Evercare Of Swansea
Inspection history, citations, penalties and survey trends for this long-term care facility in Swansea, Illinois.
- Location
- 1405 North Second Street, Swansea, Illinois 62226
- CMS Provider Number
- 145981
- Inspections on file
- 42
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 18 (3 serious)
Citation history
Health deficiencies cited at Evercare Of Swansea during CMS and state inspections, most recent first.
A resident with cognitive impairment, confusion, and lack of safety awareness was allowed to leave the facility unsupervised after signing himself out, with staff failing to verify his responsible party status, destination, or return time. The resident was later found by police several hours later, confused and injured near a highway, and required emergency medical care. Staff interviews revealed incomplete assessments, lack of documentation, and inadequate supervision contributed to the incident.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient monitoring in the area.
A resident did not receive the necessary behavioral health care and services required, as the facility failed to provide appropriate interventions and supports.
Surveyors observed improper food storage and labeling, including uncooked meat stored above ready-to-eat items, expired dairy products, and undated prepared foods in both facility and resident refrigerators. A resident reported that staff do not have time to clean out her refrigerator, and the Dietary Manager confirmed that discard dates were missing on some items. These findings were not in accordance with the facility's food storage policy.
Several cognitively intact residents reported a persistent shortage of clean towels and wash cloths, resulting in delays in bathing and the need for families to supply linens. CNAs and the DON confirmed the ongoing linen shortage, with staff attributing the issue to possible improper disposal or hoarding. The facility's policy requires adequate linen supplies, but this was not met, affecting residents' daily hygiene and comfort.
A resident with moderate cognitive impairment and multiple medical conditions was unable to access a telephone in private because the phones were located at the nurse's station and used by staff for work-related calls. The resident was told to finish his call due to other residents waiting and staff needing the phone, which did not align with the facility's policy granting residents the right to private phone use.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored by the facility.
A CNA was allowed to work with residents without the facility completing a required criminal background check, relying instead on a background check from a previous employer. The staff member transferred from a sister facility and began working before the facility conducted its own screening, contrary to the facility's abuse prevention policy. This lapse was confirmed by the Administrator and DON.
A resident with alcohol-induced dementia and moderate cognitive impairment, who frequently gave out his debit card to staff for purchases, had his card used by a CNA to pay personal rent. The care plan did not address the resident's risk for abuse or neglect, and staff interviews confirmed the resident's pattern of giving out his card. The incident was substantiated through investigation and bank records, revealing a failure to protect the resident from misappropriation of property.
A resident with multiple chronic conditions provided money and gifts to two CNAs, including paying bills and transferring funds via cash app. Despite staff awareness and prior notification to administration, the allegation of exploitation was not immediately reported to the Executive Director, and the Administrator only learned of the situation from surveyors. This resulted in a deficiency in timely abuse reporting procedures.
Surveyors found that the facility did not maintain an area free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in an environment that posed risks for resident safety.
The facility did not ensure that the Medical Director attended the required QAPI meeting, as shown by the absence of the Medical Director's signature on the attendance record and confirmation from the Administrator. Facility policy requires representation from all areas, including the Medical Director, on the QAA committee.
Multiple observations revealed unsanitary and hazardous conditions throughout the facility, including dirty floors, broken tiles, malfunctioning toilets, and pest infestations. Residents and staff reported ongoing issues with cleanliness, plumbing, and maintenance, while interviews confirmed that management was aware of these problems but had not resolved them. The environment was further compromised by exposed wiring, poor lighting, and mold in shower areas, affecting all residents.
The facility did not provide evidence of mandatory infection control training for staff, and no policy regarding such training was available. The Administrator was unaware of when staff were last trained, and the Infection Preventionist, an LPN, had no documentation of training. This deficiency potentially affected all 57 residents currently residing in the facility.
The facility did not implement or document a nurse aide training program to ensure at least 12 hours of annual continued competence, and leadership could not provide evidence or policy regarding such training for nurse aides, affecting all current residents.
The facility did not implement or document a behavioral health training program for staff, despite serving residents with various psychiatric and mood disorders and having no policy in place for such training. The administrator and VP of Clinical Services were unable to provide evidence of prior training or a relevant policy, affecting all residents currently residing in the facility.
The facility did not report allegations of abuse involving two residents to the state agency within the required 2-hour timeframe. In both cases, staff either failed to recognize or delayed reporting the allegations, and internal investigations were initiated without timely external notification. Documentation and staff interviews showed a lack of understanding of abuse reporting requirements and the facility's own policy.
Two residents with significant medical conditions reported incidents of staff being rough or abusive during care, but the facility failed to conduct thorough investigations. In both cases, there was incomplete documentation, delayed or insufficient interviews, and a lack of follow-through with required procedures, including interviewing other residents assigned to the accused staff. The care plans did not reflect the residents' risk for abuse, and staff did not consistently follow the facility's abuse prevention policy.
A resident with multiple chronic conditions and impaired mobility did not receive physician-ordered PT and OT services. The resident remained bed bound, reporting no therapy had been provided, while the therapy director confirmed the order was missed and the administrator could not locate a relevant policy.
Multiple residents and staff observed mold and musty odors in communal shower rooms, bathrooms, and a medication room, with black and orange substances present on surfaces. The DON and maintenance director confirmed the presence of mold, and the facility lacked a housekeeping supervisor at the time. Despite facility policy requiring immediate cleaning, the mold was not addressed, resulting in unsanitary conditions for residents using these areas.
