Crestwood Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Crestwood, Illinois.
- Location
- 13301 South Central Avenue, Crestwood, Illinois 60445
- CMS Provider Number
- 14E177
- Inspections on file
- 44
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Crestwood Terrace during CMS and state inspections, most recent first.
A legally blind resident who required supervision or touching assistance for ambulation and used a white cane was allowed to walk unassisted in a common area while returning a coffee cup. Without staff within arm’s reach and at times without using the cane, the resident bumped into another resident’s wheelchair, nearly fell, and a verbal exchange escalated into a physical altercation in which both residents reported being struck, and one sustained a busted lip. Multiple staff and a peer witness described the blind resident striking the other with a cane, and another resident reported that this visually impaired resident frequently stumbles into others and their wheelchairs. The DON stated that residents needing supervision with ambulation should have staff within arm’s reach, while the administrator acknowledged there was no formal supervision policy and that the incident could have been prevented with supervision, despite facility education materials stating that all staff are expected to monitor residents to prevent incidents and altercations.
A resident with a history of mental illness and risk for abuse was physically and sexually assaulted by another resident with a documented history of aggression and inappropriate behavior. The incident occurred when the assigned CNA left the central shower area unsupervised without arranging coverage, allowing the perpetrator to enter and commit the assault. The lack of required supervision and failure to follow abuse prevention policies resulted in significant harm to the victim.
A resident with significant psychiatric and medical diagnoses was prevented from returning to his room with his personal items and was physically restrained by staff after a dispute over checking his delivered groceries. Staff blocked the resident's access to his room and used a CPI hold to restrain him on the floor until police arrived, actions not consistent with facility policy prohibiting physical abuse and unreasonable confinement.
A resident with a history of aggressive behavior attacked another resident, resulting in the victim being hospitalized for facial trauma. Despite the aggressor's known history of severe mental illness and previous incidents of aggression, the facility failed to implement adequate monitoring and intervention strategies, leading to the deficiency.
A resident with a history of aggressive behavior attacked his roommate after a dispute over a sheet placed on the floor. The incident occurred during lunchtime when staff were occupied, leading to inadequate monitoring. The aggressive resident was sent for psychiatric evaluation, while the other resident received medical attention for a swollen eye.
A resident with dementia, schizophrenia, and epilepsy experienced a fall resulting in a head laceration due to the facility's failure to identify them as a high fall risk after developing a shuffling gait. Despite therapy and restorative programs addressing the gait change, the care plan lacked interventions for fall prevention, and staff were unaware of the resident's increased fall risk.
A resident with a history of mental health issues exhibited increasing aggression and anxiety, but the facility failed to update his care plan with personalized interventions. Despite multiple incidents of aggression and inappropriate behavior, the care plan did not reflect necessary changes to address his specific triggers, leading to a deficiency in care.
A facility failed to prevent and report verbal abuse by an employee towards two residents with schizoaffective disorder. The incidents involved derogatory remarks and disrespectful behavior by a staff member, V6, which were witnessed by other staff but not reported immediately as required by the facility's abuse policy. The administrator was informed of the incidents only after a resident reported them the following day, leading to the suspension and termination of the employee after substantiation of the allegations.
A facility failed to address a pharmacist's recommendation for a gradual dose reduction of an anti-depressant for a resident with multiple psychiatric diagnoses. The recommendation was not available in the electronic health record and was not reviewed by the psychiatrist until two months later, with no documentation of clinical contraindications for not reducing the medication.
The facility failed to update the care plans for six residents who tested positive for COVID-19. These residents were placed on droplet precautions, but their care plans lacked necessary interventions. The DON confirmed that care plans should be updated for significant condition changes, such as COVID-19 infections, to include isolation precautions. However, the Care Plan Coordinator was unavailable to perform these updates due to being on vacation.
The facility failed to implement proper infection control protocols for residents with COVID-19, with staff not wearing appropriate PPE and lacking written orders for droplet precautions. Monitoring and assessment of COVID-19 positive residents were inconsistent, and COVID-19 testing for non-positive residents was not conducted as claimed. The facility's policies were generic and lacked a documented COVID surveillance or testing plan.
