Countryside Nursing & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Dolton, Illinois.
- Location
- 1635 East 154th Street, Dolton, Illinois 60419
- CMS Provider Number
- 145798
- Inspections on file
- 44
- Latest survey
- October 1, 2025
- Citations (last 12 mo.)
- 52
Citation history
Health deficiencies cited at Countryside Nursing & Rehab Ctr during CMS and state inspections, most recent first.
A cognitively impaired resident with multiple medical and psychiatric diagnoses was moved to a new room after expressing a desire to change, but the emergency contact was not notified prior to the move as required by facility policy. Staff interviews confirmed that the standard notification process was not followed, resulting in a failure to honor the resident's right to have their representative informed before a room change.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
Surveyors found that medication security policies were not followed when two separate med carts on different units were left unlocked and unattended. In one case, an RN left a cart open in the hallway while administering meds behind a curtain to a resident in their room, contrary to policy requiring the cart to be locked when out of the nurse’s direct sight. In another case, a CNA discovered an LPN’s med cart unlocked and unattended and locked it; the LPN later acknowledged this was an error. Facility policies require meds and biologicals to be stored safely and securely, with access limited to licensed or otherwise authorized staff.
Surveyors found that dietary staff responsible for preparing and serving food did not consistently hold required food handling and sanitation certifications, despite job descriptions stating that cooks and dietary aides must ensure safe food handling and maintain regulatory standards. During observations, only a few of the dietary staff had current food handling certificates, and the cook and cook/dietary aide initially working alone in the kitchen lacked these certifications. The dietary manager acknowledged normal staffing patterns and was unable to explain why several staff did not have the required certificates, even though all residents receiving food by mouth could be affected.
Surveyors observed multiple dietary staff preparing pureed foods, sandwiches, and desserts while failing to follow basic sanitation and hand hygiene practices. Full garbage bags were stored on the kitchen floor near food preparation, open seasoning containers were undated, and a flour bin contained a scoop left inside. An ice machine in an employee area was visibly dirty with debris on its surfaces. A cook reused a wet food processor without allowing it to air dry between pureed items, and several dietary aides handled ready-to-eat foods after touching surfaces, wiping tables, or changing gloves without performing required hand hygiene, contrary to the facility’s written handwashing policy.
Multiple residents identified as high risk for falls were not provided with required safety interventions, such as floor mats, call lights, and proper footwear. Staff failed to consistently implement care plan measures, address environmental hazards like wet floors, and supervise residents in communal areas, resulting in unaddressed accident hazards and lapses in resident safety.
The facility did not provide enough CNAs during a night shift, resulting in only two CNAs caring for over 150 residents, despite the facility's own assessment indicating a need for nine. This led to residents experiencing delays in care, unsanitary conditions, and issues with medication administration. LPNs and RNs were assigned to large numbers of residents, and medication carts were left unattended. Additionally, a nurse managing the restorative program lacked required training, and residents did not always receive appropriate fall prevention or hygiene interventions.
The facility failed to ensure that advance directives and POLST forms were accurately completed and maintained, leading to unclear or conflicting directions about residents’ treatment preferences. One resident had an advance directive on file with no treatment options selected, while several others had POLST forms signed by both the resident and physician but with no choices marked in key sections. Another resident’s POLST contained conflicting selections between CPR/Full Treatment and Selective Treatment. The Social Services Director acknowledged that the forms were not completed correctly and that incomplete POLSTs leave staff and hospitals without clear guidance, contrary to the facility’s own advance directive policy.
Surveyors found that the facility did not follow its Identified Offenders Program and abuse-prevention policies for multiple residents with documented criminal histories. Required criminal background checks (CHIRP) were not consistently completed within 24 hours of admission, and when CHIRP results showed arrest histories such as burglary, theft, domestic battery, arson, and sexual offenses, the facility did not obtain or document required fingerprinting within the specified timeframe. In several cases, fingerprints were done weeks or more than a year after admission, or there was no evidence they were done at all. The Social Services Director reported that a former Social Services Director had been responsible for these processes and that staff were unable to locate key IOP and fingerprint documentation, despite facility policies requiring these measures to support a safe environment and residents’ freedom from abuse and exploitation.
Nursing staff failed to follow medication administration timing and documentation requirements. One LPN, a recent graduate assigned to a large number of residents, reported having given nearly all 9 a.m. medications within a short period, and observation of a single 9 a.m. medication pass showed it took significantly longer than the time implied by her report, suggesting medications were given outside the allowed time window. Multiple nurses, including RNs and LPNs, stated that residents had received their scheduled medications even though the EMAR still showed doses as late or due, and they acknowledged they had not documented administration at the time of giving the medications. These practices did not comply with the facility’s policy requiring medications to be prepared no more than 60 minutes in advance and documented on the MAR immediately after administration.
The facility failed to maintain an effective pest control program and keep resident areas free of flying insects. Surveyors observed gnats in a unit hallway and in a resident room where the resident reported pervasive gnats and kept the bathroom door shut to limit their entry. In another room, nine fly traps with multiple flies/gnats were seen, along with a urinal containing a tan, crusty substance that housekeeping staff stated should have been emptied because gnats are attracted to urine. An initial review of pest control records showed only one service report from several months prior, and the Maintenance Director confirmed there had been no pest control visit between two documented service dates, despite a facility policy requiring an effective, facility-wide pest control program.
A resident with cognitive impairment and an indwelling urinary catheter was observed in bed with an uncovered urinary drainage bag containing urine hanging from the bed frame, rather than being placed in a privacy bag as required by facility practice. The resident reported that staff had not been keeping the drainage bag in a privacy bag while in bed. The DON confirmed the bag was uncovered and not stored in a manner that promotes dignity, despite a policy stating residents have the right to be treated with dignity and respect.
Staff posted a document above a resident’s bed in a semi-private room that displayed the resident’s full name, facility name and address, PASARR-related information, and a statement about the resident’s [NAME] Class Member status and decision not to proceed with assessment, making this PHI visible to visitors, staff, and the roommate. The resident, who had major depressive disorder, borderline personality disorder, mild intellectual disabilities, and a severely impaired BIMS score, reported not knowing what the paper was and stated that a nurse had placed it there. The EMR contained no evidence of the resident’s consent to publicly display this information, despite facility HIPAA and Resident Rights policies requiring confidentiality of medical records and protection of resident privacy.
Surveyors found that the facility failed to maintain a clean, odor-free, and functional environment in resident rooms, bathrooms, hallways, and dining areas. A resident reported filthy, foul-smelling community bathrooms with gnats, and surveyors confirmed strong urine odors and broken shower handles in multiple shower rooms. In one bedroom, a soiled pullup, dirt clumps, and scattered trash were observed on the floor and dresser. Hallway and common-area floors were heavily soiled with food debris, black dirt, and grime despite ongoing mopping, and staff acknowledged that required floor buffing and deeper cleaning were not being done. In the dining room, ceiling tiles were missing and unidentified liquid dripped from the ceiling onto the floor, creating puddles that residents walked through, with one resident getting dripped on while carrying a lunch tray. These conditions conflicted with facility policies requiring a safe, clean, comfortable, and homelike environment.
A resident with documented delusional, psychotic, anxiety, and major depressive disorders was admitted and remained in the facility without a PASARR Level I screening completed at admission, despite facility policy requiring a Level I screen for all potential admissions. The resident’s care plan reflected ongoing delusions and related psychiatric diagnoses, yet during survey the PASARR could not be found in the EMR, and the SSD acknowledged that the resident should have had both a Level I and likely a Level II PASARR. A PASARR Level I outcome notice, dated during the survey, showed a determination to refer the resident for a Level II onsite review, confirming that the required PASARR screening had not been done at the time of admission.
A resident with chronic venous disease, diabetes, and mild pressure ulcer risk was observed with an open area on the left shin and a wrapped right leg dressing showing dried serosanguinous drainage, yet staff had no active wound treatments or documentation of open areas. The wound care LPN reported there were no open leg wounds and no treatments in place as of several days prior, and the record, including the most recent MDS, did not show any unhealed ulcers or skin tears. During the same visit, a physician identified skin tears on the resident’s left shin and right calf with specific measurements, and these wounds were documented as not present on admission. Despite facility policy requiring weekly skin assessments for residents at mild and moderate risk and routine skin inspection of lower extremities during care, the facility was unaware of the resident’s skin tears until they were observed and assessed during the survey.
A resident with multiple sclerosis, moderately impaired cognition, a Braden score indicating mild risk for pressure ulcers, and an existing stage IV pressure ulcer was found lying on a low air loss (LAL) mattress set between 600–1000 pounds despite a documented weight of 187.8 pounds. The resident reported the mattress felt like a cement floor. Facility policies and the LAL mattress manual require weight-based settings to promote pressure reduction and wound healing, yet the LPN responsible for wound care acknowledged the mattresses are supposed to be set to the resident’s weight but was unsure of the specifics and was not wound-care certified.