The facility failed to provide information, obtain consents, and offer influenza vaccinations to four residents. One resident, moderately cognitively impaired, had no documentation of information or consent for the vaccine. Another resident, with no cognitive deficits, reported not receiving vaccines and expressed a desire for them, yet lacked documentation of information or consent. A severely cognitively impaired resident with a POA also lacked documentation. A resident with no cognitive deficits had a record of receiving the vaccine but no documentation of information or consent. The DON acknowledged seeing consents but not vaccine administration, and the Regional Nurse Consultant mentioned ongoing efforts to determine residents' vaccine status.
The facility failed to provide information, obtain consents, and offer COVID-19 vaccinations to four residents. Despite some residents having paper chart entries showing vaccine dates, there was no documentation of information or consent in their medical records. The DON and Regional Nurse Consultant acknowledged the issue, citing recent changes in facility ownership.
Two residents experienced significant medication errors due to the unavailability of prescribed medications. One resident missed doses of Metoprolol Tartrate for several days, while another missed Warfarin doses. The LPN and DON acknowledged the issues, with the pharmacist noting the severity of missing Warfarin. The facility's policy requires medications to be administered by a licensed nurse, which was not adhered to in these cases.
The facility failed to provide an RN for at least eight hours daily and lacked a full-time DON, affecting all 39 residents. The facility was without a DON from late November until early January, and multiple days lacked RN coverage. An LPN reported working alone during a COVID outbreak, highlighting staffing issues.
The facility failed to provide sufficient staffing, resulting in delayed assistance for residents. A resident dependent on staff for daily activities had to wait over two hours to get out of bed due to short staffing. Another resident's call light went unanswered for over 30 minutes, causing concern for their family. Staff confirmed the facility was operating with fewer CNAs than usual, impacting care delivery.
A resident with dementia and other medical conditions was not assessed after being lowered to the floor during a transfer, resulting in a delayed diagnosis of a tibial plateau fracture. Despite signs of injury, the resident was not sent for evaluation until days later. The facility's fall policy was not followed, as there was no documentation or immediate assessment of the incident.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, affecting all 40 residents. This issue arose after the DON left without notice, and no replacement was hired. The only other RN works only 3 days a week, and the facility does not use agency RNs for coverage unless needed for IV medications. The facility lacks a formal RN staffing policy, leading to multiple days without RN coverage.
The facility failed to administer medications to four residents on the 200 Hall due to a lack of nursing staff. An LPN reported the absence of a nurse, but the issue was not resolved in time. An agency nurse later refused to administer the missed medications, and the residents did not receive their necessary medications, which included treatments for chronic conditions.
A failure to administer medications occurred when residents on a specific hall did not receive their prescribed doses due to a staffing issue. An LPN discovered the absence of a nurse and informed the administrator, but the agency nurse who arrived later refused to administer the missed medications. This affected residents with chronic conditions, including diabetes and hypertension, who missed critical doses of their medications.
The facility failed to store, prepare, and serve food safely, risking food-borne illness for 35 residents. Observations included improper food labeling, thawing, and storage, as well as hygiene violations by dietary staff. A turkey was left to thaw improperly, and the kitchen was found to be unclean, with staff not wearing beard nets.
The facility failed to maintain an effective infection control program, as evidenced by incomplete documentation of causative organisms for infections and inadequate implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. A resident with a gastrostomy tube did not have appropriate PPE used during medication administration, and there was a lack of signage and PPE availability for EBP.
The facility failed to provide mechanically altered diets as prescribed for residents with specific dietary needs. During a breakfast service, a dietary aid served ground ham without necessary moisture, such as gravy or sauce, to residents on a mechanical soft diet. This was inconsistent with the facility's policy and physician orders, which required such modifications to facilitate oral intake for residents with conditions like cerebral infarction and Alzheimer's disease.
The facility failed to implement an effective infection prevention and control program, leading to inappropriate antibiotic use in four residents. Antibiotics were prescribed based on symptoms without obtaining cultures, contrary to the facility's Antibiotic Stewardship Program Policy. Staff interviews revealed a lack of consistent adherence to the policy, contributing to the deficiency.
A resident with multiple medical conditions experienced significant weight loss due to the facility's failure to follow a prescribed diet and lack of personnel to perform a swallow test. The resident's weight dropped from 120 pounds to 101 pounds over several months. The dietician's monitoring was interrupted due to a payment issue, and the facility did not re-weigh the resident upon readmission, contributing to the deficiency.
The facility failed to properly store and label medications, with issues including an undated insulin pen, illegible medication labels, and expired supplements not removed from storage. Food was also improperly stored with medications, contrary to facility policy.
A facility failed to prevent abuse for three residents, leading to physical altercations involving a resident with a history of aggressive behavior. Despite known risks, the facility's interventions were insufficient, resulting in repeated incidents of violence. Staff interviews revealed inconsistencies in understanding and executing abuse prevention protocols.
The facility failed to repair roof damage, leading to water leakage in several unoccupied rooms and common areas. The administrator acknowledged the issue but had not sought repair bids, hoping for resolution through a potential sale. Staff confirmed the leaks, and a contractor assessed the need for a new roof. The facility's policy requires a safe and comfortable environment, which is compromised by the current conditions.
