common restrooms, with cigarette odors and marks present. Staff, including a CNA and an LPN, confirmed the issue, and an oxygen tank was found near a restroom where smoking occurred. The facility's policy and state law prohibit indoor smoking, but these were not enforced, impacting the safety and comfort of all residents.
A resident with diabetes, multiple sclerosis, and cerebral infarct did not receive all prescribed medications, including diabetes and antidepressant drugs, due to the facility's failure to re-order them in accordance with policy. Nursing staff confirmed that medications were not re-ordered when the bingo card indicator signaled low supply, resulting in unavailable doses at the time of review.
The facility did not enforce its smoking safety policy, allowing a resident to smoke inside a shared room where another resident was on continuous oxygen therapy. Despite staff awareness and multiple reports from non-smoking residents about cigarette smoke in rooms and hallways, the issue persisted, with staff finding a lit cigarette in the room and residents admitting to indoor smoking. The resident on oxygen, with significant respiratory and cardiac conditions, was not immediately moved after reporting the incident, and staff did not consistently search for or confiscate smoking materials. Facility policy prohibiting indoor smoking and smoking near oxygen was not effectively implemented, resulting in exposure of vulnerable residents to cigarette smoke.
A resident with significant medical needs experienced ongoing dental pain for over a year due to the facility's failure to arrange timely dental extractions as recommended by the facility dentist. Despite repeated complaints and documentation of the need for extractions, staff did not schedule necessary appointments or secure transportation, and the resident continued to receive pain medication without resolution of the underlying dental issue.
Surveyors observed unsanitary kitchen conditions, including garbage and debris on the floor, overfilled trash containers attracting flies, and unclean equipment. The freezer was not functioning properly, with the door unable to close and food items found fully defrosted at unsafe temperatures. Multiple food items in the refrigerator were not labeled or dated, and some showed signs of spoilage. Staff confirmed lapses in cleaning routines and food safety practices, and facility policies regarding sanitation and food storage were not followed.
A resident with hypertension and heart disease did not consistently receive Amlodipine at the scheduled time, with multiple late administrations and one undocumented dose. Nursing staff interviews revealed lapses in documentation and failure to notify the physician when medications were late or refused, contrary to facility policy.
Surveyors found that a resident's opened insulin pen was not discarded after expiration, an unopened insulin pen was not refrigerated, and two residents' inhalers were missing required open dates. An expired house stock medication was also stored in a medication cart. LPNs and the DON confirmed that these actions did not follow facility policy for medication labeling, storage, and disposal.
Staff failed to follow standardized pureed diet recipes by not measuring liquid when preparing pureed beef lasagna, instead adding unmeasured amounts of water and then thickener to adjust consistency. This practice resulted in diluted nutritional content for several residents on pureed diets, contrary to facility policy and dietary orders.
Staff failed to follow standardized recipes when preparing pureed diets, resulting in diluted and improperly prepared pureed lasagna for several residents. The cook added unmeasured amounts of water, leading to a thin consistency that required additional thickener, contrary to facility policy and dietitian guidance. This practice risked residents not receiving the intended nutritional value from their prescribed pureed diets.
A resident was found to be self-administering multiple medications, including expired and over-the-counter products, without a physician order or a documented assessment to determine if self-administration was appropriate. The DON confirmed that facility policy requires both a safety assessment and a physician order for bedside medication storage and self-administration, but neither was present in the resident's records.
A resident who was cognitively intact did not have a documented advance directive or physician order for code status, and their care plan did not address these issues. Facility policy requires that advance directive preferences be obtained, documented in physician orders, reflected on the face sheet, and included in the care plan, but this process was not followed for the resident.
The facility failed to ensure accurate MDS assessments for three residents, resulting in incorrect documentation of oxygen therapy, tracheostomy care, ventilator use, trunk restraint use, and catheter use. Staff interviews and record reviews confirmed that these interventions were not provided or required, and the MDS Coordinator acknowledged the errors after review. The assessments were not properly verified against clinical documentation as required by facility policy.
A resident with an order for Gabapentin 300mg was found with thirty-four capsules at the bedside after nurses had documented administration. The resident stated he did not want the medication, and staff interviews confirmed that nurses are expected to remain with residents to ensure medications are swallowed, as per facility policy.
Two residents did not receive care according to physician orders and facility policy: one with chronic liver disease and Hepatitis C lacked specialist coordination and regular lab monitoring, and another with a PICC line did not have the dressing changed weekly as required, resulting in a dressing remaining in place for 13 days.
A resident who was cognitively intact was found to have two countertop microwaves at bedside, which were used to warm up food. This was observed by a surveyor, and the resident confirmed their use. Facility policy prohibits microwaves in resident rooms due to safety concerns and requires administrative approval for such items, but the microwaves were present without proper authorization.
Three cognitively intact residents did not receive their scheduled medications within the facility's required timeframe, with administration occurring up to two hours late and documentation not completed as required. Nursing staff confirmed the delay and lack of immediate documentation, citing workload issues, in violation of facility policy.
A resident with multiple complex medical conditions received an antibiotic for a UTI, but the facility failed to accurately document the correct dosage in the medical record. An LPN transcribed the order as 1 mg instead of 1 g, and this error was reflected in the Medication Administration Record, although the correct dose was administered. Staff interviews and pharmacy records confirmed the documentation error.
The facility experienced significant delays in meal service due to insufficient dietary staff, affecting residents' dining experiences. Meals were served later than scheduled, with some residents receiving cold food on disposable plates. The dietary manager confirmed staffing shortages, leading to changes in menu items and delays in meal preparation and delivery. Residents and staff expressed frustration over the late service, highlighting the facility's failure to maintain adequate staffing levels.
The facility failed to serve adequate food portions as per the recipes and spreadsheets, affecting all 141 residents. Observations revealed incorrect serving utensils were used, leading to smaller portions of mashed potatoes, pureed and ground Country Fried Steak, and vanilla pudding. The dietary staff acknowledged the errors, and the registered dietitian highlighted the importance of following portion sizes to ensure adequate nutrition.
The facility failed to provide meals according to the posted schedule, with dinner often served past 7 PM and breakfast as late as 10 AM, causing residents to experience hunger and frustration. Staffing shortages in the kitchen contributed to these delays, and residents with conditions like Type 2 Diabetes Mellitus expressed dissatisfaction with the erratic meal schedule. The facility's policy of no more than 14 hours between dinner and breakfast was not consistently followed, violating residents' rights to timely and nourishing meals.
The facility failed to provide food at an appetizing temperature, as reported by several residents and confirmed by a surveyor's test tray. Residents expressed dissatisfaction with cold meals served on disposable plates, and staff attributed the issue to staffing shortages and the discontinuation of a heated plate system. The Registered Dietitian confirmed that food temperatures were below required standards, impacting resident satisfaction and potentially their nutritional intake.
A resident reported missing personal items, including a transportation pass and clothing, which were not addressed according to the facility's grievance policy. The Social Service Director provided ill-fitting clothing from a free rack instead of replacing the lost items, and failed to complete a concern form, leaving the administrator unaware of the issue. This violated the resident's rights to keep personal belongings and have a safe place for valuables.
A resident in a LTC facility was found in a room with a leaking bathroom sink and a moldy mattress, which had not been addressed despite being reported. The resident, who has a history of allergies and a high fall risk, expressed concerns about slipping and allergy symptoms. The Maintenance Director and Housekeeping Director acknowledged the issues, and a Paint Contractor suggested the ceiling spots were likely mold. The facility failed to provide a safe and sanitary environment as required by residents' rights.
A resident with intact cognition reported missing clothes and was unable to go to a store to purchase new ones, despite being told she could. The resident had no designated closet space, and staff confirmed her clothing was lost. The facility's policy on accommodating resident needs was not upheld.
A resident with quadriplegia and respiratory failure developed a trachea infection due to inadequate care planning. The facility failed to include the resident's tracheal infection and behavior regarding suctioning in the care plan. Despite the resident's frequent requests for suctioning, which staff believed contributed to the infection, the care plan did not address these issues. The facility also did not document a care plan meeting with the resident or family, violating their policy for person-centered care.
A resident, who is cognitively intact, was found without individual closet space for clothing, leading to her wearing the same clothes from the previous day. The closet space in her room was occupied by her roommates, and the facility's administrator stated that providing a cabinet for clothing is not a requirement. The resident expressed frustration about not being able to go to the store to purchase clothes.
