Galena Stauss Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Galena, Illinois.
- Location
- 215 Summit Street, Galena, Illinois 61036
- CMS Provider Number
- 146140
- Inspections on file
- 20
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Galena Stauss Nursing Home during CMS and state inspections, most recent first.
A resident with Alzheimer’s dementia, behavioral symptoms, and multiple comorbidities made repeated allegations that a CNA had molested her during toileting, including describing being pinned against a wall while being cleaned. Staff documented the allegation, obtained statements from the involved CNAs, and internally concluded the claims were unfounded, but did not notify IDPH or local law enforcement. The Administrator/abuse coordinator acknowledged that neither the initial nor subsequent sexual abuse allegations were reported externally, despite the facility’s abuse policy requiring all suspected abuse, including sexually based incidents and any incident where staff are unsure it meets the definition of abuse, to be reported to the state within 24 hours with a completed investigation within 5 days.
A resident with multiple chronic conditions and documented oral pain was seen by a dentist, who identified significant decay with periapical radiolucency and referred the resident for oral surgery, recommending prompt comprehensive follow-up. The resident returned from the dental visit without paperwork, and facility staff did not obtain visit information or clarify follow-up needs. A subsequent dental follow-up appointment, which the resident and transportation service had arranged, was cancelled by the facility on the day of the visit due to lack of an available staff escort, and it was not rescheduled. Nursing, transportation, social services, and administrative staff gave inconsistent accounts and did not coordinate to ensure the resident’s follow-up dental care, while the resident continued to receive PRN ibuprofen and Tylenol for oral pain.
A resident with cognitive impairments was observed groping another resident's breast in the dining room, an incident witnessed by a CNA who intervened and reported it. The female resident, who has aphasia and cognitive deficits, did not verbally respond. The facility's LPN was present but did not intervene until informed by the CNA. The facility's abuse prevention policy mandates protection from such abuse.
The facility did not submit the required quarterly reports to the PBJ for a specified period in 2024. The Administrator acknowledged the oversight, noting that corporate staff typically manage submissions but failed to do so this time. The facility lacked a policy for PBJ reporting and had been notified by IDPH about the issue.
The facility failed to implement its Legionella management policy, potentially affecting all 44 residents. The Administrator and Infection Preventionist admitted that no water management program, diagrams, surveillance, or testing processes had been completed or initiated. The facility's policy aimed to establish a water management program and surveillance process to reduce infection risks, but these objectives were not met.
The facility failed to properly assess and manage non-pressure wounds for two residents, leading to deficiencies in wound care. One resident's wound was not documented or treated in a timely manner, and the physician was not notified promptly. Another resident's wound assessments were not documented as required. The Interim DON acknowledged poor wound charting and failure to follow the facility's policy on wound care.
A resident's pressure injury was not properly assessed or treated, with significant gaps in documentation and lack of physician notification. The facility failed to conduct timely wound assessments and did not have physician-prescribed treatments until late September, despite the wound's presence since early August. The DON acknowledged the lapses in care and documentation, which were inconsistent with the facility's policy.
The facility failed to replace oxygen tubing monthly for two residents with obstructive sleep apnea and other health conditions. Both residents were observed using oxygen tubing without any indication of when it was last changed, and there was no documentation or physician orders for equipment maintenance. The facility's policy required monthly changes, but this was not followed.
A facility failed to ensure that only licensed staff administered Nystatin Powder to a resident. A CNA incorrectly applied the medicated powder to a resident's buttocks instead of the groin, contrary to the physician's order. The DON confirmed that only nurses should administer such medications, and the powder was misapplied to a wound rather than the intended area.
A resident with diabetes was allowed to choose her insulin dose, deviating from the prescribed sliding scale orders. The LPN administered 15 units of insulin instead of the 10 units indicated by the resident's blood sugar level, and this was not documented in the MAR. The DON confirmed that the resident's physician was aware of her refusal to comply with the sliding scale, but the facility's policy required documentation and physician notification if orders could not be followed.
The facility failed to store controlled medications for two residents under a double lock system. Lorazepam for agitation and anxiety was found in an unlocked medication refrigerator, contrary to facility policy requiring double locks for controlled substances. An LPN and the Infection Preventionist acknowledged the oversight.
A resident with partial leg amputations and mild cognitive impairment fell and sustained a cervical spine fracture during a transfer using a hoist mechanical lift. The fall occurred due to improper sling placement, as the resident slipped through a gap between the head and leg straps. Staff interviews indicated uncertainty about the sling's positioning, and the facility's policy requires proper use of lifting devices. The incident resulted in the resident experiencing neck pain, later confirmed as a cervical fracture.
