Crescent Care Of Elgin
Inspection history, citations, penalties and survey trends for this long-term care facility in Elgin, Illinois.
- Location
- 180 South State Street, Elgin, Illinois 60123
- CMS Provider Number
- 145004
- Inspections on file
- 18
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Crescent Care Of Elgin during CMS and state inspections, most recent first.
The facility did not provide CNAs with the required annual 12 hours of continuing competence training, including dementia management, despite caring for multiple residents with dementia and Alzheimer’s disease. Review of orientation materials and sampled CNA personnel files showed no dementia-related in-services, and interviewed CNAs reported they did not track their annual training hours or recall receiving dementia training. The HR coordinator stated dementia training hours were not tracked and she was unaware such training was required for CNAs to work on the floor. The Administrator and DON reported there was no specific policy for staff education requirements, that only a few hours of general training were provided at hire and annually, and that they believed dementia-specific training was not required because the facility did not operate a memory care unit.
Surveyors found that multiple opened inhaler medications on two medication carts were not labeled with open or discard dates, despite active orders for routine and PRN use. During observations with two RNs, several aerosol inhalers, including Symbicort, Fluticasone-Umeclidinium-Vilanterol, Atrovent (Ipratropium Bromide HFA), Levalbuterol, and Albuterol, were discovered opened and unlabeled. One RN was unsure why the inhalers were not labeled, and another acknowledged that all opened inhalers should be labeled with open dates. The facility’s medication labeling and storage policy required medications and biologicals to be labeled per accepted pharmaceutical practices, with nursing staff responsible for safe medication storage.
Surveyors found that three residents were keeping multiple medications, including inhalers, nasal sprays, eye drops, ointment, lidocaine patches, and nebulizer solutions, at their bedside without physician orders authorizing bedside storage or documented assessments for self-administration. These residents reported that the medications were always kept in their rooms and that facility staff had not provided instruction on their use, despite long-term personal use. Record review showed active medication orders but no self-administration assessments or related care plans, contrary to facility policy requiring licensed nurse evaluation, IDT documentation, periodic review, and specific MD orders for medications to be kept at the bedside. The DON acknowledged that medications from home should be secured and that staff should contact family and the MD and complete an assessment before allowing residents to self-administer medications in their rooms.
Surveyors found that the facility failed to provide required written notices for hospital transfers and bed-hold rights for two residents who were repeatedly sent to the ER for hypotension, COPD exacerbations, and chest pain. Although clinical events, vital signs, 911 calls, and family notifications were documented, there was no documentation of written reason-for-transfer forms or bed-hold notices in the medical record for any of the transfers, and the ombudsman was not notified. The DON reported that staff do not provide written transfer notices, may rely on marketing staff for bed-hold information, and do not notify the ombudsman, despite a facility policy requiring written bed-hold notices at admission and at each transfer, along with documentation of ombudsman notification.
A resident with multiple comorbidities, including prior amputation due to ulcer and documented sacral pressure injury from the hospital, was admitted without the sacral wound being identified or care-planned. Only the amputation site was documented on the initial comprehensive skin assessment, and no MD orders or TAR entries were obtained for sacral wound treatment. During incontinence care, staff found an old, peeling bordered foam dressing on the sacrum; when the wound care nurse assessed the area, she identified a large sacral pressure wound with slough and minimal granulation. The facility’s protocol requiring admission skin assessment and physician-authorized wound treatment orders was not followed for this resident’s sacral pressure ulcer.
The facility failed to provide sufficient staff to meet the ADL needs of 79 residents, resulting in unmet care needs. Residents were left in soiled incontinence briefs for extended periods, and staff were overwhelmed with responsibilities, including passing meal trays and assisting residents with high care needs. The staffing schedules revealed consistent understaffing, with only six CNAs available during the day shift, despite the facility's assessment tool indicating a need for more staff.
The facility failed to maintain window coverings in good repair, affecting 13 residents. Observations showed torn, non-adjustable paper shades and some rooms without any coverings, impacting residents' comfort and privacy. The Maintenance Director cited halted remodeling due to financial issues, leaving rooms without permanent shades for over six months.
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. One resident reported her brief was wet and had not been changed since early morning, despite her care plan requiring checks every two hours. Another resident was found with wet clothing and redness around the rectal area, indicating a lack of timely care. Both CNAs assigned to these residents were responsible for twelve residents each, which may have contributed to the delay in care.