A resident with cognitive impairment in a LTC facility was injured in two separate incidents involving other residents. The first incident involved a resident with intact cognition who admitted to punching the impaired resident, resulting in scratches and abrasions. The second incident involved another cognitively impaired resident who tapped the impaired resident's face, causing swelling and redness. Both incidents were inadequately reported and documented, and the facility's response did not align with its abuse policy.
A resident with dementia was involved in two separate incidents of abuse by other residents, resulting in injuries. The facility failed to properly investigate and document these incidents, with inaccuracies in reports and missing witness signatures, contrary to its abuse policy.
A facility failed to properly label, date, and contain oxygen equipment for a resident with multiple diagnoses, including chronic respiratory failure. The resident's trach nebulizer mask and oxygen tubing were found undated and improperly stored, contrary to facility policy. Staff interviews confirmed the equipment should be dated, changed weekly, and stored in a bag to prevent contamination.
A resident in a LTC facility was physically abused by a roommate, resulting in a hip fracture. The altercation occurred over room temperature adjustments, with the aggressor using a cane to strike the victim. Despite the incident being reported, the facility's response was inadequate, as the investigation was incomplete and previous altercations had not been addressed. The facility failed to implement its abuse prevention policy effectively.
The facility failed to supervise residents' smoking practices adequately, leading to unauthorized smoking inside the building and insufficient monitoring in designated smoking areas. A resident was found smoking in his room, and staff did not enforce the policy requiring supervision in smoking areas, allowing residents to light their own cigarettes. This poses a safety risk, especially to residents on oxygen.
A medication cart on the 3rd floor was found unlocked and unattended, contrary to the facility's policy requiring it to be locked or attended by authorized staff. A surveyor, with a housekeeping staff member, discovered the cart in this state, and the housekeeping staff was able to open the drawer. An LPN later arrived and locked the cart, acknowledging the oversight.
Two residents engaged in a verbal altercation that escalated to physical violence, with one resident hitting the other in the hallway. Staff intervened to separate them, and both were sent to the hospital. The facility's policy to prevent abuse was not effectively implemented, as the altercation involved physical contact, which is considered abuse.
A resident with severe cognitive impairment was involuntarily confined in their room by a CNA using a garbage bag to block the door, constituting involuntary seclusion. The incident was reported by another resident and confirmed by facility staff, leading to the CNA's termination. The facility's policies prohibit such actions, emphasizing residents' rights to dignity and respect.
A resident with a history of falls and high fall risk was admitted to the facility without a baseline care plan being developed within the required timeframe. The resident experienced multiple falls without appropriate interventions, highlighting a failure to adhere to facility policies and federal regulations regarding care planning.
A resident experienced mental abuse when a psychiatric technician threatened to revoke her green pass privileges due to her family's complaints. The resident, who has a history of anxiety and PTSD, felt threatened and unsafe. The incident was witnessed by the resident's roommate, and the Assistant Director of Nursing acknowledged the threat as verbal abuse, although the facility's administrator was skeptical.
The facility failed to accommodate residents using bariatric wheelchairs, preventing them from accessing the bathroom in their rooms. Despite having intact cognition, a resident with multiple health conditions could not independently use the bathroom due to the wheelchair's size. Staff confirmed that the bathroom doors were too narrow for bariatric wheelchairs, violating the facility's policy to individualize the environment for residents' needs.
The facility's kitchen was found to be in unsanitary conditions, with unclear management and understaffing contributing to the issue. Personal items were improperly stored, and kitchen equipment was dirty, posing a risk of foodborne illness. Expired milk and undated raw pork chops were found in the cooler, and the cook reported being unable to clean due to lack of staff.
A resident with a history of cerebral infarction and dementia was unable to attend church services due to a change in their community pass status, requiring supervision. Despite the resident's cognitive intactness and willingness to pay for transportation, the facility failed to make arrangements for church attendance, violating the resident's rights. Attempts to contact the resident's church for assistance were unsuccessful, and the facility's van was deemed unreliable for weekend use.
A resident with a history of mental illness was hit on the back of the head by another resident with documented aggressive behavior. Despite staff presence, the altercation occurred in the dining room, and the aggressive resident continued to exhibit threatening behavior. The facility's policy requires immediate reporting and investigation of abuse, but the claim was not substantiated, highlighting a deficiency in resident safety and abuse prevention.
A resident reported being hit by another resident in the dining room, but the facility failed to conduct a thorough investigation. Key witnesses were not interviewed, and the investigation concluded without substantiating the abuse claim, despite admissions of aggressive behavior. The Director of Nursing acknowledged the investigation's inadequacy, highlighting a deficiency in the facility's compliance with its abuse prevention policy.
A resident with multiple medical conditions did not receive the prescribed double portions of their meal, as indicated on their meal ticket. The dietary staff confirmed the oversight, citing a shortage of pork chops as the reason for not fulfilling the double portion requirement. The facility's policy on portion control was not adhered to, leading to the deficiency.
A resident with multiple diagnoses, including spinal stenosis and muscle wasting, did not receive prescribed physical therapy services due to the facility's failure to follow physician's orders. Despite an active order for therapy evaluation and treatment, the resident was not re-evaluated after discharge from therapy, and the therapy department was not informed of the need for further services. The Director of Nursing confirmed that the pain clinic's plan should have been treated as an order.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse prevention policy regarding the timely reporting of an injury of unknown origin for one resident. The resident, who had significant cognitive impairment and was dependent on staff for all mobility and transfers, was transferred to the hospital after being found weak, pale, and difficult to arouse. Hospital records revealed that the resident had sustained a fracture of the right acetabulum and a compression fracture of the first lumbar vertebra. There was no documentation or evidence of a fall or trauma at the time of the hospital transfer, and the facility only became aware of the fractures upon the resident's return from the hospital. According to the facility's abuse prevention policy, injuries of unknown origin must be reported immediately, but no later than two hours after the allegation is made if abuse or serious injury is involved, or within 24 hours if not. The facility submitted the initial report to the State Agency one day after learning of the fractures, rather than within the required 24-hour timeframe. The final investigation report did not determine how the injuries occurred. This failure to report the injury of unknown origin in a timely manner was not in accordance with the facility's policy.
Failure to Timely Assess and Update Care Plan for Pressure Injuries
Penalty
Summary
The facility failed to timely and accurately assess a resident for pressure injuries and did not update the care plan after the identification of bilateral heel deep tissue injuries. The resident, who had impaired cognition and was non-ambulatory, was admitted with significant medical diagnoses including metabolic encephalopathy and fractures. Upon admission from the hospital, the resident had right and left heel deep tissue injuries, which were treated with skin prep and foam dressing. However, the use of heel protectors was not included as a physician order or as an intervention in the care plan. The Braden assessment inaccurately documented the resident's mobility status, conflicting with the Minimum Data Set (MDS) and care plan, which indicated the resident was dependent and non-ambulatory. Weekly skin assessments conducted by the facility repeatedly documented no loss of skin integrity, even after the hospital and facility records confirmed the presence of bilateral heel pressure injuries. One assessment was recorded while the resident was not present in the facility, and subsequent assessments failed to note the existing injuries. The facility's policy required that actual pressure injuries be addressed in the care plan and that assessments be timely and accurate, but these steps were not followed for this resident.
Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to provide a safe mechanical lift transfer for a dependent resident with multiple diagnoses, including cerebral palsy, COPD, obesity, muscle wasting, and hypertensive heart disease. The resident, who had moderate cognitive impairment and was dependent on staff for transfers, experienced a fall during a transfer from wheelchair to bed using a mechanical lift. During the transfer, the mechanical lift tipped over and caused the resident's wheelchair to flip, resulting in the resident falling to the ground while still seated in the wheelchair. The incident was attributed to the staff not spreading the legs of the mechanical lift appropriately, which compromised the stability of the equipment during the transfer. Interviews and documentation confirmed that two staff members were present during the transfer, as required, but the mechanical lift was not used according to facility policy, which states that the base legs should be fully opened for stability. The resident did not sustain any injuries from the fall and was sent to the hospital for evaluation, where no injuries were found. The mechanical lift was inspected after the incident and found to be functioning properly, indicating that improper use by staff was the cause of the accident.
