Goldwater Care Toluca
Inspection history, citations, penalties and survey trends for this long-term care facility in Toluca, Illinois.
- Location
- 101 East Via Ghiglieri, Toluca, Illinois 61369
- CMS Provider Number
- 145413
- Inspections on file
- 27
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Goldwater Care Toluca during CMS and state inspections, most recent first.
A resident with multiple medical and psychosocial conditions, including anxiety, depression, hepatic encephalopathy, chronic pain, and impaired vision, was care planned as being at risk for abuse/neglect. After the resident became upset when a CNA could not obtain a requested salad, the CNA reported the interaction to the Social Service Director, who then entered the resident’s room. According to the resident and multiple staff, including a COTA and DON, the Social Service Director approached the resident with an angry attitude, got close to the resident’s face, and used profane and degrading language, calling the resident an "a******" and using additional obscenities while defending the CNA. The resident reported feeling humiliated and degraded. Other staff and a resident council leader reported prior concerns and complaints about this staff member’s behavior. These events occurred despite facility policies that prohibit abuse, define mental and verbal abuse, and require staff to treat residents with courtesy and respect at all times.
The facility failed to employ a certified Food Service Manager/Dietary Manager despite its own assessment and job description identifying this position as necessary to oversee food and nutrition services for 63 residents. For about two months, there was no designated dietary manager, with the DON intermittently overseeing the department and dietary staff informally sharing management tasks. Resident council records and interviews with residents, dietary staff, a contracted RD, an ombudsman, and a contracted dietary supplier all confirmed the absence of a manager and described significant problems with food service, including meals not matching posted menus, cold or undercooked food, lack of menu choices, frequent shortages of coffee and milk, inedible salads, and inadequate snacks for a resident with diabetes and a resident on a special diet.
The facility failed to follow its planned, dietician-reviewed menus and did not consistently provide the listed food items or nutritionally balanced meals. The facility assessment and policies required a Dietary Manager and adherence to planned menus, but the position had been vacant for months, with the DON informally overseeing the kitchen and dietary staff improvising due to supply issues and budget-driven order cuts. On multiple occasions, planned menu items such as ham in a western egg bake and baked potatoes were not served, and substitutes like sweet potatoes were used instead. Several alert and oriented residents reported that food was often cold, undercooked, not edible, lacking in variety or choice, and did not match the menu or their special diets, with frequent shortages of milk, coffee, salads, and appropriate snacks for conditions such as diabetes. Staff and a contracted supplier confirmed recurring shortages, poor portion control, and mismanagement of ingredients, leading to routine deviations from the posted menus.
A resident became upset when a CNA could not obtain a requested salad, leading to a conflict that prompted the Social Service Director to enter the room. According to multiple staff statements and the resident’s own account, the Social Service Director approached the resident aggressively, got close to the resident’s face, and used profane, degrading language, including calling the resident an “a******” and telling the resident not to be a “f****** a******” to staff. A COTA overheard the interaction while providing therapy to the roommate and immediately reported it to the DON. Although the facility’s abuse policy defines such conduct as mental and verbal abuse and requires prompt identification and reporting, the final investigation concluded that no verbal abuse occurred and treated the behavior only as unprofessional language, resulting in a failure to properly identify and substantiate abuse.
A resident with a history of wrist fracture fell and injured her left wrist when a CNA failed to use a gait belt during a transfer, contrary to facility policy. The CNA attempted to assist the resident off the toilet by grabbing her bra, causing the resident to lose balance and fall. The resident was hospitalized with an acute wrist fracture and prescribed a wrist splint and pain medication.
The facility failed to employ a certified Infection Prevention Nurse, affecting all 62 residents. An Infection Prevention Nurse was hired but is not yet certified, although she is signed up for courses. Her employee file confirmed her hire date but lacked certification or training documentation.
A registered nurse failed to follow proper infection control protocols during wound care for a resident. The nurse used the same soiled gloves to handle clean items and placed a soiled incontinence brief on the floor, compromising infection prevention measures.