The facility did not follow its policy to notify a resident's family when the resident was transferred to the hospital. A resident was sent to the hospital without documentation of family notification, as required by the facility's procedure. Staff interviews confirmed the expectation to notify the administrator, DON, and family, but this was not done in this instance.
A resident with Type 2 Diabetes Mellitus did not receive their scheduled insulin dose because the medication was unavailable in the cart. The RN acknowledged the missed dose, and the DON confirmed that medications should be administered as per physician orders.
The facility failed to provide effective supervision to prevent a resident-to-resident altercation, resulting in one resident sustaining a subdural hematoma and facial contusions. The incident involved two residents with cognitive impairments and behavioral issues, and staff did not adequately monitor or intervene in time to prevent the escalation.
The facility failed to prevent a physical altercation between two residents, resulting in one resident sustaining visible injuries. During the incident, most staff members were in the dining room and not present to supervise the residents. The attacking resident had a history of aggressive behavior, which was documented in her care plan, but no effective measures were in place to prevent such incidents.
Failure to Supervise Legally Blind Resident During Ambulation Leading to Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance with ambulation for a resident with severe visual impairment, resulting in an avoidable accident and resident‑to‑resident altercation. One resident (R1) was diagnosed with category five blindness in the right eye, category four blindness in the left eye, and atrophy of the right globe, with the MDS documenting severely impaired vision but cognitively intact status. The MDS Section GG documented that R1 required supervision or touching assistance for walking at least 10 feet, and the care plan noted an ADL self‑care performance deficit related to legal blindness, specifying that R1 used a white cane for ambulation and required assistance with ambulation and transfers as necessary, with an intervention to ensure R1 used his white cane when up and about. Despite this, R1 reported that on the day of the incident he was walking without his cane and no staff were helping him return his coffee cup. On the day of the incident, R1 attempted to return his coffee cup to a kitchen window area and bumped into another resident (R2) seated in a wheelchair, which R1 stated he did not see due to his visual impairment. R1 reported that he almost fell, asked R2 why he was sitting there, and then R2 punched him in the chest, after which R1 hit R2 two or three times with his cane. R1’s written statement indicated he bumped into R2’s chair, tried to apologize, and was verbally cursed at before being hit, leading him to hit back. R2 stated that R1 hit him in the mouth with his cane, causing a busted lip, and denied hitting R1; staff documentation noted a superficial scratch/red raised area on R2’s upper lip consistent with this account. A social service note documented that R1 was seen trying to get past another peer and lost his step, hitting the peer with his cane. Multiple witnesses described a physical altercation between the two residents in a common area without immediate staff intervention at the moment of escalation. A medical records staff member (V6) reported hearing an uproar and seeing R1 striking R2 with his walking stick while R2 covered his head, and an activity aide (V4) reported hearing arguing, seeing R1 (described as legally blind) asking R2 why he was sitting there, hearing R2 respond with profanity, and then observing R1 hit R2 several times in the mouth with his cane. A social service aide (V3) stated he heard cursing and then saw R1 physically altercating with R2, with blood coming from R2’s mouth. Another resident (R3) stated that R1 fell into R2’s wheelchair, became entangled, and that R2 hit R1, after which R1 took his folded cane from his pocket and hit R2; R3 also reported that R1 stumbles over residents and walks into their wheelchairs daily and tends to walk forward rather than backing up when entangled. The DON (V2) stated that if a resident requires supervision with ambulation, staff should be within arm’s reach, and if touching assistance is required, staff should physically touch the resident, but also stated that R1 did not need anyone to walk with him. The administrator (V1) acknowledged there was no written supervision policy and that the incident could have been prevented with supervision, while existing education materials stated that all staff are expected to monitor residents to prevent incidents and altercations.