Failure to Document Daily Temperature Checks for Resident Refrigerator
Penalty
Summary
The facility failed to consistently document daily temperature checks for a resident's personal refrigerator, as required by facility policy. During observations, the refrigerator was found to be clean, organized, and set to an appropriate temperature; however, the daily temperature log was missing entries for several dates in December. Interviews with the resident and staff confirmed that while the temperature was verbally checked and maintained within the expected range, documentation was not consistently completed. The resident reported a previous incident where the refrigerator was not plugged in, resulting in spoiled food, and expressed concern that staff do not always record the temperature as required. Staff interviews revealed that housekeeping is responsible for monitoring, cleaning, and documenting the temperature of personal refrigerators daily, with an expected range of 35-40 degrees Fahrenheit. Both nursing and housekeeping staff acknowledged the importance of daily documentation to ensure food safety, as outlined in facility policies. Despite these expectations, the lack of consistent documentation on the temperature log constituted a failure to follow established procedures for monitoring food safety in resident refrigerators.
Failure to Enforce No-Smoking Policy Creates Accident Hazard
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and healthy living environment by not enforcing its no-smoking policy on the third floor, where 59 residents reside. On multiple occasions, surveyors detected the smell of cigarette smoke inside a resident's room shortly after leaving, and cigarette butts were found on the floor next to a resident's bed. Interviews with staff, including the Assistant DON and Social Service Director, confirmed that smoking is prohibited inside the building due to safety concerns and state law, especially given the presence of oxygen in the facility. Despite these policies, a resident admitted to having smoked inside the facility in the past and was known to be non-compliant with the smoking policy, as documented in their care plan. Staff reported that they had not witnessed residents smoking in the facility and had not been notified of such incidents, although procedures were in place for searching residents and their rooms if smoking was suspected. The facility's smoking safety policy clearly states that smoking is only allowed in designated outdoor areas and that the interior of the facility must remain smoke-free at all times. The presence of cigarette smoke and cigarette butts in a resident's room, along with the resident's history of non-compliance, demonstrates a failure to adequately supervise and enforce the facility's smoking policy, resulting in an accident hazard for residents and staff.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a significant injury. On one occasion, two male residents with BIMS scores of 15/15 and histories of behavioral issues had an argument in the dining room, which was stopped by a nurse before it became physical. The following day, while on the smoking patio with approximately 15 people present, one resident sprayed a substance into the other's face, causing the second resident to fall and hit his head on a metal bench. This resulted in a 3.2 cm laceration to the top of the head, requiring 8 staples at the hospital. The incident was witnessed by staff and other residents, and the injured resident reported being unable to see after being sprayed, leading to the fall and injury. Both residents had prior incidents and were care planned for abuse potential following the initial altercation. After the first argument, the facility moved one resident to another room and increased monitoring of both individuals. Despite these measures, the second altercation occurred, resulting in physical harm. Staff responded to the code gray, provided first aid, and called 911. The injured resident was treated at the hospital and later readmitted, while the aggressor was discharged from the facility. The facility's policy prohibits abuse, neglect, and mistreatment, but the measures in place did not prevent the incident.
Failure to Administer IV Antibiotic as Ordered
Penalty
Summary
The facility failed to administer intravenous (IV) Vancomycin as ordered by the physician for a resident admitted with multiple diagnoses, including osteomyelitis and wound infection. Upon admission, the resident was supposed to receive IV Vancomycin every eight hours for seven days, as per hospital discharge instructions and physician orders. However, the medication was not administered on the first two days after admission, resulting in four missed doses. The resident reported not receiving the medication as scheduled, and this was confirmed by review of the Medication Administration Record (MAR) and nursing progress notes, which showed that IV Vancomycin was not started until the third day after admission. The Director of Nursing confirmed that the medication was available in the facility's automated medication and supply management system and should have been administered as ordered or obtained via a STAT order from the pharmacy if needed. Facility policies require medications to be administered as prescribed and in accordance with physician orders. Despite these policies and the availability of the medication, the resident's care plan and MAR indicated that the IV antibiotic was not given as ordered, resulting in a failure to meet the pharmaceutical needs of the resident.
Failure to Restrict Smoking to Designated Areas
Penalty
Summary
The facility failed to ensure that smoking was restricted to designated areas, as required by both facility policy and state law. Multiple residents reported that smoking was occurring inside resident rooms, common restrooms, shower rooms, and other non-designated areas. One resident specifically stated that this has been a continuing problem, and another resident reported smelling strong cigarette odors upon entering a common restroom. A third resident confirmed the ongoing issue and expressed concern about the impact on residents who are exposed to cigarette smoke. During an inspection of the common restroom, cigarette marks were observed on the wall, and a strong odor of cigarettes was present. Additionally, a crash cart with an oxygen tank was found just outside the restroom, raising further safety concerns. Staff members, including a CNA and an LPN, confirmed the presence of cigarette odors in the restroom and acknowledged that residents are not permitted to smoke in these areas. The Assistant Director of Nursing also observed the cigarette marks and the proximity of the oxygen tank to the restroom, reiterating that smoking should not occur near oxygen tanks or in restrooms. The facility's Smoking Safety Policy states that smoking is only allowed in designated areas and that the interior of the facility must remain smoke-free in accordance with state and local laws. The Smoke Free Illinois Act prohibits indoor smoking in healthcare facilities, including all rooms and hallways, and requires a minimum distance from entrances and ventilation intakes. Despite these policies and regulations, the facility did not prevent residents from smoking in prohibited areas, affecting the safety and comfort of all residents.
Failure to Timely Re-Order and Provide Medications
Penalty
Summary
The facility failed to re-order medications in a timely manner for one resident, resulting in the unavailability of three prescribed medications: Glipizide and Metformin (both for diabetes) and Trazodone (an antidepressant). The resident, who has a medical history of diabetes mellitus, multiple sclerosis, and cerebral infarct, reported not receiving all her medications, including eye drops and diabetes medication. Upon review of the medication cart with a registered nurse, it was confirmed that these medications were not available at the time of observation. Facility staff, including the Assistant Director of Nursing and the registered nurse, acknowledged that medications should be re-ordered when the bingo card indicator reaches the dark blue area, which corresponds to eight doses remaining. The facility's policy requires staff to request refills from the pharmacy 72 hours before the last dose. However, the nurse stated that the re-order for Glipizide and Metformin was only placed on the day of the observation, indicating a failure to follow the established policy and ensure timely medication availability for the resident.
Failure to Enforce Smoking Safety Policy and Prevent Indoor Smoking Near Oxygen Equipment
Penalty
Summary
The facility failed to follow its smoking safety policy and did not ensure that residents refrained from smoking inside shared rooms, including areas where oxygen equipment was in use. Multiple residents, including one who was on continuous oxygen therapy due to respiratory failure, were exposed to cigarette smoke in their shared room. Despite clear facility policies prohibiting smoking inside and near oxygen, staff found a resident with a lit cigarette in a shared room, and cigarette smoke was observed in the air. Other residents in adjacent rooms also reported smelling smoke coming from the hallway and from open windows, indicating that the issue was ongoing and affected several individuals. The resident on oxygen, who had significant medical conditions such as chronic obstructive pulmonary disease, heart failure, and a history of cerebral infarction, reported feeling unsafe and distressed due to being housed with smokers. This resident was not immediately moved after reporting the incident to staff, and only after a subsequent event was the resident relocated to another room. Staff interviews and documentation revealed that the resident who was smoking inside the room admitted to doing so, kept smoking materials in their possession, and had previously been found non-compliant with safe smoking regulations. Staff also observed this resident lighting cigarettes using another resident's lit cigarette during supervised outdoor smoking breaks, in violation of facility policy. Several staff members, including LPNs, CNAs, and social services staff, were aware of the ongoing issue of residents smoking inside the facility but did not consistently follow up or conduct thorough searches for contraband smoking materials. Documentation in the electronic health record was sometimes incomplete or stricken out, and there was a lack of immediate investigation or intervention when allegations of indoor smoking were reported. The facility's own policy clearly prohibits smoking in non-designated areas and near oxygen, but these rules were not effectively enforced, resulting in exposure of non-smoking residents, including those with respiratory conditions, to cigarette smoke.
