Goldwater Care Bloomington
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomington, Illinois.
- Location
- 700 East Walnut, Bloomington, Illinois 61701
- CMS Provider Number
- 145016
- Inspections on file
- 44
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Goldwater Care Bloomington during CMS and state inspections, most recent first.
Facility staff, residents, and family members reported that carpets in hallways and common areas were heavily stained, emitted persistent urine and feces-like odors, and had not been adequately cleaned for an extended period. Only a residential-grade carpet cleaner was available for spot cleaning, and a previous commercial extractor had not been replaced. Multiple interviews and observations confirmed that the carpets were not maintained in a clean, sanitary, or odor-free condition, affecting all residents.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A deficiency was cited when an area was found to contain accident hazards and lacked sufficient supervision to prevent accidents. Surveyors observed that the facility did not implement adequate measures to ensure resident safety in this environment.
A resident exhibited confusion, garbled speech, and difficulty participating in therapy, but staff failed to obtain vital signs or notify the nurse practitioner as required by policy. Multiple staff observed the resident's decline, yet appropriate medical intervention was delayed, resulting in an acute ischemic stroke with receptive aphasia.
A resident in need of pain management did not receive safe and appropriate pain control, as the facility did not adequately address the resident's pain according to their requirements.
The facility did not provide eight hours per day of RN coverage on multiple dates, as confirmed by staffing records and the scheduler, affecting all 88 residents.
A resident's facility-acquired Left Heel Stage 4 Pressure Ulcer deteriorated due to the facility's failure to assess, monitor, and implement care plan interventions. The resident, admitted with no pressure ulcers, had a medical history of metabolic encephalopathy and severe protein-calorie malnutrition. The facility did not conduct timely assessments or document the ulcer in the care plan. During a dressing change, an LPN risked cross-contamination by using supplies from a contaminated surface. The DON admitted to not implementing necessary interventions when the resident's heels were first noted as problematic.
The facility failed to respond promptly to call lights for several residents, as reported during a resident council meeting. Residents expressed concerns about long wait times, with some waiting over an hour for assistance, particularly during busy periods. The facility's call light policy, requiring prompt responses, was not followed, affecting residents with varying levels of cognitive and physical assistance needs.
The facility failed to ensure that four residents had physician orders for medications found in their rooms. A resident had Magnesium Oxide without a physician order, while another had antifungal powders without orders. A third resident had menthol gel without an active order, and a fourth had Calcium Carbonate without a physician order. The DON confirmed that medications should have active orders and be stored appropriately unless ordered otherwise.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring such measures, as staff did not wear gowns during high-contact care activities. Observations revealed a lack of accessible PPE and inadequate staff training, contributing to non-compliance with EBP protocols.
The facility failed to assess two residents for self-administration of medication, as required by policy. One resident was found with a medicine cup of medications without a physician's order or assessment for self-administration. Another resident had pills left at their bedside, with a nurse acknowledging they should have ensured the resident took the medication. The Director of Nursing confirmed the lack of orders and assessments for self-administration.
The facility failed to provide adequate call light accessibility for three residents. Two residents shared a single call light, causing accessibility issues, while a quadriplegic resident had a call light out of reach and was not provided with an alternative suitable for their condition. Maintenance and nursing staff were aware of the issues but did not resolve them in a timely manner.
A facility failed to complete a discharge summary for a resident who was discharged. The facility lacked a policy on required discharge documentation, and the resident's electronic medical record did not include a discharge summary or recapitulation of stay. The care plan indicated a need for a pre-discharge plan, but the Director of Nursing noted that while she completed her part, other disciplines did not chart any information, resulting in incomplete documentation.
A resident with Huntington's Disease experienced a decline in walking and transfer abilities, primarily using a wheelchair and requiring extensive assistance. Staff did not have time to walk with the resident regularly, and the care plan was outdated. Despite multiple falls, no therapy or restorative nursing services were offered. The facility's Restorative Nursing Program policy was not followed, and the resident had not received therapy since the previous year.
A facility failed to provide scheduled showers for a resident who requires substantial assistance, receiving only five or six showers per month instead of twice weekly. The resident's shower schedule was not followed, and a CNA noted insufficient staffing to complete all showers. The facility's policy requires bathing according to the resident's preferred frequency or at least twice weekly.
A resident with cognitive impairment and Huntington's Disease did not receive activities aligned with their interests, such as music and outdoor time, due to inadequate implementation of their care plan. Staff confirmed limited engagement, with the resident not participating in group activities and receiving minimal one-to-one interaction.
A resident with severe cognitive impairment and Huntington's Disease experienced multiple unwitnessed falls due to inadequate supervision and incomplete fall investigations. Despite requiring substantial assistance, the resident was left unsupervised on several occasions, leading to falls with minor injuries. Facility staff acknowledged gaps in supervision and documentation, contributing to the deficiency.
The facility failed to provide proper urinary catheter and incontinence care, leading to potential cross-contamination and infection risks. A resident's catheter bag was improperly handled, and incontinence care was performed without proper hygiene. Another resident's care involved using a soiled washcloth multiple times, and a third resident's care was inadequately performed with improper drying techniques.
A resident with quadriplegia and muscle spasms experienced inadequate pain management due to the facility's failure to conduct required pain assessments. Despite the resident's reports of severe pain, rated as a 10, the facility did not implement the physician's order for six daily pain assessments until later. Additionally, there were no documented assessments before and after PRN Baclofen administration, and nursing notes lacked pain ratings, as acknowledged by the DON.
A resident with a laceration requiring daily dressing changes did not receive proper wound care as ordered. The facility failed to notify the physician of the wound's deterioration, and the electronic Treatment Administration Record lacked documentation of completed treatments. A nurse observed the wound's poor condition and informed the DON, but no action was documented.