A resident with multiple sclerosis and gastrostomy status, requiring enteral bolus feedings and water flushes, was found with a tube feeding syringe hanging by the bed in an opened package dated several days earlier and not labeled with the resident’s name. The resident, who had moderately impaired cognition, was unsure how old the syringe was. Facility policies and the DON’s statement required piston/tube feeding syringes to be changed every 24 hours and labeled with the resident’s name and date, but these procedures were not followed for this resident.
Two residents’ CPAP masks were found unlabeled, undated, and not contained in plastic bags between uses, with one mask stored loose in a dresser drawer and another lying directly on a bare mattress. When questioned, a resident reported that staff did not keep the mask in a bag, and an LPN confirmed that one mask was not bagged and had no date. The facility’s respiratory therapy infection prevention policy requires nebulizer/continuous aerosol circuits to be stored in a plastic bag labeled with the date and resident’s name between uses, while noting that CPAP maintenance is excluded.
A resident’s monthly medication regimen review (MRR) referenced required follow-up actions, but the actual pharmacist recommendations for a medication change were missing from the MRR and not available to staff. When questioned, the DON reported that the pharmacist had indicated a recommendation but had not sent the specific details, contrary to facility policy requiring that consultant pharmacist observations, medication-related problems, and recommendations be documented, communicated in a timely manner, and readily accessible to nurses, physicians, and the care planning team.
Two residents experienced medication administration errors when staff did not follow physician orders or the facility’s medication policy. In one case, an LPN withheld a scheduled antihypertensive dose despite the resident’s BP being above the ordered hold parameters. In another case, a resident with glaucoma did not receive prescribed Simbrinza eye drops at the ordered morning time because an LPN misinterpreted the EMAR and confused the order with a different eye drop, resulting in the dose being given several hours late.
The facility did not post complete daily nurse staffing information as required. A staffing schedule observed near the lobby entrance lacked the facility name, resident census, and the total number or actual hours worked by licensed and unlicensed direct care staff per shift. The ADON confirmed this document was used to meet the daily staffing posting requirement and acknowledged it did not contain the missing information, despite facility policy requiring nurse staffing data to be posted each shift in accordance with state and federal regulations.
Surveyors found that the facility’s medical director did not attend or participate in QAA/QAPI meetings, as evidenced by missing signatures on QAA committee sign-in sheets and confirmation from the Administrator and a nurse consultant. Facility leadership acknowledged that the medical director is required to be involved in QAA/QAPI activities, and facility policy states that all staff and departments must participate in system and process improvement efforts, yet this did not occur for a census of 158 residents.
Multiple residents with cognitive and psychiatric conditions were not protected from physical abuse by peers, including incidents where one resident struck another with a tool and another resident hit and pushed two peers. Staff and documentation confirmed the events, and the facility's abuse prevention policy was not followed, resulting in harm and risk to vulnerable individuals.
Two residents with histories of mental illness and substance abuse were not adequately monitored or provided with individualized care plan interventions for substance use or self-harm, despite clear facility policies requiring such actions. Both residents tested positive for drugs while in the facility, and one engaged in self-harming behavior. Staff failed to conduct required room searches, notify physicians, or refer cases to law enforcement, and there was a lack of documentation and follow-through on interventions, even as staff and residents reported ongoing substance use and related behaviors.
A resident with a history of severe mental health conditions, assessed as low elopement risk and alert at the time, left the facility without authorization. Staff pursued and attempted to physically restrain the resident, resulting in a chest wall injury, instead of following the facility's policy for de-escalation and non-restraint. The incident demonstrated a failure to honor the resident's rights to dignity and self-determination.
Two residents with significant histories of self-harm, suicidal ideation, and substance use did not receive individualized care planned interventions, timely assessments, or documented therapeutic mental health and substance abuse services as required by facility policy. Facility records lacked evidence of referrals, participation in therapy, or documentation of interventions, despite clear recommendations and ongoing behavioral health needs.
The facility did not complete required background and fingerprint checks for four employees before allowing them to begin work, as mandated by facility policy. HR staff failed to obtain or document criminal background, sex offender, and abuse registry checks prior to hire, and in some cases, these checks were only initiated after surveyor inquiry. The process for verifying eligibility to work was inconsistent, resulting in staff working without completed background screenings.
A nursing staff shortage in an LTC facility resulted in missed medications and assessments for several residents. From 2:00 AM to 6:04 AM, no nurse was present, leading to delayed or missed 6:00 AM medications for four residents and unmonitored blood sugar levels and insulin administration for five diabetic residents. The absence of nursing staff also meant that no residents received scheduled assessments or vital sign monitoring during the night shift.
The facility failed to follow its medication administration policy, leading to significant errors in monitoring and documenting high alert medications for four residents. Nurses did not consistently sign out medications on the MAR and controlled substance sheets, nor did they follow up on the effectiveness of pain medications administered as needed. This resulted in discrepancies in documentation and a lack of proper assessment of medication effectiveness.
A resident with a complex medical history experienced a critical health event, but the LTC facility failed to notify the family. Despite the resident being unresponsive and transferred to the hospital, the family was not informed, and there was no documentation of follow-up attempts. The facility's protocol for notifying family and management during emergencies was not adhered to.
A resident with COPD and dependent on supplemental oxygen did not have a follow-up appointment with a pulmonologist scheduled as ordered, and did not receive prescribed medications or have vital signs monitored. The resident became unresponsive, leading to a code blue, but the emergency response was inadequately documented, with no recorded vital signs or sequence of resuscitation efforts.
A facility failed to follow professional standards during G-Tube medication administration for a resident. An LPN administered medication without checking the G-Tube placement, contrary to the facility's policy, which requires checking placement by auscultation or residuals. The resident, an elderly female with multiple health conditions, did not have her G-Tube placement verified as per the expected procedure.
A resident on hospice care was not provided necessary assistance with eating, despite expressing pain and needing help. The resident's fingernails and toenails were long, thick, and discolored, pressing into the skin, indicating a lack of proper nail care. The care plan required supervision or touch assistance with eating and partial assistance with personal hygiene, which was not adequately provided.
The facility failed to implement fall prevention measures for two residents at high risk for falls. One resident was observed with their bed in a high position, contrary to safety policies, and had a recent fall incident. Another resident fell due to improper footwear and lack of resources to obtain proper shoes, resulting in a knee sprain. The facility's policies emphasize safety interventions, but these were not adequately followed.
A resident with a history of cerebral infarction and dysphagia was not provided with continuous enteral feeding as ordered by the physician. Observations showed the resident without the feeding tube attached during various activities, and the care plan was not updated. The facility's policy on enteral nutrition was not adhered to, leading to the deficiency.
A resident reported severe knee pain after a fall, but the facility only provided acetaminophen and failed to reassess pain or notify the physician as per protocol. The DON expected regular pain assessments, but records showed no pain medication was administered or documented.
A facility failed to ensure updated hospice medical records were accessible to all IDT members, affecting a resident with breast cancer receiving palliative care. The resident's hospice plan of care was outdated, and progress notes were improperly documented, violating facility policy and contractual obligations for coordinated care.
A facility failed to implement Enhanced Barrier Precaution (EBP) for a resident on enteral feeding. Observations showed no EBP signage at the resident's room, and there was no physician order for EBP in the chart. Staff acknowledged the need for EBP due to the resident's gastrostomy, but the required precautions were not consistently followed.
A resident's medical records were not released in a timely manner despite requests from the legal representative. The resident, with severe cognitive impairment, had authorized a law office to request the records. The facility's policy requires records to be accessible within two working days, but delays occurred due to staff changes and technical issues.
A resident with a history of aggressive behavior became physically aggressive towards another resident who repeatedly opened the shower room door, despite staff attempts to intervene. The incident resulted in both residents falling to the floor, highlighting a failure in implementing the facility's abuse prevention policy.
A facility failed to protect a resident from abuse by another resident and failed to prevent verbal abuse by staff. An altercation between two residents resulted in one sustaining a head injury. Inadequate staff training and supervision contributed to the incident, as a CNA was left alone to monitor multiple residents without proper training. Another CNA verbally abused a resident during the incident. Facility policies on de-escalation and abuse prevention were not followed.
A resident with multiple health issues, including vision loss and a history of falls, was found with a swollen left eye. The facility did not report this injury of unknown origin to the state agency as required by their policy. The Director of Nursing acknowledged the oversight, and the facility's records lacked documentation of the incident.
A high fall risk resident suffered a brain bleed after the facility failed to monitor them adequately and implement timely interventions. Despite being identified as a high fall risk, the resident's call light was not within reach, and fall mats were not placed until several days after the fall. Staff interviews revealed inconsistencies in applying fall prevention measures, contributing to the resident's injury.