Failure to Provide Timely Dental Care Resulting in Prolonged Pain
Penalty
Summary
The facility failed to follow its dental policy and address negative dental findings immediately for one resident, resulting in a delay of recommended dental procedures and ongoing dental pain. The resident, who has multiple medical diagnoses including paraplegia, diabetes, and an open foot wound, was identified by the facility dentist as needing multiple tooth extractions. Despite repeated dental consults and recommendations for extractions, the necessary procedures were not arranged in a timely manner. Documentation shows that the resident missed appointments due to issues with discontinuing blood thinners, and transportation arrangements were not made as required. The resident continued to experience dental pain for over a year, as confirmed by interviews with the resident, staff, and the ombudsman. Staff interviews revealed a lack of follow-through in scheduling dental appointments, with the appointment scheduler only becoming aware of the need for a dental visit after being notified by the ombudsman. The scheduler also encountered difficulties finding a dental provider who accepted the resident's insurance and had not yet resolved the issue. The DON and administrator could not recall being made aware of the resident's ongoing dental pain prior to the most recent notification. The facility's policy requires immediate action on negative dental findings, but this was not followed, resulting in prolonged discomfort for the resident.
Sanitation and Food Storage Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary kitchen conditions, ensure proper functioning of the freezer, properly label and date food items, and maintain cleanliness of kitchen equipment. During an initial kitchen tour, surveyors observed significant garbage and debris on the floor in the tray line and food preparation areas, including used hairnets, empty cups, food particles, and greasy residue on the floor tiles. The wall behind the oven was splattered with yellow/brown stains, and the oven itself had dried food residue. Trash containers were overfilled, with lids unable to close, attracting black flies. Additional uncovered boxes of garbage were found near the hand sink and walk-in refrigerator, and a pile of cooked eggs was observed falling from an egg carton toward the floor. A mop bucket filled with dirty water and an unclean mop was also present, and staff confirmed that the floor had not been cleaned that day. The freezer was found with its door partially open and unable to close properly due to a faulty locking mechanism. Inside, there was standing water and ice accumulation on food boxes, and the temperature was recorded at 25°F, above the required 0°F or less. Several food items inside the freezer, including vegetables, pork loin, supplement treats, and oral supplement shakes, were fully defrosted. Staff acknowledged that all products in the freezer should be frozen solid and that the current state compromised food safety. The maintenance director was unaware of the freezer issue, and the dietary manager confirmed that the freezer had been functioning the previous day, with staff responsible for documenting temperatures twice daily. In the refrigerator, multiple food items were found without proper labeling or dating, including hotdogs, hamburger patties, and cheese, while some items were past their use-by dates and showed signs of spoilage. The can opener on the prep table was dirty with thick residue, and staff admitted it had not been cleaned as required. Facility policies provided by the administration outlined expectations for sanitation, garbage disposal, equipment cleaning, and food labeling, all of which were not followed as observed during the survey. The facility's diet order list indicated that two residents were receiving nothing by mouth (NPO) at the time of the survey.
Failure to Administer Medication as Scheduled and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that medications were administered as scheduled per physician orders for one resident. Specifically, the resident reported not receiving his prescribed Amlodipine at the scheduled morning time on multiple occasions within a twenty-day period, sometimes receiving it as late as the evening. Review of the Medication Administration Audit Report confirmed several instances where the medication was administered late, including times in the afternoon and evening, and one instance where there was no documentation of administration at all. Progress notes did not provide explanations for the late administration or indicate that the physician was notified, as required by facility policy. Interviews with nursing staff revealed inconsistent practices regarding documentation and notification when medications were not administered as ordered or were refused by the resident. One LPN could not recall if the medication was given or refused and admitted to not documenting the event. The Director of Nursing stated that medications should be administered within a specific time window and that late administration or refusals should be communicated to the physician and documented. The resident in question had diagnoses of essential hypertension and atherosclerotic heart disease and was cognitively intact at the time of the deficiency.
Medication Storage, Labeling, and Disposal Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and disposal of medications and biologicals. During inspection of medication carts, an opened multi-dose insulin pen was found that had not been discarded after its expiration date, and an unopened insulin pen was not stored in the refrigerator as required. Additionally, two opened multi-dose inhalers were found without the date opened written on their labels, despite manufacturer instructions to discard them after a specific period. An expired bottle of house stock medication was also found stored in the medication cart. Interviews with nursing staff and the Director of Nursing confirmed that facility policy requires medications and biologicals to be labeled and stored according to manufacturer recommendations, with opened insulins and inhalers dated and discarded after their respective expiration periods. Expired medications are to be immediately removed from stock and disposed of. The observed failures to date, store, and discard medications as required were not in accordance with facility policy or professional standards.
Failure to Follow Standardized Pureed Diet Recipe
Penalty
Summary
The facility failed to follow standardized pureed recipes during food preparation, specifically when preparing pureed beef lasagna for residents on pureed diets. During observation, the cook did not measure the amount of water added to the lasagna, instead filling the blender container halfway or until the food was covered, resulting in a watery and thin consistency. The cook then added food thickener to adjust the texture, rather than following the recipe instructions to add the smallest amount of liquid gradually and only as needed. This process was repeated for multiple batches, and the cook confirmed that he does not measure the water, which deviates from the standardized recipe requirements. The facility's Regional Director of Kitchen Operations and Registered Dietitian both stated that following the standardized recipes is essential to ensure residents receive the correct nutritional content, as adding too much liquid can dilute calories and protein. Facility documentation, including job descriptions, menu extensions, recipes, and policies, all require adherence to standardized recipes and proper procedures for consistency-modified foods. The deficiency was identified as having the potential to affect eight residents who were prescribed pureed diets as part of their physician-ordered dietary needs.
Failure to Follow Standardized Pureed Diet Recipe
Penalty
Summary
The facility failed to follow standardized recipes during the preparation of pureed diets for eight residents who required this diet texture. During observation, the cook prepared pureed beef lasagna by adding unmeasured amounts of water to the blender, resulting in a watery and thin consistency. The cook admitted to not measuring the water and instead filled the blender container halfway or until the food was covered, then added food thickener to adjust the consistency. This process was repeated for two batches, both resulting in diluted pureed lasagna. The standardized recipe required that liquid be added gradually, starting with the smallest amount, and only adding more if needed, with a specific total amount for ten portions. The facility's policies also required the use of standardized recipes and careful addition of liquids and thickeners to maintain nutrient density. Interviews with the Regional Director of Kitchen Operations and the Registered Dietitian confirmed that recipes should be followed to ensure residents receive the correct nutrition, and that adding excessive liquid can dilute the nutritional value of the food. The job description for the cook position also required preparation of food according to standardized recipes and special diet orders. Physician orders and menu extensions confirmed that the affected residents were prescribed pureed diets and were to receive pureed skillet lasagna. The failure to follow the standardized recipe and preparation procedures had the potential to affect the nutritional intake of the residents receiving pureed diets.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
A resident with a history of Guillain-Barre syndrome, autonomic nervous system disorder, sixth nerve palsy, and chronic knee pain was observed in bed with several medications at the bedside, including Opcon-A eye drops, an expired tube of Pevisone topical cream, and a bottle of vitamin B-12 lozenges. The resident reported ordering these medications online and self-administering them as needed for eye and skin allergies, as well as taking vitamin B-12 daily. The registered nurse present confirmed there was no physician order for the resident to keep medications at the bedside or to self-administer them, and no assessment had been completed to determine if self-administration was clinically appropriate. Review of the resident's clinical records revealed no documentation of a physician order permitting bedside storage or self-administration of medication, nor evidence of a completed self-administration safety assessment. Additionally, laboratory results showed the resident's vitamin B-12 level was above the normal reference range. Facility policy requires a written physician order and assessment for residents to self-administer medications or store them at the bedside, but these steps were not followed in this case.
Failure to Document and Care Plan Advance Directive and Code Status
Penalty
Summary
The facility failed to follow its own policy and procedure regarding advance directives for one resident. Specifically, the resident's face sheet had a blank section for advance directives, and the order summary report showed no physician order for the resident's code status. Additionally, the resident's comprehensive care plan did not address advance directives or code status. The resident was cognitively intact, as indicated by a BIMS score of 14. According to the Social Service Director, code status preferences are to be obtained upon admission, reviewed quarterly, and documented in the physician orders, face sheet, and care plan, with the POLST form uploaded to the electronic medical record. The facility's guidelines require that the resident's wishes, physician orders, and care plan all match regarding advance directives, but this was not done for the resident in question.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, resulting in incorrect documentation of their clinical status and care needs. For one resident, the MDS assessment inaccurately recorded the use of oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilation, despite the absence of any supporting diagnoses, physician orders, or progress notes. Interviews with nursing staff and the resident confirmed that these interventions were never provided or required. Another resident's MDS assessment incorrectly indicated the use of a trunk restraint, although there were no orders, documentation, or staff recollection of restraint use, and the resident did not recall ever being restrained. A third resident's MDS assessment documented the use of external and indwelling catheters, even though the indwelling catheter had been discontinued following a surgical procedure, with no evidence of reinsertion during the assessment period. The MDS Coordinator acknowledged errors in the assessments after reviewing the cases during the survey, confirming that the information entered did not reflect the residents' actual conditions. The facility's policy requires that MDS assessments be accurate, complete, and supported by clinical documentation, in accordance with the RAI manual. However, the assessments in question were not verified against the residents' diagnoses, physician orders, medication and treatment records, or progress notes, leading to inaccurate reporting of the residents' care and treatment during the designated observation periods.
