Generations At Regency
Inspection history, citations, penalties and survey trends for this long-term care facility in Niles, Illinois.
- Location
- 6631 Milwaukee Avenue, Niles, Illinois 60714
- CMS Provider Number
- 145237
- Inspections on file
- 27
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at Generations At Regency during CMS and state inspections, most recent first.
A ventilator‑dependent resident with severe cognitive impairment, quadriplegia, COPD, and chronic respiratory failure experienced repeated ventilator alarms overnight, including high inspiratory pressure, low inspiratory pressure, and low minute volume alarms documented in the VOCSN alarm logs. After an RN initially responded around 1:45 AM with oral and tracheal suctioning and documented no distress, there was no further documentation that nursing or RT staff assessed the resident or evaluated the ventilator in response to subsequent on‑and‑off alarms between roughly 2:38 AM and 3:04 AM. Later, an RT found the resident unresponsive, pale, without vital signs, and disconnected from the vent, with no alarm sounding, and CPR and EMS were initiated; EMS and hospital records confirmed cardiac arrest and the resident’s death. Surveyors determined the facility failed to assess and respond to ventilator alarms and to ensure the vent circuit and closed suction system were intact and functioning, resulting in Immediate Jeopardy.
A resident with diabetes and other complex conditions experienced prolonged severe hypoglycemia after nursing staff failed to promptly notify the NP or physician and did not escalate care according to protocol. Despite repeated low blood glucose readings and administration of glucagon and juice, the resident remained hypoglycemic and unresponsive for over two hours before emergency services were called, resulting in hospital transfer and subsequent death.
A facility failed to prevent resident-to-resident physical abuse involving two residents with moderate cognitive impairment. One resident, tired after dialysis, became upset with her roommate for talking continuously, leading to a physical altercation. The incident resulted in visible injuries, and the facility's lack of documentation and oversight contributed to the deficiency.
A resident with Alzheimer's and dementia fell from a wheelchair due to inadequate supervision, resulting in a forehead laceration and a left patella fracture. The resident, who was at high risk for falls, was not properly seated with feet on footrests during transport by CNAs. The facility's investigation noted the resident's cognitive impairments and communication challenges.
The facility failed to secure medication carts and properly date and discard medications, leading to the presence of expired medications and unsecured carts. These deficiencies were observed across multiple floors and involved several residents, highlighting a systemic issue in medication management and security.
The facility failed to store and label food items in accordance with professional standards for food service safety. During a kitchen observation, the surveyor noted that a large plastic bag containing frozen corn and a large bag of frozen fries in the walk-in freezer were not labeled or dated. The Food Service Supervisor acknowledged the oversight. The facility's policy requires that food taken out of its original container be tightly wrapped and labeled with the name of the item and the use-by date. This deficiency has the potential to affect 180 residents who consume food from the kitchen.
A facility failed to maintain a resident's dignity during lunch dining when a CNA was observed standing while feeding a resident, contrary to the facility's policy that staff should sit to create a relaxing environment. The resident has Alzheimer's disease and other conditions requiring assistance, and the facility's policies emphasize treating residents with dignity.
The facility failed to ensure that two residents had their call lights within reach and did not respond to another resident's call light in a timely manner. One resident's call light was on the floor, and another's was difficult to reach, forcing them to yell for assistance. Additionally, a resident's call light was not answered for over 20 minutes, despite the facility's policy requiring prompt responses.
The facility failed to involve a resident's mother and guardian in the care plan conference, despite her being present daily and expressing concerns about her son's care. The Assistant Administrator admitted that the care plan was not coordinated with the mother, and there was no documentation showing she was offered the opportunity to participate, contrary to facility policy.
A resident reported not receiving a shower in a week, despite the facility's policy of providing baths twice a week. The DON confirmed the schedule, but records showed inconsistencies and lack of documentation for refusals.
The facility failed to follow its policy to ensure a resident's nutritional status remained within acceptable parameters, leading to significant weight loss. The resident experienced delays in receiving and being fed meals, and the dietician did not update the care plan or notify the nurse practitioner with new recommendations despite the weight loss.