Failure to Notify Resident Representative Prior to Room Change
Penalty
Summary
The facility failed to follow its policy regarding notification of a resident representative prior to a room change for a cognitively impaired resident. The resident in question, an older adult male with multiple diagnoses including Type 2 diabetes, hypertensive heart disease, bipolar disorder, and moderate cognitive impairment (BIMS score of 11), was not responsible for his own decisions and had an assigned emergency contact. On the date of the room change, the Assistant Administrator moved the resident to a new room after the resident expressed a desire to change rooms. However, the resident's emergency contact was not notified of the change prior to it occurring, as required by facility policy. Interviews with facility staff confirmed that the standard procedure is for the DON or Social Service Director to notify the resident's emergency contact and document the notification in the electronic health record. In this instance, the Assistant Administrator acknowledged that the emergency contact was not informed on the day of the room change. The facility's policy specifies that both the resident and their representative must be provided with information about the room change prior to it taking place, which did not occur in this case.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Unlocked and Unattended Medication Carts on Two Units
Penalty
Summary
The deficiency involves failure to ensure that medications and biologicals were stored securely in locked compartments when unattended, as required by facility policy. On one occasion, a registered nurse on Unit B left a medication cart unlocked and unattended in the hallway while administering medications to a resident in their room. The nurse stated they believed they could see the cart from the doorway, but during medication administration they were behind the resident’s curtain, while the cart remained in the hallway. The facility’s medication administration policy dated 10/25/14 requires that during medication administration, the cart be kept closed and locked when out of sight of the medication nurse or aide, and that the cart be clearly visible and inaccessible to residents or others passing by. A second incident occurred on Unit C, where a medication cart assigned to an LPN was found unlocked and unattended. When the surveyor asked if the cart was locked, a CNA checked the cart, expressed surprise, and then locked it, confirming it had been left unlocked. Minutes later, when questioned by the surveyor, the LPN acknowledged that leaving the cart unlocked and unattended was an error. The facility’s storage of medications policy dated 10/25/14 states that medications and biologicals are to be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The facility census at the time was 158 residents.
Failure to Ensure Dietary Staff Held Required Food Handling Certifications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff possessed required food handling and sanitation certifications as outlined in their job descriptions. During an initial kitchen tour, only two dietary staff members, a cook and a cook/dietary aide, were present, and the dietary manager was absent. The dietary manager later stated that there had been a call-off and that she normally schedules three aides and one cook per shift, including herself. When surveyors requested food handling certificates for all dietary staff, the dietary manager produced a list of nine dietary staff, including herself, along with her active food manager license and three food handling certificates for three dietary aides. The cook and the cook/dietary aide who were the only staff in the kitchen when the survey team first entered did not have food handling certificates, and at that time only three of nine dietary staff had current food handling certificates. Further review of the certificates initially presented showed that two dietary staff had certificates without expiration dates, and the dietary manager later produced new certificates for those two staff dated during the survey. Surveyors identified that approximately four staff members still had no certificates, including the two staff who had been working in the kitchen upon entrance. The dietary manager stated she did not know why the dietary staff did not have food handling certificates. The job descriptions for the cook and dietary aides state that their primary purpose includes ensuring safe food handling procedures and maintaining all federal, state, and local nutritional/dietary regulations, and under qualifications and essential requirements, the cook position requires possession of a sanitation certificate. This failure had the potential to affect all 153 residents who receive food by mouth from the kitchen.
Improper Food Handling, Equipment Use, and Hand Hygiene in Dietary Services
Penalty
Summary
Surveyors identified multiple failures in food preparation and handling practices in the facility’s kitchen and related areas. During an initial kitchen tour, surveyors observed three full garbage bags placed on the floor near an active food preparation area. Several large containers of open seasonings, including paprika, onion powder, garlic powder, and Italian seasoning, were stored on a shelf without any open dates. A flour container with a lid was found with a scoop left inside the bin. In the employee break room, the ice machine was noted to have significant dirt on top and debris all over the machine. These observations were made while kitchen staff were actively preparing food for residents receiving oral diets. Further observations showed improper equipment handling and hand hygiene during food preparation. A cook preparing pureed diets washed a food processor between items but did not allow it to air dry before immediately reusing it, stating she rushed because the surveyor wanted to see the next pureed food. Multiple dietary staff were seen touching surfaces with gloved hands and then handling ready-to-eat foods such as sandwiches and desserts without changing gloves or performing hand hygiene. One staff member repeatedly changed gloves without washing hands or using hand sanitizer, and another wiped a table with a gloved hand and then used the same glove to handle cake pieces, despite the availability of utensils. The facility’s own hand hygiene policy, which requires hand hygiene before donning gloves and before and after glove use, and clarifies that gloves do not replace handwashing, was not followed during these observed food preparation activities.
Failure to Prevent Accidents and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for multiple residents, resulting in several deficiencies related to accident hazards and resident safety. One resident with a history of chronic conditions, including dementia and Parkinson’s disease, was observed in his room without appropriate fall prevention measures such as floor mats or a call light within reach, despite being identified as high risk for falls. The resident’s bed was unplugged, and unsafe items, including a G-tube plunger not belonging to him, were present in the room. The care plan indicated interventions like keeping the bed in the lowest position and ensuring the call light was accessible, but these were not in place at the time of observation. The resident had experienced multiple falls in the year, and staff were unable to specify which interventions were in place prior to the most recent fall. Another resident, who had recently undergone a leg amputation and was identified as high risk for falls, was found in bed without both required floor mats in place, with the bed not in the lowest position, and a wet floor nearby. The resident expressed concern about the lack of side rails, which staff acknowledged but had not communicated to administration. Staff confirmed that both floor mats should have been in place and that the bed should have been lowered, but these interventions were not consistently implemented. Additional deficiencies were observed in the supervision and assistance provided to residents in communal areas. One resident was seen in the dining room with improperly worn shoes, and staff failed to address this until prompted. Another resident was observed with only one shoe and a sock with holes, and staff did not offer assistance or alternative footwear. A further resident was found in a hallway with pants pulled down and one foot exposed, with staff failing to address privacy or safety concerns until questioned. The dining room was also left unsupervised with multiple residents present, and a persistent water leak created a slipping hazard that was not adequately managed. These findings demonstrate a pattern of inadequate supervision, failure to implement care plan interventions, and unaddressed environmental hazards.
Failure to Provide Sufficient Nursing Staff and Maintain Resident Care Standards
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by only two certified nursing assistants (CNAs) being assigned to care for over 150 residents during a night shift, despite the facility assessment indicating that approximately nine CNAs were needed. Both CNAs reported being solely responsible for their respective units, with one caring for residents who were mostly ambulatory and the other for residents requiring significant assistance with activities of daily living and incontinence care. Management was notified of the staffing shortage, but no additional staff were called in or arrived to assist during the shift. The Director of Nursing confirmed the inadequate staffing and that the usual number of CNAs for the shift was five to six. Multiple observations and interviews revealed that resident care and facility conditions were negatively impacted by the staffing shortage. Residents were found in unsanitary conditions, such as rooms with gnats, dirty showers, and soiled floors. Some residents did not receive timely assistance with personal hygiene, and there were instances of unsupervised residents in common areas. Medication administration was also affected, with LPNs and RNs assigned to large numbers of residents, leading to late or undocumented medication administration. Medication carts were observed left unlocked and unattended, and there were discrepancies between physician orders and medication administration records. Additional deficiencies included the lack of a licensed nurse with the required training to manage the facility's restorative program, as the assigned nurse had not completed the necessary coursework. Residents with specific needs, such as those requiring fall prevention interventions or assistance with prosthetic devices, did not always have appropriate equipment or interventions in place. Housekeeping staff also reported being unable to maintain cleanliness due to staffing issues, and maintenance concerns such as water leaks were observed. The facility's own policies and assessments indicated the need for higher staffing levels and outlined procedures for addressing shortages, which were not followed during the documented events.
Incomplete and Inconsistent Advance Directives and POLST Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that advance directives and Physician Orders for Life-Sustaining Treatment (POLST) forms were accurately completed and consistently maintained for multiple residents, resulting in discrepancies between documented wishes and the information available to guide care. One resident, R17, had an advance directive in the electronic record signed on a specified date, but the form contained no selection for the type of treatment, leaving staff without clear direction in an emergency. When this was presented to the DON, she acknowledged that there should be an indication of the type of treatment required and that completed advance directives should be uploaded into the medical record. Additional findings showed multiple problems with POLST forms for other residents. R55’s undated POLST documented a selection for “Attempt Resuscitation/CPR,” which per the form means “Full Treatment” in Section B, but Section B was instead marked for “Selective Treatment,” creating an internal inconsistency on the same form. The undated POLST forms for R69 and R145, and the dated POLST form for R92, were all signed by both the resident and the physician but contained no selections in Sections A, B, C, or D. The Social Services Director acknowledged that R55’s POLST was not documented correctly and stated that the forms should be filled out completely, and that if POLST forms are not completed and completed correctly, the hospital and the facility would not know what to do. These practices were inconsistent with the facility’s own Advance Directives policy, which requires that advance directives be copied and maintained in the medical record, reviewed by the interdisciplinary team, and used to guide orders and documentation regarding life-sustaining measures.