Failure to Ensure Proper Medication Administration and Monitoring
Penalty
Summary
The facility failed to follow professional standards of care in medication administration for one resident. The resident had an active physician order for Gabapentin 300mg to be given orally three times a day for nerve pain. During an observation, a bottle containing thirty-four Gabapentin capsules was found on the resident's bedside table, and the resident stated he had informed the nurses that he did not want the medication. The registered nurse present acknowledged that the capsules were Gabapentin and that nurses should have monitored the resident to ensure the medication was swallowed. Interviews with nursing staff, including the Director of Nursing and a registered nurse who had administered the medication, confirmed that it was their expectation and facility policy for nurses to remain with residents to ensure medications are swallowed. However, the Medication Administration Record indicated that nurses had been signing off that the Gabapentin was given, despite the accumulation of capsules at the bedside. The facility's policy specifically requires staff to remain with residents during medication administration to ensure compliance.
Failure to Coordinate Specialist Care and Adhere to PICC Line Dressing Protocols
Penalty
Summary
The facility failed to coordinate appropriate care and follow physician orders for two residents with significant medical needs. One resident with chronic liver disease and Hepatitis C did not have services coordinated for specialist care or regular monitoring as ordered by the physician. Despite multiple progress notes indicating the need for hepatology consults and regular monitoring of liver enzymes and viral load, there was no evidence that the resident had seen a hepatologist or had relevant labs drawn since 2021. Facility staff, including the nurse and Director of Nursing, were unable to provide documentation of recent specialist visits or lab results, and only initiated new orders for labs and consults after the survey began. Another resident with a peripherally inserted central catheter (PICC) line did not have the dressing changed according to physician orders and facility policy. The resident was observed with a PICC line dressing that had not been changed for 13 days, despite an order for weekly changes and a policy requiring transparent dressings to be changed every 5-7 days. The resident could not recall the last dressing change, and the Director of Nursing confirmed the required frequency for dressing changes to prevent infection, but the order and policy were not followed.
Fire Hazard: Unauthorized Microwave Use in Resident Room
Penalty
Summary
The facility failed to prevent a fire hazard by allowing a resident to keep two countertop microwaves at their bedside. During an observation, a surveyor found the microwaves in the resident's room, and the resident confirmed using them to warm up food. The resident was noted to be cognitively intact according to their clinical records. The facility's Admission Agreement specifically prohibits items such as microwaves in resident rooms due to safety regulations, and requires approval from the DON or Administrator before bringing such items into the facility. Despite these policies, the microwaves were present in the resident's room at the time of the survey.
Failure to Administer and Document Medications per Physician Orders and Facility Policy
Penalty
Summary
Facility staff failed to administer medications according to physician orders and facility policy for three residents. On the day of the survey, two residents reported not receiving their scheduled morning medications by the expected time, and one resident was unsure when medications were administered. Observations confirmed that scheduled 9:00 AM medications were given to these residents between 11:43 AM and 11:56 AM, well outside the facility's guideline of administering medications within 120 minutes of the scheduled time. The Medication Administration Reports (MARs) for these residents were marked 'red,' indicating that documentation of medication administration was not completed at the time of the survey. Interviews with nursing staff and the Director of Nursing confirmed that medications are expected to be administered within one hour before or after the scheduled time and that documentation should occur immediately after administration. The nurse responsible acknowledged administering some medications two hours late due to being delayed while escorting a resident. All three residents involved were cognitively intact, as indicated by their Brief Interview of Mental Status (BIMS) scores. The facility's own Drug Administration Guidelines require timely administration and documentation, which was not followed in these instances.
Failure to Accurately Document Antibiotic Dosage
Penalty
Summary
A deficiency occurred when the facility failed to accurately document the dosage of an antibiotic order for a resident with multiple complex diagnoses, including cerebral palsy, hydrocephalus, epilepsy, drug-induced systemic lupus, urinary tract infection, anxiety, and psychosis. The resident's Minimum Data Set indicated moderately impaired cognition. The order summary and progress notes showed conflicting documentation regarding the dosage of Meropenem prescribed for a urinary tract infection. Specifically, the order was documented as 1 mg intravenously three times a day, when it should have been 1 gram. The Medication Administration Record reflected the incorrect 1 mg dosage, although the correct 1 gram dose was actually administered. Interviews with facility staff confirmed the documentation error. The LPN responsible for transcribing the order admitted to writing the wrong dosage, and the DON acknowledged the mistake, stating that the antibiotic does not come in the documented amount. The pharmacist also verified that only 1 gram bags of Meropenem were dispensed and administered. Facility policies require accurate transcription and implementation of physician orders, as well as comprehensive assessments to inform individualized care plans, but these were not followed in this instance.
Staffing Shortages Lead to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to carry out the functions of the food and nutrition service, resulting in residents receiving their meals late. Observations and interviews revealed that meals were consistently served later than the posted schedule, with dinner trays arriving as late as 7 PM instead of the usual 5 PM. This delay affected multiple residents, including those with significant medical conditions such as quadriplegia, epilepsy, and chronic respiratory failure. Residents expressed frustration and hunger due to the late meal service, and some reported receiving cold food on disposable plates. The dietary manager confirmed that the kitchen was short-staffed, with only one cook and two dietary aides working per shift instead of the required three aides. This staffing shortage led to delays in meal preparation and delivery, as well as changes in menu items due to the inability to prepare food from scratch. The use of disposable plates was also attributed to the lack of staff to wash regular dishes, further impacting the residents' dining experience. Staff interviews corroborated the residents' complaints, with several staff members acknowledging the late meal service and the use of disposable plates. The facility's meal frequency policy and residents' rights documentation emphasize the importance of timely and respectful meal service, which was not upheld due to the staffing issues. The report highlights the facility's failure to maintain adequate staffing levels in the dietary department, leading to significant disruptions in meal service and resident dissatisfaction.
Inadequate Food Portions Served to Residents
Penalty
Summary
The facility failed to serve adequate food portions as documented on the recipes and spreadsheets, potentially affecting all 141 residents receiving food prepared in the facility's kitchen. During a survey, it was observed that the serving utensils used for various food items were not in accordance with the portion sizes specified in the recipes. Specifically, a #10 scoop was used for mashed potatoes instead of the #8 scoop, a #16 scoop was used for pureed Country Fried Steak instead of the #8 scoop, and a #20 scoop was used for ground Country Fried Steak instead of the #8 scoop. Additionally, the vanilla pudding was portioned with a #12 scoop instead of the required #8 scoop. The dietary staff, including the cook and dietary aide, acknowledged the discrepancies in portion sizes. The cook stated that the recipes were not available to him on the day of the survey, and the dietary aide admitted to using the wrong scoop for the vanilla pudding. The dietary manager confirmed that the incorrect portion sizes were served and acknowledged the potential nutritional impact on the residents, including insufficient protein and calorie intake. The registered dietitian emphasized the importance of following the portion sizes listed on the menus and recipes to ensure residents receive adequate nutrition. The facility's policies and job descriptions require adherence to planned menus and standardized recipes, with proper serving utensils to ensure accurate portions. However, the failure to follow these guidelines resulted in residents receiving less food than required, which could lead to nutritional deficiencies.
Inconsistent Meal Delivery Times in LTC Facility
Penalty
Summary
The facility failed to provide meals according to the posted mealtime schedule, resulting in residents receiving their meals late. Observations and interviews revealed that dinner trays were often served past 7 PM, breakfast trays were delivered as late as 10 AM, and lunch trays arrived around 2 PM or later. This inconsistency in meal delivery times led to residents experiencing hunger and frustration, as they were not receiving meals at expected times. The facility's dietary manager confirmed that staffing shortages in the kitchen contributed to these delays, with fewer dietary aides available than required. Several residents, including those with conditions such as Type 2 Diabetes Mellitus, Chronic Heart Failure, and Asthma, expressed dissatisfaction with the erratic meal schedule. They reported feeling hungry due to the long intervals between meals, particularly when dinner was served late and no substantial bedtime snack was offered. The facility's policy requires that no more than 14 hours should elapse between the evening meal and breakfast unless a nourishing snack is provided, which was not consistently happening. Staff members, including CNAs and nurses, corroborated the residents' complaints, noting that meal trays were often delivered late, causing frustration among residents. The dietary manager acknowledged the issue, stating that the kitchen was short-staffed, leading to delays in meal preparation and delivery. The facility's failure to adhere to the posted meal schedule and provide adequate snacks between meals violated residents' rights to timely and nourishing meals, as outlined in the facility's policies and residents' rights documentation.
