Encore Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Schaumburg, Illinois.
- Location
- 350 West Schaumburg Road, Schaumburg, Illinois 60194
- CMS Provider Number
- 145341
- Inspections on file
- 25
- Latest survey
- October 14, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Encore Village during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple medical conditions did not have a properly implemented or documented power of attorney (POA) in their medical record. Facility staff and family members were unclear about who was authorized to make decisions, and the facility's policy requiring advance directive implementation within 30 days of admission was not followed.
A resident did not receive a scheduled dose of tramadol because the facility ran out of the medication and did not obtain it from the medication tower, despite facility policy allowing this. Documentation confirmed the missed dose and lack of available medication until a new supply was delivered.
A resident's credit card was stolen from their room in a facility, leading to unauthorized charges. The resident, who was alert and oriented, had their card in a wallet attached to their phone. The theft was discovered by the resident's POA, who noticed a charge for a gaming system. The facility staff cooperated with the police investigation, which suggested the involvement of someone connected to the facility.
A resident's credit card was stolen and used without authorization, but the LTC facility failed to report the incident to the state agency within the required 24-hour timeframe. The resident's daughter discovered the theft and reported it to the police, but the facility delayed reporting until contacted by the police in December. The previous administrator was informed but did not act, leading to a significant delay in addressing the issue.
A facility failed to thoroughly investigate a resident's stolen credit card, despite police involvement and the resident's POA reporting the incident. The investigation was inadequately documented, with conflicting staff accounts and missing interviews. The resident, who was cognitively intact, had multiple medical conditions. The facility's prevention program required a complete investigation, which was not conducted.
The facility failed to monitor weight and nutrition for three residents, resulting in significant weight loss. A resident on tube feeding was not weighed weekly, leading to an 11.4% weight loss. Another resident lost 7.67% of their weight without nutritional assessment, and a third resident experienced a 6.6% weight loss due to delayed meal delivery and lack of weight monitoring upon readmission.
A resident with a history of venous thrombosis, embolism, and other conditions was found sitting in a wheelchair without proper leg support, leading to discomfort and reddish-purple legs. The Therapy Director confirmed that proper positioning requires feet to be supported, but only two left-sided footrests were available, indicating a deficiency in accommodating the resident's needs.
A resident's advanced directives were not discussed or implemented upon admission, leading to a discrepancy between the POLST form indicating DNR and a full code order in the Physician's Order Sheet. The facility's policy requires that DNR/POLST orders remain in effect unless a signed request to change them is provided, which was not followed.
Two residents requiring assistance with ADLs did not receive scheduled showers due to staff shortages and reliance on agency staff. Documentation showed significant gaps in recorded showers, contrary to the facility's policy for providing hygiene support.
The facility failed to use a gait belt during a resident transfer and did not update a care plan after a fall. A CNA removed a gait belt during a transfer, contrary to policy, and a resident with severe cognitive impairment experienced two falls without timely intervention. The resident's transfer assessment was only adjusted after the second fall, which resulted in injuries.
A resident with multiple health conditions, including dependence on supplemental oxygen, was not provided with the appropriate high flow nasal cannula for oxygen administration. Despite a physician's order for 7 liters of oxygen, the resident was observed using a regular flow cannula, which was confirmed by a respiratory therapist to be inadequate for the prescribed oxygen level. The facility's policy lacked guidance on when to use a high flow nasal cannula.
A resident with multiple health conditions was found with a cup of crushed medications left on her bedside table, indicating a failure in proper medication administration. The DON confirmed that medications should not be left unattended and that the resident was not assessed for self-administration, except for a nasal spray.
A resident with Parkinson's disease did not receive her Carbidopa-Levodopa medication on time, with a delay of approximately three hours. The facility's policy requires timely administration, but the medication was given late due to the resident being in the dining room during the scheduled time.
A resident was found with medications unsecured on a bedside table, contrary to the facility's policy requiring locked storage. The resident's electronic medical record lacked an assessment allowing for self-administration and bedside storage, as confirmed by the DON and LPNs.