A facility failed to check a resident's G-tube infusion and water flush rate, leading to an incorrect setting of 350ml instead of the physician-ordered 250ml. The error was not corrected until identified by a surveyor, despite facility policies requiring adherence to physician orders.
A resident with severe cognitive impairment and respiratory failure was not provided continuous oxygen therapy as ordered. The surveyor observed the oxygen concentrator off and the oxygen tank empty. The respiratory therapist confirmed the resident required continuous oxygen and rectified the situation. The CNA had informed the respiratory therapist of the resident's return from dialysis, but the oxygen therapy was not promptly resumed.
Failure to Respond to Ventilator Alarms and Maintain Vent Circuit Leading to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary respiratory care and monitoring to a ventilator‑dependent resident by not adequately assessing and responding to ventilator alarms and not ensuring the ventilator circuit and closed suction system were intact and functioning. The resident was an older adult female with encephalopathy, quadriplegia, COPD, vascular dementia, chronic respiratory failure, and complete dependence on mechanical ventilation via tracheostomy. Her MDS documented severely impaired cognitive skills and short‑ and long‑term memory problems. Physician orders specified continuous ventilator support (assist‑control mode, rate 18, tidal volume 400 ml, PEEP 5, FiO2 28% with 2 L/min O2), and care plans directed staff to monitor for signs and symptoms of hypoxia and acute respiratory insufficiency. During the night in question, progress notes show that at approximately 1:45 AM the ventilator alarms were intermittently sounding. The RN responded by entering the room, performing oral suctioning for copious thin secretions, and tracheal suctioning once for a moderate amount of blood‑tinged thin secretions. Vital signs were checked and documented, the G‑tube dressing was changed, and the nurse recorded that the resident was in no distress and that the ventilator was no longer alarming. The nurse later stated in interview that after this suctioning, everything was still connected, the resident’s oxygen saturation was acceptable, and the ventilator stopped alarming. She reported not hearing any further alarms prior to the later emergency. However, review of the ventilator’s VOCSN alarm logs showed multiple high inspiratory pressure and low minute volume alarms between approximately 2:38 AM and 2:39 AM, and low inspiratory pressure and low minute volume alarms between approximately 3:03 AM and 3:04 AM. These alarms alternated between triggered and resolved, indicating on‑and‑off alarm activity. There was no documentation in the resident’s progress notes that nursing or respiratory staff assessed the resident or evaluated the ventilator in response to these alarms. The lead RT and other clinical leaders stated that such alarms require immediate or prompt physical assessment of the resident and ventilator circuit, and that staff are mandated to answer all alarms. At approximately 3:55–4:15 AM, the RT entered the room during rounds and found the resident unresponsive, pale, with no breathing and no vital signs, and disconnected from the ventilator. The RT reported that there was no ventilator alarm sounding at that time and that the ventilator tubing was disconnected and close to the tracheostomy. The RN, called to the room, also found the resident pale, not moving, with no chest rise, and assisted in initiating CPR and calling a code blue and EMS. The ambulance crew documented that staff reported the resident was last seen normal around 2:00 AM and was later found in cardiac arrest with the ventilator disconnected and no alarms sounding. Hospital records documented that the resident arrived in cardiac arrest with absent heart sounds, no palpable carotid pulse, fixed and dilated pupils, and no purposeful response, and she was pronounced dead after resuscitation efforts. The surveyors concluded that the facility failed to assess and respond to ventilator alarms and failed to ensure the ventilator circuit and closed suction system were intact and functioning, resulting in the resident being found unresponsive and disconnected from the ventilator and expiring, and this failure constituted Immediate Jeopardy.
Removal Plan
- Initiate high quality CPR, call a code blue, call EMS, continue CPR until EMS arrives, and transfer the resident to the hospital.
- Check all ventilator-dependent residents for proper connection and alarm function.
- Identify other potentially affected residents, including residents with an open airway and residents utilizing a ventilator.