Failure to Supervise Cognitively Impaired Resident Resulting in Elopement and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident with fluctuating cognitive impairments, resulting in the resident leaving the facility unsupervised. The resident, who had diagnoses including Parkinson's, diabetes, bipolar disorder, schizophrenia, and dementia, was noted to have episodes of forgetfulness, confusion, impaired vision, and a lack of safety awareness. Despite these conditions, the resident was allowed to sign himself out of the facility with no documentation of his destination, who he was with, expected return time, or what he was wearing. Staff were unaware of his whereabouts for several hours. Multiple staff interviews revealed that the resident was new to the facility, and several staff members did not know his cognitive status or medical history. The assigned LPN admitted to not completing or documenting the required initial clinical assessment and did not update the resident's record to reflect his confusion and lack of safety awareness. The agency nurse who facilitated the resident's sign-out did not verify whether the resident had a power of attorney, did not check his medical record for responsible party status, and did not inquire about his plans or ensure he had necessary medications. Other staff members were either not assigned to the resident or were preoccupied with other duties, resulting in a lack of supervision and monitoring on the resident's hall. The resident was later found by police several hours after leaving the facility, sitting confused and lethargic by a busy highway, with multiple abrasions, bruises, and signs of exposure to cold. He was transported to the emergency room, where he was found to be disoriented, unable to provide his name or location, and required medical treatment for his injuries and dehydration. The facility did not notify the resident's family or report the incident to the state, and there was confusion among staff regarding responsibility for the resident's safety once he had signed himself out.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified based on observations and records indicating that the required behavioral health interventions and supports were not provided to residents in need. The lack of appropriate behavioral health care and services was directly noted during the survey process.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
The facility failed to store food in a manner that prevents foodborne illness, as evidenced by multiple observations of improper food storage and labeling practices. In the kitchen's refrigerator/freezer, uncooked beef patties were stored directly above a box of popsicles, creating a risk of cross-contamination. In the standing refrigerator, a tub of sour cream was found with a past Best By date, and several containers of prepared foods, including hamburger patties, banana pudding, chocolate pudding, and tuna, were either not labeled or lacked discard dates. The Dietary Manager acknowledged that discard dates were not written on some labels. Additionally, in the dry storage room refrigerator, a package of turkey was found with a future Use By date, but the report does not specify if this was an issue. A resident's personal refrigerator contained expired items, including a carton of milk and two protein shakes, as well as a Styrofoam container with a meal ticket dated well before the inspection. The resident stated that staff do not have time to clean out her refrigerator. The facility's policy requires all foods to be covered, labeled, and dated with an expiration or use-by date, and for storage areas to be maintained in a clean, safe, and sanitary manner. The administrator confirmed that dietary staff are expected to follow food service policies.
Failure to Maintain Adequate Clean Linen Supplies
Penalty
Summary
The facility failed to provide adequate clean linen supplies for four cognitively intact residents, resulting in a lack of towels and wash cloths necessary for daily hygiene and bathing. Multiple residents reported that there were not enough towels and wash cloths available, with some stating that their families had to bring in these items from outside the facility. Residents also reported delays in receiving showers, sometimes waiting up to two weeks, due to the shortage of clean linens. These observations were corroborated by staff, who confirmed the frequent absence of towels in the clean utility closet and attributed the shortage to possible improper disposal or hoarding of linens. Interviews with CNAs and the DON revealed ongoing issues with linen management, including suspicions that some towels were being thrown away or kept in residents' rooms. The facility's own policy requires that clean linens be stored to prevent contamination and that laundry personnel ensure adequate supplies are available on each unit. Despite this policy, the facility was unable to maintain sufficient clean linen supplies, directly impacting residents' ability to maintain personal hygiene and comfort.
Failure to Provide Private Telephone Access
Penalty
Summary
The facility failed to provide reasonable access to a telephone in an area where calls could be made without being overheard for one resident. The resident, who was moderately cognitively impaired and had diagnoses including depression, hypertension, and heart failure, became upset when he was unable to use the phone because a nurse was already using it. The resident reported that an LPN would not allow him to use the phone at the nurse's station, and the LPN confirmed that she asked the resident to finish his call due to other residents waiting and the need to make important nursing calls. The Director of Nursing acknowledged that phones for resident use were located at the nurse's stations, which were also used by staff for work-related calls, and stated that the facility should have phones available for residents to use. The facility's policy documented that residents have the right to use a phone in privacy.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulations. Specific actions or inactions leading to this deficiency are not detailed in the provided report excerpt. No additional information about the residents involved, their medical history, or their condition at the time of the deficiency is included in the report.
Failure to Complete Required Background Checks for Direct Care Staff
Penalty
Summary
The facility failed to implement its written policy regarding abuse prevention by not ensuring that required criminal background checks were completed prior to allowing direct care staff to work with residents. Specifically, a Certified Nursing Assistant (CNA) was employed and worked at the facility without a new criminal background check being conducted by the facility, despite the CNA having a background check from a previous employer. The CNA transferred from a sister facility and began working without the facility completing its own screening process. Interviews with the Administrator and Director of Nursing confirmed that the facility did not follow its established procedures for onboarding and background checks, as outlined in its abuse prevention policy. At the time of the deficiency, there were 52 residents residing in the facility.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with alcohol-induced dementia and moderate cognitive impairment from misappropriation of property. The resident, who required assistance with personal care and was known to frequently give out his debit card to staff and others to make purchases, had his debit card used without authorization. The facility's records and interviews revealed that the resident's debit card was used on multiple occasions in various cities, including a transaction to pay rent for a certified nursing assistant (CNA) employed at the facility. The resident was unable to recall to whom he had given his card or the circumstances surrounding the transactions. Staff interviews confirmed that the resident regularly asked staff and others to make purchases for him using his debit card, and it was common knowledge among staff that he would give out his card. The facility's care plan did not address the resident's risk for abuse or neglect, despite his cognitive impairment and behavior. The investigation determined that a staff member used the resident's debit card for personal expenses, which was corroborated by bank statements and a reverse search of the transaction. The staff member implicated was subsequently terminated, but the incident demonstrated a failure to prevent misappropriation of resident property as required by facility policy.