Facility Fails to Serve Food at Proper Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature for several residents, as observed and reported by both residents and staff. Residents R4, R7, R12, and R13 all expressed dissatisfaction with the food being served cold, which made it unappealing and inedible. R4 mentioned the lack of access to a microwave to reheat food, while R12 and R13 noted the use of disposable plates and the cold temperature of their meals. The surveyor's test tray confirmed that the food temperatures were below the required standards, with hot food items like Country Fried Steak and Mashed Potatoes measuring significantly below the recommended 140 degrees Fahrenheit. The dietary staff, including the Dietary Manager and Dietary Aide, acknowledged the issues with food temperature and attributed them to staffing shortages. The facility had stopped using a heated plate system, which previously helped maintain food temperatures during delivery, due to the increased labor required for cleaning the equipment. The Dietary Manager confirmed that the use of disposable plates was a result of insufficient staff to wash regular plates, particularly affecting the 2nd floor, which was the last unit served. The Registered Dietitian highlighted that the food temperatures were not meeting the required standards and emphasized the importance of serving hot food hot and cold food cold to ensure resident satisfaction and prevent potential negative impacts on residents' nutritional intake. The facility's policy on Resident Satisfaction mandates that food should be palatable, attractive, and served at the proper temperature, which was not being adhered to, as evidenced by the residents' complaints and the surveyor's observations.
Failure to Address Resident Grievances and Missing Property
Penalty
Summary
The facility failed to adhere to its grievance policy and resident rights, specifically in handling a resident's missing personal items. A resident, who is cognitively intact, reported that her Free Ride transportation pass and six dollars were missing from her belongings. Despite informing the social worker, no immediate action was taken to address the missing items. Additionally, the resident's clothing sent to the laundry was not returned, and the facility did not replace the items to her satisfaction. The Social Service Director provided the resident with clothing from the free clothes rack, which were not new and did not fit properly. The resident expressed dissatisfaction with the replacement clothing and was not offered reimbursement or replacement of her original items. The Social Service Director admitted to not completing a concern form regarding the missing items, which is a requirement under the facility's grievance policy. The facility's administrator was unaware of the missing items due to the lack of a completed concern form. The facility's policy requires immediate reporting of any alleged violations involving misappropriation of resident property to the administrator. The failure to follow this protocol resulted in the resident's grievances not being addressed promptly, violating her rights to keep and wear her own clothing and to have a safe place for her valuables.
Facility Fails to Maintain Safe and Sanitary Environment for Resident
Penalty
Summary
The facility failed to provide a safe and sanitary environment for a resident, identified as R12, who was observed with a leaking bathroom sink. The sink had a garbage can placed underneath to catch the water, which was filled approximately 25% with water. R12 reported that the sink had been leaking since her admission to the facility, and she had to be cautious not to knock the garbage can out of place to prevent water from spilling onto the floor. R12 expressed concern about the potential for slipping, as she had previously broken her wrist from a fall at home due to slipping on water. Despite the Certified Nursing Assistant (CNA) reporting the issue to the Maintenance Director a month prior, the leak had not been addressed. Additionally, the room contained an empty bed with a mattress that appeared to have black mold-like spots and multiple rips and holes in the plastic covering. R12, who has a history of allergies, reported symptoms such as watery eyes, a stuffed nose, and headaches, which she attributed to the moldy mattress and ceiling spots. The Maintenance Director and Housekeeping Director acknowledged the condition of the mattress and the ceiling, with the Maintenance Director noting that the ceiling spots were from a previous flood. The Paint Contractor suggested that the spots were likely mold and recommended using special paint to treat the area. R12, who has a diagnosis of seizures, type 2 diabetes, osteoarthritis, anemia, hypertension, difficulty walking, weakness, and allergic rhinitis, was assessed as having intact cognition and a high fall risk. The facility's job description for the Maintenance Director includes ensuring that residents' rooms are safe and free from hazards. The Illinois Long-Term Care Residents' Rights document also mandates that the facility must be safe, clean, comfortable, and homelike, which was not upheld in this case.
Failure to Accommodate Resident's Clothing Needs
Penalty
Summary
The facility failed to accommodate the basic needs and preferences of a resident, identified as R12, regarding clothing and personal storage space. R12, who has intact cognition and a BIMS score of 13, reported that her clothes were lost within the facility and expressed a desire to go to a store to purchase new clothing. Despite being told by the Activity Director that she could go, R12 was not taken to the store. During an observation, it was noted that R12 was wearing the same clothes from the previous night and had no additional clothing in her room. The Licensed Practical Nurse confirmed that R12's closet space was occupied by her roommates, leaving R12 without a designated area for her belongings. The Director of Social Service acknowledged R12's lack of clothing and the absence of a personal storage area, stating that R12 was under a specific program that required accompaniment when leaving the facility. Despite efforts to locate R12's clothing, including a search by housekeeping staff, no additional clothes were found. The facility's policy states that residents have the right to retain personal possessions and appropriate clothing, yet R12's needs were not met, as she was left without adequate clothing or storage space, contrary to the facility's stated policies on resident rights and accommodation of needs.
Failure to Provide Person-Centered Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide a person-centered care plan for a resident with a tracheostomy, leading to a deficiency in care. The resident, who has quadriplegia, seizure disorder, and respiratory failure with hypoxia, was admitted to the facility and later developed a trachea infection with MRSA. Despite the resident's intact cognition, the care plan did not address the tracheal infection or the resident's behavior concerning suctioning requests. The Director of Nursing confirmed that these issues were not included in the care plan, and there was no documentation of a care plan meeting involving the resident or their family to address these concerns. The resident frequently requested suctioning, even when not clinically indicated, which staff believed contributed to the infection. The Respiratory Therapist noted that excessive suctioning could lead to infection, trauma, or bleeding, and emphasized the importance of clinical judgment in assessing the need for suctioning. Despite these observations, the facility's care plan did not reflect these issues, and there was no evidence of the resident's participation in care planning, as required by the facility's policy. This lack of a comprehensive, individualized care plan that addresses the resident's specific needs and behaviors constitutes a deficiency in care.
Resident Lacks Individual Closet Space for Clothing
Penalty
Summary
The facility failed to provide individual closet space for a resident, identified as R12, which is a requirement for addressing residents' needs for functional furniture. R12, who is cognitively intact and alert, reported not having any clothes in her room and expressed frustration about not being able to go to the store to purchase clothes. During an observation, it was noted that R12 was wearing the same clothes from the previous day, and there were no clothes delivered for her. The closet space in the room was occupied by R12's roommates, R15 and R16, leaving R12 without a designated area for her clothing. The Licensed Practical Nurse (LPN) confirmed the absence of clothing for R12 and acknowledged that the closet space was allocated to the other residents in the room. The Director of Social Service was informed of the situation, and it was confirmed that R12 did not have a place to store her clothes. The facility administrator stated that providing a cabinet for clothing is not a requirement but something the facility offers. The admission packet indicates that residents have the right to retain personal possessions and appropriate clothing, as space permits, unless it infringes on the rights or safety of others.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident with cognitive impairment from abuse by other residents, resulting in injuries on two separate occasions. The first incident involved a resident with dementia, who sustained scratches and abrasions on the neck and face after an altercation with another resident. The resident with intact cognition admitted to punching the cognitively impaired resident because he was blocking the way. Despite the altercation being witnessed by a Certified Nursing Assistant, there was a delay in reporting the incident to the Registered Nurse, who was on break at the time. The incident was not immediately documented, and the facility's response was inadequate, as the administrator later suggested that the injuries might have been self-inflicted. In a second incident, the same cognitively impaired resident was injured when another resident, who also had cognitive impairments, tapped the resident's face, resulting in swelling and redness around the eye. This incident occurred in the hallway when the resident with dementia accidentally bumped into the other resident. The staff was busy at the time, and the incident was observed from the nurse station. The injured resident was subsequently sent to the hospital for further evaluation, where the incident was classified as an assault. The facility's abuse policy prohibits resident abuse and requires staff to report and document any incidents of abuse or injury. However, in both incidents, there were delays in reporting and inadequate documentation. The facility's administrator downplayed the severity of the incidents, attributing them to the residents' cognitive impairments and suggesting that the injuries were not intentional. This response was not in accordance with the facility's abuse policy, which mandates the prevention and prohibition of resident abuse.