- Check all ventilator-dependent residents for proper connection and alarm function.
- Check all ventilators to ensure all required maintenance is performed.
- Have the assigned respiratory therapist check all ventilator-dependent residents for proper connection and alarm function every 2 hours and as needed, and document these checks once per shift.
- Conduct staff education by the ADON, lead respiratory therapist, Regional Nurse Consultant, and shift supervisor.
- Provide education to all staff assigned to the respiratory unit, including PRN staff.
- Implement a monitoring process in which the respiratory therapist randomly audits ventilator residents to ensure ventilator settings, connections, and alarm functionality are assessed after care activities that could disrupt the ventilator circuit.
- Implement observation audits of ventilator-dependent residents for secure connections.
- Have the Director of Nursing or designee conduct direct observation in the respiratory unit to ensure prompt response to alarms on random shifts.
- Have the Director of Nursing or designee conduct direct observation of staff to ensure residents with an open airway are repositioned appropriately and carefully to prevent interruption of respiratory tubing.
- Conduct audits for all residents with an open airway, then continue audits weekly.
- Present audit results to the QAPI committee for recommendations of further auditing and actions as appropriate.
- Complete a code blue debrief and have the action plan discussed and approved by the Ad-Hoc committee.
Failure to Promptly Intervene and Escalate Care for Severe Hypoglycemia
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including type II diabetes mellitus, experienced a severe hypoglycemic episode that was not managed according to professional standards of practice and facility policy. The resident was first found to have a critically low blood glucose level of 42 mg/dl in the early morning by a night shift LPN, who administered glucagon but did not promptly notify the nurse practitioner or physician as required. Despite repeated low blood glucose readings and additional doses of glucagon and oral carbohydrates, the resident's condition did not improve, and there was a prolonged period—over two hours—where the resident remained hypoglycemic and increasingly unresponsive. The nursing staff failed to escalate care in a timely manner. The night shift LPN endorsed the situation to the incoming day shift LPN without notifying the medical provider, and both nurses continued to monitor and treat the resident without achieving a safe blood glucose level or seeking immediate higher-level intervention. Documentation and interviews confirm that the nurse practitioner was not notified until the resident developed respiratory distress and further decline in condition. Only at this point was 911 called and the resident transferred to the hospital. Throughout this episode, facility policy and standard hypoglycemia protocols were not followed, specifically regarding prompt provider notification and emergency escalation for persistent severe hypoglycemia. The lack of timely intervention and failure to follow established protocols resulted in the resident experiencing prolonged hypoglycemia, decreased responsiveness, and ultimately requiring emergent hospital transfer, where the resident expired the same day.
Removal Plan
- Juice was provided to the resident to improve the blood glucose level.
- Glucagon was administered.
- Blood glucose monitoring was performed.
- Nurse Practitioner was notified and resident transferred to ER via 911.
- R1 no longer resides in the facility.
- 1:1 education was provided to the day shift nurse and night shift supervisor regarding hypoglycemia protocol, change of condition policy, following physician orders, and emergency response associated with severe hypoglycemia.
- The night shift nurse is no longer employed by the facility.
- DON/designee conducted a whole-house audit of residents who require blood glucose monitoring to ensure blood glucose results are within the ordered parameters, and if physician / NP is notified if the results are outside the parameters.
- Residents who are at risk for hypoglycemia (residents with diagnosis of diabetes, receiving insulin) were reviewed to ensure the plan of care includes a physician order for parameters of blood glucose level to monitor signs and symptoms of hypoglycemia, administer interventions for treatment of hypoglycemia, and physician notification.
- Staff education was conducted by the DON, Regional Nurse Consultant and shift supervisor. Education included: Notification of a change in condition, Medical emergency procedure associated with hypoglycemia, Following the physician's orders, Hypoglycemia Protocol.
- All licensed nurses received education prior to working their next scheduled shift. Staff not on site for education were contacted by telephone and received verbal education. They will sign in-service education forms at the time of their next shift. This includes PRN staff.
- Understanding of the in-service content was evaluated at the time of in-service through questions and answers.