The facility failed to conduct the required quarterly QA meetings and did not ensure the attendance of required committee members. Missing signatures from key members and the absence of meeting minutes for several months were confirmed by the Administrator. These failures have the potential to affect all 63 residents currently residing in the facility.
The facility failed to utilize appropriate PPE, audit for PPE compliance, and screen staff during a COVID-19 outbreak, potentially affecting 63 residents. Staff did not consistently adhere to PPE guidelines, and non-approved KN95 masks were used. Agency staff were not included in COVID-19 source testing, and specific incidents showed lapses in infection control practices.
The facility failed to provide clean, stain-free linens for bathing, compromising the dignity of nine residents. Observations and interviews revealed that residents were given discolored washcloths with brown/tan stains for personal hygiene. The Housekeeping Manager confirmed that stained linens were supposed to be repurposed, but soiled washcloths were observed in the laundry bin ready for washing with other whites. The Administrator acknowledged the policy change to no longer provide disposable wipes, requiring staff to use washcloths instead.
The facility failed to perform a PASARR rescreen for a resident diagnosed with Bipolar Disorder and Major Depressive Disorder upon admission, despite the facility's policy requiring rescreening with any significant change of status. The DON confirmed the oversight.
A resident with multiple diagnoses fell in the facility's transport van due to an improperly secured seatbelt. The van driver, new to the job, had loosened the seatbelt at the resident's request, leading to the fall. The resident required hospital evaluation for pain in his right leg.
The facility failed to attempt a gradual dose reduction for a resident prescribed Seroquel for a year, despite minimal documented episodes of agitation and anxiety. The DON confirmed that the resident's behaviors did not warrant the continued use of the antipsychotic medication, and a GDR had not been attempted as required by the facility's policy.
Failure to Protect a Resident From Verbal and Mental Abuse by Social Services Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from mental and verbal abuse by staff, as required by its Abuse Prevention and Reporting Policy and Resident Rights Policy. The facility’s policies define abuse as the willful infliction of intimidation, punishment, or mental anguish, and specifically describe mental and verbal abuse as conduct that can cause humiliation, intimidation, fear, shame, agitation, or degradation. The policies also require staff to treat residents with courtesy, professionalism, and respect at all times, and emphasize staff training on resident rights, what constitutes abuse, and the obligation to report suspected abuse. The incident centers on one resident with multiple medical and psychosocial conditions, including anxiety disorder, depression, hepatic encephalopathy, psychoactive substance abuse, vertebral disc degeneration with discogenic back pain, heart failure, liver disease, fall history, abnormal gait, lack of coordination, abnormal posture, impaired visual function, and a care plan identifying an activities of daily living performance deficit and risk for abuse/neglect. The resident’s care plan notes that the resident is at risk for abuse/neglect and is to be cared for in a safe manner and to verbalize any incidences of abuse or neglect. On the day of the incident, a CNA delivered the resident’s lunch tray, and the resident requested a salad. The CNA went to the kitchen, found it closed, and reported back that a salad was not available. The resident became angry, told the CNA to get out of the room, and, according to staff statements, called the CNA derogatory names, including “piece of s***,” and allegedly threw a tray. The CNA then informed the Social Service Director that the CNA did not want to return to the room alone. The Social Service Director then went to the resident’s room. According to multiple staff and resident statements, the Social Service Director approached the resident with an angry attitude, got very close to the resident’s face, and used profane and degrading language. A Certified Occupational Therapy Assistant, who was in the bathroom providing therapy to the roommate, reported overhearing the Social Service Director tell the resident, “You have to quit being an a****** to my staff,” and that the Social Service Director argued with the resident, stating the resident could go get their own salad and could not yell at staff, emphasizing that the CNA was the only CNA on the unit. The COTA described the Social Service Director as aggressive, rude, and berating, using “a lot of other bad words,” and reported that the resident was very upset. The Director of Nursing reported being told by the COTA that the Social Service Director told the resident, “do not be a f****** a****** to my staff,” and immediately reported this to the Administrator. The resident stated that they had an “explosive attitude” and acknowledged not being nice to the CNA, but reported that the Social Service Director came into the room right after the conflict with the CNA, got inches from the resident’s face, and was “cussing and screaming,” telling the resident to “f*** off” and calling the resident an “a******.” The resident reported feeling belittled, humiliated, helpless, and like an “idiot,” and expressed that the Social Service Director, who was supposed to help with discharge planning, instead degraded them. Other staff, including the Therapy Director and Resident Council President, reported hearing that the Social Service Director had been fired for cursing at the resident and described prior concerns and complaints about the Social Service Director’s behavior toward residents and staff. The facility’s own final abuse investigation documented that the Social Service Director was overheard telling the resident not to be an “a******” to staff and acknowledged unprofessional conduct by cursing during the conversation, although the facility’s internal conclusion stated that verbal abuse did not occur. These actions and interactions, as documented by multiple witnesses and the resident, constitute the basis for the cited deficiency related to failure to protect the resident from mental and verbal abuse.