The facility failed to maintain an operational Legionella water management plan, potentially affecting all 72 residents. The Water Management Program was last reviewed in June 2023, but the Facility Assessment lacks procedures for risk assessment and testing protocols. The Maintenance Director reported that a room has been closed due to water leakage and mold, with no Legionella testing conducted in two years. The Administrator confirmed the Maintenance Director's responsibility for the Water Management Plan.
The facility failed to maintain water temperatures at comfortable levels, affecting all 72 residents. Despite a policy requiring water temperatures between 100-110°F, logs and resident council minutes revealed ongoing issues with insufficient hot water. The Maintenance Director found temperatures as low as 74°F in some rooms, indicating inconsistent monitoring and resolution of the problem.
The facility failed to provide adequate bathing assistance to two residents, as per their preferences and needs. One resident reported not receiving showers on scheduled days, while another had not received a shower or sponge bath since admission. Staff interviews revealed issues with staffing and documentation, leading to missed showers.
A resident with moderate cognitive impairment did not receive proper fingernail care, as their nails were observed to be long, jagged, and dirty. The facility's policy requires fingernail care during bathing assistance, but the resident's care plan did not document any refusal of care. CNAs confirmed that fingernail care should be part of morning and shower day routines, yet the resident's nails remained untrimmed and uncleaned.
The facility failed to maintain proper documentation and physician orders for urinary catheter care for two residents. One resident with moderate cognitive impairment had a catheter removed without a physician's order for size and frequency of changes, and experienced dark, bloody urine. The resident's family was not notified of these changes. Another cognitively intact resident had no documented order for catheter size, despite having an order for monthly changes. This indicates a failure to adhere to the facility's policies for urinary catheter care.
The facility failed to have physician orders and care plans for oxygen use and did not consistently monitor oxygen saturation levels for three residents. One resident lacked physician orders for oxygen upon admission, another used oxygen without active orders or care plan documentation, and a third resident's care plan did not include oxygen use despite ongoing need. The DON confirmed these deficiencies.
A resident with multiple medical conditions, including an amputation, experienced an incontinence episode due to delayed toileting assistance. The resident waited two and a half hours for help, despite repeated requests, leading to feelings of humiliation. The facility's DON confirmed the delay and acknowledged the need for timely responses to call lights, as emphasized in the facility's dignity policy.
The facility failed to implement necessary interventions and conduct thorough investigations for two residents with a history of falls. One resident experienced multiple falls with head injuries, yet interventions and neurological checks were inconsistent. Another resident had an unwitnessed fall with a head injury, but the investigation was incomplete, and neurological assessments were not fully documented. The facility's fall prevention program was not effectively implemented, as required interventions and documentation were lacking.
A resident, who was mildly cognitively impaired and required assistance for daily activities, fell and sustained a rib fracture after the facility failed to respond to their request to be put to bed. The resident, identified as at risk for falls due to hemiplegia and muscle weakness, attempted to transfer themselves from their wheelchair to the bed, resulting in a fall. The incident was unwitnessed, and the resident was later diagnosed with a rib fracture, highlighting a lapse in supervision and timely response to the resident's needs.
A resident with a fractured ankle experienced uncontrolled pain for 24 hours due to the facility's failure to obtain and administer prescribed narcotic pain medication. The facility did not promptly contact the physician for signed prescriptions or utilize the backup medication supply and emergency pharmacy. This resulted in significant pain and distress for the resident, highlighting a lapse in the facility's pain management protocol.
A facility failed to provide adequate nursing staff, resulting in delayed medication administration and a resident elopement. Insufficient staffing on the East wing led to residents not receiving timely care, including medications and incontinence care. A resident with severe cognitive impairment eloped from the facility due to inadequate supervision. Staff interviews and Resident Council Minutes highlighted ongoing concerns about staffing shortages affecting resident care.
A resident with severe cognitive impairment eloped from the facility unnoticed, resulting in a fall and head injury. The facility failed to ensure staff were trained on exit door alarms and identifying residents at risk for elopement. The resident's care plan included a departure alert device, but it was not consistently in place, and staff were unaware of the resident's elopement risk. The facility's documentation and care planning for residents at risk of elopement were inadequate, contributing to the deficiency.
The facility experienced significant medication errors due to delayed administration of medications for two residents. Medications such as Lyrica, Levetiracetam, Reglan, and Insulin Lispro were administered over 90 minutes late on multiple occasions. The delays were linked to staffing changes, with only one LPN assigned to the East wing, leading to increased workload and lack of routine for agency nurses. The facility's pharmacy policy requires timely administration within a one-hour window, which was not adhered to.
A resident with a history of significant medical conditions experienced a fall while being assisted to the bathroom, resulting in skin tears. The facility failed to notify the resident's POA about the incident, as required by their policy. Staff interviews revealed a misunderstanding about the notification requirement, leading to the deficiency.
A resident with significant medical conditions and mobility impairments experienced a fall due to inadequate staff assistance during a transfer. Despite the care plan requiring two staff members for transfers, a CNA attempted the task alone, resulting in the resident falling and sustaining skin tears. The facility's fall prevention policy was not properly implemented, and the fall investigation was incomplete.
A facility failed to secure caustic cleaning chemicals, leading to a severely cognitively impaired resident accessing an open bottle of cleaner. The resident was sent to the hospital as a precaution, and staff interviews revealed that the cleaner was left unsecured behind the nurses' station.
The facility failed to notify a resident and their representative in writing of an involuntary discharge. The resident, who had multiple medical conditions including Amyotropic Lateral Sclerosis, was ready to be discharged back to the facility from the hospital. However, the facility refused to readmit the resident due to behavioral issues without providing the required written notification.
A facility failed to readmit a hospitalized resident with ALS, citing behavioral issues and previous complaints. Despite the resident being ready for discharge, the facility refused readmission, and there was no documentation of behavioral issues during the hospital stay.