A resident with cognitive impairment and amputations experienced a fall from a mechanical lift, resulting in neck pain. The facility failed to notify the physician of the new-onset neck pain promptly, delaying imaging and diagnosis of a neck fracture. Despite the delay, the prognosis and treatment were not negatively impacted.
Two residents reported incidents where an RN failed to treat them with dignity and respect. One resident described a dismissive and loud response from the RN when questioned about a potential trip hazard. Another resident recounted a past issue with the RN's loud and disrespectful behavior. Both residents had intact cognition, and the facility's resident rights brochure emphasizes the right to safety and good care.
A facility failed to implement its abuse policy when an RN did not immediately report an incident where another RN forcibly took an ice cream from a resident and made a derogatory remark. The incident was reported after the weekend, allowing the alleged perpetrator to continue working without intervention. The facility's policy requires immediate removal of the alleged perpetrator, which was not followed.
A facility failed to ensure timely reporting of an alleged abuse incident involving a resident. An RN witnessed another RN take an ice cream from a resident and make a derogatory remark but did not report the incident immediately. The RN reported the incident via email days later, leading to a delay in the facility's required reporting to the state.
Failure to Report Resident’s Sexual Abuse Allegations to State and Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report a resident’s allegation of sexual abuse to the Illinois Department of Public Health (IDPH) and local law enforcement as required by policy. The resident had multiple diagnoses including congestive heart failure, type 2 diabetes, Alzheimer’s disease, dementia with behaviors, major depressive disorder, and schizotypal disorder, and had refused a formal cognitive assessment, though a surveyor later determined she was alert and oriented to person, place, and time. Her care plan documented Alzheimer’s dementia with visual hallucinations, long-held delusions, agitation, and a history of combative behaviors that had improved over the past quarter. On one occasion, a CNA reported to a nurse that the resident stated a CNA was not allowed in her room because the CNA had “molested” her. In a later interview, the resident again stated that a staff member had molested her, though she declined to identify the person or involve the Ombudsman. The facility conducted an internal investigation documented as an accusation that a CNA molested the resident, with statements obtained from the involved CNAs and a conclusion that the claims were unfounded and non-credible. There was no documentation that IDPH or local police were notified of the allegation. Social Services described the incident as occurring during toileting, when the CNA allegedly pinned the resident against the wall while cleaning her. The CNA involved reported that the resident had first made an allegation in a prior month, after which she was told not to care for the resident and believed there was no investigation. The Administrator, who serves as the abuse coordinator, acknowledged that this situation had been ongoing since an initial allegation earlier in the year and confirmed that neither the initial nor subsequent allegations were reported externally, explaining that they were unsure if the later statement was a new allegation and that if every allegation from this resident were reported, surveyors would be present frequently. This inaction occurred despite the facility’s written Abuse Prevention Policy stating that all incidents of abuse, including sexually based incidents, are to be reported to the state within 24 hours, with a completed investigation within 5 days, and that if staff are unsure an incident meets the definition of abuse, the policy is to report.
Failure to Arrange Follow-Up Dental Care for Resident with Ongoing Oral Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and the resident’s preferences and goals by not ensuring a follow-up dental visit for a resident experiencing oral pain. The resident had multiple diagnoses, including congestive heart failure, Type 2 diabetes, Alzheimer’s disease, major depressive disorder, hypertension, and schizotypal disorder, but the facility assessment documented no cognitive impairment and noted delusions. The resident reported having seen a dentist the prior month, being told that four upper teeth needed extraction, receiving antibiotics from a hospital for suspected infection, and relying on ibuprofen for pain relief. Medication administration records showed the resident received ibuprofen and Tylenol 15 times for oral pain over a little more than a month, with most doses occurring in the latter part of that period. Dental records from the 2/19 visit documented that the resident presented with upper anterior tooth pain, had a periapical x-ray showing decay and a periapical radiolucency on tooth #10, and was referred to an oral surgeon for extraction, with a recommendation to return for a full exam and further evaluation of other teeth. The dentist office scheduler later confirmed that the resident had been seen for an urgent care appointment, that oral surgery was needed, and that the resident was a no-show for a scheduled follow-up appointment on 3/4, with no subsequent contact from the facility or the resident to reschedule. Facility staff interviews revealed that the resident had left with a friend for the 2/19 appointment instead of using arranged transportation and returned without any paperwork, leaving staff unaware of what was done or what follow-up was required. Nursing, transportation, social services, and administrative staff provided conflicting and incomplete accounts regarding responsibility for arranging and rescheduling the follow-up dental appointment. Nurses stated that the transportation company required an escort and that the appointment was cancelled when no staff were available to ride with the resident, and that the resident subsequently called 911 seeking transport, resulting instead in a hospital visit. The transportation staff member stated that the resident had independently arranged the follow-up appointment and transportation, but that the facility cancelled on the day of the appointment due to lack of an escort and did not reschedule because no paperwork had been received from the prior visit. The Social Service Director and Administrator both acknowledged that the resident returned from the 2/19 appointment without paperwork and that there were no further appointments scheduled, with the Administrator indicating a belief that the appointment was only for a cleaning and did not need rescheduling. The DON stated that nurses should follow up with providers when residents return without paperwork and that any missed follow-up appointment should have been rescheduled. The facility’s resident appointment policy contained no guidance on staff responsibilities when a resident returns from an appointment without documentation.