Facility staff failed to follow infection control protocols during care for two residents. A CNA did not change gloves or wash hands after providing incontinence care to a resident, contrary to the facility's hand hygiene policy. Additionally, a wound nurse did not wear a gown while treating a resident under Enhanced Barrier Precautions, violating the facility's EBP policy.
Two residents requiring assistance with ADLs did not receive timely incontinence care. One resident was found with a saturated brief and urine-soaked clothing and bedding, while another was left in a wet brief that leaked onto her wheelchair pad. Both residents reported not receiving care as per their needs, contrary to the facility's policy of providing toileting and incontinence care every two hours and as needed.
A resident with Alzheimer's, dementia, and diabetes experienced significant weight loss due to the facility's failure to assist with eating and provide prescribed nutritional supplements. Despite a care plan that included house shakes and meal assistance, staff did not provide the necessary support, leading to continued weight decline.
A resident with a history of dementia and behavioral disturbances was hospitalized due to excessive drowsiness caused by psychotropic medications. Despite orders to hold medications if lethargy occurred, facility staff failed to do so and did not notify the physician. The resident's daughter raised concerns about her mother's condition, leading to her being sent to the hospital. Documentation showed inconsistencies in following medication orders and communication with the physician.
A resident's pain medication, Norco, was misappropriated by an LPN who initially lied about discontinuing the medication due to dizziness. The LPN later admitted to taking the medication home due to personal financial and health struggles. This incident violated the facility's policy on protecting residents from misappropriation of property.
Failure to Implement and Document Advance Directive/POA for Resident
Penalty
Summary
The facility failed to follow its advance directive and life-sustaining treatment policy by not ensuring that a power of attorney (POA) was properly implemented for a resident with moderate cognitive impairment and multiple medical conditions, including heart failure, atrial fibrillation, urinary retention, UTI, history of falls, and benign prostatic hyperplasia. Interviews revealed confusion among staff and family members regarding who was designated as the resident's POA. The nurse practitioner reported that the resident's daughter was making decisions, but the daughter questioned why the facility was not contacting the individual who actually held the POA. The social service staff was unsure who the POA was and indicated they would need to ask the administrator. The resident's son-in-law stated he was the POA but was not informed about the resident's condition or decline until after the resident passed away, and noted that the facility always contacted another family member instead. The administrator confirmed that the facility did not have any POA paperwork on file for the resident and that staff had mistakenly documented the son-in-law as the POA. The facility's policy required the social service director or designee to assess, care plan, and implement advance directives within 30 days of admission, but the resident's medical record did not contain documentation designating a POA in writing. This lack of proper documentation and implementation of the advance directive policy resulted in the facility not honoring the resident's right to have a designated representative make decisions on their behalf.
Missed Scheduled Pain Medication Dose Due to Medication Unavailability
Penalty
Summary
A cognitively intact resident did not receive a scheduled dose of tramadol, a pain medication, due to the facility running out of the medication. The resident was scheduled to receive tramadol four times daily and as needed, but the Medication Administration Record (MAR) showed that the 12:00 PM dose on 6/11/24 was not administered. Progress notes indicated that the medication was unavailable at the time and would be delivered later that day, but there was no documentation that the medication was retrieved from the medication tower, which was available for such situations. The Controlled Substance Proof of Use sheets confirmed that after the previous evening dose, there was no tramadol remaining on hand until a new supply arrived later the next day. The Director of Nursing confirmed that medications should be reordered before supplies run out and that the medication tower could be used to obtain medications in the interim. Facility policy also stated that staff may obtain medications from the medication tower while waiting for pharmacy delivery, but this was not done in this instance.