Failure to Implement Identified Offenders Program and Timely Criminal Background Checks
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies and procedures related to the Identified Offenders Program (IOP), criminal background checks, and fingerprinting for multiple residents. Surveyors reviewed records for 10 residents and found that required Criminal History Information Response Process (CHIRP) checks were not consistently completed within 24 hours of admission as required by facility policy. For several residents, including those with documented criminal histories such as burglary, theft, domestic battery, aggravated arson, and sexual offenses, CHIRP reports were either delayed or missing within the required timeframe. In addition, when CHIRP results showed “hits” and arrest charges that triggered the need for fingerprinting under the facility’s IOP process, the facility failed to obtain fingerprint orders within 72 hours and, in many cases, could not produce any documentation that fingerprinting was ever completed. For some residents, fingerprints were obtained weeks or more than a year after admission, and for others, staff were unable to locate any fingerprint documentation at all. The Social Services Director (V4) repeatedly stated that staff were unable to find when fingerprints were ordered and that they could not locate confirmation that certain residents had been fingerprinted. The facility’s written Abuse Prevention Policy and Resident Rights Guideline require pre-admission and post-admission criminal history checks, including CHIRP, sex offender registry checks, and fingerprinting when indicated, to help ensure a safe environment and residents’ freedom from abuse, neglect, exploitation, and misappropriation of property. Despite these policies, the facility did not follow the required timelines for CHIRP completion, did not consistently obtain or document fingerprinting after CHIRP hits, and did not maintain the necessary IOP documentation for all 10 reviewed residents. The Social Services Director indicated that the prior Social Services Director had been responsible for IOP tasks and was unsure why the IOP requirements had not been completed as required.
Failure to Administer and Document Medications Within Required Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication administration and documentation met professional standards and followed facility policy. During a survey, one LPN reported being a new graduate of one month and assigned to 44 residents. She stated that by 8:52 a.m. she had already given 9 a.m. medications to 40 residents since 8 a.m., and observation of one resident’s 9 a.m. medication pass took 22 minutes, including time spent locating a scheduled medication and waiting for the resident to get dressed and use the bathroom before obtaining blood pressure and administering medications. Based on the time required for this observed pass, the surveyor concluded that 9 a.m. medications were likely administered before 8 a.m., outside the regulatory time frame. The facility census at that time was 158 residents, and the cited deficiency involved 14 residents in the sample. Additional observations showed that multiple nurses did not document medication administration at the time medications were given, contrary to the facility’s medication administration policy dated 10/25/14. One RN assigned to 26 residents stated that all but one resident had received 9 a.m. medications and that she had started passing them around 7:30 a.m., but seven residents on the EMAR were highlighted red and marked late; she acknowledged that these residents had received their medications but had not been documented immediately after administration. Another LPN assigned to 31 residents stated that all but one resident in therapy had received their 9 a.m. medications, yet five residents remained highlighted green and marked due on the EMAR; the nurse stated she still needed to sign for the medications. A further RN stated that all her assigned residents had received 9 a.m. medications, but two residents remained highlighted green and marked due on the EMAR and were identified as assigned to another nurse on a split assignment. The facility’s policy requires medications for the immediate administration time to be prepared no more than 60 minutes in advance and that the individual administering the medication record administration on the MAR directly after the medication is given and review the MAR at the end of each pass to ensure all doses are administered and documented.
Failure to Maintain Effective Pest Control and Insect-Free Resident Areas
Penalty
Summary
The facility failed to maintain an effective pest control program and to ensure the environment remained free from flying insects, affecting two identified residents and with the potential to affect the entire census of 158 residents. On the specified survey date, gnats were observed flying in a hallway on one unit and in a resident’s room, where a can of insect repellent was lying on the bed. That resident reported that gnats were present "all over the place" and described the bathroom as having significant gnat presence, stating the door was kept shut to prevent gnats from entering the room. An inspection of the room did not reveal food or trash that might attract pests. In another resident’s room, surveyors observed nine fly traps hanging on the walls, each containing multiple flies and/or gnats. Housekeeping staff acknowledged seeing gnats on the traps and attributed the issue to the resident allegedly keeping food in drawers or in the room, although an inspection of the drawers at that time did not reveal any food. A urinal with a tan, crusty substance inside was noted on the dresser, and housekeeping staff stated that staff were supposed to pour out the urine and that gnats were attracted to it, indicating it had not been properly emptied or replaced. When surveyors requested pest control documentation, the facility initially produced only one pest control service report from several months earlier, despite a policy stating the facility would maintain an effective pest control program with facility-wide strategies. The Maintenance Director stated that pest control services were provided every three months and that the pest control company came when called for issues, but confirmed there had been no pest control visit between the two documented service dates, leaving a gap in regular pest control services during the period when gnats and flies were observed in resident areas.
Failure to Maintain Dignity by Not Covering Urinary Drainage Bag
Penalty
Summary
Surveyors identified a deficiency related to resident dignity when a resident with cognitive impairment and an indwelling urinary catheter was observed lying in bed with an uncovered urinary drainage bag hanging from the bed frame. The bag contained approximately 500 mL of straw-colored urine and was not placed in a privacy bag. The resident reported that staff had not been keeping the drainage bag in a privacy bag while the resident was in bed. The Director of Nursing observed the same uncovered drainage bag and confirmed that it was not stored in a manner that promotes resident dignity, despite the facility’s standard that all urinary drainage bags be kept in privacy bags. The facility’s Resident Rights Guideline policy states that residents have the right to be treated with dignity and respect. This sequence of observations, resident interview, and staff acknowledgment demonstrated that the facility failed to ensure the urinary drainage bag was covered in a manner that promotes dignity for this resident.
Failure to Protect Confidentiality of Resident’s Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of one resident’s personal and medical information when staff posted a document containing protected health information directly above the resident’s bed in a semi-private room. During a room tour, the surveyor observed a paper that included the name of the company performing PASARRs, the resident’s full name, the full name and address of the facility, and a statement that the resident is a [NAME] Class Member who requested not to proceed to assessment. This information was clearly visible to visitors, staff, and the roommate. When asked about the posting, the resident stated they did not know what the paper was and that a nurse had put it there. The resident’s face sheet documented diagnoses including major depressive disorder, borderline personality disorder, and mild intellectual disabilities, and a BIMS score of 5 indicating severely impaired cognition. On a subsequent tour two days later, the surveyor again observed the same paper with the resident’s personal and medical information posted above the bed. Review of the electronic medical record revealed no documentation that the resident had consented to having personal medical information displayed in view of others. Facility policies on HIPAA and Resident Rights state that medical records must remain confidential and that residents are entitled to privacy and confidentiality, but these policies were not followed in this instance.
Failure to Maintain Clean, Odor-Free, and Functional Environment in Resident Rooms and Common Areas
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, odor-free, and homelike environment for multiple residents and in common areas. One resident reported that the community bathroom was a “s**t show” with gnats and that the community shower was filthy and smelled bad. During observations, surveyors noted a strong urine odor in the A/B unit bathroom and confirmed by the DON that the shower room smelled of urine and needed cleaning. The shower handle in the A/B unit shower room was broken off, and later the Maintenance Director affirmed that shower faucet handles in both the A/B and C/D units were in disrepair and that he had been unaware of these issues. In a resident room, surveyors observed a pullup on the floor next to a thick clump of dirt, with the pullup appearing to have been stepped on, and trash scattered on the dresser and floor. When questioned, a CNA acknowledged the presence of the brief, paper, and dirt, and stated that the resident did not let anybody come into his room, although no one was in the room at the time of observation. In the B unit hallway, floors were notably soiled with dirt and grime while housekeeping staff were mopping, yet the dirt and grime remained. The following day, another housekeeping staff member stated that the appearance was due to dirt and paint and that the floors required stripping, buffing, and waxing, and affirmed that night shift staff assigned to buff the floors were not completing this task. Common areas were also found to be unsanitary and poorly maintained. Over half of the flooring in the A/B unit common area was covered in food debris and black dirt or other stains; when a tissue was wiped across the floor, it turned black, and the Maintenance Director acknowledged the floor was dirty and needed cleaning. Black dirt stains were also observed around the nursing station, and the Housekeeping Director stated that the stains were from residents and that floors were cleaned daily. In the dining room, ceiling tiles were missing over resident tables, with unidentified liquid steadily dripping from the ceiling into a bucket and forming puddles on the floor. Residents were observed ambulating under the leak and through the puddles, and one resident was observed walking through the puddles and having the liquid drip onto their body and lunch tray, reacting with surprise. These conditions occurred despite facility policies requiring a clean, odor-free, comfortable, and orderly environment and proper maintenance of the environment of care.