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident where one resident was observed groping another resident's breast in the dining room. The incident was witnessed by an agency CNA, who reported that the male resident, who has cognitive impairments and physical limitations due to a stroke, was touching and squeezing the female resident's breast. The female resident, who has aphasia and cognitive deficits, did not respond verbally during the incident. The CNA intervened by instructing the male resident not to touch other residents and removed him from the table. The facility's Licensed Practical Nurse (LPN) was present in the dining room at the time and observed the male resident self-propelling his wheelchair towards the female resident with a purpose. The LPN continued with her tasks until the CNA reported the incident. The facility's administrator was informed of the incident later that evening and expressed surprise at the male resident's behavior, noting it was unusual for him. The facility's abuse prevention policy clearly states that all residents should be free from abuse, including sexual abuse by another resident, which includes intentional sexual touching without permission or the ability to consent.
Failure to Submit PBJ Quarterly Reports
Penalty
Summary
The facility failed to submit quarterly reports to the Payroll-Based Journal (PBJ) for the period of April 1 to June 30, 2024. This deficiency was identified through interviews and record reviews. The facility's roster dated October 1, 2024, indicated that there were 44 residents residing in the building at the time. The Administrator, identified as V1, acknowledged the failure to submit the data, stating that the corporate staff usually handle the submission but did not do so for this quarter. The Administrator also mentioned that there was no existing policy regarding PBJ reporting. The facility had already received a notification from the Illinois Department of Public Health (IDPH) regarding this issue.
Failure to Implement Legionella Management Policy
Penalty
Summary
The facility failed to implement its policy regarding Legionella management, which has the potential to affect all residents in the building. The resident census report dated 10/1/24 showed 44 residents currently residing in the building. On 10/3/24, the Administrator stated that they had been working with a hospital infection preventionist on their policy but had not set any plan yet. They acknowledged that they had not completed or initiated any water management program, diagrams, surveillance process, or testing process. The Infection Preventionist also confirmed that no actions regarding Legionella had been taken, and the plan was still in process. The facility's undated policy titled 'Legionella and Waterborne Pathogens Policy' outlined objectives to establish a water management program and surveillance process to reduce the risk of infections due to waterborne pathogens, but these had not been implemented.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to properly assess and manage non-pressure wounds for two residents, R10 and R41, leading to deficiencies in wound care. For R10, the facility did not document a wound bed description, measurements, or notifications when a wound was first identified on the coccyx. Despite the wound being noted on 7/11/24, the physician was not notified until 7/16/24, and no treatment orders were in place until 9/27/24. The Interim Director of Nursing acknowledged that the wound charting was poor and difficult to follow, and that the provider should have been notified earlier. The facility's policy requires assessments and notifications, which were not followed in this case. For R41, a wound was identified on 7/13/24, but there were no documented assessments on or before 7/20/24 and 7/27/24, as required by the facility's policy. The Interim Director of Nursing stated that wound assessments are crucial for tracking the progression of wounds and determining the effectiveness of treatments. The lack of documented assessments during this period indicates a failure to adhere to the facility's policy, which mandates regular assessments and documentation of wounds.
Failure to Properly Assess and Treat Pressure Injury
Penalty
Summary
The facility failed to properly assess, treat, and notify the physician regarding a pressure injury for one resident, identified as R10, out of a sample of 13 residents. On multiple occasions, the facility did not conduct timely wound assessments, as evidenced by gaps in documentation. For instance, there was an 11-day gap between assessments in August and a 9-day gap in September. Additionally, the facility did not have physician-prescribed treatments for R10's pressure injury until late September, despite the presence of the wound since early August. The facility's Director of Nursing (DON) acknowledged that wound assessments should be conducted weekly and should include detailed measurements and descriptions. However, R10's assessments were inconsistent, and the documentation was incomplete. The DON also noted that the physician and family should have been notified of the wound when it was first identified, which did not occur. Furthermore, the facility's policy required that wounds be monitored in the treatment book until healed, but this was not adhered to in R10's case. The facility's failure to follow its own policy and procedures for wound care and documentation resulted in inadequate care for R10's pressure injury. The lack of timely assessments and physician involvement potentially delayed appropriate treatment. The DON admitted that the order for R10's dressing change was poorly written and misinterpreted, leading to further lapses in care. This deficiency highlights significant gaps in the facility's wound care management and communication processes.