Failure to Timely Report Alleged Exploitation of Resident
Penalty
Summary
The facility failed to immediately report allegations of exploitation involving a resident to the Executive Director as required. The incident involved a resident with a BIMS score of 15 and multiple diagnoses, including Major Depressive Disorder, COPD, Type 2 Diabetes with Hyperglycemia, hypertension, and chronic congestive heart failure. Documentation and interviews revealed that the resident had provided money, gifts, and other financial benefits to two Certified Nurse's Aides (CNAs), including paying bills, giving gifts, providing house keys, and transferring money via cash app. One CNA confirmed receiving money for coffee and donuts, while another staff member reported that the administration had been informed of these actions prior to a change in facility ownership. The Administrator stated that they only became aware of the abuse allegation when informed by surveyors, and that the CNA involved had already been terminated for tardiness. The facility's abuse policy requires the prevention, identification, investigation, and reporting of abuse, neglect, and misappropriation of property in accordance with federal and state requirements. However, the failure to promptly report the allegations to the Executive Director constituted a deficiency in the facility's abuse reporting procedures.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents.
QAPI Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) meetings included all required members, specifically the Medical Director. During the last QAPI meeting, as evidenced by the attendance record dated 4/25/25, the line for the Medical Director's attendance was left blank, and the Administrator confirmed that the Medical Director was not present due to the meeting being scheduled at the last minute. The facility's own policy requires that each area, including the Medical Director, be represented on the Quality Assessment and Assurance (QAA) committee. At the time of the survey, the facility census showed 57 residents residing in the facility.
Failure to Maintain Safe, Clean, and Well-Maintained Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and well-maintained environment for all residents, as evidenced by multiple observations of unsanitary and hazardous conditions throughout the building. Surveyors documented the presence of brown sticky substances, dirt, debris, dried feces, and urine in resident rooms and restrooms. Several rooms had toilets that were not functioning, with signs indicating they were out of order, and plumbing issues were reported by both staff and residents. Floors and cove bases were observed with significant buildup of dirt, stains, and residue, and in many areas, the flooring was damaged, with missing or broken tiles, chipped concrete, and uneven surfaces. These conditions were present in both private and common areas, including shower rooms, hallways, and the dining room, where missing cove base and crumbling drywall were also noted. Interviews with residents, staff, and the ombudsman confirmed ongoing concerns about the cleanliness and maintenance of the facility. Residents reported seeing mice, dead insects, and flies, and expressed distress about the state of their living environment. Staff members, including CNAs and housekeepers, stated that the facility was filthy, that plumbing frequently backed up, and that housekeeping was unable to keep up with the cleaning demands due to persistent maintenance issues. The Housekeeping/Laundry Supervisor and other housekeepers indicated that the floors required stripping and scraping, but there was no dedicated floor technician, and management was aware of these issues but had not taken sufficient action. The ombudsman and a resident's power of attorney also reported repeated complaints to facility leadership about the poor condition of the building and lack of timely repairs. Additional hazards were observed, such as exposed electrical wires, missing light fixture covers, poorly lit hallways, loose hand railings, and damaged furniture. Mold and black residue were noted in shower rooms, and a large fan covered in dust was found blowing air onto the food preparation area in the kitchen. Facility records, including Resident Council minutes and the facility's own policy, documented that maintenance and housekeeping were understaffed and unable to keep up with the required upkeep. The facility's failure to address these environmental deficiencies affected all residents, including those who were cognitively intact and able to articulate their concerns, as well as those with cognitive impairments.
Failure to Implement Infection Control Training Program
Penalty
Summary
The facility failed to implement a mandatory infection control training program for its staff as part of its infection prevention and control program. During interviews and record reviews, the Administrator was unable to provide evidence of recent staff training on infection control and was unaware of when such training last occurred. Additionally, the Vice President of Clinical Services confirmed that there was no available policy regarding infection control training. The facility's assessment documented that it has 90 licensed beds for long-term care nursing services, including care for infectious organisms, and the current census showed 57 residents residing in the facility. The designated Infection Preventionist is a Licensed Practical Nurse, but no documentation of infection control training was available for review.
Failure to Provide Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to implement a nurse aide training program that ensures continued competence equivalent to at least 12 hours per year, as required. During interviews and record reviews, the Administrator was unable to provide evidence of recent nurse aide training and was unaware of when staff last received such training. Additionally, the Vice President of Clinical Services confirmed that there was no available policy regarding nurse aide training. At the time of the survey, the facility had 57 residents and 90 licensed beds for long-term care nursing services, but lacked documentation or reproducible evidence to support that nurse aide training had occurred.