Failure to Employ a Dietary Manager Resulting in Ongoing Food and Menu Problems
Penalty
Summary
The deficiency involves the facility’s failure to employ a certified Food Service Manager/Dietary Manager as identified as necessary in its own Facility Assessment Tool and Dietary Manager job description. The assessment specifies that a Food Service Manager/Dietary Manager is needed to care for the resident population, and the job description outlines responsibilities such as planning, organizing, developing, and directing the Food and Nutrition Services Department, maintaining menus, participating in survey inspections, and possessing Food Service Sanitation Manager Certification. Despite these documented requirements, the facility census showed 63 residents on 12/24/25, and on multiple survey dates (12/27/25, 12/28/25, and 12/29/25) the facility could not identify or provide evidence of an employed Food Service Manager/Dietary Manager, nor a contact person for that role. The employee contact list also documented “Dietary Manager none.” Resident Council minutes from two separate meetings documented that the facility was looking for a new Dietary Manager, that the DON was handling dietary questions, and that there was no Food Committee meeting due to the absence of a manager. Multiple staff interviews confirmed that the former Dietary Manager had left about two months earlier and that no replacement had been hired. The DON stated that the facility did not currently have a Dietary Manager and that she helped out in the department when she could, while dietary staff reported that they “all just pitch in,” with certain cooks handling “a lot of the kitchen stuff” and one cook stating that they “pretty much do everything” in the kitchen because there had been no manager since the former manager left. The contracted registered dietician and the ombudsman both corroborated that the facility was still looking for a Dietary Manager and had not hired one. Multiple alert and oriented residents reported ongoing problems with food quality and service during the period without a Dietary Manager. The Resident Council President stated that there had not been a kitchen manager for a long time and described the kitchen as run “terrible,” with menus not matching what was served and food being cold and undercooked. Other residents reported that they did not receive what was on the posted menu, that food was “not edible,” undercooked, cold, and sometimes consisted only of carbohydrates without fruit or vegetables. Several residents stated that the facility frequently ran out of coffee and milk, that salads were brown, mushy, and slimy, and that they could not obtain requested items such as turkey sandwiches. One resident on a special diet reported not receiving what they were supposed to get and inadequate assistance when requesting alternatives, and another diabetic resident reported insufficient evening snacks. Staff, including the MDS RN/manager on duty, acknowledged hearing resident complaints that the food was terrible and that the posted menu was not followed.