A resident's room had a damaged electrical outlet with exposed wires near their metal bed frame, posing a safety hazard. The resident, who is dependent on staff for repositioning, reported that the bed frequently hits the outlet. The Maintenance Director was aware of the issue but had not implemented measures to prevent further damage. The resident has multiple health conditions and requires assistance with all ADLs.
The facility failed to follow its water management plan and infection control policies, including neglecting weekly checks for Legionella prevention and improper hand hygiene during resident care. Staff did not adhere to Enhanced Barrier Precautions, and urinary catheter care was inadequate, with drainage bags placed on the floor and improper glove use observed.
The facility did not follow its policy to offer the updated COVID-19 vaccine to eligible residents, as shown by the lack of documentation for four residents with various medical conditions. The Nurse Consultant confirmed that these residents should have been offered the vaccine, in line with CDC recommendations.
A resident with a history of urinary infections and other medical conditions experienced catheter-related trauma due to the facility's failure to secure an indwelling urinary catheter. The unsecured catheter was pulled out, causing bleeding and discomfort. The facility's policy required securing the catheter to prevent such incidents, which was not adhered to in this case.
The facility did not follow its policy to offer and administer pneumococcal vaccines according to CDC guidelines for three residents. Despite consent, these residents did not receive the recommended follow-up vaccinations, as confirmed by a nurse consultant. The facility lacked documentation to show that the necessary vaccines were offered or administered.
The facility's arbitration agreements were found deficient as they lacked language stating that signing was not a condition for admission or care. Additionally, agreements did not include provisions for rescinding within 30 days or mutual decision-making for arbitrator selection. This affected all 70 residents, with specific deficiencies noted in agreements signed by three residents.
Failure to Provide Required Annual CNA Dementia Training
Penalty
Summary
The facility failed to provide the required 12 hours per year of continuing competence training for CNAs, including dementia management training, for a census of 68 residents. Surveyors’ review of the CNA orientation packet showed no evidence of dementia-related in-services, and the Human Resources Coordinator stated that dementia training hours are not tracked and that she had not been informed dementia training was required for CNAs to work on the floor. A sample review of three CNA personnel files revealed no documentation of dementia training, and three CNAs interviewed reported they do not keep track of their annual training hours and did not recall receiving dementia training in the past year. Review of the facility’s diagnosis report identified 31 current residents with diagnoses of dementia and/or Alzheimer’s disease. The Administrator and DON stated the facility does not have a specific policy regarding staff education requirements, including dementia training, and reported that the facility provides only 6 hours of general staff training upon hire and 3 hours of annual training thereafter. They also stated they believed they were not required to provide a specific number of dementia training hours because the facility does not have a memory care unit.
Failure to Label Opened Inhaler Medications on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling practices related to multiple residents’ inhaler medications. During an observation of the first-floor medication cart #2 with an RN, one resident’s Symbicort inhalers were found opened without any label indicating the open or discard dates, despite an active order for Symbicort 160-4.5 mcg/act, 2 puffs inhaled orally twice daily. On the same cart, another resident’s Fluticasone-Umeclidinium-Vilanterol inhaler was also opened and not labeled with an open or discard date, even though there was an active order for one inhalation orally once daily. The RN present stated she was unsure why the opened inhalers were not labeled. On the second floor, during a check of medication cart #1 with another RN, a third resident’s Symbicort, Atrovent (Ipratropium Bromide HFA), and Levalbuterol aerosol inhalers were all opened and not labeled with open or discard dates, despite active orders for Symbicort twice daily, Levalbuterol every 6 hours as needed, and Ipratropium Bromide four times daily. On the same cart, a fourth resident’s Albuterol inhaler was also opened and not labeled with an open or discard date. The RN on the second floor stated that all opened inhalers should be labeled with open dates to ensure they are stored and discarded properly. The facility’s undated Medication Labeling and Storage policy stated that medications and biologicals are to be labeled in a manner consistent with currently accepted pharmaceutical practices and that nursing staff are responsible for maintaining medication storage in a safe manner.