Failure to Complete Required PASARR Screening on Admission for Resident With Serious Mental Disorder
Penalty
Summary
The deficiency involves the facility’s failure to complete a required PASARR Level I screening on admission for a resident with documented serious mental disorders. The resident’s face sheet shows an admission and latest return in early January 2019 and lists diagnoses including delusional disorders, psychotic disorders, anxiety disorder, and major depressive disorder. The resident’s care plan, last revised in early May 2025, identifies ongoing delusions related to diagnoses of delusional disorder, unspecified dementia with behavioral disturbance, and other psychotic disorder not due to substance or psychological condition. During the survey on July 29, 2025, the surveyor was unable to locate any PASARR documentation in the resident’s EMR and requested it from the Administrator and DON. On July 29, 2025 at 12:25 p.m., the Social Services Director stated that the former Social Services Director had been responsible for PASARR submissions and acknowledged that the resident should have had a PASARR Level I completed, and that the resident’s psychiatric diagnoses would have triggered a PASARR Level II. The Social Services Director also stated that all residents should at least have a PASARR Level I completed. On July 30, 2025, the surveyor received a Notice of PASRR Level I Screen Outcome for the resident dated July 29, 2025, indicating a determination of “Refer to Level II Onsite,” demonstrating that the PASARR Level I was only completed during the survey and not at the time of admission. This failure occurred despite a facility policy, revised in November 2017, that requires a Level I screen for all potential admissions and coordination of care based on PASARR determinations, including referrals for Level II review for residents with newly evident or possible serious mental disorder, intellectual disability, or related condition.
Failure to Identify and Treat Resident Skin Tears
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to assess, document, and treat two skin tears on a resident with multiple risk factors for skin breakdown. During observation, the resident was seen in a wheelchair with a quarter-sized open area on the left shin and the right leg wrapped in a dressing showing two golf ball-sized areas of dried serosanguinous fluid on the calf. The resident stated that his legs “always be like that” and that he sometimes hits his legs on the wheelchair. The resident’s diagnoses included chronic venous hypertension with ulcer of the left lower extremity, left lower leg venous ulcer, peripheral vascular disease, cellulitis of the right lower limb, and type 2 diabetes mellitus with unspecified complications. His BIMS score indicated moderately impaired cognition, and his Braden Scale score of 16 indicated mild risk for pressure ulcer development, which under facility policy required weekly skin assessments. When the wound care nurse was interviewed shortly after the observation, she reported that as of several days earlier there were no open areas on the resident’s legs, that there were no current treatments because everything was crusted over, and that the right leg was wrapped per the resident’s preference. At that time, the facility had no documented treatment orders or wound assessments for the observed open areas. Later that morning, the physician assessed the resident and identified a left shin skin tear measuring approximately 4 cm by 1 cm and a right calf skin tear measuring approximately 4 cm by 6.2 cm, stating the resident might have hit his legs on something. The medical record, including the most recent MDS, did not reflect any unhealed pressure ulcers or skin tears, and the wounds were not documented as present on admission. The facility’s own policy required that residents at mild and moderate risk receive weekly skin assessments, and that skin be inspected during routine care with attention to lower extremities, but evidence in the record and staff statements showed the facility was unaware of the resident’s skin tears until after the surveyor’s observation and physician assessment.
Incorrect Low Air Loss Mattress Settings for Resident With Stage IV Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a low air loss (LAL) mattress was correctly set according to the resident’s weight for a resident with a chronic stage IV pressure ulcer and identified risk for pressure ulcer development. On observation, the resident was found lying on a LAL mattress set at 600–1000 pounds, while the most recent documented weight was 187.8 pounds, meaning the mattress was set at least 412.2 pounds above the recommended setting. During the same observation, the resident reported that the mattress was not comfortable and described feeling as though lying on a cement floor. The facility’s own LAL mattress manual and policy indicate that the pressure/weight setting should be adjusted using the resident’s weight as a guide, and the facility’s pressure ulcer and wound prevention/management policy requires necessary treatment and services to promote healing and prevent new sores. The resident had multiple medical diagnoses including multiple sclerosis, gastrostomy status, urinary incontinence, neuromuscular dysfunction of the bladder, and urinary tract infection, with a BIMS score of 12 indicating moderately impaired cognition. A Braden assessment documented a score of 15, indicating mild risk for pressure ulcer development, and wound documentation showed a stage IV pressure ulcer with moderate serous drainage. The care plan identified the need for a Foley catheter due to urinary incontinence and poor healing of the sacral stage IV pressure ulcer. When interviewed, the LPN responsible for wound care stated that LAL mattresses are supposed to be set at the resident’s weight but was unsure of the specifics and acknowledged not being certified in wound care. Facility and external documents presented by surveyors, including CMS guidance on pressure-reducing support surfaces and residents’ rights materials, further outlined expectations that support surfaces be used to provide adequate pressure reduction and that the facility provide services to maintain residents’ highest practicable physical and mental health and a comfortable environment.
Failure to Change and Label Tube Feeding Syringe per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and procedures for tube feeding equipment management for one resident. During a room tour, a surveyor observed a tube feeding syringe hanging on a pole next to the resident’s bed in an opened package dated 7/25, with no label indicating the resident’s name. The resident stated they were unsure how old the syringe was and requested a new one if needed. The resident’s face sheet documented multiple medical diagnoses, including multiple sclerosis, gastrostomy status, urinary incontinence, neuromuscular dysfunction of the bladder, and urinary tract infection. A BIMS score of 12 indicated moderately impaired cognition. The resident’s care plan documented that nutritional needs were not met by oral feeding and that tube feeding was required related to a diagnosis of multiple sclerosis. The resident’s active physician orders included enteral bolus feedings of Jevity 1.5 twice daily with specified volume, and water flushes before and after each bolus feeding. The DON stated that tube feeding syringes should be changed every 24 hours to prevent infection. Facility policy titled “Gastric Tube Feeding” specified that the syringe for flushing is to be changed daily and labeled with the resident’s name and date. Another facility policy, “Equipment Change Schedule Policy,” documented that piston syringes are to be changed daily, every 24 hours. Despite these policies and orders, the observed syringe remained in use beyond 24 hours and was not labeled with the resident’s name, constituting the failure to ensure proper tube feeding syringe change and labeling for this resident.
Failure to Properly Store and Label CPAP Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that respiratory equipment was labeled with a name and date and contained in a plastic bag between uses for two residents using CPAP masks. On 7/28/25 at 9:44 a.m., one resident’s unlabeled and undated CPAP mask was observed stored loose in a dresser drawer and not contained in a bag; when asked if staff kept the CPAP mask in a bag, the resident responded that they did not and questioned why it needed to be bagged. Later that morning at 10:10 a.m., another unlabeled and undated CPAP mask was observed lying directly on top of a mattress without a sheet and not contained in a bag. At 10:19 a.m., when the surveyor asked whether this CPAP mask was dated or contained in a bag, an LPN inspected the mask and confirmed that it was not in a bag and had no date. The facility’s respiratory therapy prevention of infection policy, revised August 2008, states that for medication nebulizers/continuous aerosol equipment, the circuit is to be stored in a plastic bag marked with the date and resident’s name between uses, although the policy notes that maintaining CPAP is excluded.
Failure to Obtain and Document Consultant Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that the consultant pharmacist’s monthly medication regimen review (MRR) for one resident was complete and that the pharmacist’s recommendations were received and available to staff. For this resident, the MRR dated 7/14/25 stated, “Please take the following action described below,” but the actual actions and/or recommendations were missing from the document. When the surveyor inquired on 7/30/25 about the pharmacist’s recommendations that were referenced but not included, the DON (V2) reported that the pharmacist had checked off a recommendation for a medication change for the resident but had not sent the facility the actual recommendation. The facility’s written policy dated 10/25/14 on documentation and communication of consultant pharmacist recommendations requires that the consultant pharmacist work with the facility to establish a system to ensure that observations and recommendations regarding residents’ medication therapy are communicated to those with authority to implement them and that these are documented and made available in an easily retrievable form to nurses, physicians, and the care planning team. The policy further states that the consultant pharmacist documents potential or actual medication-related problems, irregularities, and other MRR findings appropriate for prescriber and/or nursing review, and that comments and recommendations concerning medication therapy are communicated in a timely fashion. In this case, the pharmacist’s recommendation for a medication change for the resident was not present in the MRR and was not available to facility staff in accordance with the policy.