Resident's Credit Card Stolen in Facility
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property when a credit card was stolen from a resident's room. The incident involved a long-term resident who was alert and oriented but occasionally forgetful. The theft was discovered when the resident's Power of Attorney (POA), who is also the resident's daughter, noticed an unauthorized charge on the credit card statement for a gaming system. The charge was made at a store, and the POA contacted the facility management and the police. The police investigation suggested that the person who used the credit card might have been connected to someone working at the facility. The facility's staff, including the unit manager and the Assistant Director of Nursing, were informed of the incident and cooperated with the police investigation. The unit manager confirmed that the individual in the photo provided by the police did not work at the facility. The resident's credit card was kept in a wallet attached to her phone, which was in her room. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention emphasizes the residents' right to be free from such incidents, but the theft still occurred, indicating a lapse in the facility's protective measures.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state surveying agency within the required timeframe. A resident's credit card was stolen from their room, and charges were made on the card on October 1, 2024. The resident's daughter, who is also the Power of Attorney, discovered the unauthorized charges and reported the theft to the police. However, the facility did not report the incident to the state agency until December 17, 2024, well beyond the 24-hour reporting requirement. The social worker had informed the previous administrator about the missing credit card in October, but the administrator did not follow up, leading to a delay in the investigation. The resident involved, identified as R2, had a BIMS score indicating no cognitive impairment and had multiple medical diagnoses, including congestive heart failure and type 2 diabetes mellitus. The facility's policy requires immediate reporting of such incidents, but this was not adhered to, as the initial incident report was only filed after the police contacted the facility in December. The executive director and other staff acknowledged the reporting failure, noting that the previous administrator was overwhelmed and did not act on the information provided by the social worker.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of resident property involving a resident's stolen credit card. The incident was initially reported when the unit manager received an email from the police regarding a case involving the resident's stolen credit card. The police provided an image of an individual suspected of using the card. The facility's initial incident report indicated that an investigation was initiated and ongoing, but the final incident report lacked evidence of a thorough investigation. The investigation process was inadequately documented, with conflicting accounts from staff members about who conducted the investigation and what steps were taken. The Assistant Director of Nursing (ADON) and the Registered Nurse/Unit Manager were involved in the investigation, but neither conducted interviews with staff or the resident. The Executive Director acknowledged that the investigation should have been completed to protect residents' rights, but the necessary interviews and documentation were missing. The resident involved was a long-term resident with multiple medical conditions, including congestive heart failure and diabetes, but was cognitively intact with a BIMS score indicating no cognitive impairment. The resident's Power of Attorney (POA) discovered the unauthorized charge on the credit card statement and reported it to the facility and the police. Despite the ongoing police investigation, the facility did not have a complete internal investigation documented, as required by their Abuse, Neglect, Exploitation, and Misappropriation Prevention Program.
Failure to Monitor Weight and Nutrition
Penalty
Summary
The facility failed to ensure proper weight monitoring and nutritional assessment for three residents, leading to significant weight loss. A newly admitted resident on tube feeding was not weighed weekly as required, resulting in a weight loss of 16.8 pounds (11.4%) in 18 days. The Registered Dietitian (RD) acknowledged that weekly weights were not documented and that this oversight delayed the identification of weight loss, preventing timely intervention. Another resident experienced a significant weight loss of 12.6 pounds (7.67%) over one month without any nutritional assessments or interventions. The RD was not informed of the resident's reweigh results promptly, which delayed the recognition of the weight loss. The RD only became aware of the issue when it was highlighted by the surveyor, indicating a lapse in communication and monitoring. A third resident lost 10.2 pounds (6.6%) in 13 days. The resident was not weighed upon readmission, and there was a delay in meal delivery, which contributed to the resident's malnourished state. The RD was unaware of the resident's request for earlier meal delivery before therapy sessions, which could have addressed the resident's hunger and potentially mitigated the weight loss.