Failure to Assess and Obtain Orders for Resident Self-Administration of Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders for medications to be kept at the bedside and to complete required self-administration of medication assessments and care plans for three residents. One resident with emphysema and chronic bronchitis had multiple prescribed respiratory inhalers, nasal spray, and topical hydrocortisone ointment stored on the bedside table. The resident reported that these medications were always kept in the room and that no one at the facility had instructed her on their use. Review of the physician order sheet confirmed active orders for all of these medications but no orders authorizing them to be kept at the bedside. The electronic medical record contained no self-administration of medication assessment form, and there was no care plan addressing self-administration. A second resident had ordered ophthalmic drops and an over-the-counter saline nasal spray kept in the room and stated that these medications were always kept there and that the nurse had not taught him how to use them, although he had used them for a long time. The physician order sheet contained an order for the eye drops but no order for the nasal spray or for bedside storage of either medication, and there was no self-administration assessment or related care plan in the record. A third resident kept lidocaine patches, saline nasal spray, nebulization solution vials, and lubricant eye drops on the nightstand, stating they were kept there for easier access and that no assistance or teaching was needed. The physician order sheet contained orders for these medications but no authorization for bedside storage, and the record lacked a self-administration assessment and care plan. The facility’s own policy required a licensed nurse to complete a self-administration evaluation, IDT documentation and care planning, periodic reevaluation, and a physician order specifying which medications could be kept at the bedside, none of which were completed for these residents. The DON confirmed that medications brought from home should be locked and that staff should contact family and the physician and complete an assessment before allowing bedside self-administration.
Failure to Provide Written Transfer Reasons, Bed-Hold Notices, and Ombudsman Notification
Penalty
Summary
Surveyors identified that the facility failed to provide required written notifications related to hospital transfers, bed-hold rights, and ombudsman notification for multiple residents. One resident, originally admitted on 12/4/25, experienced hypotension with blood pressures of 73/39 and 79/32, pulse changes, and a temperature increase, leading the NP to order transfer to the ER via 911. Progress notes documented the vital signs, the NP’s order, the 911 call, transport to the hospital, and that the son and daughter were notified, but there was no documentation in the electronic medical record of a written reason-for-transfer form or a bed-hold notice being provided to the resident or POA. Another resident, originally admitted on 4/15/2018, had three separate transfers related to COPD exacerbations and a complaint of possible heart attack. Progress notes showed episodes of shortness of breath with low oxygen saturation despite nebulizer treatment, 911 calls, transport to the ER, hospital admissions for COPD exacerbation, and a later transfer for chest pain with normal vital signs and oxygen saturation. For all three transfers, the electronic medical record contained no uploaded reason-of-transfer forms or bed-hold notices, and progress notes did not indicate that written notices were given to the resident or representative. In an interview, the DON stated the facility does not give residents or POAs anything in writing regarding the reason for transfer, that nurses only provide clinical information to paramedics, that they do not notify the ombudsman, and that no written reason-of-transfer forms, bed-hold notices, or ombudsman notification documentation could be produced, despite a facility policy requiring written bed-hold notices at admission and each transfer and documentation of ombudsman notifications.
Failure to Assess and Treat Known Sacral Pressure Ulcer
Penalty
Summary
The facility failed to assess, monitor, and obtain treatment orders for a resident with a known sacral pressure wound. The resident was admitted with multiple comorbidities, including a prior surgical amputation of the left foot due to a foot ulcer, type II diabetes mellitus, peripheral vascular disease, congestive heart failure, and other chronic conditions. The resident was cognitively intact but totally dependent on two staff for transfers and required partial to moderate assistance with bed mobility. Hospital records immediately prior to admission documented a sacral pressure wound measuring 7 cm x 8.5 cm x 0.1 cm, described as purplish, non-blanchable erythema and an open deep tissue injury. Despite this, on admission and during a comprehensive skin assessment on 11/25/25, only the left lower extremity amputation wound was documented, and no sacral wound was recorded. During incontinence care observed on 12/1/25, staff noted an undated bordered foam dressing on the resident’s sacrum that appeared old and was peeling. A CNA removed the dressing and notified the nurse. The wound care nurse initially believed the dressing was a pain patch, then, upon assessment of the sacrum, identified a pressure wound with slough and a small area of granulation, measuring 9 cm x 8.5 cm x 0.1 cm. The wound care nurse stated she had not been informed of the sacral wound and that it had not been present at her last assessment. Review of the physician order sheet and treatment administration records for November and December showed no treatment orders for a sacral pressure wound, and the care plan contained no interventions for a sacral wound. The facility’s own clinical protocol required skin examination of new admissions for ulcerations and physician-authorized wound treatment orders, but these were not implemented for this resident’s sacral pressure ulcer.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient staff to meet the Activities of Daily Living (ADL) needs of all 79 residents. On multiple occasions, residents were left in soiled incontinence briefs for extended periods due to inadequate staffing. For instance, one resident reported being left in a wet brief from 3:00 AM until after 9:00 AM, despite the care plan requiring checks every two hours. This resident, who has moderate cognitive impairment and is dependent on staff for all ADLs, was not provided timely incontinence care, highlighting the staffing shortfall. Another resident, who is always incontinent of bowel and bladder and requires substantial assistance with transfers, was found sitting in a wheelchair with wet clothing and a strong odor of urine and stool. The resident's care plan also mandates regular checks and cleaning after incontinence episodes to prevent skin breakdown. However, the resident was not attended to promptly, resulting in redness and tenderness around the rectal area, indicating a failure to meet the care plan's goals. The facility's staffing schedules revealed consistent understaffing, with only six CNAs available during the day shift to care for 79 residents, despite the facility's assessment tool indicating a need for more staff. CNAs were overwhelmed with responsibilities, including passing meal trays and assisting residents with high care needs, such as those requiring mechanical lifts and feeding assistance. The staffing coordinator confirmed the inability to meet the ideal staffing levels due to restrictions on using agency staff, further exacerbating the issue.