- Director of Nursing or designee will audit resident records to ensure prompt notification to physician/ NP of an episode of hypoglycemia (change in condition) and following the physician's orders for notification of blood sugars outside of established parameters.
- Director of Nursing or designee will review the clinical record to monitor staff response to residents with signs and symptoms of hypoglycemia, monitor residents experiencing hypoglycemia, including severe hypoglycemia, administer interventions for treatment of hypoglycemia, and when emergency transport (911) and the medical provider are notified.
- Audits will be conducted 5 times a week for all residents with blood glucose monitoring orders.
- Audits will be conducted weekly for a sample of 10% of residents with blood glucose monitoring.
- Results of the audits will be presented to the QAPI committee for recommendations of further auditing and actions as appropriate.
- Root cause analysis is completed, and the action plan is discussed and approved by the Ad-Hoc committee.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and protect a resident from resident-to-resident physical abuse, involving two residents with moderate cognitive impairment. The incident occurred when one resident, who was tired after dialysis, became upset with her roommate for talking continuously. This led to a physical altercation where the resident slapped and scratched her roommate's face, resulting in visible red marks and scratches. The incident was reported by the affected resident to a nurse, who noted the injuries and administered bacitracin medication. The facility's staff, including a CNA, witnessed the altercation and confirmed the aggressive behavior was unusual for both residents. The language barrier between the residents exacerbated the situation, contributing to the misunderstanding and subsequent conflict. The facility's policy on abuse prevention was presented, emphasizing the commitment to protect residents from abuse and mistreatment. However, the facility failed to document the interdisciplinary team's meeting or the social services assessment that evaluated the safety of returning the aggressive resident to the same unit. This lack of documentation and oversight contributed to the deficiency in preventing resident-to-resident abuse.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to effectively supervise and ensure a resident was properly seated in a wheelchair with feet on footrests or elevated off the floor prior to being transported. This deficiency resulted in the resident falling from the wheelchair, sustaining a laceration to the forehead requiring seven sutures and a left patella fracture. The resident, who has Alzheimer's disease and dementia, was observed sitting in a wheelchair in the dining room and later being transported to her room by two CNAs. During the transfer from the wheelchair to the bed, the resident was totally dependent on the CNAs due to her inability to straighten her legs and support her weight. The resident's care plan indicated a high risk for falls due to decreased mobility, muscle weakness, and cognitive impairments. Despite these documented risks, the resident was not adequately supervised during the transfer process. The CNAs involved in the transfer did not witness the resident leaning forward or attempting to stand unassisted, yet the resident fell forward from the wheelchair, resulting in injuries. The resident's medical records and assessments highlighted her severe cognitive impairment and dependency on staff for transfers and locomotion. The facility's investigation noted that the resident communicates primarily in Polish and was cognitively impaired with memory and recall problems. The CNA responsible for the resident at the time of the fall reported that the resident appeared tired and leaned forward suddenly, leading to the fall. The CNA involved in the incident is no longer employed at the facility and was unavailable for an interview during the survey.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to properly manage and secure medications, leading to several deficiencies. On multiple occasions, medication carts were found unlocked and unattended, including one instance on the dementia unit where a cart containing narcotics, insulins, and syringes was left unsecured. This lapse in security was acknowledged by the LPNs on duty, who admitted that the cart should have been locked to prevent unauthorized access. Additionally, the facility failed to properly date and discard medications. Eyedrops for two residents were not labeled with the dates they were opened or their discard dates, and insulin vials for three residents were found to be expired but still in use. These observations were confirmed by the LPNs, who stated that expired medications should not be administered as they may not work effectively and could potentially harm residents. The Director of Nursing confirmed that medication carts should be locked when not in use and that medications should be labeled with both the date opened and the discard date. Facility policies also mandate that no outdated or deteriorated drugs should be available for use and that all compartments containing drugs must be locked when not in use. Despite these policies, the survey revealed that the facility did not adhere to these standards, resulting in the presence of expired medications and unsecured medication carts. The deficiencies were observed across multiple floors and involved several residents, highlighting a systemic issue in medication management and security within the facility.