Failure to Supervise Leads to Resident-on-Resident Sexual and Physical Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not protect a resident from both physical and sexual abuse by another resident. The incident occurred when a female resident, who had diagnoses including major depressive disorder and suicidal ideations, went to take a shower in the central shower room. While she was showering, a male co-resident entered the shower room without consent, despite the resident's verbal protests and demands for him to leave. The male resident used physical force, restraining the female resident against the wall, and sexually assaulted her. The assault was interrupted when another resident heard the victim's screams for help, entered the shower room, and then alerted staff, who intervened and separated the two residents. The investigation revealed that staff were expected to monitor the central shower area, especially given the facility's behavioral health population and the known risks associated with certain residents. On the day of the incident, the certified nursing assistant (CNA) assigned to monitor the shower area left his post to use the restroom without arranging for coverage, leaving the area unsupervised. Other staff members confirmed that coverage should have been arranged before leaving the monitoring area, and that there were other staff available to provide coverage if needed. The lack of supervision allowed the male resident, who had a documented history of aggressive and inappropriate behaviors, to access the shower room and commit the assault. Both residents involved had documented mental health diagnoses, and the male resident had a history of aggression and criminal charges, as well as care plans noting socially inappropriate and maladaptive behavior. The female resident was assessed as being at risk for abuse and had a care plan reflecting this risk. The facility's failure to ensure proper supervision and monitoring, as required by their own policies and procedures, directly led to the incident of abuse and resulted in significant physical and psychosocial harm to the victim.
Failure to Follow Abuse Policy: Resident Restrained and Prevented from Accessing Room
Penalty
Summary
The facility failed to follow its abuse policy and procedures when staff restricted a resident from returning to his room with his personal items and physically restrained him against his will. The incident involved a male resident with a history of Schizoaffective Disorder, Major Depressive Disorder with Psychotic Symptoms, PTSD, Generalized Anxiety Disorder, brain cancer, and suicidal ideations. The resident became upset when staff attempted to check his delivered groceries, leading to a verbal altercation and subsequent physical confrontation. During the incident, staff members blocked the resident from accessing his room with his groceries, and when the resident became agitated and attempted to push past staff, two staff members physically restrained him using a CPI hold and took him to the ground. The resident was held in this position until police arrived. Witness statements confirmed that the resident was pinned to the floor by his arms and legs, and that staff physically intervened to prevent him from returning to his room. The facility's abuse policy prohibits physical abuse, mistreatment, and unreasonable confinement, including separating a resident from their room against their will. Interviews with staff indicated that the physical restraint and prevention of the resident from accessing his room were not in accordance with facility procedures, and that all physical interventions should be a last resort. The facility's final abuse investigation report did not include all relevant witness statements or information about the physical restraint, indicating incomplete documentation of the incident.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R2, from physical abuse by another resident, R3, who had a known history of aggressive behavior. R3 attacked R2 without provocation, putting her in a chokehold and punching her in the head and face. This incident resulted in R2 being emergently transferred to the hospital for evaluation of facial trauma. The attack occurred despite R3's documented history of aggressive behavior and previous incidents of physical aggression towards other residents, including an attack on R1 that resulted in a concussion. R3 had a history of severe mental illness, including schizoaffective disorder and major depressive disorder with psychotic symptoms, and was known to exhibit aggressive and inappropriate behavior. Despite this, there were no special monitoring measures in place for R3, and staff were not adequately prepared to manage her behavior. On the day of the incident, R3 was observed talking to herself more than usual, but no interventions were taken to prevent the escalation of her behavior. The facility's staff, including CNAs and psychiatric rehabilitation service aides, were unable to prevent the attack, and there was a delay in responding to the situation. The facility's internal investigation concluded that R2 was attacked as a result of R3 exhibiting symptoms of her mental illness. However, the report highlights a lack of adequate monitoring and documentation of R3's behavior, as well as insufficient interventions to prevent such incidents. The facility's abuse policy emphasizes the importance of creating a secure environment for residents, but the failure to implement effective monitoring and intervention strategies for residents with known aggressive behavior led to this deficiency.