Facility Fails to Maintain Window Coverings, Affecting Resident Comfort
Penalty
Summary
The facility failed to provide a clean, homelike environment for its residents by not maintaining window shades or equivalent coverings in good repair. Observations revealed that several residents' rooms had temporary, pleated paper shades that were torn and could not be adjusted, leaving residents unable to control the amount of light entering their rooms. In some cases, rooms lacked any window coverings entirely, exposing residents to the courtyard/patio without privacy. Residents expressed dissatisfaction with the inability to adjust the shades, which affected their comfort and the ambiance of their rooms. The deficiency affected 13 out of 18 residents reviewed, with some residents unable to be interviewed due to cognitive impairments. The Maintenance Director acknowledged that a remodeling update had been initiated but halted due to financial constraints, leaving resident rooms without permanent window shades for over six months. The facility had received a quote for window treatments, but the previous administrator did not proceed with the purchase, and the remodeling has not resumed under the new administration.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. One resident, who was frequently incontinent of urine and always incontinent of stool, reported that her brief was wet and had not been changed since 3:00 AM, despite the next shift starting at 6:00 AM. The resident's care plan required checking every two hours and cleaning the peri-area with each incontinence episode, which was not adhered to. The CNA assigned to her care was responsible for twelve residents, which may have contributed to the delay in care. Another resident, who was always incontinent of bowel and bladder, was found sitting in a wheelchair with wet sweatpants and a strong odor of urine and stool. Upon being transferred back to bed, it was observed that the resident's incontinence brief was wet with urine and stool, and there was redness around the rectal area and sacrum. The resident's care plan also required checking every two hours and cleaning the peri-area with each incontinence episode, which was not followed. The CNA assigned to this resident was also responsible for twelve residents, including two who required feeding assistance, which may have impacted the timeliness of care provided.
Exposed Electrical Wires Near Resident's Bed
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not addressing a damaged electrical outlet in the resident's room. The outlet box was hanging off the wall with exposed electrical wires, located approximately two to four inches from the resident's metal bed frame. The resident, who is dependent on staff for repositioning in bed, reported that the bed frequently hits the outlet during repositioning, which was confirmed by the Maintenance Director. The resident has multiple diagnoses, including rheumatoid arthritis and major depressive disorder, and is dependent on staff for all activities of daily living. The Maintenance Director acknowledged the ongoing issue with the outlet, stating that it had been reported three months prior but had not been adequately addressed. Despite being informed of the hazard by the surveyor, the Maintenance Director had not implemented any interventions to prevent further damage to the outlet. The resident's electronic medical record and Minimum Data Set indicate moderate cognitive impairment and frequent incontinence, further emphasizing the need for a safe environment. The deficiency was observed over several days, with no corrective actions taken to secure the outlet or prevent future incidents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its water management plan, specifically in the prevention of Legionella growth. The Maintenance Director admitted to not performing weekly checks and recording the temperatures of the hot water boiler/storage tank, nor flushing the eye wash stations weekly as required. Additionally, the ice machine was cleaned less frequently than the monthly schedule outlined in the plan, and the cooling tower was inspected only monthly instead of weekly. This lack of adherence to the water management plan was confirmed by the facility administrator, who acknowledged the need for weekly documentation of water temperatures. The facility also failed to follow its policy regarding catheter care and hand hygiene, which was observed during the care of several residents. For instance, two CNAs were observed providing incontinence care to a resident without performing hand hygiene between glove changes. They also failed to change gloves appropriately during the care process, which included cleaning the perineal area and applying barrier cream. Similar lapses in hand hygiene and glove changes were noted during the care of another resident, where CNAs did not perform hand hygiene before donning new gloves after providing incontinence care. Furthermore, the facility did not adhere to Enhanced Barrier Precautions for a resident with a history of ESBL and an indwelling urinary catheter. Staff failed to use gowns during direct care and placed the urinary drainage bag on the floor, contrary to facility policy. Hand hygiene was again neglected during the care process, as staff did not wash hands between tasks or after handling the urinary catheter. These deficiencies in infection prevention and control practices were observed across multiple residents, indicating a systemic issue within the facility.