Failure to Properly Label and Date Food Items in Freezer
Penalty
Summary
The facility failed to store and label food items in accordance with professional standards for food service safety. During a kitchen observation, the surveyor noted that a large plastic bag containing more than a liter of frozen corn and a large bag of frozen fries in the walk-in freezer were not labeled or dated. The Food Service Supervisor acknowledged that the items should have been labeled and dated. The facility's policy on the storage of frozen foods, dated 2017, requires that food taken out of its original container be tightly wrapped and labeled with the name of the item and the use-by date. The facility census report documented 197 residents, with 17 residents having orders for nothing by mouth (NPO). This deficiency has the potential to affect 180 residents who consume food from the kitchen.
Failure to Maintain Resident's Dignity During Meal Time
Penalty
Summary
The facility failed to maintain a resident's dignity during lunch dining for one resident. On two separate occasions, a surveyor observed a CNA standing while feeding a resident in the dining room of a locked memory care unit. Other staff members were observed sitting while feeding residents, indicating that the CNA's actions were not in line with the facility's standard practice. The CNA supervisor and the Director of Nursing both confirmed that staff should sit while feeding residents to create a relaxing and home-like environment, emphasizing that standing while feeding is a dignity issue. The resident involved has a history of Alzheimer's disease, torticollis, muscle weakness, need for assistance with personal care, dysphagia, and unspecified dementia. The resident's care plan highlights the importance of ensuring the resident's safety, security, and dignity. The facility's policy and the Long-Term Care Ombudsman Program Residents' Rights document both stress the importance of treating residents with dignity and respect, including during feeding. Despite these guidelines, the CNA's actions were inconsistent with the facility's policies and the resident's care plan, leading to the identified deficiency.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach and did not respond to another resident's call light in a timely manner. On 05/21/2024, a surveyor observed that one resident's call light was on the floor, and the resident was unaware of its location. This resident had multiple diagnoses, including unspecified dementia and chronic obstructive pulmonary disease, and their care plan specified that the call light should be within reach. Another resident was found lying in bed without a call light in place. The resident indicated that the call light was behind their head and difficult to reach, forcing them to yell for assistance. A Certified Nursing Assistant confirmed that the call light was on the floor and not secured properly, acknowledging that the resident would yell for help if they could not reach it. The Director of Nursing stated that all residents should have accessible call lights and that staff should ensure they are within reach at all times. Additionally, the facility failed to respond promptly to a resident's call light. The resident, who had moderate cognitive impairment and multiple medical conditions, including acute and chronic respiratory failure, was observed struggling with tangled oxygen tubing and a spill on the floor. The resident activated the call light at 12:49 AM, but it was not answered until 01:10 PM when a CNA entered the room to deliver food. The CNA admitted to not noticing the call light and mentioned that the resident frequently pressed it multiple times. The Director of Nursing and an LPN both emphasized that call lights should be answered promptly to determine the resident's needs and provide necessary assistance. The facility's call light policy, dated 06/21, mandates that functioning call lights be placed where they are accessible to residents and that staff should answer call lights promptly and courteously. The failure to adhere to this policy resulted in residents not having their call lights within reach and experiencing delays in receiving assistance, which could potentially compromise their safety and well-being.
Failure to Involve Resident's Representative in Care Plan Conference
Penalty
Summary
The facility failed to follow their policy and routinely invite a resident's representative to participate in a care plan conference. Specifically, the facility did not involve the mother and guardian of a resident, who is a [AGE] year-old male with multiple serious diagnoses including encephalopathy, persistent vegetative state, and dependence on a ventilator. Despite the resident's mother being present at the facility every day and expressing concerns about her son's care, she was not asked to participate in the care planning process. This was confirmed through interviews and record reviews, where the mother stated she had not been offered to attend a care plan conference for her son. The Assistant Administrator, who is responsible for care plans, acknowledged that the resident's mother is involved in the resident's care but admitted that she had not coordinated the care plan for this resident. The facility's documentation indicated that the last care conference was held on 09/15/2023, and the next one was scheduled for 12/14/2023. However, there was no documentation showing that the resident's mother was offered the opportunity to participate in these meetings, which is a requirement according to the facility's policies on interdisciplinary team care planning and comprehensive care plans.