Failure to Follow Planned Menus and Provide Nutritionally Appropriate Meals
Penalty
Summary
The deficiency involves the facility’s failure to follow its planned, dietician-reviewed menus and ensure that meals met residents’ nutritional needs as required by policy and facility assessment. The facility’s assessment tool identified the need for a Food Service/Dietary Manager to ensure appropriate food services and menus. Facility policies and the Dietary Manager job description required that menus be planned in advance, maintained, followed, and that residents be offered items from the planned menu. Resident Council minutes over several months documented ongoing dietary concerns, including removal of available off‑menu options, lack of a Dietary Manager, and complaints that substitutes were becoming regular meals instead of true alternatives. Surveyor observations on specific dates showed that posted menu items were not served as planned. The week-at-a-glance menu listed western egg bake with ham for breakfast and baked potato with sour cream and margarine for lunch on a specific date, but the western omelet served that morning contained no ham, and residents at lunch received sweet potatoes instead of baked potatoes. Multiple alert and oriented residents reported that the menu was frequently not followed, that food was cold, undercooked, or not edible, that there was often no choice, and that they did not receive what was listed on the menu or what their special diets required. Residents also reported frequent lack of milk and coffee, inability to obtain requested items such as turkey sandwiches, brown and slimy salads, meals composed only of carbohydrates without fruit or vegetables, and inadequate evening snacks for a resident with diabetes. Staff interviews confirmed that the facility had been without a Dietary Manager for about two months, with the DON informally overseeing the department and dietary staff “pitching in” without clear management. Dietary staff and the contracted dietary supplier reported ongoing problems obtaining and managing ingredients needed to follow the menus, frequent running out of key items such as milk and ham, and corporate-driven budget constraints that led to cutting orders and improvising menu items. The contracted supplier noted that ham supplies were depleted after a Christmas potluck, leaving no ham for the planned western omelet, and that sweet potatoes were substituted for baked potatoes due to lack of regular potatoes. Staff also described poor portion control and failure to properly use or prepare produce such as lettuce, contributing to food waste and further deviation from the planned menus. These actions and inactions resulted in the facility not following its posted menus and not consistently providing the planned, nutritionally appropriate meals to its 63 residents.
Failure to Identify and Substantiate Verbal Abuse Toward a Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify and substantiate verbal and mental abuse toward a resident in accordance with its Abuse Prevention and Reporting Policy. The policy defines abuse as including willful mental abuse and verbal abuse, such as harassing, insulting, yelling, or threatening a resident, and requires staff to promptly investigate and report all allegations. An incident occurred involving the former Social Service Director (V4) and a resident (R1) after R1 became upset when a Certified Nursing Assistant (V17) could not obtain a requested salad because the kitchen was closed. R1 reacted by telling V17 to get out of the room, calling V17 derogatory names, and allegedly throwing a tray. V17 then reported to V4 that V17 did not want to return to R1’s room alone. Multiple staff and the resident provided statements describing V4’s subsequent interaction with R1. The Certified Occupational Therapy Assistant (V13), who was in the bathroom providing therapy to R1’s roommate, reported overhearing V4 approach R1’s bedside with an attitude, get close to R1’s face, and berate R1 using profanity, including calling R1 an “a******” and telling R1 not to be a “f****** a******” to staff. V13 stated that V4 was aggressive, rude, and degrading toward R1 and immediately reported the incident to the Director of Nursing (V2). R1’s own written and verbal statements corroborated that V4 entered the room right after the conflict with V17, got inches from R1’s face, screamed and cursed, told R1 to “f*** off,” and called R1 an “a******,” which R1 described as belittling, humiliating, and degrading. Despite these statements, the facility’s Final Abuse Investigation, completed by the former Administrator/Abuse Coordinator (V18), concluded that verbal abuse did not occur and characterized V4’s conduct only as unprofessional use of profanity not directed at the resident. The investigation documented that V4 used profane language during the conversation but did not substantiate abuse, even though staff statements and R1’s account indicated cursing and degrading language directed at R1. V2 later stated that, based on the information and statements collected, V4 did mentally and verbally abuse R1 and that the investigation could have reached a more thorough determination by substantiating the abuse. The failure to recognize and substantiate this conduct as abuse, despite corroborating evidence, represents the facility’s failure to follow its own abuse policy and to properly identify abuse for one of three residents reviewed for abuse investigations.