Failure to Offer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to adhere to its policy of offering and administering the COVID-19 vaccine to residents, as evidenced by the lack of documentation for four residents. These residents, identified as R1, R22, R32, and R39, were not documented as having been offered the updated 2023-2024 COVID-19 vaccine, despite their eligibility and the facility's policy requiring such an offer. The facility's policy, dated October 2023, mandates that all residents and employees without medical contraindications be offered the vaccine annually, in line with CDC recommendations. The residents involved had various medical conditions, including chronic obstructive pulmonary disease, asthma, heart failure, type 2 diabetes mellitus, epilepsy, anemia, rheumatoid arthritis, and chronic kidney disease. The facility's failure to document the offer of the updated vaccine was confirmed through interviews and record reviews, with the Nurse Consultant acknowledging that these residents should have been offered the vaccine. The CDC's guidelines recommend the updated vaccine for everyone six months and older, emphasizing the importance of following these guidelines to ensure resident safety.
Failure to Secure Indwelling Catheter Leads to Resident Trauma
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to catheter-related trauma. The resident, who was cognitively intact and had a medical history including type 2 diabetes, prostate cancer, and a history of urinary infections, was observed with an unsecured catheter. This resulted in the catheter being pulled out approximately four inches, causing moderate bleeding around the tip of the penis and soaking through the incontinence brief. The catheter tubing was noted to be freely dangling between the resident's legs, which was confirmed by a registered nurse as improperly secured. The facility's policy and procedure for urinary catheter care required that the catheter be secured with a strap to prevent pulling and tugging, which was not followed in this instance. The care plan for the resident included maintaining comfort and preventing infection, with interventions such as assessment and notifying the physician for any changes. However, the failure to secure the catheter as per the policy and care plan led to the observed trauma and discomfort for the resident.
Failure to Administer Follow-up Pneumococcal Vaccines
Penalty
Summary
The facility failed to adhere to its policy of offering and administering pneumococcal vaccines in accordance with CDC guidelines, affecting three residents. The first resident, a [AGE] year-old with multiple health conditions, consented to receive pneumococcal vaccinations and was administered the PPSV23 vaccine. However, there was no documentation to show that a second pneumococcal vaccine was offered or administered, as per CDC guidelines. Similarly, the second resident, also with multiple diagnoses, consented to pneumococcal vaccinations and received the PPSV23 vaccine, but again, there was no documentation of a follow-up vaccine being offered or administered. The third resident, with a history of rheumatoid arthritis and other conditions, consented to receive pneumococcal vaccines but had only received the PCV13 vaccine in 2012. The facility's policy, which aligns with CDC recommendations, requires that residents who have received PPSV23 should be offered a second pneumococcal vaccine, and those who received PCV13 should receive a PPSV23 dose. The lack of documentation for these follow-up vaccinations indicates a failure to comply with the established vaccination policy, as confirmed by the nurse consultant during the survey.
Deficient Arbitration Agreements in Facility
Penalty
Summary
The facility's arbitration agreements were found to be deficient as they did not include necessary language indicating that signing the agreement was not a condition for admission or receiving care. This issue was identified during interviews and record reviews, where it was noted that the facility's most recent arbitration agreements lacked this critical information. Additionally, the facility failed to update previously signed agreements to include language that allowed residents to rescind the agreement within 30 days and to ensure that the selection of an arbitrator and meeting location would be mutually decided by the parties involved. These deficiencies affected all 70 residents residing in the facility. Specific examples of the deficiency were observed in the arbitration agreements of three residents. One resident's agreement, signed recently, did not include the necessary language about the agreement not being a condition for admission or care. Two other residents had agreements signed in 2022 that also lacked the required language about rescinding the agreement within 30 days and the mutual decision-making process for selecting an arbitrator and meeting location. The facility's Acting Administrator acknowledged the oversight in the updated contracts, confirming the absence of the required language.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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