Failure to Investigate Resident Abuse Incidents Properly
Penalty
Summary
The facility failed to follow its policy on investigating incidents of abuse for a resident with severe cognitive impairment. The resident, who has a medical history of dementia and Alzheimer's disease, was involved in an incident where another resident admitted to punching him in the face. Despite the admission, the facility's investigation did not conclude that the injury was caused by the other resident, and the final report submitted to the state agency inaccurately documented that there were no injuries. In another incident, the same resident was hit in the face by a different resident, resulting in swelling and redness around the eye. The facility's report to the state agency again inaccurately stated that there were no injuries, despite medical records and witness statements indicating otherwise. The facility's investigation process was flawed, with missing witness signatures and discrepancies in the documentation of the incidents. The facility's abuse policy requires immediate reporting and thorough investigation of any alleged abuse, including documentation of injuries and witness statements. However, the facility's handling of these incidents did not comply with its policy, as evidenced by incomplete and inaccurate reports, lack of proper documentation, and failure to conclude investigations based on known facts.
Failure to Properly Label and Contain Oxygen Equipment
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling, dating, and proper containment of oxygen equipment for a resident requiring respiratory care. The resident, who is cognitively intact and has multiple diagnoses including quadriplegia, asthma, and chronic respiratory failure, was observed with a trach nebulizer mask and oxygen tubing that were not dated or properly contained. The equipment was found lying in a grey basin with wound care cleaner and antifungal powder, which were also uncontained and undated. Interviews with facility staff, including a Registered Nurse, the Director of Nursing, and the Infection Prevention Nurse, confirmed that the oxygen equipment should be dated, changed weekly, and stored in a zip lock bag when not in use to prevent contamination and infection. The facility's policy on oxygen administration requires that tubing, humidifier bottles, and filters be changed, cleaned, and maintained at least weekly, with each item labeled with the date, time, and initials of the staff member completing the service. Despite these requirements, the facility failed to ensure compliance, leading to a deficiency in the provision of safe and appropriate respiratory care for the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and protect a resident, identified as R8, from physical abuse by another resident, R9. The incident occurred when R8 and R9, who were roommates, got into a verbal and physical altercation over room temperature adjustments. R9 used his walking cane to strike R8, resulting in R8 being sent to the hospital with a left hip fracture. The altercation was reported by another roommate, R3, who witnessed the incident and informed the nurse on duty, V12. Despite the severity of the incident, the facility's response was inadequate as the administrator, V1, had not yet completed the investigation or spoken to other residents involved. R8, who uses a wheelchair and has a history of osteoarthritis of the hip, epilepsy, and other mobility issues, was left vulnerable to the attack. The nursing progress notes indicate that R8 complained of pain in the left hip and was administered pain medication while awaiting an ambulance. R8's medical records confirmed a femoral fracture upon hospital admission. R9, who has diagnoses including major depressive disorder and insomnia, was also sent to the hospital following the altercation. The facility's initial report to the state agency was submitted, but the investigation was still ongoing at the time of the survey. The administrator had not yet received confirmation of R8's hip fracture and had not contacted the hospital for further information. Additionally, R3 reported that this was not the first altercation between R8 and R9, indicating a pattern of unresolved conflict that the facility failed to address adequately. The facility's policy on abuse prevention was not effectively implemented, leading to this deficiency.
Inadequate Supervision of Smoking Practices
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent residents from smoking inside the facility, which is against the established policy. On multiple occasions, a resident was reported to be smoking in his room and bathroom, which was confirmed by the smell of cigarette smoke detected by staff and a surveyor. Despite being informed of the situation, the social worker delayed addressing the issue due to other responsibilities, and the resident was found with cigarette ashes in his nightstand. The facility's policy prohibits smoking inside and requires supervision in designated smoking areas, but this was not enforced effectively. Additionally, the facility did not ensure proper supervision in the designated smoking area. Two activity aides were observed monitoring residents from inside the building rather than being present outside with the residents. This lack of direct supervision allowed a resident to light his own cigarette, which is against the facility's policy. The aides admitted that residents sometimes hide lighters, and cigarette butts were improperly discarded on the ground, increasing the risk of fire hazards. The facility's failure to enforce its smoking policy and provide adequate supervision poses a significant safety risk, especially to residents who are prescribed oxygen. The facility document lists 22 residents on oxygen, with several residing on the same floor as the resident who was smoking inside. The facility's policy clearly outlines the need for staff to control smoking materials and supervise residents while smoking, but these measures were not adequately implemented, compromising resident safety.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that the medication cart on the 3rd floor was locked or attended by authorized staff, as required by their policy. During a surveyor's visit, it was observed that the medication cart was left unlocked and unattended in the hallway and nursing station area. The surveyor, accompanied by a housekeeping staff member, found no staff present in the vicinity, and the housekeeping staff was able to open the drawer of the medication cart, confirming it was not locked. When a Licensed Practical Nurse (LPN) arrived shortly after, they immediately locked the cart. Upon inquiry, the LPN initially claimed the cart was locked but acknowledged the oversight when informed that the drawer had been opened. The facility's medication storage policy mandates that medication carts be locked or attended by authorized personnel, such as licensed nurses or pharmacy staff, to ensure the safety and security of medications and biologicals.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse, resulting in a physical altercation between two residents, R3 and R4. The incident occurred in the hallway when R3 and R4 engaged in a verbal argument that escalated to physical violence, with R3 hitting R4. Interviews with staff members, including a CNA and the Director of Social Services, confirmed that the altercation involved physical contact, which is considered a form of physical abuse. The facility's abuse policy, which prohibits and prevents resident abuse, was not effectively implemented in this situation. The altercation was witnessed by staff members who intervened to separate the residents. R3 was noted to have a history of being verbally aggressive and combative when redirected, as documented in a care plan revision. The incident was reported to the Assistant Director of Nursing, who confirmed that both residents were sent to the hospital following the altercation. The facility's policy on resident rights and protection emphasizes the right to be free from abuse and neglect, highlighting a deficiency in the facility's ability to uphold this standard during the incident.
Involuntary Seclusion of a Resident Using a Garbage Bag
Penalty
Summary
The facility failed to adhere to its abuse policy by involuntarily confining a resident, identified as R2, in their room using a garbage bag to block the door. This incident involved a severely cognitively impaired male resident with a diagnosis of unspecified dementia, Alzheimer's disease, and other conditions requiring assistance with personal care. On the night of the incident, a CNA, identified as V11, placed a bag around R2's door to prevent him from pacing in the hallway, which was later identified as involuntary seclusion. The resident was observed pacing in his room and appeared confused, unable to recall the incident due to his cognitive impairment. The incident was reported by another resident, R7, who witnessed the door being tied with a plastic garbage bag, preventing R2 from leaving his room. The Director of Social Services and the Assistant Director of Nursing confirmed that the action constituted involuntary seclusion, which is not tolerated by the facility. The facility's abuse policy and resident rights documentation emphasize the prohibition of abuse and the right to dignity and respect. The investigation led to the termination of V11 for blocking R2's door, as there was no documentation or order justifying the need to confine R2 as a protective measure.
Failure to Implement Baseline Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident with a high risk of falls upon admission, as required by regulations. The resident, who was admitted with a history of multiple falls and diagnoses including vascular dementia and hemiplegia, experienced several falls within the facility without appropriate interventions or preventive measures in place. Despite being consistently assessed as high risk for falls, the resident's fall concerns were not addressed in a care plan until after multiple incidents had occurred. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident in question. Interviews with staff revealed a lack of clarity regarding the timing and responsibility for creating baseline care plans. The facility's failure to adhere to its own policies and federal regulations resulted in the resident experiencing multiple falls without adequate preventive measures being implemented.