Failure to Provide Regular Baths to Resident
Penalty
Summary
The facility failed to ensure that residents are provided with regular baths twice a week, as evidenced by the case of one resident (R53) out of a sample of 35. On 05/21/2024, R53 reported not having received a shower in a week and expressed a desire for a shower on the previous Saturday, which was not provided. The Director of Nursing (V2) confirmed that all residents are supposed to receive baths twice a week, specifically on Wednesdays and Saturdays for R53. However, records showed that R53 only received baths on 5/22, 5/15, 5/8, 5/5, and 4/28, with no documentation of refusals. Additionally, the 3rd floor shower binder lacked shower sheets for the specified dates, indicating a failure in documentation and adherence to the bathing schedule.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to follow its policy to ensure a resident's nutritional status remained within acceptable parameters, leading to significant weight loss for one resident. The surveyor observed that the resident did not receive lunch in a timely manner, with delays in both receiving and being fed the meal. The resident's weight dropped from 114 lbs in March to 97 lbs in April, and no new interventions were added to address this significant weight loss. The dietician acknowledged the weight loss but did not update the care plan or notify the nurse practitioner with new recommendations. The facility's weight maintenance policy requires monitoring and investigating significant weight changes, determining a plan of action, and notifying the physician and responsible party. However, the dietician did not follow these steps, as evidenced by the lack of new interventions and failure to update the care plan. The resident's diet order included specific supplements, but the facility did not provide additional supplements beyond what was already prescribed, contributing to the resident's continued weight loss.
Failure to Check G-Tube Infusion and Water Flush Rate
Penalty
Summary
The facility failed to check the gastrointestinal tube (G-tube) infusion and water flush rate for a resident. On 05/22/24, a surveyor observed the resident's G-tube feeding infusing Nepro Carb Steady at 45ml/hr with a water flush set at 350ml, contrary to the physician's order of 250ml. The nurse on duty, who had just taken over care, was unaware of the incorrect water flush setting initiated by the previous nurse. The error was not corrected until it was pointed out by the surveyor. The consultant dietician confirmed the physician's order for the water flush and emphasized the importance of following these orders to maintain the resident's nutritional and fluid status. Another nurse admitted to not checking the infusion rate and water flush settings, assuming they were correct. The facility's policy requires that physician orders be implemented by staff, but this was not followed, leading to the deficiency.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide continuous oxygen therapy per physician order for a resident (R160). R160, a severely cognitively impaired [AGE] year-old female with diagnoses including anoxic brain damage, acute and chronic respiratory failure with hypoxia, and dependence on renal dialysis, was observed by a surveyor without the prescribed continuous oxygen therapy. The surveyor noted that the oxygen concentrator was off and the oxygen tank was empty. The respiratory therapist (V3) confirmed that R160 was supposed to be on continuous oxygen via trach collar at 2 liters per minute but found the oxygen tank empty and the concentrator off upon inspection. V3 then placed R160 on the oxygen concentrator and turned it on. The CNA (V25) who transferred R160 back from dialysis stated that the oxygen tank was not empty at the time of transfer and that he had informed V3 of R160's return before going on his lunch break. The Director of Nursing (V2) stated that either the nurse or respiratory therapist should attend to the resident as soon as possible to switch from the oxygen tank to the concentrator. The physician order sheet confirmed that R160 required continuous oxygen therapy at 4 liters per minute via oxygen concentrator. The facility's policy on oxygen therapy indicated that oxygen should be used safely and effectively per physician orders, and that both nurses and respiratory therapists are responsible for starting oxygen therapy. The failure to provide continuous oxygen therapy as ordered was observed and documented by the surveyor, indicating a deficiency in the facility's respiratory care practices.
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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