Failure to Follow Physician Orders Resulting in Medication Administration Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents remained free from significant medication errors by not following physician orders and its own medication administration policy. For one resident, the physician’s order dated 2/16/24 directed Hydralazine 50 mg to be given every 8 hours at 6 a.m., 2 p.m., and 10 p.m., with instructions to hold the dose only if blood pressure was below 100/60. On 7/29/25 at 1:12 p.m., an LPN obtained the resident’s blood pressure as 108/70 prior to the scheduled 2 p.m. Hydralazine dose. When asked, the LPN stated she was going to hold the Hydralazine and call the physician so the resident’s blood pressure would not go too low. After the surveyor questioned whether there were parameters to hold the medication, the LPN reviewed the EMAR and confirmed the order specified to hold only if blood pressure was below 100/60, which it was not at the time. For another resident with glaucoma, physician orders dated 7/26/25 included Simbrinza eye drops, one drop to the left eye three times daily at 9 a.m., 1 p.m., and 9 p.m., and Latanoprost eye drops, one drop to both eyes at bedtime. On 7/28/25 at 12:22 p.m., the resident reported not having received the morning Simbrinza eye drops. At 12:31 p.m., when the surveyor asked why the 9 a.m. eye drops had not been given, an LPN reviewed the EMAR and stated the resident received eye drops at 9 p.m., referring to Latanoprost, and initially affirmed the resident did not have another eye drop prescribed. At 12:50 p.m., the resident reported receiving the Simbrinza a few minutes earlier, indicating the 9 a.m. dose was administered roughly three hours late. The facility’s medication administration policy dated 10/25/14 states that medications are to be administered in accordance with written prescriber orders, which did not occur in these instances.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information contained all required elements. On observation of the staffing schedule posted in the hallway near the lobby entrance, surveyors noted that the document did not include the facility name, the current census, or the total number or actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The Assistant Director of Nursing confirmed that this document was what the facility used to meet the daily nurse staffing posting requirement and acknowledged that it lacked the facility name, census, and any numerical values indicating hours worked by direct care staff. Facility policy titled "Posting Direct Care Daily Staffing Numbers" stated that at the beginning of each shift the facility shall post nurse staffing data as required by state and federal regulations in a clear, readable format and in a prominent place accessible to residents and visitors, but the observed posting did not meet these requirements. This failure has the potential to affect all 153 residents residing in the facility, with census documentation also indicating a current census of 158 residents.
Lack of Medical Director Participation in QAA/QAPI Program
Penalty
Summary
The facility failed to ensure that the medical director participated in the facility’s QAA/QAPI program as required. Surveyors reviewed QAA committee meeting sign-in sheets for two meetings and found no signature from the medical director indicating attendance. During an interview, the Administrator confirmed that the medical director did not attend the QAA meetings and acknowledged that the medical director is required to be present. A nurse consultant, identified as a member of the governing body who sometimes attends QAA meetings, also reviewed the QAA meeting minutes and confirmed the absence of the medical director’s signature, affirming that the medical director’s attendance and involvement in QAA/QAPI is a requirement. The facility’s undated QAPI Program Overview/Preamble policy states that all consumers, staff, facility services, and departments will participate in system and process improvement analysis, evaluation, and modification. The facility census documented 158 residents who could be affected by this lack of medical director participation in QAA/QAPI activities. No specific residents, their medical histories, or clinical conditions at the time of the deficiency are described in the report, only that the deficiency had the potential to affect all residents in the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, in violation of its abuse prevention policy. In one incident, a male resident with a history of bipolar disorder and dementia struck another male resident with a pair of pliers near the nurse's station. The aggressor had previously found and hidden the pliers, which were not permitted in the facility, and used them during a confrontation. Both residents involved had cognitive impairments, and staff intervened after hearing a commotion. Documentation confirmed that the aggressor was sent to the hospital for evaluation following the altercation. In a separate series of events, another resident with schizoaffective disorder and a history of aggressive behavior physically assaulted two other residents. One resident was struck in the face, resulting in a red mark and bruising, while another was pushed from a wheelchair. Staff and social service notes indicated that the aggressor had a pattern of physical aggression towards peers, and the incidents were witnessed and reported by staff. The aggressor was subsequently sent to the hospital and not permitted to return to the facility. The facility's records, including care plans and risk assessments, documented that the residents involved were at risk for abuse due to their diagnoses and behaviors. Despite these known risks, the facility did not prevent the physical altercations or ensure that residents were free from abuse as required by policy. Staff interviews and documentation confirmed that tools were not allowed in the facility and that the incidents constituted physical abuse.
Failure to Monitor and Address Substance Abuse and Self-Harm Risks
Penalty
Summary
The facility failed to follow its own policies and procedures for behavior and substance abuse management, resulting in inadequate monitoring and communication regarding suspected or observed substance use among residents. Specifically, staff did not conduct room searches as required when there was suspicion of substance abuse, did not refer suspected substance abuse cases to law enforcement, and failed to document or implement personalized care plan interventions for the prevention of suicidal or self-harming behavior and substance use. These failures were observed in two residents who subsequently tested positive for drug use while in the facility, with one resident engaging in self-harming behavior. One resident with a history of severe mental illness, substance abuse, and self-harm was admitted following psychiatric hospitalization for suicidal ideation and self-injurious behavior. Despite documented risks and a care plan indicating the need for monitoring, the resident's care plan did not include specific interventions for substance abuse or self-harm. The resident was found participating in rule-violating group activities, eloped from the facility, and later tested positive for cannabinoids and cocaine after reporting ongoing drug use and self-harm within the facility. There was no documentation of room searches, physician notification, or counseling regarding substance use during the resident's stay. Another resident with a history of polysubstance use disorder and psychiatric diagnoses also lacked a care plan with personalized interventions for substance abuse triggers or diversions. This resident was found with contraband, suspected of drug use, and later tested positive for cocaine after being sent to the hospital for psychiatric evaluation. Staff and other residents reported frequent observations of drug use, odors, and paraphernalia in the facility, but there was a lack of consistent documentation, communication, and follow-through on required interventions such as room searches, physician notification, and law enforcement referral. The facility's policies required these actions, but they were not implemented or documented as required.
Failure to Follow Behavior Management Policy and Resident Rights During Elopement
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's right to a dignified existence and self-determination by not following their behavior management policy and procedures during an elopement incident. The resident, an alert and oriented male with a history of severe bipolar disorder with psychotic features, generalized anxiety disorder, hypertensive heart disease, cannabis use, and nicotine dependence, was assessed as low risk for elopement and had no prior incidents of unauthorized exit. Despite this, the resident left the facility without authorization, and staff attempted to physically intervene to return him to the facility, contrary to the facility's policy emphasizing de-escalation and non-restraint interventions. During the incident, multiple staff members pursued the resident after he exited the building. Accounts from staff and the resident indicate that staff attempted to physically restrain him, with one staff member reportedly grabbing his shirt and another attempting to catch him. The resident described being chased, sitting down voluntarily due to being winded, and then being physically brought to the ground, which he described as being 'slammed.' Hospital records corroborated that the resident sustained a chest wall injury and elevated troponin levels, suspected to be related to minor blunt chest trauma from the incident. Staff interviews revealed confusion and inconsistent adherence to the facility's policy, with some staff attempting to physically intervene and others later being instructed by the clinical director to let the resident go, acknowledging his right to leave. The facility's behavior management policy specifically directs staff to use de-escalation techniques such as verbal redirection, distraction, and active listening, and to avoid physical restraint. In this case, staff actions did not align with these guidelines, as physical intervention was attempted despite the resident being alert, oriented, and expressing a desire not to return. The failure to follow established procedures and respect the resident's rights resulted in a situation where the resident sustained an injury and his dignity and autonomy were not upheld.
Failure to Provide Individualized Behavioral Health and Substance Use Services
Penalty
Summary
The facility failed to follow its own policies and procedures for behavior and substance use management by not ensuring that residents with significant histories of self-harm, suicidal behavior, and substance use received appropriate therapeutic mental health or substance abuse counseling or services. Two residents with documented histories of severe mental illness, suicidal ideation, self-harm, and substance abuse did not receive individualized care planned interventions based on the identified causes of their behaviors, preferences, or interests. The facility also did not perform timely and accurate assessments of substance abuse history to inform person-centered treatment interventions, as required by their policies. One resident, a male with diagnoses including severe bipolar disorder with psychotic features, generalized anxiety disorder, schizoaffective disorder, and substance use, was admitted following psychiatric hospitalization for suicidal ideation and self-harm. Despite recommendations for psychotherapy, group therapy, and substance abuse programming, there was no documentation of referrals to such services, participation in therapeutic groups, or individualized care plan interventions addressing his mental health and substance use needs. The resident later eloped from the facility, expressed suicidal ideation, and was transferred to the hospital, where he reported ongoing self-harm and substance use within the facility. Facility records did not show evidence of psychiatric or substance abuse counseling being offered or refused, nor were there records of activities based on his interests and preferences. Another resident with a history of depression, bipolar disorder, polysubstance use, and recent suicidal ideation also did not have a care plan with personalized interventions addressing his substance use triggers, goals for sobriety, or alternatives to substance use. Progress notes did not document any substance abuse counseling or participation in substance abuse groups for several months. Interviews with staff confirmed that specialized substance abuse counseling was not consistently available, and documentation of interventions was lacking. The facility's own policies required individualized behavioral care plans, documentation of interventions, and provision of substance use treatment services, but these were not implemented or documented for the residents reviewed.