Failure to Replace Oxygen Tubing Monthly for Residents
Penalty
Summary
The facility failed to ensure that oxygen tubing was replaced monthly for two residents who were receiving oxygen therapy. The first resident, a female with multiple diagnoses including obstructive sleep apnea and heart failure, was observed with oxygen tubing in her nostrils without any indication of when it was last changed. The resident confirmed that she wore her oxygen continuously. The facility's Infection Preventionist highlighted the importance of changing oxygen tubing monthly to prevent moisture and bacteria buildup, but there was no documentation in the resident's treatment administration record to confirm that the tubing had been changed. Additionally, there was no physician order for the care and maintenance of the oxygen equipment, and the resident's care plan did not address oxygen use. Similarly, the second resident, also a female with diagnoses including obstructive sleep apnea and heart failure, was observed with oxygen tubing in use without a date indicating its last change. This resident also reported using oxygen continuously except during showering or toileting. Like the first resident, there was no documentation in the treatment administration record of the tubing being changed, no physician order for equipment maintenance, and no care plan addressing oxygen use. The facility's policy required nasal cannulas and masks to be changed monthly, but this was not adhered to for these residents.
Improper Administration of Medicated Powder by Unlicensed Staff
Penalty
Summary
The facility failed to ensure that licensed staff administered medicated powder to a resident, leading to a deficiency in pharmaceutical services. A resident, identified as R10, had a physician's order for Nystatin Powder to be applied topically to the groin for excoriated areas. However, a skin/wound note indicated that a CNA applied the treatment powder to the resident's buttocks instead of the groin, which was not in accordance with the physician's order. The Director of Nursing confirmed that Nystatin Powder is a medication intended for fungal infections and should only be administered by nurses, not CNAs. Furthermore, the powder was incorrectly used on a buttock wound rather than the prescribed area, highlighting a failure in following proper medication administration protocols.
Failure to Adhere to Insulin Administration Orders
Penalty
Summary
The facility failed to protect a resident from a significant medication error involving insulin administration. The resident, who has diagnoses including type 2 diabetes and chronic kidney disease, was observed to have received an incorrect dose of insulin. The resident's physician's orders specified a sliding scale for insulin administration based on blood sugar levels, but the resident was allowed to choose her insulin dose, which deviated from the prescribed orders. On one occasion, the resident requested and received 15 units of insulin when the sliding scale indicated she should have received 10 units. This deviation was not documented in the medication administration record (MAR), and there was no area for staff to document the administration of the medication. The Licensed Practical Nurse (LPN) involved stated that the resident had a history of choosing her insulin dose and that the facility allowed this practice to continue. The Director of Nursing (DON) confirmed that the resident's physician was aware of her refusal to comply with the sliding scale and that the facility allowed her to manage her insulin as she did at home. However, the facility's policy required documentation of medication administration and notification of the physician if orders could not be followed. The lack of documentation and adherence to the prescribed insulin orders led to the deficiency, as the facility did not ensure safe and accurate medication administration procedures.
Failure to Double Lock Controlled Medications
Penalty
Summary
The facility failed to store controlled medications for two residents, identified as R9 and R12, under a double lock system as required by regulations. R9 had a physician's order for Lorazepam oral concentrate to be administered sublingually as needed for agitation, while R12 had a similar order for anxiety. During an observation, it was noted that the medication refrigerator, which contained both unopened and partially used bottles of Lorazepam for these residents, was not equipped with a lock, nor were the medications stored in a locked container within the refrigerator. A Licensed Practical Nurse (LPN) acknowledged that the Lorazepam had always been stored in the refrigerator without a double lock and expressed uncertainty about the necessity of such a measure. The Infection Preventionist confirmed that all controlled medications should be under a double lock system to prevent diversion and ensure proper administration. The facility's policy mandates that Schedule II-V controlled medications be stored in separately locked, permanently affixed compartments, but this was not adhered to in the case of R9 and R12's medications.