Improper Transfer Technique Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to adhere to its policy of using a gait belt for all physical assist transfers, which resulted in a resident falling and injuring her left wrist. The incident involved a CNA who attempted to assist the resident off the toilet by grabbing her bra instead of using a gait belt, leading to the resident losing her balance and falling to the bathroom floor. This action was contrary to the facility's documented procedures, which mandate the use of a gait belt for all transfers to ensure resident safety. The resident involved in the incident had a history of a previous wrist fracture and required assistance with toileting due to mobility limitations. At the time of the incident, the resident was being assisted by the CNA, who was reportedly in a hurry and did not follow the proper transfer protocol. The resident's care plan indicated a risk for falls and injury, highlighting the importance of following established safety procedures during transfers. Following the fall, the resident was transported to the hospital, where X-rays confirmed an acute fracture of the left wrist. The resident was subsequently prescribed a wrist splint and pain medication. The facility's failure to use a gait belt during the transfer and the improper handling by the CNA directly contributed to the resident's fall and subsequent injury.
Failure to Employ Certified Infection Prevention Nurse
Penalty
Summary
The facility failed to employ a certified Infection Prevention Nurse, which has the potential to affect all 62 residents residing in the facility. The Administrator stated that an Infection Prevention Nurse was hired, but she is not yet certified. Although the nurse is signed up for the necessary courses, she has not started them. The nurse was hired in October 2024 and began work on October 29, 2024. A review of her employee file confirmed the hire date but showed no certification or Infection Preventionist Training documentation.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care for a resident. A registered nurse (RN) was observed preparing to perform wound care on a resident who had a bowel movement. The RN, while wearing clean gloves, removed the resident's stool-covered wound dressing and placed it in the soiled incontinence brief, which was then placed on the floor. The RN, still wearing the same soiled gloves, touched the door handle and accepted clean linens from a certified nursing assistant (CNA), thereby contaminating clean items. The RN continued to provide incontinence care to the resident without changing the soiled gloves, further compromising infection control protocols. The RN later stated that she was unaware that she should not touch clean items with soiled gloves and typically placed dirty incontinence briefs on the floor if a trash can was not available. This incident highlights a breach in the facility's infection prevention and control program, which aims to prevent and control infections among residents and staff.
Failure to Conduct Required QA Meetings and Ensure Attendance
Penalty
Summary
The facility failed to conduct the required quarterly Quality Assurance meetings and did not ensure the attendance of the required Quality Assurance committee members. Specifically, the Quality Assurance Performance Improvement Meeting Minutes attendance sign-in sheets were missing signatures from key members such as the Medical Director and Director of Nursing Services for meetings held in April 2023 and April 2024. Additionally, there were no available meeting minutes for July 2023, October 2023, and January 2024. The facility's policy mandates that the Quality Assessment and Assurance Committee meet at least quarterly and include specific members such as the Medical Director, Director of Nursing Services, and other key personnel. The Administrator confirmed the missing signatures and the absence of meeting minutes for the specified months. These failures have the potential to affect all 63 residents currently residing in the facility.
Inadequate PPE Use and COVID-19 Screening During Outbreak
Penalty
Summary
The facility failed to utilize appropriate PPE, audit for PPE compliance, and screen staff during a COVID-19 outbreak, potentially affecting 63 residents. The facility's Infection Control-Interim COVID-19 policy required the use of NIOSH-approved N95 respirators, gowns, gloves, and eye protection for healthcare providers entering rooms of residents with suspected or confirmed COVID-19. However, observations revealed that staff, including agency CNAs and registered nurses, did not consistently adhere to these guidelines. For instance, an agency CNA entered a resident's room without properly tying the gown, and a registered nurse entered another resident's room without any PPE. Additionally, residents with confirmed COVID-19 were observed wandering the halls without proper PPE, and staff failed to redirect them effectively. The facility also failed to ensure the availability of NIOSH-approved PPE. PPE supply cabinets contained non-approved KN95 masks, which were used by staff entering COVID-19 isolation rooms. The Infection Control Preventionist admitted to not conducting PPE audits and only monitoring hand hygiene compliance. Furthermore, the facility did not include agency staff in COVID-19 source testing, despite having multiple agency staff working during the outbreak. This omission was confirmed by both agency CNAs and the Infection Control Preventionist, who acknowledged that excluding agency staff from testing skewed the sampling and was not all-inclusive. Specific incidents included a registered nurse entering a resident's room on droplet precautions with only a surgical mask and face shield, failing to don full PPE, and not changing the mask after exiting. The facility's documentation showed that 63 residents resided in the facility at the time of the survey. These deficiencies highlight significant lapses in infection control practices, particularly during a COVID-19 outbreak, putting residents and staff at risk of infection.