Failure to Complete Required Background Checks Prior to Employment
Penalty
Summary
The facility failed to follow its own policy regarding the completion of background and fingerprint checks for four employees at the time of hire. Specifically, the Human Resources (HR) staff did not have background checks for one maintenance employee and could not locate the Illinois Sex Offender check for a Certified Nursing Assistant. Another maintenance employee, who was later terminated, also had no background checks on file. For an Activity Aide, the fingerprinting process was incomplete, and the application status was still pending on the state website, despite the individual having been hired months earlier. In several cases, background checks and sex offender registry checks were only initiated after surveyor inquiry, rather than prior to or at the time of hire as required by facility policy. Interviews with HR and administrative staff revealed that the process for conducting background checks was inconsistent and not always completed before allowing staff to begin work. The HR representative described a process where applications and required documents were collected, but background checks and fingerprinting were sometimes delayed until after orientation or after the employee had already started working. The administrator acknowledged that background checks should be completed in a timely manner and ideally before hire, but could not explain why this was not done for the employees in question. The facility's policy requires comprehensive background screening, including criminal, sex offender, and abuse registry checks, prior to employment, but this was not consistently followed for the four employees identified.
Nursing Staff Shortage Leads to Missed Medications and Assessments
Penalty
Summary
The facility failed to adhere to its staffing policy by not having the required number of nurses on the overnight shift from 12/31/24 to 1/1/25. Specifically, there was no nurse present in the facility from 2:00 AM until 6:04 AM on 1/1/25. This absence resulted in several residents not receiving their scheduled medications and assessments. Four residents did not receive their 6:00 AM medications on time, and five diabetic residents did not have their blood sugar levels checked or insulin administered as scheduled. Additionally, no residents received their scheduled assessments or vital sign monitoring during the night shift. Interviews and record reviews revealed that the absence of nursing staff led to overdue documentation in the Medication Administration Records (MARs) for the day shift. Licensed Practical Nurses (LPNs) and a Registered Nurse (RN) had to document reasons for the overdue medications and assessments to proceed with their duties. The Director of Nursing (DON) was notified of the absence at 5:00 AM and arrived at the facility by 5:30 AM, followed by the administrator. The DON conducted rounds and in-serviced staff on the importance of notifying her immediately if anything out of the norm occurs. The facility's staffing policy, dated 11/2017, requires adequate staffing on each shift to meet residents' needs, with licensed nursing staff available 24/7. However, on the night in question, two LPNs scheduled to work did not show up, and the remaining LPN left at 2:00 AM, leaving the facility without nursing coverage. This staffing failure had the potential to affect all 155 residents in the facility, as evidenced by the medication error reports completed for each resident due to the missed medications and assessments.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to its medication administration policy, resulting in significant medication errors for four residents who were receiving high alert medications. The errors included inconsistent monitoring of the effectiveness of pain medications and inaccurate documentation of the administration of controlled substances. Specifically, the facility did not ensure that nurses signed out high alert medications on the residents' medication administration records (MAR) and controlled substance sheets as required. Additionally, there was a lack of follow-up with residents to assess the effectiveness of pain medications administered on an as-needed basis. The report highlights discrepancies in the documentation of medication administration for residents R3, R17, R18, and R19. For instance, R3's MAR and controlled substance sheet showed inconsistencies in the times and dates when hydrocodone-acetaminophen was administered and signed out. Similar issues were observed for R17, R18, and R19, where the documentation did not match the actual administration times, and there were missing follow-up assessments for the effectiveness of the pain medication. These deficiencies indicate a failure to comply with the facility's medication administration policy, potentially compromising the residents' care.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition, which was identified during a survey. The resident, a male with a complex medical history including rheumatoid arthritis, hypertensive heart disease, and dependency on supplemental oxygen, was admitted to the facility. On one occasion, the resident was found unresponsive, and a code blue was called. Despite the severity of the situation, the facility staff did not successfully notify the resident's family, and there was no documentation of any follow-up attempts to reach them. Additionally, the resident had been sent to the hospital previously for chest pain, and again, the family was not informed of the transfer or return. Interviews with the resident's family member revealed that she was not informed by the facility about the resident's critical condition or hospitalizations. The family member only learned of the resident's heart attack and subsequent brain death from the hospital. The Director of Nursing was also unaware of the incident until returning to work after the weekend. The facility's protocol requires notifying the physician, family, and nursing management during emergencies, and if the family cannot be reached, the responsibility should be passed to the next shift. However, this protocol was not followed, leading to a deficiency in communication and documentation.
Failure to Schedule Follow-Up and Administer Medications
Penalty
Summary
The facility failed to ensure that a follow-up appointment was scheduled with a pulmonologist for a resident as ordered. The resident, who had a history of chronic obstructive pulmonary disease and was dependent on supplemental oxygen, was discharged from the hospital with instructions to see a pulmonologist within two days. However, the appointment was not scheduled, and the resident did not see the specialist as required. The Licensed Practical Nurse (LPN) involved was unaware of the need to schedule the appointment, citing a misunderstanding of the discharge instructions. Additionally, the facility did not administer prescribed medications or monitor and document the resident's respiratory and oxygen status as per physician orders and the care plan. On the day of the incident, the resident did not receive any scheduled medications, and there were no documented vital signs prior to or during the code blue event. The resident had requested a breathing treatment, which was administered by an LPN who did not monitor the resident's vital signs during the process. The resident subsequently became unresponsive, leading to a code blue being called. The emergency response was inadequately documented, with no recorded vital signs or sequence of resuscitation efforts. The staff involved in the emergency response, including LPNs and a Registered Nurse (RN), did not document the vital signs or the resident's response to resuscitation efforts. The facility's policy on medication administration and emergency response documentation was not followed, contributing to the deficiency in care provided to the resident.
Failure to Check G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards during the administration of medication via a G-Tube for one resident. On September 11, 2024, at 1:15 PM, an LPN administered medication to a resident through a G-Tube without checking the tube's placement beforehand. The LPN later stated that she checks the placement by observing and palpating the G-Tube site. However, the Director of Nursing indicated that the expected procedure is to check the G-Tube placement by auscultation or checking for residuals before administering medication. The resident involved is an elderly female with multiple diagnoses, including end-stage multiple sclerosis, anxiety disorder, essential hypertension, and hyperlipidemia. The facility's policy on enteral tube medication administration requires checking the placement and patency of the tube before administering medication, which was not followed in this instance.
Failure to Provide ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident, specifically in the areas of feeding, nail care, and foot care. The resident, who is on hospice care, was observed with an untouched lunch tray and expressed needing help with eating due to pain and a swollen right arm. Despite the resident's request for assistance, the social worker and LPN both stated that the resident eats independently. However, the Director of Nursing later acknowledged that the resident requires assistance with eating and noted the need for nail care. The resident's fingernails and toenails were observed to be long, thick, discolored, and pressing into the skin, indicating a lack of proper nail care. The CNA assigned to the resident reported having noticed the condition and claimed to have informed a nurse, though the nurse's name was forgotten. The LPN admitted awareness of the nail condition and stated that the physician and podiatrist were notified, but this was not documented. The resident's care plan indicated a need for supervision or touch assistance with eating and partial assistance with personal hygiene, which was not adequately provided, leading to the deficiency.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement fall preventive measures for residents at high risk for falls, affecting two residents in the sample reviewed. One resident, identified as R91, was observed in bed with the bed in a high position, contrary to the facility's policy that requires the bed to be in the lowest position for safety. Despite being at high risk for falls, as indicated by a recent fall incident in July 2024 where the resident attempted to get out of bed without assistance, the bed control was not accessible to the resident, and the assigned CNA was unaware of the requirement to keep the bed in the lowest position. Another resident, R141, was observed wearing slide open-toe shoes, which contributed to a fall incident a week prior. The resident reported falling in the hallway due to water on the floor and improper footwear, which was not addressed by the facility. The resident did not have proper footwear, and the facility's intervention was limited to encouraging the resident to wear proper shoes, despite the resident's lack of resources to obtain them. The fall resulted in a sprain of the left knee, as documented in the hospital's after-visit summary. The facility's policies on safety and fall prevention emphasize individualized, resident-centered approaches and the importance of implementing interventions to reduce accident risks. However, the observations and interviews indicate a lack of adherence to these policies, as evidenced by the failure to maintain bed safety for R91 and to provide appropriate footwear for R141, both of whom are at high risk for falls.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to adhere to the physician's order for continuous enteral feeding for a resident identified as R108. Observations on multiple occasions revealed that R108 was not receiving the prescribed continuous enteral feeding. Specifically, on two separate days, R108 was seen without the enteral feeding tube attached while in a high back wheelchair and during restorative exercise treatment. The facility staff, including the Director of Nursing and a Licensed Practical Nurse, acknowledged that the feeding tube was disconnected during activities of daily living and treatments, as well as during a dental appointment, without notifying the primary care physician of these interruptions. R108 was readmitted with diagnoses including cerebral infarction, dysphagia, and gastrotomy, and had an active physician order for continuous gastrotomy tube feeding of Osmolite 1.2 at 70ml/hour with free water flushes three times a day. The resident's care plan was not updated to reflect these needs, and progress notes indicated that on several occasions, the resident received bolus feedings instead of the prescribed continuous feeding. The facility's policy on enteral nutrition, which requires consistent volume infusion and necessary adjustments for interruptions, was not followed, contributing to the deficiency.