Failure to Support Resident's Legs in Wheelchair
Penalty
Summary
The facility failed to ensure that a resident's legs were properly supported while sitting in her wheelchair, which is a deficiency in accommodating the needs of the resident. The resident, who has a history of venous thrombosis, embolism, back pain, scoliosis, osteoporosis, a history of a fracture, and left foot pain, was observed sitting in her wheelchair with her feet hanging approximately six inches from the floor and without any leg rests. Her legs appeared reddish purple in color. The resident expressed discomfort when her legs were hanging and mentioned that she felt more comfortable when her feet were supported on the bar of a tray table. The Therapy Director confirmed that proper wheelchair positioning requires feet to be either flat on the ground or supported by footrests to prevent swelling or pressure on the back of the legs. However, only two left-sided footrests were found in the resident's room, indicating a lack of proper support for the resident's legs.
Failure to Implement Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were discussed and implemented upon admission. The resident, identified as R282, was admitted to the facility with a POLST form indicating a preference for Do Not Resuscitate (DNR). However, the resident's Physician's Order Sheet later showed an order for full code status, which contradicted the POLST form. There was no documentation in the resident's Electronic Medical Record (EMR) that social services had discussed the advanced directives with the resident or their power of attorney prior to the discrepancy being noted. The Director of Nursing (V2) stated that advanced directives are typically discussed by a nurse upon admission and that residents are considered full code until a valid POLST form is received. V2 acknowledged that the facility staff should follow the directives on a valid POLST form unless the resident expresses other wishes, which should be documented and verified with the physician. Despite this protocol, the facility did not implement the resident's POLST directives or follow up with the resident the day after admission, as per their policy. The facility's policy indicates that DNR/POLST orders remain in effect until a signed request to end them is provided, which was not adhered to in this case.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents requiring assistance with activities of daily living (ADLs) received showers or baths as scheduled. This deficiency was observed in two residents, R58 and R39, who were part of a sample of 26 residents reviewed. R58, a cognitively intact resident with multiple health conditions including Parkinson's disease and congestive heart failure, reported not receiving her scheduled showers twice a week due to staff shortages and reliance on agency staff. Documentation revealed that R58's last recorded shower was 17 days prior to the survey, with no showers documented for 30 days in the electronic health record (EHR). Similarly, R39, who requires assistance with bathing, reported not receiving her scheduled showers twice a week. The shower binder and EHR confirmed that R39's last documented shower was 10 days before the survey, with no showers or refusals recorded in the interim. The facility's policy mandates appropriate care and services for residents unable to perform ADLs independently, including hygiene support, which was not adhered to in these cases.
Failure to Use Gait Belt and Update Care Plan After Falls
Penalty
Summary
The facility failed to ensure the proper use of a gait belt during a resident transfer and did not update a resident's care plan following a fall. In the first incident, a Certified Nursing Assistant (CNA) transferred a resident, R39, to the toilet using a gait belt but removed it while providing care. The CNA did not reapply the gait belt before instructing R39 to stand, despite the resident expressing difficulty in holding onto the support bar. The facility's policy recommends the use of a gait belt for one-person transfers, except in specific situations, which was not adhered to in this case. In the second incident, another resident, R110, who has severe cognitive impairment and is at high risk for falls, experienced two falls during transfers. On 9/27/24, R110's knee buckled during a transfer, and the resident was lowered to the floor. No fall intervention was implemented after this incident. On 10/4/24, R110 was again lowered to the floor during a transfer, resulting in injuries. It was only after the second fall that the resident's transfer assessment was adjusted to require two staff members or a sit-to-stand assist. The lack of timely intervention after the first fall contributed to the subsequent incident.