Failure to Maintain Clean and Odor-Free Carpets in Resident Areas
Penalty
Summary
The facility failed to maintain the resident hallways and common seating area carpets in a clean, sanitary, and odor-free condition, affecting all 76 residents. Multiple observations revealed widespread black and brown stains, some as large as six to eight feet, and a persistent urine odor throughout the hallways and common areas. In one hallway, a foul feces-like odor and a five-foot section of black mold-like substance were noted, reportedly resulting from a previous toilet overflow. The carpets were described as more stained than not, with the original color difficult to discern due to the extent of soiling. Interviews with residents, family members, and staff consistently described the carpets as dirty, stained, and odorous. Several residents with no cognitive impairment confirmed the presence of strong urine odors and visible stains, particularly in the hallways outside their rooms. Staff, including CNAs and an LPN, acknowledged the poor condition of the carpets, noting that spot cleaning was insufficient and that the carpets had not been thoroughly cleaned for an extended period. Family members also reported noticing the dirty and stained carpets during their visits, with some stating that the carpets should have been replaced long ago. The facility's maintenance and housekeeping staff confirmed that only a residential-grade carpet cleaner was available for use, which was primarily used for spot cleaning rather than deep cleaning. The previous commercial carpet extractor had broken and was not replaced, leaving the facility without adequate equipment to maintain the carpets. Resident council meeting minutes documented ongoing grievances about the carpet's cleanliness, with the only resolution being to spot clean, which did not address the underlying issue.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Ensure Timely Medical Treatment After Change in Condition
Penalty
Summary
The facility failed to ensure timely medical treatment for a resident who experienced a significant change in condition. On the morning in question, the resident exhibited garbled speech, confusion, inability to hold a cup, and difficulty following commands, as observed by both family and staff, including a CNA, OT, and speech and physical therapy staff. Despite these concerning symptoms, the LPN responsible for the resident did not obtain vital signs or notify the nurse practitioner of the resident's worsening condition, as required by facility policy. The nurse practitioner, who had seen the resident earlier and instructed the LPN to monitor and report any changes, was not contacted when the resident's condition declined further. The resident's electronic medical record lacked documentation of vital signs for the day, and multiple staff members noted the resident's confusion and inability to participate in therapy. The DON later confirmed that the LPN should have taken vital signs and notified the nurse practitioner when the resident's condition deteriorated. This failure to follow established protocols for monitoring and reporting changes in condition resulted in the resident suffering an acute ischemic stroke with receptive aphasia.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to employ a registered nurse (RN) for at least eight hours per day, seven days a week, as required. Staffing sheets provided by the facility for multiple dates in February, March, and April 2025 documented that there was not eight hours per day of RN coverage on those specific dates. This deficiency was confirmed by the facility's scheduler during an interview, who acknowledged the lack of required RN coverage on the identified dates. The facility census indicated that 88 residents resided in the facility at the time of the deficiency.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate care for a resident's facility-acquired Left Heel Stage 4 Pressure Ulcer, which led to the ulcer's deterioration, surgical debridement, and infection requiring antibiotic therapies. The resident, who was admitted with no pressure ulcers, had a medical history of metabolic encephalopathy, severe protein-calorie malnutrition, lack of coordination, and cognitive communication deficit. Despite these conditions, the facility did not assess, monitor, or implement care plan interventions for the pressure ulcer in a timely manner. The resident's care plan, initiated on 10/30/24, did not document the Left Heel Stage 4 Pressure Ulcer or the associated wound infection and antibiotic therapies. The facility failed to conduct weekly assessments of the pressure ulcer from 11/1/24 to 12/12/24, and the first review by a Registered Dietician was not until 1/26/25. Additionally, the facility did not provide pressure ulcer risk assessments for the resident from 10/28/24 to 12/3/24, and the initial observation of the ulcer was not documented in the nursing progress notes. During a dressing change on 2/24/25, a Licensed Practical Nurse (LPN) placed dressing supplies on a contaminated bedside table and used contaminated scissors, risking cross-contamination of the wound. The Director of Nurses (DON) acknowledged that the resident's heels were noted as 'soft and mushy' on 11/1/24, but care plan interventions were not implemented at that time. The DON admitted that the facility should have identified the resident's risk for pressure ulcers earlier and that weekly assessments should have been conducted from the first observation of the pressure ulcer.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to provide timely responses to call lights for six residents, as identified during interviews and record reviews. During a resident council meeting, several residents expressed concerns about the prolonged wait times for call light responses. One resident mentioned that their roommate often cries and calls out due to the delay, prompting them to activate the call light on their behalf. Another resident reported waiting over an hour for assistance, particularly during busy times like breakfast and showering. These issues have been repeatedly raised in resident council meetings without resolution, as confirmed by the Activity Director. The Minimum Data Set (MDS) assessments for the affected residents indicate varying levels of cognitive and physical assistance needs. For instance, one resident with moderate cognitive impairment requires supervision for toileting and transfers, while another requires substantial assistance for daily activities. Despite these needs, the facility's call light policy, which mandates prompt responses from all staff, was not adhered to, resulting in significant delays. The ongoing concerns documented in resident council minutes further highlight the persistent nature of this deficiency.