Failure to Follow Pain Management Protocol
Penalty
Summary
The facility failed to adhere to its pain management policy for a resident who experienced a fall and subsequent knee pain. On September 11, 2024, the resident reported significant pain in the left knee following a fall in the hallway, but was only provided acetaminophen. The Licensed Practical Nurse (LPN) acknowledged that the resident did not request additional pain medication and noted that only acetaminophen was ordered. The Director of Nursing (DON) stated that nurses are expected to assess pain every shift and follow up with a physician if a resident complains of pain. The resident's fall was documented on September 4, 2024, with a hospital summary indicating a knee sprain. A physician had recommended acetaminophen for pain management. However, the medication administration record showed no pain medication was given, nor was there any documented pain assessment. The facility's pain management policy requires regular pain assessment and documentation, as well as notifying the physician of any unrelieved pain, which was not followed in this case.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure that a resident's updated hospice medical records were available and accessible to all interdisciplinary team (IDT) members. This deficiency was identified during an observation and record review of a resident who was on hospice care. The resident, who had a diagnosis of malignant neoplasm of the right breast and was receiving palliative care, was observed with a swollen right arm and unkempt fingernails. Upon reviewing the hospice record binder with the Director of Nursing, it was noted that the plan of care was outdated, and the interdisciplinary progress notes were improperly documented on plain paper without proper identification of the IDT members. The last documented notes were several months old, indicating a lack of updated information and coordination. The facility's policy on hospice services requires that hospice care be integrated with the resident's overall plan of care and that progress notes be properly documented and accessible. However, the facility did not adhere to these standards, as evidenced by the outdated plan of care and inadequate documentation practices. The facility's contract with the hospice service provider also emphasizes the need for regular communication and documentation to ensure the needs of hospice patients are met. Despite these requirements, the facility failed to maintain updated and accessible hospice records, affecting the quality of coordinated care for the resident.
Failure to Implement Enhanced Barrier Precaution
Penalty
Summary
The facility failed to implement its infection control policy for a resident on Enhanced Barrier Precaution (EBP). During an observation, it was noted that there was no signage indicating EBP at the door of the resident's room. The social worker was unaware of the resident's isolation status, and there was no physician order for EBP in the resident's chart. The resident, who was readmitted with conditions including cerebral infarction and gastrostomy, was on continuous tube feeding, which necessitated EBP according to the facility's policy. However, the required signage and documentation were missing. Further observations revealed that staff, including the Infection Control Coordinator and an LPN, acknowledged the need for EBP due to the resident's enteral feeding. Despite this, the necessary precautions were not consistently followed, as evidenced by the lack of signage and the absence of a physician order. The facility's policy mandates the use of EBP for residents with indwelling medical devices to prevent the transmission of multidrug-resistant organisms, but this was not adequately implemented in this case.
Delayed Release of Medical Records for Resident
Penalty
Summary
The facility failed to release medical records in a timely manner for a resident with severe cognitive impairment, as requested by the resident's legal representative. The resident, who has diagnoses including Dementia, Alzheimer's disease, and bipolar disorder, had a legal guardian who authorized a law office to request the medical records. The initial request was made on April 30, 2024, and a second request was documented on May 17, 2024. Despite these requests, the records were not released promptly, and the facility's legal team was still attempting to fulfill the request as of August 19, 2024. The facility's policy states that medical records should be accessible to the resident or their legal representative within two working days of a request. However, the process was delayed due to a change in staff responsible for handling medical records and technical difficulties in transmitting the records. The administrator and quality assurance assistant were involved in the process, but there was a lack of communication and follow-up, leading to the delay in providing the requested records.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident abuse involving two residents. One resident, with a history of aggressive behavior and diagnoses including schizophrenia, violent behavior, paranoid personality disorder, and bipolar disorder, was taking a shower when another resident repeatedly opened the shower room door. Despite attempts by a CNA to redirect the second resident, the first resident became increasingly agitated and verbally asked the second resident to close the door. The situation escalated when the first resident lunged at the second resident, resulting in both residents falling to the floor. The incident was observed by staff members, including two LPNs and a CNA, who were present at the nurses' station and attempted to manage the situation. The facility's abuse prevention policy, which aims to protect residents from abuse by anyone, was not effectively implemented in this case. The first resident's care plans for verbal and physical behaviors, which included interventions such as anticipating needs, separating the resident from others, and referring to a psychologist or psychiatrist, were not sufficient to prevent the escalation of aggression during this incident.
Failure to Prevent Resident Abuse and Inadequate Staff Training
Penalty
Summary
The facility failed to protect a resident, R3, from abuse by another resident, R5, and failed to protect R5 from verbal abuse by staff. R3, a male with a history of vision loss, falls, and other medical conditions, was involved in a physical altercation with R5, who has a history of multiple fractures and psychosis. The altercation occurred in the dining area, where R3 sustained a bump on his head after being punched by R5. The incident was observed on video recordings, showing a delay in staff intervention and inadequate supervision, as only one staff member, V8, was present and was not adequately trained to handle such situations. V8, a Certified Nursing Assistant, had only been working at the facility for four days and had not yet received training on handling resident altercations. She was assigned to monitor more than ten residents in the dining area alone and was unaware of any residents' aggressive behavior history. V10, another CNA, had previously intervened in a verbal altercation between R3 and R5 but did not report it to social services, which could have prevented the physical altercation. The facility's administrator acknowledged that more than one staff member should be present during such incidents and that communication between staff regarding resident behavior was lacking. Additionally, V7, a CNA with six years of experience, was observed swearing at R5 while restraining him after the altercation, which is considered verbal abuse. The facility's policies on de-escalating behavior and abuse prevention emphasize the importance of calm and respectful communication, separating conflicting parties, and reporting incidents immediately. However, these protocols were not followed, leading to the deficiencies observed in the report.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy and procedures for identifying and reporting an injury of unknown origin to the State agency. This deficiency was identified in the case of a male resident with a history of vision loss, falls, abnormal posture, unsteadiness, prostate cancer, hypertensive heart disease, and type 2 diabetes mellitus. The resident was admitted to the facility in May 2024. A grievance form documented that a family member reported the resident had a swollen left eye, and the resident was unsure of the cause. The resident's roommate mentioned a fall, but this was not documented in the grievance form. The resident was assessed by nursing staff, sent to the emergency room for evaluation, and returned to the facility. The Director of Nursing acknowledged that the incident should have been reported to the state agency, as per the facility's policy. The facility's records from May to August 2024 did not include a report regarding the resident's swollen eye. According to the facility's Abuse Prevention Program Policy, an injury should be classified as of unknown source if it was not observed or explained and is suspicious due to its extent or location. If classified as such, the procedures for reporting and investigating abuse should be followed, including informing the Department of Public Health and submitting a complete written report within five working days. The facility failed to report the incident as required by their policy.
Failure to Monitor High Fall Risk Resident
Penalty
Summary
The facility failed to monitor a high fall risk resident (R2) adequately, leading to a severe injury. R2, a [AGE] year old with chronic obstructive pulmonary disease and nontraumatic intracranial hemorrhage, was admitted to the facility with a high fall risk score of 17. Despite being identified as a high fall risk due to intermittent confusion, confinement to a chair, and recent functional decline, the facility did not implement sufficient interventions to address R2's behavior of moving around in bed. On 2/27/24, R2 was found on the floor with a small amount of blood on the left forehead after an unwitnessed fall, and a subsequent hospital evaluation revealed a brain bleed in two areas of the brain. The call light was not within R2's reach, and the fall event form was not completed post-fall, indicating a lack of proper documentation and follow-up. The care plan for R2, dated 2/27/24, included interventions such as frequent observation, placing R2 in supervised areas when out of bed, and keeping the call light within reach. However, these interventions were not effectively implemented. The fall mats were not placed until 3/5/24, several days after the fall occurred. Interviews with staff members revealed that R2 was known to be restless, yelling out, and moving around in bed, yet the necessary precautions were not taken in a timely manner. The call light was found clipped to the comforter at R2's feet, making it inaccessible, and staff admitted that the call light should have been within reach. The facility's failure to monitor R2 adequately and implement timely interventions directly contributed to the fall and subsequent injury. Staff interviews indicated a lack of awareness and consistency in applying fall prevention measures. The facility's policy on falls, which emphasizes identifying and implementing permanent interventions to prevent falls, was not followed. This deficiency highlights the need for better communication, documentation, and adherence to care plans to ensure resident safety.
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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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