Failure to Provide Behavioral Health Training for Staff
Penalty
Summary
The facility failed to implement a behavioral health training program for its staff, as required by its own facility assessment and regulatory standards. During interviews and record reviews, the administrator was unable to provide evidence that staff had received behavioral health training, nor could she recall when such training last occurred. The administrator confirmed that staff would receive behavior training at an upcoming meeting, but no documentation was available to show that training had previously taken place. Additionally, the Vice President of Clinical Services confirmed that there was no policy regarding behavior training available. The facility assessment documented that the facility accepts and serves residents with a range of psychiatric and mood disorders, including psychosis, impaired cognition, depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, and behaviors requiring intervention, with an average of 40-60 residents needing behavioral health services. At the time of the survey, the facility census was 57 residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the administrator immediately and to the state agency within the required 2-hour timeframe for two residents. In the first case, a resident with diabetes, hemiplegia, anemia, and anxiety alleged that a CNA hurt her arm and abused her during a transfer. The CNA who witnessed the allegation did not report it to other staff, believing the accused CNA was not rough with residents. The LPN documented the resident's statement and performed a skin assessment, then notified the DON. However, there was no documentation in the resident's progress notes about the abuse allegation, and the DON did not report the incident to the state agency, instead documenting a 'soft file' and initiating an internal investigation the following day. In the second case, a resident with chronic pain, cancer, and a fractured pelvis reported that a CNA intentionally dropped her legs onto the bed and made inappropriate comments, which the resident perceived as abusive and intentional. The resident reported the incident to the DON, who stated that the initial report was about unmet needs and staff attitude, not abuse. The resident later reported the incident to the administrator, who delayed reporting to the state agency because the staff member's identity was unknown. The abuse investigation was not started until several days after the initial report, and the resident continued to be assigned to the same CNA despite her request for a change. In both cases, the facility's documentation did not reflect timely reporting of the abuse allegations to the state agency as required by federal and state regulations. Staff interviews revealed a lack of understanding of the definition of abuse and the facility's abuse reporting policy. The facility's abuse prevention program requires immediate reporting of suspected abuse, but this protocol was not followed in these instances.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents, both of whom had significant medical conditions and reported incidents involving staff. In the first case, a resident with diabetes, hemiplegia, anemia, and anxiety alleged that a CNA was rough during a transfer, resulting in the resident landing on the floor. The resident described the incident as not accidental and stated that the CNA was frustrated and had previously had confrontations with her. Documentation in the progress notes and initial abuse investigation report indicated that the resident complained of being hurt, but there was no detailed follow-up on what the resident meant by being hurt. Additionally, the investigation did not include interviews with other residents cared for by the accused CNA, and there was a lack of documentation regarding the resident's risk for abuse in her care plan. In the second case, another resident with chronic pain, cancer, and a fractured pelvis reported that a CNA intentionally dropped her legs onto the bed and made inappropriate comments, which the resident perceived as abusive. The resident reported the incident to the DON, who did not initiate an immediate investigation or suspend the CNA. The CNA was not asked to provide a written statement at the time, and the resident continued to be assigned to the same CNA after the allegation. The administrator was unaware of the definition of abuse and did not report the allegation to the state agency promptly, as she was still trying to identify the staff member involved. The investigation into this incident was delayed and only began after further reporting by the resident. Both cases revealed deficiencies in the facility's abuse investigation process, including incomplete documentation, lack of timely and thorough interviews, and failure to follow the facility's abuse prevention policy, which requires prompt and comprehensive investigations and interviews with other residents assigned to the accused staff. The care plans for both residents did not document their risk for abuse, and staff did not consistently follow procedures for reporting and investigating abuse allegations.
Failure to Provide Ordered Rehabilitative Services
Penalty
Summary
A deficiency occurred when the facility failed to provide specialized rehabilitative services, specifically physical therapy (PT) and occupational therapy (OT), as ordered by a physician for a resident who was bed bound. The resident's medical record documented diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Diastolic Congestive Heart Failure, Morbid Obesity, and musculoskeletal symptoms. The care plan identified impaired physical mobility, and the Minimum Data Set (MDS) indicated the resident required substantial to maximal assistance for mobility and that other mobility assessments were not attempted due to medical or safety concerns. Despite a physician's order for PT and OT evaluation and treatment, the resident did not receive these services. During interviews, the resident reported not having received physical therapy during the year and expressed a desire to get out of bed, stating that staff told him they could not assist him without therapy involvement. The Director of Therapy confirmed that the therapy department had not worked with the resident and was unaware of why the therapy order was missed. The facility administrator was unable to locate a policy regarding following physician orders. These findings demonstrate that the facility did not implement the physician's order for specialized rehabilitative services for the resident.
Failure to Maintain Sanitary Shower and Bathroom Areas Due to Mold
Penalty
Summary
The facility failed to maintain clean and sanitary shower rooms and bathrooms, resulting in the presence of mold and musty odors in multiple areas used by residents. Observations revealed black, slimy, and orange substances on shower walls, shower heads, and bathroom floors in both the 100-hall and 200-hall shower rooms, as well as in a medication room. Several staff members, including CNAs, a laundry aide, and a housekeeper, confirmed noticing mold in shower rooms, resident rooms, and bathrooms. Residents also reported seeing mold and smelling musty odors, particularly in the 100-hall shower room and adjacent areas. The facility's own maintenance director and DON acknowledged the presence of mold after accompanying surveyors to the affected areas. The DON also confirmed that a significant number of residents use the communal shower rooms, which were found to be contaminated. The facility lacked a housekeeping supervisor at the time, with the DON temporarily overseeing housekeeping duties. Despite the facility's policy requiring immediate cleaning and notification when mold is found, the mold remained present and was not addressed prior to the survey. Facility policy and CDC guidance provided in the report highlight that mold and mildew are expected to be controlled through routine deep cleaning, and that exposure to mold can cause health effects, especially in individuals with respiratory conditions or compromised immune systems. The failure to maintain a clean, safe, and homelike environment as required resulted in unsanitary conditions for residents using the affected shower rooms and bathrooms.
Failure to Provide Information and Obtain Consent for Influenza Vaccinations
Penalty
Summary
The facility failed to provide information, obtain consents, and offer influenza vaccinations to four residents reviewed for immunization. Resident 1, who is moderately cognitively impaired, had no documentation in their medical record regarding the provision of information or consent for the influenza vaccine, despite a previous vaccination recorded in 2020. Resident 2, who has no cognitive deficits, reported not receiving any vaccines during the winter and expressed a desire for them, yet there was no documentation of information or consent for the flu vaccine in their medical record. Resident 3, who is severely cognitively impaired and has a Power of Attorney (POA), also lacked documentation of information or consent for the flu vaccine in their medical record. Resident 5, who has no cognitive deficits, had a record of receiving the influenza vaccine in 2023, but there was no documentation of information or consent in their medical record. The Director of Nursing, who recently started, acknowledged seeing consents for various vaccines but not the administration of the vaccines. The Regional Nurse Consultant mentioned that the facility was recently acquired and that they were still working on determining the vaccine status of residents. The facility's policy states that residents or their representatives should be provided with education about immunizations and that consent for the influenza vaccine is valid for the duration of the resident's stay, with annual administration unless contraindicated or already received.