Lack of Physician Orders for Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that four residents had physician orders for medications found in their rooms. Resident 65 had a bottle of Magnesium Oxide 500 mg on his bedside dresser without a physician order documented in his Physician Order Sheet (POS). The Director of Nurses (DON) acknowledged that the facility was unaware of the medication's presence and confirmed that Resident 65 was not supposed to have medications at his bedside. Similarly, Resident 19 had bottles of Zeasorb antifungal powder and another antifungal powder 1% on her bedside dresser without a physician order. The DON confirmed that Resident 19 did not have an order to self-administer medications and should not have medications left at her bedside. Resident 36 had a tube of menthol topical gel on her bed, which was applied by staff, but there was no active order for this medication or permission for it to be stored at the bedside. The Licensed Practical Nurse (LPN) confirmed the absence of an active order. Additionally, Resident 24 had an open bottle of Calcium Carbonate Ultra Strength 1000 mg on a table next to her recliner without a physician order. The facility's Medication Storage Policy states that medications should not be administered or provided at the bedside without a physician order. The DON confirmed that all medications should have an active order and be stored appropriately unless there is an order to keep them in the resident's room.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four residents reviewed for infection control. Observations revealed that staff did not wear gowns during high-contact care activities for residents with indwelling medical devices or chronic wounds, as required by the facility's EBP policy. For instance, a Certified Nursing Assistant (CNA) was observed handling a resident's urinary catheter without wearing a gown, despite signage indicating the need for such precautions. Additionally, staff members expressed confusion about the EBP requirements and reported a lack of training on the subject. Further observations during a facility tour showed that rooms of residents requiring EBP did not have PPE carts with gowns, gloves, or masks readily available outside the rooms. The Infection Control Preventionist explained that the carts were not placed outside due to concerns about residents running into them, and staff were expected to retrieve PPE from a utility room. The lack of accessible PPE and inadequate staff training contributed to the failure to adhere to EBP protocols, as evidenced by the absence of proper protective measures during resident care activities.
Failure to Assess Residents for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that residents were assessed for self-administration of medication, affecting two residents. The facility's policy requires a self-administration of medication assessment, a physician's order, and care planning for residents to self-administer medications. However, one resident was observed with a medicine cup containing morning medications on their bedside table without any licensed nursing staff present. This resident, who is cognitively intact, did not have a physician's order, assessment, or care plan documenting their ability to self-administer medication. Another resident was found with a medication cup containing pills on their overbed table. The resident was unsure of the medication's identity and stated that nurses do not always wait for them to take their medications before leaving the room. A Licensed Practical Nurse confirmed that the pills were probiotics and acknowledged that they should have ensured the resident took all medications. The resident's medical record lacked orders, assessments, or care plans for self-administration. The Director of Nursing confirmed that there were no orders for self-administration and that nurses should not leave medications at the bedside without observing consumption.
Inadequate Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that resident rooms were equipped with appropriate call lights, affecting three residents. In the case of two residents sharing a room, only one call light was available, which was attached to one resident's bed. The other resident had no call light or bell on their side of the room and had to rely on the shared call light, which was not always accessible. The maintenance staff was not aware of the issue until it was brought to their attention, and although the Director of Nursing and Assistant Director of Nursing were informed in January 2025, the problem persisted due to delays in obtaining necessary parts. Another resident, who was quadriplegic and unable to use their arms, had a call light that was consistently out of reach. The staff attempted to position the call light within reach, but the resident could only activate it inconsistently due to limited hand movement. The resident expressed a preference for a mouth-activated call light, which they had used in the hospital, but the facility did not have this type of call light available. The Director of Nursing was unaware of alternative call light options, and no other styles were trialed for this resident.
Incomplete Discharge Documentation for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged from the facility. The facility did not have a policy regarding the documentation required upon a resident's discharge to home or another facility. The resident's electronic medical record did not include a discharge summary or a recapitulation of their stay. The resident's care plan indicated a desire to return home and outlined the need for a pre-discharge plan with family and caregivers. However, the Director of Nursing noted that while she completed her part of the documentation, other disciplines did not chart any information, leading to incomplete discharge documentation.
Failure to Address Decline in Resident's Mobility
Penalty
Summary
The facility failed to provide adequate services to address a decline in walking and transfer abilities for a resident diagnosed with Huntington's Disease. Observations over several days revealed that the resident, who previously required only supervision or minimal assistance for transfers and ambulation, was now primarily using a wheelchair and needed extensive assistance from staff for walking. Staff members indicated that they did not have enough time to walk with the resident regularly, and the resident's care plan had not been updated to reflect the current level of functioning. Additionally, the resident had experienced multiple falls, yet there was no documentation of therapy or restorative nursing services being offered or implemented to address the decline. The facility's Restorative Nursing Program policy, which aims to promote residents' independence, was not followed as the resident was not screened for restorative needs after significant changes in condition. The Director of Nursing and Assistant Director of Nursing confirmed that the resident had not received therapy services since the previous year and that the facility did not have restorative nursing programs implemented or documented. This lack of intervention and failure to update the care plan contributed to the resident's decline in mobility and independence.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers as scheduled for a resident who was reviewed for shower frequency. The resident, who is cognitively intact and requires substantial assistance for bathing, reported during a resident council meeting that they were supposed to receive showers twice per week but had only been receiving them five or six times per month. The resident's shower schedule indicated showers were to be provided on Mondays and Thursdays, but documentation showed no showers were offered after a specific date in February. A Certified Nursing Assistant (CNA) acknowledged that staffing levels were insufficient to complete all scheduled showers, suggesting the need for a dedicated shower aide. The facility's policy mandates bathing according to the resident's preferred frequency or at least twice weekly, with documentation in the resident's electronic medical record.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide and implement activities of interest for a resident, identified as R42, who was observed sitting in a wheelchair near the nurses' station without participating in any individual or group activities. Despite having a care plan that included interventions such as allowing the resident to use the outside area for leisure time, encouraging attendance at group activities, and providing one-to-one activities, these were not implemented. The resident's Minimum Data Set (MDS) indicated preferences for activities such as reading, listening to music, and spending time outdoors, yet these interests were not catered to during the observed period. Staff interviews revealed that the resident did not attend any group activities because they did not like the options provided, such as BINGO. The Activity Director and Activity Aide confirmed that the resident only received minimal interaction, such as brief conversations, and was not offered opportunities to engage in preferred activities like listening to music or going outside, despite suitable weather conditions. The Director of Nursing noted that the resident had previously fallen on the patio, leading to restrictions on outdoor access without supervision, and acknowledged that one-to-one activities were no longer provided.