Inadequate Monitoring Leads to Resident Altercation
Penalty
Summary
The facility failed to prevent a physical altercation between two residents, one of whom had a history of delusions, agitation, and aggressive behavior. The incident occurred when the resident with a history of aggressive behavior placed a sheet on the floor in front of the bathroom entrance, which his roommate moved to access the bathroom. This action led to the aggressive resident hitting his roommate, grabbing him by the shirt, and attempting to pull him out of the room. The altercation escalated into the hallway, where staff intervened to separate the residents. The aggressive resident was subsequently sent to a psychiatric hospital for evaluation, while the other resident was sent to a local hospital for medical evaluation. The facility's failure to adequately monitor the residents, especially during lunchtime when staff were occupied, contributed to the incident. The aggressive resident had a documented history of hallucinations, delusions, and aggressive behavior towards peers, with previous incidents noted in his electronic health record. Despite this history, the facility did not implement sufficient monitoring measures to prevent the altercation. Staff were unaware of the resident's habit of placing a sheet on the floor, which was a precursor to the conflict. The facility's educational in-service on supervision and monitoring of residents emphasized the importance of preventing altercations and monitoring residents, but these measures were not effectively implemented in this case.
Failure to Address Fall Risk Due to Shuffling Gait
Penalty
Summary
The facility failed to identify a resident as a high fall risk after the onset of a shuffling gait and did not implement appropriate interventions in the care plan to address this change. This oversight resulted in the resident attempting to get up unassisted, leading to a fall and a laceration on the forehead that required hospital treatment. The resident, who has a medical history of dementia, schizophrenia, and epilepsy, experienced a fall while trying to use the bathroom, which was not witnessed by staff. Interviews with staff revealed that the resident had been participating in restorative programs and therapy due to a new shuffling gait, which developed four to five months prior to the fall. Despite this, the Director of Nursing (DON) did not update the care plan with interventions for fall safety related to the shuffling gait. The staff, including the nurse and CNA on duty, were unaware of any specific interventions in place before the fall occurred, and the resident was not identified as a high fall risk at the time of the incident. Documentation and assessments, such as the Fall Scale and therapy notes, indicated inconsistencies in recognizing the resident's shuffling gait and fall risk. The care plan lacked documentation of the shuffling gait or any interventions addressing safety for this change. The facility's policy on fall prevention requires evaluations and care plan updates upon changes in condition, which were not adequately followed in this case.
Failure to Update Care Plan for Resident with Aggressive Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as R4, who exhibited increasing anxiety, agitation, and verbal and physical aggression. Despite having a history of mental health issues, including Schizoaffective Disorder and Schizophrenia, the care plan was not updated to address these behaviors effectively. The resident's care plan, initiated upon admission, did not include personalized interventions for his specific triggers, such as difficulty managing money and a desire to control others. Throughout his stay, R4 was involved in multiple incidents of aggression and inappropriate behavior, including altercations with peers and staff, and attempts to leave the facility unauthorized. These incidents were documented in progress notes, yet the care plan was not revised to include new interventions or strategies to manage his behavior. The facility's policy requires care plans to be updated within 24 hours of significant behavioral changes, but this was not adhered to in R4's case. Interviews with facility staff revealed that while they recognized the resident's behavioral triggers and the need for updated interventions, these were not reflected in the care plan. The facility's Care Plan Development Policy emphasizes the need for person-centered care plans with measurable objectives and timeframes, but this was not achieved for R4, leading to a deficiency in meeting his care needs.
Failure to Prevent and Report Verbal Abuse by Staff
Penalty
Summary
The facility failed to prevent verbal abuse by an employee towards residents and did not adhere to its abuse policy of immediate reporting. This deficiency involved two residents, R4 and R5, who were affected by the actions of an employee, V6. R4, a resident with schizoaffective disorder, reported an incident where V6 verbally abused them by making derogatory remarks. R5, who also has schizoaffective disorder, complained about a verbal altercation with V6 on a separate occasion. The facility's census at the time was 109 residents, indicating the potential for widespread impact. The incident involving R4 occurred in the social services office, where V6 told R4 to leave, leading to an exchange of insults. V7, another staff member, witnessed the incident but failed to report it immediately to the abuse coordinator or any supervisor, as required by the facility's policy. V8, another witness, confirmed hearing V6's disrespectful behavior and noted that such incidents had occurred before. Despite witnessing the altercation, V8 did not report it immediately, highlighting a breakdown in the facility's internal reporting procedures. The facility's administrator, V1, was only informed of the incident by R4 the following day, and no staff member had reported the incident prior to this. V6 was suspended and later terminated after the facility substantiated the allegations of verbal abuse. The facility's abuse policy mandates immediate reporting and investigation of any abuse allegations, which was not followed in this case, leading to a delay in addressing the abusive behavior and protecting the residents involved.