Failure to Provide COVID-19 Vaccine Information and Obtain Consent
Penalty
Summary
The facility failed to provide information, obtain consents, and offer COVID-19 vaccinations to four residents reviewed for COVID-19 immunization. Resident 1, who is moderately cognitively impaired, had no documentation in their medical record indicating that the facility attempted to provide information or obtain consent for the COVID-19 vaccination, despite a paper chart entry showing a vaccine date. Resident 2, who has no cognitive deficits, reported not receiving any vaccines and expressed a desire for vaccination, yet there was no documentation of information or consent in their medical record. Resident 3, who is severely cognitively impaired and has a Power of Attorney (POA), also lacked documentation of information provided to the POA or consent obtained for vaccination, despite a paper chart entry showing a vaccine date. Similarly, Resident 5, who has no cognitive deficits, had no documentation of information or consent for vaccination in their medical record, despite a paper chart entry showing a vaccine date. The Director of Nursing and Regional Nurse Consultant acknowledged the lack of vaccine administration and documentation, citing recent changes in facility ownership and plans to address the issue.
Significant Medication Errors Due to Unavailability
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, resulting in missed doses of critical medications. One resident, diagnosed with hypertension and congestive heart failure, did not receive their prescribed Metoprolol Tartrate for several days due to the medication running out at the end of February. The medication was ordered on March 3rd and arrived on March 5th, but the resident missed doses on March 1st, 2nd, 3rd, and 7th. The resident confirmed not receiving their heart medication for a few days, and the LPN acknowledged the delay in medication availability. Another resident, with diagnoses including congestive heart failure and hypertension, missed doses of Warfarin on March 5th, 6th, and 7th. The resident reported being out of Warfarin for a couple of days, and the DON, who had been in the position for three weeks, was unaware of the missing medications. The pharmacist emphasized the significance of missing Warfarin, an anticoagulant, as a major medication error. The facility's policy mandates that medications be administered by a licensed nurse per the physician's order, highlighting a failure in adherence to this policy.
Deficiency in RN Staffing and DON Availability
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for a minimum of eight hours per day, seven days a week, and did not have a Director of Nursing (DON) on a full-time basis. This deficiency was identified through interviews, observations, and record reviews. The facility had been without a DON since November 27, 2024, and although a new DON was offered the position on December 13, 2024, she did not start until January 6, 2025. On January 15, 2025, it was observed that the facility was staffed with only three Certified Nursing Assistants (CNAs) and one Licensed Practical Nurse (LPN) at the start of the day, with the administrator stepping in to pass medications due to an agency nurse and the DON calling off. The facility's schedule for December 2024 and January 2025 showed multiple days without an RN on duty, including December 20, 23, 24, 26, 28, 29, 31, and January 1, 3, 7, 9, 12, 14, and 15. An LPN expressed concerns about staffing, particularly during a recent COVID outbreak when 75% of the building was positive, and she had to work alone at night. The facility's nurse staffing policy states that sufficient licensed and unlicensed nursing staff should be provided to maintain the highest practical wellbeing of each resident, but this was not adhered to, affecting all 39 residents in the facility.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, as evidenced by the experiences of three residents. One resident, who is dependent on staff for all activities of daily living and transfers, reported having to wait until 9:20 AM to be assisted out of bed, despite normally getting up at 7:00 AM. This delay was attributed to the facility being short-staffed, with priority given to residents who eat in the dining room. The resident expressed anxiety about the wait, fearing an anxiety attack due to the delay. Another resident, who requires substantial assistance for activities of daily living, reported that call lights are sometimes not answered promptly when the facility is understaffed. The resident's daughter corroborated this, stating that during a visit, she had to wait at least half an hour for assistance after activating the call light. She expressed concern about the lack of staff available to respond to residents' needs, feeling compelled to visit daily to ensure her parent's well-being. A third resident, who is generally independent but requires minimal assistance with toileting and hygiene, also noted that call lights are not answered promptly when staffing is insufficient. Staff interviews confirmed that the facility was operating with fewer CNAs than usual, making it challenging to provide adequate care. The facility's staffing records showed multiple instances where the staffing pattern did not meet the expected levels, indicating a recurring issue with maintaining sufficient staff to meet resident needs.
Failure to Assess Resident After Fall Leads to Delayed Fracture Diagnosis
Penalty
Summary
The facility failed to physically assess a resident after a fall, resulting in a delay in identifying a tibial plateau fracture. The resident, who has a history of dementia, cerebrovascular accident, seizures, hypothyroidism, and hypertension, was involved in an incident on 11/22/2024 where she was lowered to the floor by a CNA during a transfer. The CNA reported that the resident locked her arms on the wheelchair and had to be lowered to the floor, but there was no documentation of this fall or any assessment on file for that date. The resident's care plan indicated she was at risk for falls and required substantial assistance with transfers. Despite the resident's leg appearing swollen and bruised on 11/25/2024, it was not until 11/26/2024 that an X-ray was ordered, revealing a tibial plateau fracture. The resident was then sent to the hospital for evaluation. Interviews with staff revealed inconsistencies in communication and documentation, as the LPN on duty was not informed of the fall, and the CNA involved did not know the nurse's name to report the incident. The facility's fall policy emphasizes the need for immediate evaluation and intervention to prevent injury, which was not adhered to in this case.