Improper Sling Placement Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to safely transfer a resident using a hoist mechanical lift, resulting in the resident falling and sustaining a cervical spine fracture. The resident, who had partial leg amputations, diabetes, and mild cognitive impairment, was dependent on staff for transfers. During a transfer from bed to chair, the resident fell out of the sling and hit her head, neck, and shoulder on the floor. The incident report indicated that the resident leaned too far to the left and slipped out of the sling, despite attempts by the CNA to brace the fall. Interviews with staff revealed that the CNAs involved in the transfer were unsure if the sling was positioned correctly, which may have contributed to the resident's fall. The CNAs described the resident falling through a gap between the head and leg straps of the sling. The resident began experiencing neck pain the day after the fall, which was later confirmed to be due to a cervical fracture. The physician expressed concern about the fracture and emphasized the expectation for safe mechanical transfers. The Director of Nursing and other staff members suggested that improper sling placement was likely the cause of the fall. The facility's policy on safe resident handling and transfer requires the use of mechanical lifting devices according to instructions and training, with the sling placed appropriately under the patient. The incident highlights a failure to adhere to these procedures, resulting in the resident's injury.
Failure to Notify Physician of Resident's Neck Pain After Fall
Penalty
Summary
The facility failed to notify a resident's physician of new-onset neck pain following a fall from a hoist mechanical lift. The resident, who had partial left and right leg amputation, type 2 diabetes, and mild cognitive impairment, was cognitively intact with a BIMS score of 14 out of 15. After the fall, the resident began experiencing neck pain, but it took at least a week before she was sent out for X-rays. The facility's Serious Injury Incident Report indicated that the resident fell on 8/12/24, and the physician was not notified of the neck pain until 8/21/24, when an X-ray confirmed a fracture of the neck. Interviews with the CNAs involved in the transfer revealed that the resident fell out of the sling and hit her head, neck, and shoulder on the floor. The resident began complaining of neck pain the following day, but the physician was not informed until much later. The facility's policies required notifying the physician of any change in assessment, which was not followed in this case. The physician stated that if he had been notified earlier, he would have sent the resident for imaging sooner, although the delay did not negatively impact the resident's prognosis or change the treatment provided.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by interactions involving two residents and a registered nurse (RN). One resident reported an incident where the RN responded inappropriately when questioned about a potential trip hazard caused by a rug brought in by a neighboring resident's family. The RN reportedly gestured dismissively and spoke loudly, which the resident found undignified. Another resident recounted a past issue with the same RN, who had responded loudly and disrespectfully when the resident answered a question. Both residents involved had intact cognition according to their Minimum Data Set assessments. The facility's brochure on resident rights emphasizes the right to safety, good care, and satisfaction, which was not upheld in these interactions.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy by not immediately protecting a resident from an alleged perpetrator following an incident of alleged abuse. On the evening of April 25, 2024, a Registered Nurse (RN) witnessed another RN, identified as V3, forcibly take an ice cream from a resident, R1, and dispose of it. V3 then handed a tissue to R1 in an angry manner and made a derogatory remark. Despite witnessing this incident, the observing RN, V4, did not report the event immediately, as required by the facility's abuse prevention policy, which mandates the immediate removal of the alleged perpetrator from the facility. The incident was only reported to the facility's administrator, V1, after the weekend, resulting in V3 continuing to work her shift without any intervention. The administrator stated that had the incident been reported immediately, V3 would have been sent home, and an abuse investigation would have commenced right away. The facility's undated Abuse Prevention Policy and Procedure clearly states that it is the responsibility of the Abuse Prevention team and/or shift supervisor to ensure the alleged perpetrator is removed from the facility within minutes of the incident, which did not occur in this case.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that a staff member immediately reported an alleged abuse incident involving a resident. On the evening of April 25, 2024, a Registered Nurse (RN) witnessed another RN, V3, grab an ice cream from a resident, R1, and throw it away, followed by angrily handing a tissue to R1 and making a derogatory remark. Despite witnessing this incident, the RN, V4, did not report it immediately, as required by the facility's abuse prevention policy. Instead, V4 continued with her duties and left the facility without notifying the administrator or any other authority. V4 later reflected on the incident over the weekend and decided to email the administrator on April 28, 2024, acknowledging her delay in reporting the incident. The facility's policy mandates that all abuse incidents be reported to the state within 24 hours, but the report was not filed until April 29, 2024. The delay in reporting was confirmed by the Interim Director of Nursing (DON), who was informed by V4 on the morning of April 30, 2024, and subsequently notified the administrator. The facility's failure to adhere to its abuse reporting policy resulted in a deficiency being cited.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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