Inappropriate Oxygen Administration for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen administration. The resident, identified as R281, had multiple diagnoses including dependence on supplemental oxygen, hypertension, chronic kidney disease, and chronic obstructive pulmonary disease, among others. The physician's order specified that the resident should receive 7 liters of oxygen continuously. However, observations on two consecutive days revealed that the resident was using a regular flow nasal cannula instead of a high flow nasal cannula, which is necessary for administering more than 5 liters of oxygen. The respiratory therapist confirmed that the resident's cannula was not suitable for high flow oxygen, as it lacked the larger bore size required for such administration. The facility's policy on oxygen administration did not specify when a high flow nasal cannula should be used, contributing to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure proper administration of medications to a resident, leading to a deficiency in pharmaceutical services. A resident, a [AGE] year old female with multiple diagnoses including congestive heart failure, type 2 diabetes, and hypertension, was observed with a cup of crushed medications left on her bedside table. The resident confirmed that the medications were hers and that they were crushed to aid swallowing. Despite this, the medications remained on the table when the surveyor left the room. The Director of Nursing acknowledged that medications should not be left at the bedside and confirmed that the resident did not have an assessment to self-administer medications. The resident's physician orders included several medications for her conditions, but her self-administration safety screen only listed a nasal spray as approved for self-administration.
Medication Administration Delay for Parkinson's Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Carbidopa-Levodopa for a resident with Parkinson's disease. The resident, a female with a history of Parkinson's disease, congestive heart failure, and other conditions, reported that her medication was not administered at the scheduled time. On one occasion, the medication, which was supposed to be given at 11:00 AM, was administered at 1:47 PM, approximately three hours late. This delay was confirmed by the Medication Administration Audit Report. The Director of Nursing acknowledged the importance of administering medications on time, especially for residents with Parkinson's disease, as delays can affect their movements and cause increased stiffness. The nurse responsible for administering the medication reported that the resident was in the dining room at the scheduled time, which coincided with lunch preparations. The facility's Medication Administration Policy and Procedure emphasizes the need for medications to be administered in a safe and timely manner, in accordance with prescriber orders, which was not adhered to in this instance.
Failure to Securely Store Medications for a Resident
Penalty
Summary
The facility failed to ensure medications were securely stored for one resident, identified as R121, who was observed with a fluticasone-salmeterol respiratory inhaler and an azelastine nasal decongestant spray on the bedside table. These medications were prescribed to be administered twice daily. The resident confirmed that the medications were kept on the bedside table, which was corroborated by a Licensed Practical Nurse (LPN), who mentioned that R121 needed reminders on how to use the medications properly. Further investigation revealed that the facility's policy required medications to be stored in locked compartments unless an assessment determined that a resident could safely self-administer and store medications. The Director of Nursing (DON) stated that an assessment should be present in the resident's electronic medical record to allow for bedside storage of medications. However, no such assessment was found for R121, indicating a failure to comply with the facility's medication storage and self-administration policies.
Infection Control Deficiencies in Hand Hygiene and EBP
Penalty
Summary
The facility staff failed to adhere to proper infection control protocols during the provision of incontinence care to a resident identified as R20. On the observed date, two CNAs, V9 and V10, were involved in providing care to R20, who had a bowel movement. V10, after completing the incontinence care, did not change her soiled gloves or wash her hands before proceeding to apply a new incontinent pad and assist R20 into a wheelchair using a mechanical stand lift. V10 continued to touch multiple surfaces and adjust R20 without changing gloves or performing hand hygiene until all tasks were completed. This action was contrary to the facility's hand hygiene policy, which emphasizes the integration of glove use with routine hand hygiene to prevent healthcare-associated infections. In another instance, the facility staff failed to comply with Enhanced Barrier Precautions (EBP) for a resident identified as R12. A sign outside R12's door indicated the need for EBP, which includes wearing gloves and a gown during high-contact care activities. However, V12, a wound nurse, only donned gloves and did not wear a gown while providing wound treatment to R12's sacral wound. This was against the facility's EBP policy, which is designed to reduce the transmission of multi-drug resistant organisms and other pathogens during high-contact resident care activities.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility staff failed to provide timely incontinence care for two residents who required assistance with activities of daily living (ADLs). Resident R2's care plan indicated a need for staff assistance with toileting and transferring, and the resident was frequently incontinent of urine and stool. On the morning of the observation, a strong odor of urine was noted in R2's room, and the resident reported not having received incontinence care since the previous night. When a CNA finally attended to R2, the resident's incontinence brief was found to be saturated with urine, which had leaked onto her clothing and bedding. Similarly, Resident R1 required staff assistance with toileting and was frequently incontinent of urine and stool. R1 reported being gotten out of bed without being toileted or having her incontinence brief changed, despite wearing a diaper and feeling wet. Later, when a CNA provided care, R1's incontinence brief was also saturated with urine, and urine had leaked onto the pad on her wheelchair. The CNA claimed R1 had refused care, which R1 immediately denied. The facility's policy indicated that toileting and incontinence care should be provided every two hours and as needed, but this was not adhered to in these cases.