Inadequate Supervision and Fall Investigation for Resident with Huntington's Disease
Penalty
Summary
The facility failed to provide adequate supervision and thorough investigation of falls for a resident with severe cognitive impairment and Huntington's Disease, identified as R42. R42 experienced multiple unwitnessed falls, some resulting in minor injuries, due to unsteady gait and attempts to self-transfer. The facility's records indicate that R42 required substantial staff assistance for toileting and supervision for transfers and walking. Despite this, R42 was left unsupervised on several occasions, including an incident on the patio and another in R42's room after leaving the dining room without assistance. The facility's fall reports lacked critical information, such as the timing of the last toileting and checks prior to the falls. Interviews with facility staff revealed inconsistencies in supervision and documentation practices. A Registered Nurse confirmed that R42 had an unwitnessed fall on the patio without staff present, and a Licensed Practical Nurse noted R42's unsteady condition and the need for close monitoring. The Director of Nursing admitted to incomplete fall investigations and difficulties in obtaining staff statements, particularly from agency staff. The facility's fall prevention program mandates safety interventions and thorough documentation, which were not adhered to in R42's case, contributing to the deficiency in supervision and fall prevention.
Deficiencies in Urinary and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters and incontinence, leading to potential cross-contamination and infection risks. One resident's urinary catheter was observed lying on the floor mat, and during a transfer, the catheter bag was improperly positioned above the bladder and dragged on the floor. The CNAs involved were not trained on the proper handling of catheter bags, and the resident's catheter care was performed without proper hand hygiene between glove changes. Additionally, there were no active physician's orders for the resident's catheter size or changes, and the resident had not been seen by a urologist as recommended. Another resident received incontinence care where the CNA used a washcloth with visible bowel movement to clean the vaginal area multiple times without changing the cloth. The CNA also touched clean surfaces with soiled gloves, and there was a lack of awareness about the resident's recent urinary tract infection. This indicates a failure to adhere to proper incontinence care protocols, increasing the risk of infection. A third resident's incontinence care was inadequately performed as the LPN used a dry washcloth with no rinse wash and did not dry the resident's skin afterward. The LPN acknowledged the need to use a clean area of the washcloth and to dry the skin to prevent cross-contamination and infection. The LPN also noted the issue with water temperature in the resident's room, which contributed to the improper care provided.
Inadequate Pain Management for Resident with Quadriplegia
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with quadriplegia and muscle spasms, identified as R66. Despite the resident's consistent reports of severe pain, rated as a 10 on a 0-10 scale, the facility did not conduct adequate pain assessments as required. The resident's pain was supposed to be assessed six times daily according to a physician's order, but this was not implemented until a later date. Additionally, there were no documented pain assessments before and after the administration of PRN Baclofen, which was given five times, indicating a lack of adherence to the facility's pain management protocol. Observations and interviews revealed that the resident experienced muscle spasms and expressed that the prescribed muscle relaxers were ineffective in managing the pain. The resident's Minimum Data Set indicated frequent pain affecting daily activities and sleep. Despite these indicators, the nursing notes failed to document the resident's pain ratings, and the Director of Nursing acknowledged that pain assessments should have been documented on the MAR and completed every shift, as well as before and after PRN medication administration.
Failure to Notify Physician and Provide Wound Care
Penalty
Summary
The facility failed to notify the physician of the deterioration of a wound and did not provide wound care as ordered for a resident. The resident, who is cognitively intact, sustained a laceration during a doctor's appointment and received stitches at a local emergency room. The physician's order required daily dressing changes, but the resident reported that the facility's nurses were not changing the dressing as instructed, often stating they would do it later and then leaving without completing the task. Upon observation, a registered nurse noted that the wound was not healing well, with a foul odor and brown drainage, and informed the Director of Nursing/Wound Nurse of these concerns. However, there was no documentation in the resident's progress notes or electronic Treatment Administration Record indicating that the physician was notified of the wound's changes or that the prescribed treatment was completed over a specific period. The Quality Assurance Nurse confirmed that the lack of documentation indicated the dressing changes were not performed.
Failure to Maintain Legionella Water Management Plan
Penalty
Summary
The facility failed to maintain an operational Legionella water management plan, which has the potential to affect all 72 residents. The Water Management Program for Prevention of Legionella Growth was last reviewed on June 27, 2023, and it outlines the need for additional monitoring or action in response to risk factors such as hot water temperature drops and water stagnation. However, the Facility Assessment, last reviewed in December 2024, lacks a procedure for conducting a facility risk assessment to identify potential Legionella growth and other waterborne pathogens, as well as specific testing protocols and acceptable ranges for control measures. The Maintenance Director, identified as V15, reported that a room with a zipper wall has been closed for several months due to water leakage from an adjoining shower room, which also remains closed. V15 noted that mold was found and removed from the wall, but no water testing for Legionella has been conducted in the two years of his tenure. The facility only runs water in out-of-order rooms for 10 minutes once a month, and V15 stated he was never informed that water testing was necessary. The Administrator, identified as V1, confirmed that V15 is responsible for overseeing the Water Management Plan and any required water testing.