Failure to Provide Clean Linens for Bathing
Penalty
Summary
The facility failed to provide clean, stain-free linens for bathing for nine residents, compromising their dignity and self-worth. Observations and interviews revealed that residents were given discolored washcloths with brown/tan stains for personal hygiene. One resident expressed disgust at the stained washcloths, stating it was undignified and unsanitary. Another resident was upset about being given a filthy washcloth to wash her face and mentioned being asked to use a blood-stained towel on a community shower chair. The Housekeeping Manager confirmed that stained linens were supposed to be repurposed for housekeeping or kitchen use, but soiled washcloths were observed in the laundry bin ready for washing with other whites. The Resident Council President and other residents voiced concerns about being demeaned by using feces-stained washcloths for bathing. During a group meeting, multiple residents agreed that the stained washcloths were demeaning. The facility's Administrator acknowledged the policy change to no longer provide disposable wipes for incontinence care, requiring staff to use washcloths instead. The Administrator stated that staff were not supposed to use stained washcloths and would remind the laundry staff to discard them.
Failure to Perform PASARR Rescreen for Resident with Severe Mental Illness
Penalty
Summary
The facility failed to perform a PASARR (Pre-Admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for one of two residents reviewed for PASARR screening, in the sample of 30. The facility's policy mandates that PASARR Level 1 screens be completed annually and with any significant change of status. Resident 2 (R2) was admitted with diagnoses of Bipolar Disorder and Major Depressive Disorder, but the current PASARR screen provided by the Director of Nurses indicated no diagnosis of Severe Mental Illness at the time of the original admission. The Director of Nurses confirmed that R2 had not undergone a PASARR rescreen upon admission to the facility, despite the severe mental illness diagnoses.
Failure to Ensure Safe Transport Leading to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was safely transported in the facility's transport van, resulting in a fall. The incident involved a resident with diagnoses including dependence on a wheelchair, diabetes mellitus with diabetic autonomic neuropathy, and an acquired absence of the left leg. The resident fell in the transport van while en route to a doctor's appointment. The fall investigation revealed that the resident was not wearing his wheelchair seatbelt, and the van's lap belt was too loose, allowing the resident to slip forward out of his wheelchair when the van came to a stop. The van driver, who was new to the job, admitted to loosening the seatbelt at the resident's request because it was uncomfortable, which contributed to the fall. During a group meeting, the resident recounted the fall and the subsequent pain in his right leg, which required evaluation at a local hospital emergency room. The resident also mentioned that he was not sitting in his usual spot in the van due to another resident being transported. The van driver confirmed the details of the incident, acknowledging that the seatbelt should have been much tighter and that he now understands the importance of ensuring seatbelt safety. The facility's fall risk care plan was updated to include educating the bus driver and resident on seatbelt safety while in a wheelchair.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident prescribed Seroquel, an antipsychotic medication, within the first year of its prescription. The facility's policy mandates that residents on psychotropic drugs should receive GDRs and behavioral interventions unless clinically contraindicated, with GDRs encouraged at least twice yearly. However, for one resident with multiple diagnoses including Major Depressive Disorder, Generalized Anxiety Disorder, and Dementia, the facility did not attempt a GDR despite the resident being on the same dose of Seroquel for a year. The resident's behavior monitoring sheets documented minimal episodes of agitation, anxiety, and restlessness, which did not justify the continued use of the antipsychotic medication according to the Director of Nursing (DON). The DON confirmed that the resident's behaviors did not warrant the use of Seroquel and acknowledged that a GDR had not been attempted. During an interview, the resident expressed that he was doing well at the facility and was in the process of applying for disability with plans to discharge and live independently. The resident did not display any adverse behaviors during the observation. The DON stated that loud noises could trigger and agitate the resident but confirmed that the resident was not a harm to himself or others. Despite this, the facility did not follow its policy to attempt a GDR, leading to the deficiency noted in the report.
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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