Resident Threatened with Privilege Removal by Staff
Penalty
Summary
The facility failed to protect a resident, identified as R2, from mental abuse by a staff member, V12, a psychiatric technician. On October 11, 2024, V12 allegedly threatened R2 with the removal of her green pass privileges if her family continued to call the facility with complaints. This incident was corroborated by R2's roommate, R1, who heard V12 say that R2's green pass was in jeopardy. R2 reported feeling threatened and abused by this interaction, which caused her mental anguish. V12 claimed that he only relayed a message from V13, the social service coordinator, but V13 denied requesting R2 to speak with her about pass privileges. R2's medical history includes chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, with a BIMS score indicating intact cognition. The facility's policies emphasize the prohibition of resident abuse and the right of residents to be free from mental abuse. Despite these policies, the incident involving V12's threat to R2's privileges was perceived as verbal abuse by the Assistant Director of Nursing, V2, who acknowledged that such a threat constitutes verbal abuse. The facility's administrator, V1, however, expressed skepticism about the situation being abusive, noting a history of abuse allegations involving R2.
Inadequate Bathroom Access for Bariatric Wheelchair Users
Penalty
Summary
The facility failed to provide adequate accommodations for residents requiring bariatric wheelchairs to access the bathroom in their rooms. This deficiency affected two residents, one of whom was diagnosed with multiple health conditions including type 2 diabetes, morbid obesity, and chronic respiratory failure. Despite having an intact cognitive status, the resident was unable to independently access the bathroom due to the size of their bariatric wheelchair, which was too wide to fit through the bathroom door. Observations and interviews with staff confirmed that the wheelchair's width exceeded the bathroom door's width, preventing the resident from using the bathroom independently. The facility's policy on ensuring reasonable accommodation of needs was not adhered to, as the physical environment was not individualized to support the independence of residents with bariatric needs. Staff, including the Maintenance Director and Assistant Director of Nursing, acknowledged the issue, noting that the bathroom doors in all resident rooms were of the same size and did not accommodate bariatric wheelchairs. The Maintenance Director also highlighted that this situation did not provide a homelike environment and posed a safety risk for residents attempting to use the bathroom independently.
Deficiencies in Kitchen Cleanliness and Food Safety
Penalty
Summary
The facility failed to maintain cleanliness and proper food safety standards in the kitchen, which has the potential to affect all 139 residents receiving food prepared there. The kitchen lacked a dietary manager, and the staff were unclear about who was in charge. Observations revealed that personal items were improperly stored on clean dish racks, leading to potential cross-contamination. The kitchen equipment, including the steam table pans and meat slicer, was found to be dirty with food residues and substances that could cause foodborne illnesses. The kitchen counters and stove were covered with various colored crumbs and sticky substances, indicating a lack of regular cleaning. The oven was also found to be in a similar state, with thick black substances inside and on the door handles. Garbage cans were uncovered, and food crumbs were found on the floor, further contributing to unsanitary conditions. The facility's policy documents outlined specific cleaning procedures that were not being followed, such as covering and dating foods in the refrigerator and maintaining sanitation buckets to prevent cross-contamination. Additionally, the walk-in cooler contained expired milk and uncovered, undated raw pork chops, posing a risk of foodborne illness. The cook reported being unable to clean the kitchen due to understaffing, as there was no pan washer available. This situation led to the cook having to choose between cleaning and preparing meals, resulting in unclean conditions. The Director of Nursing acknowledged the staffing issue and mentioned that a new cook was expected to start soon.
Failure to Facilitate Resident's Attendance at Religious Services
Penalty
Summary
The facility failed to make arrangements for a resident, identified as R7, to attend religious services of their choice, which is a violation of the resident's rights. R7, who has a medical history including cerebral infarction, type II diabetes, and dementia, among other conditions, was previously able to attend church services independently using a transportation service. However, after an incident where R7 was seen crossing the street in a wheelchair against traffic, the facility changed R7's community pass from green (independent) to yellow (requiring supervision), restricting R7's ability to attend church independently. Despite R7's cognitive intactness and expressed desire to continue attending church services, the facility did not make alternative arrangements to accommodate this change. The Social Service Director and Assistant attempted to contact R7's church to arrange for transportation assistance, but no arrangements were made, and R7 missed several church services. The facility's van, which was used for other appointments, was not considered a viable option for church transportation due to its unreliability and lack of staff availability on weekends. The facility's policy states that residents have the right to attend religious services of their choice, and the facility must make arrangements for this if the resident agrees to pay any associated costs. However, the facility did not fulfill this obligation, as no plan or agreement was made to ensure R7 could attend church services, despite R7's willingness to pay for transportation. This inaction led to a deficiency in honoring the resident's rights to a dignified existence and self-determination.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident, identified as R2, from physical abuse by another resident, R4, who has documented aggressive behavior. R2, who has a history of mental illness and other medical conditions, reported being hit on the back of the head by R4 in the dining room. Despite the presence of staff, the altercation occurred, and R2 was offered but declined pain medication. Neuro checks were initiated for R2 following the incident. R4, who also has a history of mental illness and aggressive behavior, was involved in the altercation with R2. R4 claimed that R2 provoked him, leading to the physical aggression. R4's care plan noted ongoing aggressive behavior, and staff were instructed to intervene when inappropriate behavior was observed. Despite these measures, R4's aggression towards R2 and staff continued, resulting in a recommendation for psychiatric evaluation. The facility's policy on abuse prevention requires immediate reporting and investigation of any incidents of abuse. However, the report indicates that the facility did not substantiate the abuse claim, despite multiple staff members witnessing the altercation and R4's known aggressive behavior. The facility's failure to effectively manage R4's aggression and protect R2 from harm constitutes a deficiency in ensuring resident safety and preventing abuse.
Inadequate Investigation of Alleged Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving two residents, R2 and R4. R2, who has a history of mental illness and cognitive communication deficits, reported being hit on the back of the head by R4 in the dining room. Despite the incident being witnessed by staff, including a certified nurse assistant, the investigation was not comprehensive. Key staff members, such as the activity aide who witnessed the event, were not interviewed, and there was a lack of documentation and signed statements from those involved. R4, who also has cognitive communication deficits and a history of aggressive behavior, admitted to hitting R2, claiming provocation due to racial slurs. Despite this admission and the ongoing aggressive behavior exhibited by R4, the facility's investigation concluded without substantiating the abuse claim. The facility's policy requires a thorough investigation, including interviews with all witnesses and involved parties, which was not adhered to in this case. The Director of Nursing acknowledged the inadequacy of the investigation, noting that not all staff were interviewed and that the necessary documentation was incomplete. The facility's failure to follow its abuse prevention policy and conduct a thorough investigation into the alleged abuse incident represents a significant deficiency in ensuring resident safety and compliance with regulatory standards.
Failure to Provide Double Portions as Prescribed
Penalty
Summary
The facility failed to provide double portions as listed on a resident's meal ticket, which was observed during a survey. The resident, who has a range of medical conditions including Type 2 Diabetes Mellitus and Schizoaffective Disorder, was supposed to receive double portions of their meal as per their dietary requirements. However, during a lunch service, the resident received only a single portion of pork chop, corn, and sweet potatoes, despite the meal ticket indicating a double portion. The resident expressed dissatisfaction with the meal, stating it was not enough food. The dietary staff, including a cook and a registered dietitian, confirmed that the resident should have received double portions, which would include two servings of each item on the menu. The cook mentioned that the failure to provide double portions was due to running out of pork chops. The interim dietary manager acknowledged the oversight and explained the process for ensuring dietary orders are followed, which involves communication between dietary staff, nurses, and physicians. The facility's policy on portion control emphasizes adherence to planned menus and proper communication of dietary requests, which was not followed in this instance.
Failure to Follow Physician's Orders for Therapy Services
Penalty
Summary
The facility failed to follow physician's orders for therapy evaluation and treatment for a resident diagnosed with spinal stenosis, radiculopathy, morbid obesity, osteoarthritis, and muscle wasting and atrophy. The resident's care plan included a focus on spinal stenosis with interventions for physical and occupational therapy evaluation and treatment as indicated. Despite an active order for therapy screening and potential treatment, the resident reported not receiving physical therapy services, with the facility citing insurance issues as the reason for not providing additional sessions. The Therapy Manager was unaware of the resident's desire for more therapy, and the Physical Therapist confirmed that the resident was discharged from therapy and not re-evaluated despite a physician's note recommending therapy twice a week. The nurse who attended to the resident after a pain clinic appointment did not report any new orders, including the therapy order. The Director of Nursing acknowledged that the pain clinic's plan constituted orders that should have been followed. The facility's policies require following physician orders and completing evaluations upon receipt of such orders, which were not adhered to in this case.
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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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