Failure to Address Pharmacist's Recommendation for Dose Reduction
Penalty
Summary
The facility failed to address a pharmacist's recommendation for a gradual dose reduction of an anti-depressant medication for a resident, and did not ensure that the pharmacist's recommendations were readily available in the resident's electronic health record. The resident, who was admitted with diagnoses including Schizoaffective disorder, Major Depressive Disorder, Bipolar Disorder, and Epilepsy, expressed concerns about being overdosed with medications. The pharmacist's recommendation to reduce the dose of trazodone from 100mg to 75mg was made in February, but the recommendation was not located in the electronic health record and was only available upon request. The psychiatrist responsible for reviewing the medication regimen did not assess the resident until two months after the recommendation was made, and the progress notes did not mention the review of the recommendation. The facility was unable to provide a signed copy of the February Medication Regimen Review by the psychiatrist. The facility's policy on psychotropic medication use emphasizes the need for gradual dose reductions unless clinically contraindicated, but there was no documentation of clinical contraindications for not reducing the medication in the resident's medical record.
Failure to Update Care Plans for Residents with COVID-19
Penalty
Summary
The facility failed to update the care plans of six residents who tested positive for COVID-19, as observed during a survey conducted on August 20, 2024. The residents, identified as R1, R14, R16, R53, R54, and R89, were placed on droplet precautions due to their COVID-19 infections. However, upon reviewing their medical records, it was found that no care plan interventions had been developed for these residents. R89 tested positive on August 12, 2024, while the other residents acquired the infection on August 13, 2024. The Director of Nursing (DON) acknowledged that the care plan should be updated when there are significant changes in a resident's condition, such as a COVID-19 infection, to include isolation precautions and appropriate nursing interventions. Despite this requirement, the care plans for the affected residents were not updated. The Care Plan Coordinator, responsible for these updates, was unavailable for an interview as she was on vacation. The facility's policy, effective April 2020, mandates that the care planning team review and update care plans when there is a significant change in a resident's condition.
Inadequate COVID-19 Infection Control and Monitoring
Penalty
Summary
The facility failed to implement proper infection control protocols for residents with COVID-19 infections, affecting all ten residents in the sample reviewed for the Infection Control Prevention Program. During rounds, the Infection Preventionist (IP) was observed entering rooms of residents on droplet precautions without wearing appropriate personal protective equipment (PPE) such as gloves, gowns, and facial shields. Additionally, there were no written orders for droplet precautions in the active physician order sheets for six residents who tested positive for COVID-19, despite the facility's policy requiring such documentation. The facility's infection control practices were further compromised by inconsistent monitoring and assessment of residents with COVID-19. Daily monitoring and assessments were not consistently documented in the residents' electronic charts, with several residents missing entries for multiple days. The facility also failed to conduct COVID-19 testing for non-COVID positive residents twice a week as claimed, with inconsistencies noted in the testing records of several residents. The facility's policies on infection control and outbreak management were found to be generic and not specific to COVID-19, lacking a documented COVID surveillance monitoring or testing plan. The Infection Preventionist and Assistant Director of Nursing (ADON) acknowledged the lack of a COVID surveillance monitoring/tracking log and contact tracing log. They also admitted to not having a documented COVID testing plan for residents and employees to investigate the outbreak. The facility's policy required monitoring residents with COVID-19 every four hours for clinical worsening, but this was not consistently implemented. The facility's failure to adhere to CDC guidelines and its own policies contributed to the deficiency in infection control practices.