Inadequate Water Temperature Management
Penalty
Summary
The facility failed to maintain water temperatures at comfortable levels, potentially affecting all 72 residents. The Shower and Tub policy, last revised in 2018, requires staff to ensure water temperatures are between 100-110 degrees Fahrenheit. However, the Room Water Temperature log from November to December 2024 shows that water temperatures were not consistently monitored or maintained. Resident Council Meeting Minutes from July and September 2024 document ongoing concerns about insufficient hot water in the beauty shop and showers, with the Maintenance Department acknowledging the issue but not resolving it. On December 24, 2024, the Maintenance Director, V15, recorded water temperatures in resident rooms and shower rooms, finding one room at 74 degrees Fahrenheit and another at 99 degrees Fahrenheit after several minutes of running hot water. V15 admitted that water temperatures should not be this low and that he checks temperatures twice a week in only one room on each side of the building. This inconsistency in monitoring and addressing water temperature issues led to the deficiency, as the facility did not ensure a comfortable and safe environment for its residents.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to two residents, R8 and R9, as per their preferences and needs. According to the facility's policy, residents should be offered a shower, tub bath, or bed/sponge bath twice a week or as needed. However, R8 reported not receiving a shower on their scheduled days, Monday, Wednesday, and Friday, and was unsure of the reason. R9, who had been at the facility for about three weeks, stated they had not received a shower or sponge bath since admission and had to request wet wipes to clean themselves, which were unavailable. Observations noted R9's hair appeared greasy, and they had an odor, indicating a lack of personal hygiene care. Interviews with facility staff revealed systemic issues contributing to the deficiency. A CNA mentioned that due to a high number of residents with dementia and behaviors, along with insufficient staffing, showers were not consistently completed. A Registered Nurse confirmed that shower schedules were not consistently updated, especially for new admissions, leading to missed showers. The Director of Nursing acknowledged the absence of shower sheets for R8 and R9, further highlighting the lack of proper documentation and oversight in ensuring residents received necessary bathing assistance.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident with moderate cognitive impairment who requires supervision and assistance for personal hygiene. During an observation, the resident's fingernails were found to be long, jagged, and dirty, with a black substance underneath. The facility's policy mandates that fingernail care should be performed during bathing assistance. Interviews with CNAs revealed that the resident is cooperative with care and is scheduled for showers twice a week, during which fingernail care should be provided. However, the resident's care plan did not document any refusal of care, and the CNAs acknowledged that fingernail care is expected to be part of morning care routines and on shower days. Despite these expectations, the resident's fingernails remained untrimmed and uncleaned, indicating a lapse in the facility's adherence to its own hygiene policies.
Deficiency in Urinary Catheter Care Documentation and Orders
Penalty
Summary
The facility failed to maintain proper documentation and physician orders for urinary catheter care for two residents. One resident, who had moderate cognitive impairment, had a urinary catheter removed without a physician's order for catheter size and frequency of changes. The resident experienced dark and bloody urine, and there was a lack of documentation regarding the removal of the catheter, a voiding trial, and changes in urine characteristics. Additionally, the resident's family was not notified of these significant changes, contrary to the facility's policy. The Director of Nursing confirmed that there should have been physician orders and proper documentation of the resident's condition and catheter care. Another resident, who was cognitively intact, had a urinary catheter with no documented physician order for the catheter size, despite having an order for monthly changes. The resident's care plan did not specify the catheter size, and the nursing notes failed to document the catheter size during changes. This lack of documentation and physician orders for catheter size indicates a failure to adhere to the facility's policies and procedures for urinary catheter care, potentially compromising the residents' health and safety.
Failure to Document and Monitor Oxygen Use
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents by not having physician orders and care plans for oxygen use and not consistently monitoring oxygen saturation levels. One resident, who had been using oxygen prior to admission, did not have physician orders for oxygen use until two days after admission. The resident's oxygen saturation levels were not consistently documented, with only 12 entries recorded over a two-week period. The Director of Nursing confirmed that the resident should have had oxygen orders upon admission and that oxygen saturation should be checked every shift. Another resident, admitted after a hospital stay for respiratory failure due to pneumonia, was using oxygen at 3 liters per minute but did not have active physician orders for oxygen use or monitoring of oxygen saturation. The resident's care plan did not document oxygen use, despite the resident's ongoing need for it. A third resident, who was cognitively intact, was using oxygen at 2 liters per minute but did not have physician orders specifying the oxygen flow rate. The resident's care plan also failed to document oxygen use, and the Director of Nursing acknowledged that oxygen should be included in the care plan.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance to a resident, resulting in an incontinence episode. The resident, who has multiple medical diagnoses including muscle wasting, diabetes, morbid obesity, COPD, and a left above-knee amputation, requires maximum assistance with toileting and other personal care activities. On the night of the incident, the resident requested assistance to use the bedpan after supper but was left waiting for two and a half hours, during which time the resident experienced incontinence. The resident expressed feelings of humiliation and distress over the incident, noting that this was not the first time such delays had occurred. The facility's Director of Nurses acknowledged awareness of the incident and confirmed that the call light had been activated for one hour and twenty minutes. The resident's grievance form documented the delay and the partial substantiation of the complaint. The facility's policy on dignity emphasizes the importance of maintaining residents' dignity and self-worth, which was not upheld in this instance. The resident council minutes also highlighted concerns about delayed responses to call lights, indicating a broader issue with staffing and response times.
Inadequate Fall Prevention and Investigation
Penalty
Summary
The facility failed to implement necessary interventions and conduct thorough investigations for residents with a history of falls, affecting two residents. One resident, with a history of cerebellar stroke syndrome and repeated falls, experienced multiple falls with head injuries. Despite these incidents, the facility did not consistently implement new interventions, complete fall risk assessments, or conduct thorough neurological checks. For instance, after a fall on 8/27/24, the resident required emergency treatment for a scalp laceration, yet the fall mat was not in place, and neurological checks were incomplete. Another resident, with cerebrovascular disease and mobility issues, also experienced an unwitnessed fall resulting in a head injury. The facility's records did not document complete neurological assessments following the fall. The Director of Nursing acknowledged that the investigation was incomplete, as not all staff or residents present at the time were interviewed. Furthermore, the neurological checks that were supposed to be initiated after the fall were not fully documented. The facility's fall prevention program, which aims to ensure resident safety through risk assessments and appropriate interventions, was not effectively implemented. The program requires that fall risk interventions be identified in care plans and that accident reports be reviewed by the interdisciplinary team. However, the facility did not adhere to these standards, as evidenced by the incomplete investigations and lack of thorough documentation for the residents involved.