Failure to Provide Consistent RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, which has the potential to affect all 40 residents residing in the facility. The deficiency arose after the Director of Nursing (DON) left without notice on November 15, 2024, and no new DON was hired. The Regional Nurse, who is not present every day, admitted that there is not RN coverage every day because the only other RN, who works in the facility, is available only 3 days a week. The facility does not use agency RNs for coverage unless there is a need for an RN to administer intravenous medications. The facility's schedules for November and December 2024 document multiple days without RN coverage. Additionally, the facility does not have a policy for RN staffing and attempts to follow regulations without a formalized plan.
Failure to Administer Medications Due to Staffing Issues
Penalty
Summary
The facility failed to administer ordered medications to four residents on the 200 Hall on the morning of December 15, 2024. This failure occurred because there was no nurse present on the 200 Hall to administer the medications. A resident reported that they did not receive their medications, which included critical medications for heart issues and mental illness. The medication administration records for the residents showed that their medications were not signed out as administered at the scheduled time. The residents had various diagnoses, including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Essential Hypertension, and Adult Failure to Thrive. The deficiency was further compounded by communication and staffing issues. The administrator was informed by an LPN that there was no nurse on the 200 Hall, but the issue was not resolved in time to administer the morning medications. An agency nurse arrived later but refused to administer the missed medications, and the LPN did not intervene further due to the agency nurse's attitude. The facility's policy requires medications to be administered by a licensed nurse per the physician's order, but this was not adhered to, resulting in the residents not receiving their necessary medications.
Medication Administration Failure Due to Staffing Issues
Penalty
Summary
The facility failed to administer prescribed medications to residents on the 200 Hall on the morning of December 15, 2024. This failure affected four residents, each with significant medical conditions requiring consistent medication management. Residents reported not receiving their medications due to the absence of a nurse on their hall, and the subsequent refusal of an agency nurse to administer the missed doses. This lapse in medication administration was confirmed through interviews with residents and staff, as well as a review of medication administration records. Resident 8, diagnosed with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and essential hypertension, did not receive their scheduled doses of Insulin Lispro and Glipizide, nor was their blood glucose monitored as ordered. Similarly, Resident 10, with chronic atrial fibrillation and a history of cerebral infarction, missed doses of Diltiazem, Isosorbide Mononitrate, Metoprolol Tartate, and Insulin Lispro. Resident 11, suffering from congestive heart failure and type 2 diabetes, did not receive Insulin Aspart and Metformin, and Resident 12, with hypertension and type 2 diabetes, missed doses of Basaglar, Glipizide, and Losartan Potassium. The facility's administrator, V1, was informed of the staffing issue on the 200 Hall but was not aware of the medication administration failure until later in the day. Licensed Practical Nurse V18, who was working on the 100 Hall, discovered the absence of a nurse on the 200 Hall and notified V1. Despite this, the agency nurse who arrived later refused to administer the missed morning medications, leading to the residents not receiving their necessary treatments. This incident highlights a significant breakdown in communication and responsibility among the nursing staff, resulting in a failure to meet the residents' medical needs as per their care plans.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a manner that prevents food-borne illness, potentially affecting all 35 residents. During an inspection, several issues were observed in the dry storage room and kitchen areas. Uncooked bacon was stored above fresh vegetables, and various food items, including deli meats and poultry, were not properly labeled or dated. The ice machine scoop was improperly stored with the handle directly on the ice, and the refrigerator was found to be dirty and sticky. Additionally, a turkey was left to thaw in a sink without running water, contrary to the facility's food thawing policy. The dietary staff, including the Dietary Manager and Dietary Aids, were observed not following proper food safety protocols. The Dietary Manager admitted to not having the oven hood professionally cleaned since February 2023 due to a change in ownership. Furthermore, staff members were not wearing beard nets while handling food, which is a violation of hygiene standards. The Registered Dietitian acknowledged the improper thawing method of the turkey, which was eventually discarded. These lapses in food safety and hygiene practices indicate a systemic issue within the facility's dietary department.
Inadequate Infection Control Program and PPE Use
Penalty
Summary
The facility failed to develop an ongoing infection control program that adequately collects data to calculate and analyze infection rates, potentially affecting all 35 residents. The Infection Control Log for various months in 2024 lacked documentation of causative organisms for infections in several residents, including a urinary tract infection and a right lower extremity infection. The Infection Preventionist acknowledged that not all infections have cultures, which prevents identification of the organisms. The Administrator in Training expected the facility to obtain cultures and track organisms, but this was not consistently done. Additionally, there was a failure to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, such as a gastrostomy tube. A Licensed Practical Nurse administered medications without wearing the appropriate personal protective equipment (PPE), and there were no signs or PPE available indicating the need for EBP. The Infection Preventionist stated that gloves and a gown should be worn during such procedures. The Administrator in Training later acknowledged that residents with certain medical conditions should have been on EBP, and it was the Director of Nursing's responsibility to ensure proper signage and PPE availability.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to ensure that food was prepared in a form to meet the individual needs of residents on a mechanical soft diet. During a breakfast service, a dietary aid, V7, was observed plating food without adding necessary moisture, such as gravy or sauce, to the mechanically altered meat for four residents. These residents, identified as R8, R9, R11, and R13, had specific dietary requirements due to their medical conditions, including cerebral infarction, Alzheimer's disease, Wernicke's encephalopathy, and other diagnoses. Despite the physician orders specifying a mechanical soft diet, the dietary aid did not adhere to these requirements, serving ground ham without the necessary moistening agents. The facility's policy on therapeutic and mechanically altered diets, which was revised in October 2024, mandates that such diets be ordered by a physician and planned by a dietitian to facilitate oral intake. However, during the breakfast service, no sauces, gravies, or broths were observed being used in the kitchen, and the dietary aid indicated that the addition of gravy depended on the type of meat. This practice was inconsistent with the facility's policy and the general guidance provided by the registered dietitian, V11, who confirmed that ground meats should typically be served with a sauce, broth, or gravy to meet the dietary needs of residents on mechanically altered diets.