Failure to Notify Family of Hospital Transfer
Penalty
Summary
The facility failed to adhere to its policy regarding the notification of a resident's family when the resident was transferred to the hospital. This deficiency was identified in the case of one resident, R63, out of a sample of 23 residents reviewed for discharge. On March 16, 2024, R63 was sent to the hospital, but the nurses' notes lacked documentation of this transfer. Interviews with staff members, including an RN, the Assistant Director of Nursing, and the Director of Nurses, confirmed that the facility's procedure requires notifying the administrator, the Director of Nursing, and the resident's family when a resident is sent to the hospital. However, this protocol was not followed in R63's case, as there was no record of the family being notified of the hospital transfer.
Failure to Administer Scheduled Insulin
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically affecting one resident in a sample of 23 reviewed for medication administration. On the morning of August 20, 2024, during a medication pass, a registered nurse indicated that a resident would receive their scheduled insulin medication later when the morning tray was available. However, the resident ate breakfast in their room, and the surveyor followed up multiple times regarding the insulin administration. By 11:25 AM, the surveyor was informed that the resident's morning scheduled insulin was not administered as ordered and was recorded as a missed dose. The registered nurse stated that the insulin medication was not given because it was not available in the medication cart. The Director of Nursing confirmed that medication should be administered as scheduled per physician order. The resident has a diagnosis of Type 2 Diabetes Mellitus without complications and is at risk for complications, with a care plan that includes diabetes medication as ordered by the doctor.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide effective supervision to prevent a resident-to-resident altercation from escalating into a physical confrontation. This incident involved two residents, both of whom have cognitive impairments and behavioral issues related to their diagnoses. The altercation resulted in one resident sustaining a subdural hematoma and facial contusions, requiring hospitalization. The incident occurred in the resident's room and was not immediately observed by staff, despite the facility's policy of increased monitoring for these residents. The first resident (R1) has a history of mild intellectual disabilities, disruptive mood dysregulation disorder, impulsive disorder, and schizophrenia. R1's care plan did not adequately address his behavior of shadow boxing and delusional thoughts of being [NAME] Ali, which had been observed since February 2024. On the day of the incident, R1 approached the second resident (R2) and initiated a physical altercation. R2, who has a history of schizoaffective disorder and schizophrenia, responded by hitting R1 back. Staff intervened only after the altercation had escalated, and R1 was found on the floor with a bleeding head injury. Interviews with staff and residents revealed that the monitoring procedures were not effectively implemented. The CNA assigned to the wing was positioned in a way that did not allow for proper observation of the hallway where the incident began. Additionally, the facility's camera system did not capture the altercation, and staff were unaware of the incident until it had already resulted in injury. The facility's failure to update R1's care plan and adequately monitor both residents contributed to the escalation of the altercation and the resulting injuries.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent a physical altercation between two residents, resulting in one resident sustaining visible injuries. Resident R3, who has diagnoses including Schizoaffective Disorder and Major Depressive Disorder, was physically attacked by Resident R4, who has a history of anger problems and mood swings. The incident occurred when R3 opened the bathroom door and R4, who was already in the room, began screaming and hitting R3. This resulted in R3 sustaining scratches on her chest, arms, and head, which were later confirmed by multiple staff members and documented in medical records. Staff interviews revealed that during the time of the incident, most staff members, including CNAs, were in the dining room and not present to supervise the residents. V2, a Certified Nursing Assistant, mentioned that R4 thought R3 was involved with her boyfriend, which led to the altercation. V4, the Housekeeping Manager, witnessed the fight and described R4 swinging at R3 with her left arm, while R3 tried to defend herself. The incident was reported to the nursing staff, and R3 was taken to the nurses' station for assessment and treatment of her injuries. Further investigation showed that R4 had a history of aggressive behavior, including verbal and physical altercations, as documented in her care plan. Despite this, there were no effective measures in place to prevent such incidents. The facility's policy on abuse emphasizes the importance of preventing abuse and ensuring a secure environment for residents, but this policy was not effectively implemented in this case. The lack of staff presence and supervision during the incident contributed to the failure to protect R3 from physical abuse by R4.
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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