Failure to Timely Respond to Resident's Request Leads to Fall and Injury
Penalty
Summary
The facility failed to respond in a timely manner to a resident's request to be put to bed, which resulted in the resident falling and sustaining a left rib fracture. The resident, who was mildly cognitively impaired and required substantial assistance for daily activities, had a history of hemiplegia and muscle weakness, making them at risk for falls. On the night of the incident, the resident requested to go to bed earlier in the evening, but the request was not fulfilled. Later, the resident was found on the floor after attempting to transfer themselves from their wheelchair to the bed, resulting in a fall and injury. The resident's care plan and fall risk assessment had previously identified them as being at risk for falls, and interventions were in place to ensure the call light was within reach. However, the resident's request to go to bed was not addressed, leading to the fall. The fall was unwitnessed, and the resident was found on the floor with a skin tear and later diagnosed with a rib fracture. The incident highlights a lapse in supervision and timely response to the resident's needs, contributing to the accident.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, received appropriate pain management following their admission. R5, who had a displaced bimalleolar fracture of the left lower leg, experienced uncontrolled pain for 24 hours due to the facility's failure to obtain and administer narcotic pain medication as ordered. Upon admission, R5 did not receive the prescribed Norco and Tramadol because the hospital had not sent electronically signed prescriptions, and the facility did not take timely action to rectify this. On the day of admission, R5 reported severe pain, rating it a 10 on a 0-10 scale, and was observed to be in distress. Despite having orders for Norco and Tramadol, the facility did not administer these medications until almost 24 hours later. The facility's staff, including the MDS Coordinator and the Director of Nursing, acknowledged that there were no attempts made to contact the physician or obtain the necessary prescriptions promptly. The facility had a backup medication supply and an emergency pharmacy available, but these resources were not utilized effectively. The delay in obtaining and administering the pain medication was compounded by a lack of communication and follow-up with the pharmacy and the physician. The pharmacy did not receive signed prescriptions until the day after R5's admission, and the facility did not contact the after-hours pharmacy to expedite the process. As a result, R5 endured significant pain, which affected their sleep and daily activities, highlighting a critical lapse in the facility's pain management protocol.
Inadequate Staffing Leads to Delayed Care and Resident Elopement
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. The facility's assessment indicated a staffing plan for 10 nurses and 21 nurse aides per day, but the actual staffing levels were insufficient. On multiple occasions, only one nurse was assigned to the East wing, which led to delays in medication administration. Residents reported not receiving their medications on time, which affected their health and comfort. For instance, one resident did not receive bedtime medications timely, impacting their sleep and incontinence care. Another resident with a fractured ankle experienced delays in receiving pain medication and gastric reflux medication. The report also highlights the facility's failure to prevent the elopement of a resident with severe cognitive impairment. This resident, who was at risk for elopement and required one-to-one supervision, managed to leave the facility unnoticed and was found outside by a pedestrian. The incident occurred when the East wing was staffed with only one nurse and two CNAs, which was insufficient to monitor residents with wandering behaviors. Staff interviews confirmed that the East wing was understaffed, particularly during busy times, making it challenging to provide adequate supervision and care. The Resident Council Minutes further document ongoing concerns about staffing, including delayed call light responses and missed showers due to staffing shortages. Staff interviews corroborated these issues, with several staff members expressing concerns about the inadequate number of CNAs and nurses, particularly during evening shifts. The Director of Nursing acknowledged the staffing challenges, noting that the East wing used to have two nurses assigned but now operates with only one, contributing to the difficulties in providing timely care and supervision.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Training
Penalty
Summary
The facility failed to prevent the elopement of a severely cognitively impaired resident, identified as R6, who exited the facility unnoticed. R6 was found outside the facility by a pedestrian after falling and hitting his head. The incident occurred despite R6 having a documented history of wandering and being at risk for elopement. The care plan for R6 included interventions such as a departure alert device and monitoring, but these were not effectively implemented or followed. Nursing notes indicated that the departure alert device was not consistently in place, and staff were not adequately informed or trained on R6's elopement risk. The report highlights that staff were not trained on exit door alarms or identifying residents at risk for elopement. On the night of the incident, the staff on duty, including an agency LPN and CNAs, were unfamiliar with the East wing and the residents' specific needs. The door alarms were not effectively monitored, and the staff could not distinguish between the sounds of call lights and door alarms. The facility's list of residents with departure alert devices was outdated, and R6 was not included on this list, leading to a lack of proper supervision and monitoring. Additionally, the facility's documentation and care planning for residents at risk of elopement were inadequate. R6's care plan did not identify family visits as a trigger for exit-seeking behavior, and the behavior tracking did not reflect R6's wandering tendencies. Other residents, R7 and R8, also had issues with the placement and documentation of departure alert devices, indicating a broader problem with the facility's management of elopement risks. The facility's policies and procedures for elopement prevention were not effectively implemented, contributing to the deficiency.
Significant Medication Errors Due to Staffing Issues
Penalty
Summary
The facility failed to ensure timely administration of medications, resulting in significant medication errors for two residents. On multiple occasions, medications were administered over 90 minutes late, which is outside the facility's policy of a one-hour window for medication administration. One resident received Lyrica and Levetiracetam significantly late for numerous doses in June and July, while another resident experienced delays in receiving Reglan, Insulin Lispro, and Levetiracetam, with some doses administered close to the next scheduled dose. These delays were attributed to staffing issues, as only one nurse was assigned to the East wing, which previously had two nurses. The report highlights that the nurse on duty, who was an agency nurse, struggled to administer medications on time due to the increased workload and lack of routine. The Director of Nursing acknowledged the staffing change and expressed a preference for having their own nurses for consistency. The facility's pharmacy policy requires documentation when medications are not given at the ordered time, but it is unclear if this was consistently done. The report does not mention any corrective actions taken to address these deficiencies.