Inadequate Antibiotic Stewardship in Infection Control
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, particularly in antibiotic stewardship, as evidenced by inappropriate antibiotic use in four residents. The facility's Infection Control Log lacked documentation of the type of infection or causative organism for residents treated with antibiotics. For instance, one resident was treated with Keflex for toe redness and warmness without obtaining a culture. Another resident was initially treated with Keflex for a right lower extremity infection, which was later changed to Clindamycin after a culture was obtained. Additionally, a resident with a urinary tract infection was treated with Keflex without a culture, and another resident was treated with Doxycycline without documentation of a causative organism. Interviews with facility staff revealed that antibiotics were sometimes prescribed based on symptoms rather than confirmed cultures. The Director of Nursing acknowledged that cultures were not always obtained, and the Infection Preventionist noted that providers occasionally ordered antibiotics based on symptoms. The Administrator in Training expressed an expectation for infections to be cultured to ensure appropriate antibiotic treatment. The facility's Antibiotic Stewardship Program Policy aims to optimize antibiotic use and reduce antibiotic resistance, but the lack of adherence to this policy contributed to the identified deficiencies.
Failure to Prevent Significant Weight Loss
Penalty
Summary
The facility failed to provide appropriate services to prevent significant weight loss for a resident with multiple medical diagnoses, including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Type 1 Diabetes Mellitus. The resident, who had severely impaired cognitive skills and required feeding assistance, experienced a considerable weight loss from 120 pounds in February to 101 pounds by May or June. The resident's sister-in-law reported that the facility did not follow the diet prescribed by the hospital, and the facility lacked personnel to perform a swallow test, resulting in the resident remaining on a pureed diet. The dietician evaluated the resident in February, noting specific caloric, protein, and fluid needs, and recommended monitoring and encouraging intake. However, the dietician did not monitor the resident in March due to a payment issue with the facility. The facility's administrator in training acknowledged that the resident should have been re-weighed upon readmission. The resident's care plan included monitoring for signs of dysphagia and malnutrition, but the facility failed to adequately address the resident's nutritional needs, leading to significant weight loss.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to properly store and label medications and dispose of expired medications for three residents. During an inspection of the medication cart on the 200 Hall, it was found that an insulin pen for one resident was not dated upon opening, and a bottle of Guaifenesin had an illegible label, making it unclear which resident it belonged to. The Licensed Practical Nurse initially misidentified the owner of the medication, indicating a lack of proper labeling and tracking. Further inspection of the medication rooms revealed additional issues. In the 200 Hall Medication Room, a box of frozen pizza was stored above a resident's medication, despite a sign indicating that no food or drink should be kept in the medication refrigerator. In the 100 Hall Medication Room, expired nutritional supplements were found, which had not been removed from the active medication storage area as required by the facility's policy. The Director of Nursing acknowledged the presence of food in the medication storage area, citing residents' limited income as a reason for storing food there temporarily.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse for three residents, identified as R2, R5, and R8, in a sample of 14, placing them at risk for physical and psychological harm. R5, who has a history of schizophrenia, dementia, and aggressive behaviors, was involved in two separate incidents of resident-to-resident physical altercations. On one occasion, R5 picked up a wet floor sign and hit R2 in the head, resulting in a bruise and cuts that required medical attention. Despite being sent to the hospital for evaluation, R5 returned to the facility without any changes in medication or behavior management. In another incident, R5 slapped R8 in the face when R8 approached asking for food. Although no injuries were noted, the altercation was witnessed by staff, and both residents were separated. R5's care plan was updated to include 1:1 monitoring and medication review, but the facility's actions were insufficient to prevent further incidents. R5's cognitive impairments and history of aggressive behavior were not adequately addressed, leading to repeated episodes of violence against other residents. The facility's policy on abuse prevention emphasizes the importance of training staff to recognize and report abuse immediately. However, interviews with staff members revealed inconsistencies in their understanding and execution of these protocols. The facility's failure to implement effective interventions and monitoring for R5, despite his known aggressive tendencies, contributed to the ongoing risk of abuse for other residents. The lack of timely and appropriate responses to these incidents highlights deficiencies in the facility's abuse prevention and management strategies.
Facility Roof Damage and Water Leakage
Penalty
Summary
The facility failed to ensure that roof damage was repaired to prevent water leakage, which has the potential to affect all 34 residents. The administrator acknowledged that the facility has a flat roof that leaks during rain, leading to the use of buckets in affected rooms, which are currently unoccupied. Despite recognizing the need for a new roof, no bids for repair have been requested, and the facility is in the process of being sold, with hopes that new ownership will address the issue. Observations revealed multiple rooms and areas with water damage, including discolored ceiling tiles and streaks on walls. Interviews with staff, including the maintenance director and housekeeping personnel, confirmed the presence of leaks and the need for repairs. The maintenance director, who recently assumed the role, mentioned ongoing efforts to remodel and repair affected rooms but emphasized the necessity of a new roof. A third-party contractor assessed the facility and noted the requirement for a complete roof replacement. The facility's Resident Right Policy mandates a safe, clean, comfortable, and homelike environment, which is compromised by the current state of the roof.
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A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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