Failure to Provide Nutritional Support for Resident with Weight Loss
Penalty
Summary
The facility failed to assist a resident, identified as R4, with eating and did not implement a nutritional intervention for significant weight loss. R4, who has Alzheimer's Disease, dementia, and diabetes, was at nutritional risk due to inadequate oral intake and significant weight loss. The care plan for R4 included providing 8 ounces of a house shake twice a day with lunch and dinner, along with supervision and assistance during meals. However, observations showed that R4 was not assisted with eating during breakfast, and the prescribed house shake was not provided during lunch. On multiple occasions, staff failed to provide the necessary nutritional supplements to R4, despite the resident's documented weight loss and the care plan's directives. Dining room servers and the Dietary Director confirmed that R4 did not receive the required house shake at lunch. Additionally, R4's weight continued to decline, with a recorded weight of 115 pounds, indicating further weight loss. This lack of adherence to the care plan and failure to provide necessary nutritional support contributed to R4's ongoing weight loss.
Failure to Monitor Psychotropic Medication Use Leads to Hospitalization
Penalty
Summary
The facility failed to properly monitor and manage the use of psychotropic medications for a resident, leading to adverse effects and hospitalization. The resident, a female with a history of vascular dementia and behavioral disturbances, was receiving multiple psychotropic medications, including Depakote, Seroquel, and Clonazepam, three times a day. Despite orders to hold these medications if the resident showed signs of lethargy, the facility did not consistently follow these instructions, resulting in the resident experiencing excessive drowsiness and being sent to the hospital for evaluation of stroke-like symptoms. Observations and interviews revealed that the resident was frequently lethargic, unable to express her needs, and required assistance with meals due to her sedated state. The facility staff, including an agency nurse, failed to hold the medications as ordered and did not notify the physician of the adverse effects. The resident's daughter expressed concern about her mother's condition, noting that she was unusually sleepy and drooling, which prompted the decision to send her to the hospital. The facility's documentation showed inconsistencies in following the orders to hold medications and a lack of communication with the physician regarding the resident's condition. The Medication Administration Record did not reflect the orders to hold the medications, and there was no documentation of physician notification when the resident exhibited lethargy. This oversight in medication management and monitoring contributed to the resident's hospitalization and the subsequent adjustment of her medication regimen.
Misappropriation of Resident's Medication by LPN
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically involving the theft of medication. A resident, who is cognitively intact and has a medical history including urine retention, urinary tract infection, atrial fibrillation, heart failure, and osteoarthritis, reported that her pain medication, Norco, was stolen. The incident was reported by the unit manager after the PM nurse could not locate the medication, which had been delivered two days prior. The resident denied feeling dizzy or requesting a change in medication, contradicting the LPN's initial claim that the medication was discontinued due to dizziness. The investigation revealed that the LPN had taken the Norco home, citing personal financial and health struggles as the reason. The LPN initially lied about the situation, claiming the medication was discontinued and replaced with Tramadol after consulting with a doctor, which was later proven false. The LPN admitted to the theft in an email to the unit manager, acknowledging the wrongdoing and apologizing for the actions. The facility's policy on abuse, neglect, exploitation, and misappropriation of property emphasizes the residents' right to be free from such incidents. However, the LPN's actions directly violated this policy, leading to the misappropriation of the resident's medication. The facility's failure to prevent this incident highlights a significant deficiency in protecting residents' property rights.
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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