Failure to Notify POA of Resident's Fall with Injury
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) about a fall with injury, which was a deficiency identified during the survey. The resident, who has a history of left femur fracture, muscle weakness, and other significant medical conditions, experienced a fall while being assisted to the bathroom by a Certified Nurse Aide (CNA). The resident was lowered to the ground without hitting his head, but sustained two skin tears on the left forearm. Despite the incident, the POA was not informed by the facility, and only learned of the fall through the resident. Interviews with staff revealed that the Registered Nurse (RN) did not notify the POA because the CNA reported the resident was lowered to the floor, not realizing it constituted a fall. The Care Plan Coordinator confirmed that the POA inquired about the fall and was not notified as per the facility's policy. The Director of Nurses acknowledged that the POA should have been informed regardless of whether the fall resulted in injury, as per the facility's policy on physician-family notification for changes in condition.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention interventions and conduct a thorough fall investigation for a resident with a history of significant medical conditions, including a left femur fracture, muscle weakness, and hemiparesis following a cerebral infarction. The resident, who is moderately cognitively impaired, requires maximum assistance for toileting and dressing, and moderate assistance for personal hygiene and transferring. Despite these needs, the resident experienced a fall while being transferred from the toilet to a wheelchair, resulting in two skin tears on the left forearm. The incident occurred when a Certified Nurse Aide (CNA) attempted to assist the resident alone, despite the care plan indicating that two staff members should assist with transfers due to the resident's size and medical condition. The CNA used a gait belt and a hemi-walker, but the resident's walker became entangled with the wheelchair, causing the resident to lean into the CNA and subsequently fall. The resident, who is six feet four inches tall and weighs 275 pounds, was too large for the CNA to manage alone, leading to the fall and subsequent injuries. Interviews with the resident, the CNA, and other staff members revealed that the CNA did not seek additional help for the transfer, which was against the care plan's directives. The Director of Nurses acknowledged that the fall investigation was not thorough, as the CNA involved was not initially contacted for details about the incident. The facility's fall prevention program policy, which requires safety interventions for residents at risk, was not adequately followed in this case.
Failure to Secure Caustic Cleaning Chemicals
Penalty
Summary
The facility failed to store and maintain caustic cleaning chemicals in a manner to prevent access by an ambulatory resident diagnosed with dementia. This deficiency was identified when a resident, who was severely cognitively impaired and displayed behaviors such as wandering and rummaging, was found with an open bottle of a caustic cleaner. The resident was unable to communicate whether they had ingested the cleaner, leading to their precautionary transfer to the hospital. The incident occurred after a CNA borrowed the cleaner from a housekeeper and left it unsecured behind the nurses' station, which was easily accessible to residents. The resident involved had a history of severe cognitive impairment, anxiety, major depression, and dementia with behavioral disturbances. On the day of the incident, the resident was found holding an open bottle of cleaner by an LPN, who was preoccupied with another resident's emergency. The LPN could not determine if the resident had ingested the cleaner and decided to send the resident to the hospital as a precaution. The emergency room report was inconclusive regarding ingestion but noted the absence of chemical burns around the resident's mouth and throat. Interviews with staff revealed that the cleaner was not returned to the housekeeper after use and was instead placed behind the nurses' station, where it was accessible to residents. The nurses' station was described as having a counter that was easily reachable from the front, with no secure place to lock the cleaner. The facility administrator acknowledged that chemicals should have been locked and mentioned that staff had been educated on this matter, although this information is not part of the deficiency itself.
Failure to Notify Resident and Representative of Involuntary Discharge
Penalty
Summary
The facility failed to notify a resident and their representative in writing of an involuntary facility-initiated discharge. This deficiency affected one resident who was reviewed for involuntary discharge. The facility's policy states that Medicaid-eligible residents must be readmitted to the first available bed even if they have outstanding Medicaid balances, and that proper documentation and notice requirements must be followed for transfers due to non-payment. However, the facility did not adhere to this policy in the case of the resident in question, who had multiple diagnoses including Alcoholic Cirrhosis of the Liver, Chronic Atrial Fibrillation, and Amyotropic Lateral Sclerosis, among others. The resident was admitted to the hospital with a perianal abscess and was ready to be discharged back to the facility, but the facility refused to readmit the resident without providing the required written notification of discharge to the resident or their representative. The Social Service Director confirmed that the resident was alert and oriented but had trouble speaking due to muscle weakness from Amyotropic Lateral Sclerosis, which prevented the completion of the Brief Inventory of Mental Status (BIMS) assessment. The facility decided not to readmit the resident due to behavioral issues, including difficulty swallowing, refusal to come to the dining room, cursing at staff, and refusal of personal care. Despite these issues, the facility did not follow the proper procedure for involuntary discharge, as neither the resident nor their representative was notified in writing of the facility's intent to discharge the resident involuntarily.
Failure to Readmit Hospitalized Resident
Penalty
Summary
The facility failed to allow a hospitalized resident to return to the facility after hospitalization, exceeding the bed-hold policy. The resident, who had multiple diagnoses including Amyotrophic Lateral Sclerosis (ALS), was cognitively intact but had trouble speaking due to muscle weakness. The resident had a history of refusing certain care measures, such as going to the dining room to be fed and having fall mats placed by the bed. Despite these refusals, there was no documentation of falls or alternative care options being discussed with the resident. The resident was hospitalized for a perianal abscess and was ready for discharge, but the facility refused to readmit the resident, citing difficulty in managing the resident's behavior and previous complaints made by the resident to the state. The Social Service Director stated that the facility would not readmit the resident due to the resident's behavior, which included cursing at staff and refusing personal care. The resident's family member confirmed that the facility refused to take the resident back, despite the hospital being ready to discharge the resident. A hospital RN also noted that there were no documented behavioral issues during the resident's hospital stay. The facility's policy on bed-hold and return to the facility was reviewed, which outlines conditions under which a resident may not be permitted to return, but the facility did not provide sufficient documentation to support their refusal to readmit the resident.
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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